Diagnostic Criteria for Chronic Pelvic Pain
Chronic pelvic pain is defined as at least 6 months of noncyclical pain originating from the lower abdomen or pelvis that is not associated with pregnancy. 1, 2
Core Diagnostic Definition
The temporal criterion is straightforward: pain must persist for a minimum of 6 months to meet the threshold for chronicity 1, 2. This distinguishes chronic pelvic pain from acute or subacute presentations and frames it as a symptom rather than a diagnosis itself 1.
Anatomical Localization Patterns
Pain distribution helps guide the diagnostic workup and should be documented precisely:
- Deep or internal pelvic pain suggests etiologies including pelvic venous disorders (pelvic congestion syndrome), intraperitoneal adhesions, hydrosalpinx, chronic inflammatory disease, or cervical stenosis 3
- Perineal, vulvar, or vaginal pain points toward vaginal atrophy, vaginismus, vaginal or vulvar cysts, vulvodynia, or pelvic myofascial pain 3
- Lower abdominal pain may indicate gastrointestinal or musculoskeletal involvement 4
Essential Clinical History Components
The psychosocial history is mandatory and must include screening for depression, anxiety, posttraumatic stress disorder, and physical/sexual abuse, as nearly half of women with chronic pelvic pain report a history of sexual, physical, or emotional trauma. 1, 5
Additional history elements that must be documented:
- Gynecologic history: endometriosis and adenomyosis are primary gynecological causes 4
- Gastrointestinal symptoms: irritable bowel syndrome and inflammatory bowel diseases are common contributors 4, 2
- Urologic symptoms: bladder pain syndrome (interstitial cystitis) frequently coexists 2
- Associated symptoms: abdominal bloating, low back pain, and dyspareunia 1
Physical Examination Requirements
The examination must systematically evaluate three domains:
- Musculoskeletal assessment: evaluate for pelvic girdle pain and myofascial pain, as these are distinct musculoskeletal causes 4
- Abdominal examination: assess for tenderness patterns and masses 1
- Gynecologic examination: perform comprehensive pelvic assessment 1
In postmenopausal women specifically, vaginal bleeding and suspected adnexal masses require immediate attention due to endometrial and ovarian neoplasia risk. 4
Diagnostic Imaging Algorithm
For postmenopausal women with deep pelvic pain, combined transabdominal and transvaginal ultrasound is the initial imaging study of choice. 3
Imaging considerations by presentation:
- Standard approach: Combined transabdominal and transvaginal ultrasound provides anatomic overview plus high-resolution detail of uterine size, endometrial canal distension, fallopian tube dilation, ovaries, and adnexal masses 3
- Perineal/vulvar/vaginal pain: Translabial/transperineal ultrasound or side-firing transvaginal probes provide superior visualization compared to standard end-firing probes 3
- Color and spectral Doppler: Routinely employed to evaluate internal vascularity and distinguish fluid/cysts from soft tissue 3
- Dynamic ultrasound: Real-time imaging or cine clips may document abnormal adherence or lack of mobility when adhesions are suspected, though adhesive disease remains difficult to confirm nonoperatively 3
Plain radiography has no role in evaluating chronic pelvic pain. 3
Laboratory Testing Strategy
Laboratory tests should be guided by history and physical examination findings rather than ordered routinely 1. The evidence does not support a standardized laboratory panel, emphasizing targeted testing based on suspected etiologies.
Critical Diagnostic Pitfall
Chronic pelvic pain is most often the result of multiple coexisting pain conditions and central nervous system hypersensitivity rather than a single identifiable cause. 2 This multifactorial nature means that failure to identify one specific etiology does not represent diagnostic failure—it reflects the complex pathophysiology involving peripheral and central pain generators 6.