Clinical overview
Chronic pelvic pain (CPP) is defined as non-cyclical pain of at least 6 months' duration, in the pelvic region of either sex, severe enough to cause functional disability or to lead to medical care. In gynaecology practice the figure is closer to 15–25% of women of reproductive age experiencing CPP at some point. It is a diagnosis where the registrar's job is not to find a single causal lesion and excise it — that approach fails most patients. The job is to characterise the pain, identify all contributing mechanisms, address each systematically, and walk alongside the patient through what is often a multi-year management arc.
CPP is the diagnosis where biomedical thinking alone fails. A purely structural lens ("find the lesion, cut it out") misses central sensitisation, comorbid mood disorder, sexual function impact, and the role of physiotherapy and psychology. The biopsychosocial model is not a soft optional add-on — it is the first-line approach. Conversely, a purely psychological framing is harmful when there is a treatable structural cause being missed. The skill is to hold both lenses simultaneously.
The chapter covers definition and epidemiology, the multiple contributing mechanisms (gynaecological, urological, gastrointestinal, musculoskeletal, neuropathic, central sensitisation, psychosocial), systematic assessment, evidence-based interventions, and the place of surgery — which is smaller than registrars often assume.
Core knowledge
Mechanisms contributing to CPP
Chronic pelvic pain usually reflects overlapping gynaecological, urological, bowel, pelvic floor and neuropathic contributors.
It is almost always multifactorial. The contributors:
Gynaecological.
- Endometriosis — see endometriosis-pathophysiology. Up to 70% of women with CPP have endometriosis at laparoscopy, but the correlation between lesion volume and pain severity is poor.
- Adenomyosis — myometrial endometriosis-equivalent, presents with dysmenorrhoea + heavy menstrual bleeding + bulky tender uterus.
- Pelvic adhesions — from previous surgery, PID, endometriosis. Evidence that adhesiolysis improves CPP is weak overall; reserved for selected cases.
- Pelvic congestion syndrome — ovarian vein incompetence with engorged pelvic veins. Worse on standing and after sex.
- Chronic PID / hydrosalpinx — residual inflammation post acute infection.
- Fibroids — see fibroids; rarely the sole cause of pain, more often heavy bleeding.
- Ovarian remnant syndrome — residual ovarian tissue post-oophorectomy causing cyclical pain.
Urological.
- Interstitial cystitis / bladder pain syndrome — bladder filling pain, urgency, frequency, nocturia, often dramatically improved on void.
- Recurrent UTI.
- Urethral diverticulum.
Gastrointestinal.
- Irritable bowel syndrome — Rome IV criteria; coexists with CPP in up to 50%.
- Inflammatory bowel disease — needs exclusion in any chronic pain with bowel symptoms.
- Coeliac disease — rarely presents as CPP but should be considered.
- Chronic constipation, diverticular disease.
Musculoskeletal.
- Myofascial pain syndromes — trigger points in pelvic floor (levator ani spasm), abdominal wall, gluteal muscles.
- Pubic symphysis dysfunction, sacroiliac joint dysfunction.
- Hip pathology referred (e.g., labral tear).
- Pelvic floor hypertonicity / non-relaxing pelvic floor — a common, treatable cause that requires specific pelvic floor physiotherapy.
Neuropathic.
- Pudendal neuralgia — pain in the perineum/vulva, worse sitting, relieved standing or sitting on toilet seat.
- Ilioinguinal/iliohypogastric/genitofemoral nerve entrapment — common after Pfannenstiel incision, Joel-Cohen incisions, or laparoscopic port placement.
- Post-surgical nerve damage.
Central sensitisation. Repeated nociceptive input over time alters spinal and supraspinal processing — windup phenomenon, descending modulation impairment, expansion of receptive fields. The result: pain disproportionate to peripheral findings, allodynia (pain to non-painful stimuli), hyperalgesia, fatigue, sleep disturbance, mood symptoms. This is a real neurobiological state, not "psychological" pain.
Psychosocial contributors. History of sexual or physical abuse is significantly more prevalent in CPP populations (50–60% in some series). Depression, anxiety, and PTSD coexist with CPP at rates 2–3× the general population. Sexual dysfunction is common (dyspareunia, vaginismus). Relationship strain and impact on work/social function feed back into pain perception.
The biopsychosocial framework
The patient experiences pain through three interacting domains:
- Biological — tissue pathology, sensitisation, hormonal modulation.
- Psychological — mood, cognitions about pain, catastrophising, coping strategies.
- Social — work, family, intimate relationships, support, financial.
Effective management addresses all three.
Assessment
History — protected time
A CPP consultation needs at least 45 minutes, not 10. The history is your most powerful diagnostic tool because investigations rarely give a single answer.
Pain characterisation:
- Duration, time course, evolution.
- Site, radiation, character (sharp, burning, aching, throbbing, dragging).
- Timing — cyclical (catamenial → endometriosis/adenomyosis), constant, on activity, post-coital.
- Severity — numerical rating scale, impact on daily activities, sleep, work.
- Aggravating/relieving factors.
- Effect of position (sitting → pudendal; lying flat → pelvic congestion).
- Pain "map" — ask her to mark a diagram of where the pain is.
Associated symptoms:
- Menstrual: dysmenorrhoea, menorrhagia, intermenstrual or postcoital bleeding.
- Urinary: frequency, urgency, nocturia, dysuria, void-improvement.
- Bowel: stool frequency, consistency, urgency, blood, mucus, post-defaecation pain.
- Sexual: dyspareunia (entry vs deep), libido, orgasm.
- Musculoskeletal: back pain, hip pain, leg pain.
Past history:
- Previous PID, STIs, ectopic, pelvic surgeries, deliveries.
- Mood symptoms past and present, prior trauma (asked sensitively, with chaperone if appropriate).
- Medication history including chronic opioid use.
Social and impact:
- Effect on work, relationships, parenting, intimacy.
- Support structure.
- Patient's own understanding of what is causing the pain — this is diagnostic gold and shapes the alliance.
Examination
Pelvic floor tenderness, trigger points and pudendal nerve tenderness are key examination targets.
A two-part examination:
- Abdominal exam including identifying abdominal wall trigger points (Carnett's sign — pain reproduced or worsened with tense abdominal wall confirms abdominal wall, not visceral, origin).
- Pelvic exam:
- External: vulval inspection, vulval pain mapping (cotton swab test for vestibulodynia — see vestibulitis).
- Single-finger digital exam before a speculum or bimanual to identify pelvic floor trigger points, levator ani tenderness, pudendal nerve tenderness at the ischial spine.
- Speculum: cervix, discharge, lesions.
- Bimanual: uterine size, mobility, tenderness, adnexal masses, uterosacral nodularity (endometriosis).
Investigations
- Pregnancy test.
- STI screen (chlamydia, gonorrhoea PCR; HIV; syphilis).
- Urinalysis ± urine culture.
- Transvaginal ultrasound — identify endometriomas, fibroids, hydrosalpinx, adenomyosis features (heterogeneous myometrium, cysts, asymmetric wall thickening).
- MRI pelvis — for suspected deep infiltrating endometriosis, complex adenomyosis, suspected adhesions, suspected pelvic congestion.
- Diagnostic laparoscopy — not first-line. Reserved for women in whom less invasive evaluation is non-diagnostic and where the result will change management.
Management
Stepped, multidisciplinary care
Effective care addresses biological, psychological and social drivers while reserving surgery for selected lesions.
Step 1 — explanation, alliance, expectation-setting.
- Validate that the pain is real.
- Explain the biopsychosocial model with the patient.
- Set realistic goals: reduction (not always elimination) of pain; restoration of function; improved sleep, mood, intimacy.
- Provide written information; signpost to support groups (e.g., Endometriosis SA, RCOG patient information).
Step 2 — non-pharmacological foundations.
- Pelvic floor physiotherapy — for any patient with pelvic floor tenderness or musculoskeletal contributors. Strong evidence base.
- Cognitive-behavioural therapy (CBT) for pain — moderate-to-strong evidence in CPP.
- Sleep hygiene, graded exercise, dietary modifications (low-FODMAP if IBS features).
- Mindfulness-based stress reduction.
Step 3 — pharmacological.
For cyclical pain / suspected endometriosis or adenomyosis:
- Combined hormonal contraception (continuous, not cyclical, dosing).
- Progestogen-only options: medroxyprogesterone acetate, dienogest, levonorgestrel-IUS (Mirena).
- GnRH agonists with add-back HRT — limited duration due to bone effects.
For non-cyclical pain:
- Paracetamol + NSAIDs — first-line.
- Amitriptyline 10–25 mg nocte (titrated to 50–75 mg) for neuropathic and central sensitisation features.
- Gabapentin or pregabalin for neuropathic pain.
- Tramadol cautiously for moderate pain; avoid chronic opioids — they worsen pain and function in CPP.
Step 4 — interventions for specific subtypes.
- Trigger point injection for abdominal wall or pelvic floor trigger points.
- Pudendal nerve block (diagnostic and therapeutic) for pudendal neuralgia.
- Embolisation of ovarian veins for pelvic congestion syndrome.
- Selective sacral nerve stimulation for refractory neuropathic pain (specialist centre).
Step 5 — surgery. Reserved and selective. Indications:
- Confirmed endometriosis with severe symptoms — laparoscopic excision (excision > ablation) by an experienced surgeon. See endometriosis-pathophysiology.
- Symptomatic fibroids contributing to pain — myomectomy or hysterectomy depending on context.
- Hysterectomy for adenomyosis — definitive treatment in women who have completed family.
- Salpingectomy for symptomatic hydrosalpinx.
Hysterectomy for CPP without an identified gynaecological lesion has a ~25% failure rate (persistent pain post-op). Counsel realistically.
Multidisciplinary management
Refer early:
- Pelvic floor physiotherapy.
- Pain medicine clinic for refractory neuropathic pain.
- Gastroenterology for IBS/IBD.
- Urology for bladder pain syndrome.
- Psychology/psychiatry for mood, trauma, CBT.
- Pelvic floor surgery centres for complex endometriosis.
Red flags / pitfalls
- Treating one mechanism in isolation — almost all CPP is multifactorial.
- Operating without a plan — laparoscopy "to see what's there" without a hypothesis or counselling about likely findings and unchanged pain post-op.
- Missing trauma history — gentle, structured enquiry essential. See gender-based-violence.
- Chronic opioid prescription — worsens pain via opioid-induced hyperalgesia; high addiction risk.
- Premature hysterectomy — counsel on the 25% rate of persistent pain.
- Not addressing pelvic floor — single most under-used effective intervention.
- Ignoring depression — untreated depression is a major modifier of pain experience.
- Failure of continuity of care — CPP needs a long-term relationship with one trusted clinician.
- Forgetting non-gynae causes — bladder, bowel, musculoskeletal often dominant.
Evidence anchors
- RCOG Green-top Guideline No. 41 — The Initial Management of Chronic Pelvic Pain.
- ESHRE Endometriosis Guideline (2022).
- NICE NG73 — Endometriosis: diagnosis and management.
- ACOG Practice Bulletin No. 218 — Chronic Pelvic Pain.
- European Association of Urology — Chronic Pelvic Pain Guideline (2023).
- Engeler D, et al. EAU Guidelines on Chronic Pelvic Pain.
- South African National Department of Health STG — chronic pain management chapter.
- Cochrane Reviews — antidepressants for chronic pelvic pain; surgical treatments for CPP.
- World Endometriosis Society Consensus Statement (Vercellini et al., 2017+).