History and exam
Key diagnostic factors
common
dysuria
Typically occurs with other irritative voiding symptoms.
dyspareunia
Deep dyspareunia is considered more frequent in endometriosis.[38]
dysmenorrhea
Indicates uterus or gynecologic organs as 1 source of pain.
abdominal trigger points
Highly localized tenderness, typically at the lateral margin of the rectus sheath or an old scar. Responds well to anesthetic infiltration.
levator ani tenderness
Often unilateral. The pinpoint location of tenderness must be isolated if anesthetic infiltration is to be helpful.[39]
cervical motion tenderness
Indicates upper pelvic organs are likely involved: uterus, ovaries. May also occur with bladder pain.
uterine tenderness
Indicates pain of gynecologic origin
uncommon
abdominal tenderness
If diffuse, suggests a more acute condition overlapping with chronic pain.
vestibular tenderness
May be only a portion of the vestibule. Must be distinguished from hymenal remnant pain.
rectal tenderness
Suggests a component of endometriosis involving the bowel. May indicate an inflammatory bowel disease.
adnexal tenderness
If unilateral, suggests the need for ultrasound characterization of potential cysts or masses. May be difficult to distinguish following uterine exam.
bladder tenderness
Suggests interstitial cystitis, but is not definitive
urethral tenderness
Strongly suggests urethritis or urethral diverticulum
Other diagnostic factors
common
abdominal pain
Generally in the lower abdomen; suggests a trigger point if at the location of an old scar.
nocturia
Typically occurs with other irritative voiding symptoms.
incomplete voiding
Typically occurs with other irritative voiding symptoms.
headache
Commonly associated and suggests multiple pain generators are involved.
uncommon
dyschezia
A symptom of irritable bowel syndrome.
low back pain
Commonly associated and suggests multiple pain generators are involved.
Risk factors
strong
sexual abuse
pelvic inflammatory disease
Previous pelvic scarring from surgery or infection often leads to chronic pain.[22]
poor hygiene
Personal hygiene may affect the microflora of the vagina, leading to common infections of the lower reproductive tract. Poor hygiene might result from lack of access to medical services or sanitary products.[21]
anxiety or depression
All pain syndromes are worsened in the presence of anxiety or depression.[23] The actual causal relationship is less clear.
drug or alcohol use
Patients with chronic pain frequently self-medicate with alcohol. Opioid addiction may precede or result from chronic pain.
pregnancy
Adenomyosis is considered to only occur following pregnancy of some type. It is unclear whether miscarriage or term delivery increases the risk for adenomyosis. Adenomyosis is associated with chronic pelvic pain.[24]
polymenorrhea
The actual cause of endometriosis is unknown, but it is felt to be associated with having many menstrual periods, during which time endometrial tissue has more of an opportunity to seed the pelvis through retrograde flow. Endometriosis is associated with chronic pelvic pain.
previous cesarean section
Adhesions from surgery, or abdominal wall pain relating to nerve injury, scar tissue formation, or seeding of the surgical wound with endometrial tissue.
endometriosis
Endometriomas provides a pathologic basis for chronic pain symptoms. Of women with chronic pelvic pain, 71% to 87% are diagnosed with endometriosis.[25]
weak
adhesions
Adhesive disease provides a pathologic basis for chronic pain symptoms.
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