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To diagnose and treat chronic pelvic pain, your doctor will need to learn as much as possible about the conditions that are contributing to your pain. A knowledgeable doctor will ask you many questions about your condition and perform a thorough physical exam.

Which tests your doctor uses to diagnose your condition and determine your treatment will depend on your symptoms.

There are a number of conditions that are commonly associated with chronic pelvic pain, including endometriosis, pelvic inflammatory disease, adhesions, nerve entrapment, irritable bowel syndrome, bladder problems, back pain, pelvic prolapse and depression.

Your Health History

Your doctor will want to know how your pain started, where and when you experience it, and what impact is has on your life. She or he will also want all of your records from past doctors.

Because your doctor will require such detailed information, this conversation may take place over several visits. Your doctor may ask you to fill out a lengthy questionnaire at home, which you can discuss during your visit. An example of this sort of form is available on the website of the International Pelvic Pain Society. (This form is in PDF format, so you will need Adobe Acrobat Reader to look at it.)

Providing accurate and detailed information about your condition is one of the most important things you can do to contribute to your healing. As your treatment progresses, you may be asked to keep a pain diary or to provide other detailed information about changes in your condition. The information you provide is a vital part of your diagnosis and treatment.

The Physical Exam

Your doctor will need to do a detailed physical exam before diagnosing and treating chronic pelvic pain (CPP). Which exams are done will depend on your symptoms. They may include the following:

Routine Pelvic Exam
Chances are you’ve already had many routine pelvic exams.

Vulvar Exam
To learn about what a physical exam of the vulva entails, click here.

Rectovaginal Exam
To do a rectovaginal exam, the doctor will place fingers inside both your vagina and rectum, to check for any weaknesses in the muscle wall that supports the pelvis. This exam can also help detect tumours, cysts or endometriosis.

Blood Tests
Your doctor may order blood tests, such as a complete blood count (or CBC) test, which can detect infection, anemia and abnormalities of the blood cells, and/or an erythrocyte sedimentation rate (ESR) blood test, which can detect inflammation in the body.

Trigger Point Exam
Trigger points are tender areas in the abdominal wall due to referred pain. The doctor will examine your abdomen, in a grid pattern, looking for tender spots and making note of these areas. You may be asked to tense or relax your muscles, to help distinguish between muscle pain and pain originating from your organs.

Vaginal Inspection
Similar to a trigger point exam, the doctor will use a finger to look for tender spots inside the vagina.

Movement Observation
You doctor may want to see you walk, sit and perform other common movements. Changes in your movements may indicate areas of concern in the pelvic muscles and muscles of the abdominal wall.

Stool Analysis
Stool analysis tests may be done to check for signs of blood in the stool, which can help diagnose certain conditions of the digestive tract.

Based on the findings from these initial exams, further tests may be useful:

Ultrasound and X-Rays
Ultrasound and x-ray procedures can help your physician "see" abnormalities and changes in the pelvic organs.

Laparoscopic surgery can help a doctor diagnose the underlying cause(s) of the pain. This procedure uses a fibreoptic device, called a laparoscope, to examine the inside of the pelvic cavity. See the page on surgical treatments for more information about this procedure.

Conditions that Contribute to Chronic Pelvic Pain

To diagnose and treat chronic pelvic pain (CPP), it is important to identify and treat the underlying cause. Sometimes a woman's pain is the direct result of a disease or physical condition. More often, pain is partially due to neuropathic and referred pain which was initiated when the condition first developed.

These are some of the conditions associated with CPP:

Some reports suggest that endometriosis is present in up to 70 percent of women of childbearing age who have CPP.

Pelvic Inflammatory Disease (PID) and Other Pelvic Infections
PID can cause internal swelling and pelvic pain. If a woman has had PID, scar tissue can form, which may also cause pelvic pain. Sometimes scar tissue will form adhesions (see below). Other pelvic infections, such as appendicitis or peritonitis, can cause similar problems.

Adhesions are bands of scar tissue that link two or more internal organs. Scar tissue that is formed when organs are cut or damaged, as a result of a surgery or infection, can become an adhesion. A woman's movements can pull on these adhesions and cause pain.

Nerve Entrapment
Nerve entrapment can also result from a surgery, or sometimes an accident. A nerve cut or damaged during surgery may be trapped or compressed in the muscle layer of the abdomen, which causes pain.

Irritable Bowel Syndrome (IBS) and Other Gastrointestinal Disorders
It is estimated that up to 60 percent of women who visit a gynecologist for pelvic pain have IBS. To learn more about IBS and other bowel diseases, visit our Health A-Z section section.

Interstitial Cystitis and Other Bladder Problems
Painful bladder problems, such as interstitial cystitis and urethral syndrome, can contribute to CPP.

Back Pain
Damage to the muscles and nerves in the back can contribute to CPP.

Pelvic Prolapse
Weakness in the pelvic muscles and/or prolapsed organs can lead to pain and spasms.

Pelvic Congestion
In women with pelvic congestion, the veins in the pelvis are unusually dilated and convoluted. This causes pressure and pain. Pelvic congestion appears to be related to a high level of estrogen, which can cause some veins to widen. Pelvic congestion usually affects women of reproductive age and is very rare after menopause. Women with pelvic congestion often have other signs of hormone imbalance, such as heavy and painful periods and ovarian changes.

Depression, Child Abuse
The relationship between CPP and a woman's emotional health is important and needs further study. The majority of women with CPP also have some symptoms of depression although it is unclear whether depression is a symptom of pelvic pain or a factor that contributes to it. Studies have shown that people who are depressed have a lower threshold for pain.

Some studies have also shown that women with CPP are more likely to be survivors of childhood sexual abuse. Child abuse survivors are also more likely to experience depression. We do not know exactly why childhood sexual abuse is associated with CPP, although in some cases physical damage caused by the abuse may contribute. Childhood trauma may also affect a woman's perception of pain, as depression does. High rates of childhood sexual abuse have also been noted in other chronic pain conditions.

Prolonged stress associated with childhood abuse or neglect changes the structure of the brain and the way neural signals are processed.


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