Silent Struggles: Screening for Risk Factors of Chronic Pelvic Pain

Have you ever heard of a headache in the pelvis? Better known as chronic pelvic pain (CPP), this can be a debilitating condition that affects nearly a quarter of women in their lifetime (Ahangari, 2014). Chronic pelvic pain is described as pain in the front of the abdomen from the level of the umbilicus radiating down to the level of the thighs and genitals. It lasts at least six months and is severe enough to cause functional disability and require treatment. 

Pelvic health physical therapists and physical therapist assistants play a vital role in the treatment and management of chronic pelvic pain, but its multifactorial nature can make it challenging to determine a specific cause and therefore, appropriate treatment. Having an understanding of the various systems and risk factors that could be contributing to a person’s chronic pelvic pain can help clinicians determine an appropriate treatment plan as well as if and when it is necessary to refer out to other specialties. To improve your evaluation and assessment of chronic pelvic pain, here are five factors to screen for and take into consideration when treating patients with CPP. 

Five Risk Factors to Consider When Treating Patients with Chronic Pelvic Pain:

Cyclical or non-cyclical: do the patient’s symptoms follow a pattern, such as an increase in pain in the days leading up to or during menstruation? Cyclical pain, especially when associated with severe dysmenorrhea can be indicative of underlying conditions such as endometriosis or adenomyosis. Non-cyclical pain is more often associated with gynecological or obstetric factors such as pelvic congestion syndrome, pelvic inflammatory disease, or pelvic adhesions. 

Surgical history: has the patient had any abdominal or hip surgeries that could be contributing to restrictions or dysfunction in the pelvis? One of the most common contributing factors is cesarean scar adhesions, but don’t forget to ask about any organ removals (like appendectomies), hip procedures (labral repairs, hernia repairs), or hysterectomies. It’s important to note too that chronic pelvic pain is the primary indication for hysterectomy for benign disease (Farquhar & Steiner, 2002). 

Bladder and bowel health: has the patient been evaluated for and received a diagnosis related to bladder or bowel dysfunction? The top bladder and bowel etiologies associated with chronic pelvic pain include interstitial cystitis (IC) and irritable bowel syndrome (IBS). Other diagnoses to take into consideration include celiac’s disease, inflammatory bowel disease, or chronic urinary tract infections. It’s important to note too that although IC and IBS are non-hormonally responsive conditions, symptoms may worsen before or during menstruation. 

Neurological and musculoskeletal conditions: does the patient report any pain in the sacrum, tailbone, pubic symphysis, hip, abdominals, or low back? Be sure to ask about any specific injuries, strains or accidents, including injury timeline, that could be related to their CPP’s onset or subsequent flare ups. Don’t forget to screen for nerve injuries or entrapments that are common with prolonged sitting or childbirth. This will be especially helpful in the evaluation process when determining the source(s) of pain. It is estimated that approximately 85% of individuals with CPP present with musculoskeletal dysfunction (Montenegro et  al., 2008). 

Mental health and abuse: does the patient have a history of psychological, physical, or sexual abuse, depression, or opiate dependency? Similar to other risk factors, depression can be both a contributing factor and further exacerbated by chronic pelvic pain, so it’s important to screen for and refer out for additional care when psychological conditions or trauma is suspected. 

Chronic pelvic pain can be a complex condition that takes a multidisciplinary approach to treat.  Although one disorder may be the cause of CPP, it is more than likely that several medical conditions are contributing to a person’s pain and dysfunction. Knowing how you can screen for and further assess CPP is essential to offering patients the most appropriate guidance and developing a treatment plan that addresses the underlying cause(s). 

For more information on the evaluation, assessment, and treatment of chronic pelvic pain, check out the CAPP-2A Course on the management of various pelvic pain conditions. 

References: 
Ahangari, A. (2014). Prevalence of chronic pelvic pain among women: an updated review. Pain Physician, 17(2),  E141‐E147

Farquhar, C. M., & Steiner, C. A. (2002). Hysterectomy rates in the United States 1990–1997. Obstetrics &  Gynecology, 99(2), 229–234. 

Montenegro, M. L., Vasconcelos, E. C., Candido Dos Reis, F. J., Nogueira, A. A., & Poli‐Neto, O. B. (2008). Physical  therapy in the management of women with chronic pelvic pain. International Journal of Clinical Practice,  62(2), 263–269.

Author: Lindsay Durand Massumi, PT, DPT

2023 EPSIG CAPP Scholarship Recipient

Author Bio: Dr. Lindsay Durand Massumi is a practicing pelvic health physical therapist in the Northern Virginia area. She and her husband own a private practice where Lindsay primarily works with female athletes suffering from pelvic floor dysfunction including leakage and chronic pelvic pain.