Chronic Pelvic Pain

1. A 23-year-old nulligravid woman with a history of severe dysmenorrhea, moderate chronic pelvic pain, chronic culture-negative dysuria, and infertility presents 2 months after undergoing laparoscopic excision of stage 2 endometriosis. Her dysmenorrhea is much improved. However, she still has moderate chronic pelvic pain, moderate dyspareunia, and mild &dysuria, for which she seeks relief. She reports no symptoms of depression or anxiety. Physical examination reveals minimal pelvic tenderness to deep palpation, moderate tenderness of the pelvic rectus muscle with flexion, and sacroiliac tenderness bilaterally. Vaginal examination reveals moderate tenderness of the pelvic floor muscles bilaterally and mild tenderness of the bladder without significant uterine or adnexal tenderness. She desires pregnancy as soon as possible. The treatment strategy most appropriate to address her pain is:

Opioid therapy

Gonadotropin-releasing hormone agonist

Pelvic physical therapy

Trigger point injection

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Chronic pelvic pain is defined as noncyclic pain it the pelvis that persists for more than 6 months.
Centralized pain involves a dysregulation of pain sensitivity and dysfunction in the pathways that regulate pain sensitivity, muscular pain reflexes, and tissue inflammation. It can present as a primary pain disorder or a secondary rection to a primary pain stimulus. Treatment often includes addressing the primary condition that initiated pain, as well as multimodal treatment to address the central pain regulation system.
Signs of myofascial pain include tenderness to palpation of pelvic floor muscles and abdominal wall muscles, often including exquisitely tender trigger points, especially with muscle flexion.
Pelvic physical therapy can include external and internal/intravaginal muscle manipulations, trigger point release maneuvers, localized heat, and biofeedback, as well as exercises that mobilize, strengthen, and relax muscles.
Hormonal suppression of underlying endometriosis and and associated inflammation can lessen the pain trigger, but is not appropriate while attempting conception. Long-term use of opiods can lead to increased sensitivity to pain stimuli (hyperalgesia). Trigger point injections can be beneficial but are a less comprehensive treatment in isolation.

2. A 28-year-old nulligravid woman presents for evaluation of pain in her lower abdomen and pelvis for the past 3 years. She describes the daily pain as "cramping" and at its worse during menses. She also reports urinary frequency. Urinalysis was negative. She reports no gastrointestinal symptoms. Pelvic examination is significant for fullness and tenderness in the right adnexa. The best next step in diagnosis is

Cystoscopy

Diagnostic laparoscopy

Computed tomography

Transvaginal ultrasonography

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Transvaginal ultrasonography is considered the first-line evaluation of a pelvic mass because it is accurate, relatively inexpensive, and readily available. It is appropriate when exam findings suggest adnexal pathology.
This patient has cyclic pain and a pelvic mass, concerning for the presence of an endometrioma. Endometriosis can lead to cyclic pelvic pain. It can be diagnosed and treated by laparoscopy, but surgery is not indicated until further evalation is completed and consideration is given to conservative, medical management.
Bladder pain syndrome may coexist with endometriosis or be a component of chronic pelvic pain. It can be assessed with cystoscopy. Patients who have suspicious symptoms can be evaluated with the use of a validated questionnaire, such as the Pelvic Pain and Urgency/Frequency questionnaire.

3. A 43-year-old woman visits your office with a 3-month history of suprapubic pain and pressure symptoms, which she relates to bladder filling. She also has symptoms of urgency, which usually are relieved with bladder emptying. She has frequency up to 10 times a day but has neither dysuria nor incontinence. She has experienced several episodes of exacerbated symptoms lasting 2-3 days that have precluded her from being able to go to work. She has not noticed any correlation of these episodes to her menstrual cycles. The diagnostic test that is most important in the initial evaluation of this patient is

Urodynamic testing

Urinalysis with culture

Potassium sensitivity test

Cystoscopy

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These symptoms are consistent with painful bladder syndrome, also known as interstitial cystitis.
A main component of evaluation includes excluding other conditions or causes of pain, including urinary tract infection, endometriosis, sexually transmitted infections, suburethral diverticulum, carcinoma of the bladder wall, renal or bladder stones.
Initial evaluation includes a urine culture and urine microscopy. Cystoscopy and pelvic ultrasound are not necessary for women with uncomplicated presentations. Urodynamic testing is not necessary unless prolapse or incontinence is present.
Cystoscopy findings can include Hunner ulcers, and on hydrodistension, petechiae, glomerulations, or terminal hematuria.
Treatment can include dietary adjustments, pelvic floor relaxation techniques, bladder retraining and over-the-counter analgesics, as well as oral pentosan sulfate (Elmiron) and intravesical instillation of dimethyl sulfoxide.