How an OB/GYN Approaches Chronic Pelvic Pain

Chronic pelvic pain is usually multifactorial, and endometriosis is only one part of the differential. In the ED, the high-value move is to exclude ovarian torsion, ectopic pregnancy, and tubo-ovarian abscess, then use a careful history and targeted pelvic exam to separate gynecologic from myofascial pain.

ED Approach to Chronic Pelvic Pain

• Broad differential diagnosis: Chronic pelvic pain means abdominopelvic pain causing distress or dysfunction for more than 3 to 6 months, with common causes including dysmenorrhea, pelvic floor myalgia, vestibulodynia, interstitial cystitis, and endometriosis.
• Dangerous diagnoses first: Before labeling pain as chronic, rule out ovarian torsion, ectopic pregnancy, and tubo-ovarian abscess, especially when the current episode is new, different, or clearly escalating.
• Pattern-based pain history: Pain quality, cyclicity, baseline pain with flares, and triggers such as intercourse, bowel movements, position, or heating pads often narrow the source faster than a broad undirected review of symptoms.
• Musculoskeletal pain clues: A sensation that something is falling out can point to levator pain, while pain shooting down the back of the leg or wrapping like a belt suggests piriformis or other pelvic floor involvement.
• Targeted abdominal screening: Start with the back and abdomen before the pelvic exam; scoliosis, prior surgical scars, and a positive Carnett sign can shift suspicion toward abdominal wall or musculoskeletal pain. We get into how that changes the exam sequence in the episode.
• Expectation setting early: Set up chronic pelvic pain care as a multimodal process rather than a one-visit diagnosis, because early validation and a concrete follow-up plan can keep patients from falling through the cracks.

Pelvic Exam Pearls and Initial Treatment

• Single-digit bimanual technique: Using one finger instead of two during the bimanual exam often improves comfort and cooperation without sacrificing useful information in a patient already sensitized by pain.
• Judicious speculum use: A speculum exam is not mandatory in every chronic pelvic pain evaluation; reserve it for situations where it will answer a specific question rather than reflexively adding another painful step.
• Systematic pelvic floor exam: Pressing the levator plate at the 5 and 7 o'clock positions and the obturator internus at 3 and 9 o'clock helps identify reproducible myofascial pain before moving to cervix, uterus, and adnexa.
• Internal versus external tenderness: Pain that is mainly internal raises concern for an adnexal source, while pain provoked more by external abdominal hand pressure points toward a muscular disorder. That bedside distinction is worth hearing in the chapter.
• Ultrasound for endometriosis clues: Pelvic ultrasound can help when endometriosis is suspected, particularly if an endometrioma is on the table, but a normal scan does not settle the broader chronic pelvic pain workup.
• First-line symptom treatment: NSAIDs, muscle relaxants, pelvic floor physical therapy, and hormonal therapy such as oral contraceptives are common starting points, with SNRIs, tricyclics, or gabapentinoids sometimes used to turn down pain amplification.

References:

1. Nicholas M, Vlaeyen JWS, Rief W, et al; IASP Taskforce for the Classification of Chronic Pain. The IASP classification of chronic pain for ICD-11: chronic primary pain. Pain. 2019 Jan;160(1):28-37. PMID: 30586068.
2. Lamvu G, Carrillo J, Ouyang C, Rapkin A. Chronic Pelvic Pain in Women: A Review. JAMA. 2021 Jun 15;325(23):2381-2391. PMID: 34128995.