What investigations are recommended for female chronic pelvic pain?

Investigations for Female Chronic Pelvic Pain

Initial Imaging: Pelvic Ultrasound is First-Line

Combined transvaginal and transabdominal ultrasound with Doppler is the initial imaging study of choice for evaluating female chronic pelvic pain. 1 These three modalities (transvaginal, transabdominal, and Doppler) are complementary and should be performed together as a single comprehensive examination. 1

Ultrasound Components and Findings

• Transvaginal ultrasound provides superior spatial and contrast resolution for evaluating the uterus, endometrial canal, fallopian tubes, ovaries, and adnexal masses 1
• Transabdominal ultrasound provides an anatomic overview of the entire pelvis and should always accompany transvaginal imaging 1
• Doppler ultrasound is a standard component that evaluates uterine artery blood flow (low-resistance waveforms are associated with chronic pelvic pain) and assesses for pelvic venous disorders 1

Special Ultrasound Techniques

• Translabial/transperineal ultrasound should be used when pain is localized to the vulva, perineum, or vaginal wall, as it provides better visualization than standard end-firing transvaginal probes 1, 2
• Dynamic real-time ultrasound or cine clips can document abnormal adherence or lack of mobility of structures when pelvic adhesions are suspected 1

Problem-Solving Imaging: MRI Pelvis

MRI pelvis with gadolinium contrast is the problem-solving examination of choice when ultrasound findings are nondiagnostic or inconclusive. 1, 2

MRI Indications and Capabilities

• Pelvic venous disorders (pelvic congestion syndrome): Time-resolved postcontrast T1-weighted imaging directly demonstrates ovarian vein reflux and engorged periuterine/periovarian veins; MRI diagnostic performance is comparable to conventional venography 1
• Chronic pelvic inflammatory disease: T2-weighted imaging demonstrates edema, fluid collections, and distension of endometrial canal or fallopian tubes; postcontrast T1-weighted and diffusion-weighted imaging distinguish inflammatory from neoplastic masses 1
• Adhesive disease: Low-signal bands between structures on non-fat saturated T2-weighted imaging or peritoneal inclusion cysts 1
• Pelvic floor dysfunction: MRI accurately depicts pelvic floor muscular anatomy, integrity, function, and muscular hypertonicity in chronic pelvic pain syndromes 1
• Perineal/vulvar/vaginal masses: MRI provides anatomic detail and evaluation of enhancing soft-tissue components that might favor infection or neoplasia 1

CT Imaging: Limited Role

CT abdomen and pelvis has no established role as a primary imaging modality for chronic pelvic pain. 1 CT may be useful when there is poorly localized pain with a broad differential diagnosis including non-gynecologic etiologies, or as second-line imaging after equivocal ultrasound in specific clinical scenarios. 1

CT Findings When Performed

• Pelvic venous disorders: Contrast-enhanced CT can demonstrate engorged periuterine and periovarian veins, but requires abdominal coverage to evaluate drainage into renal vein or cava 1
• Chronic inflammatory disease: CT may show pelvic fluid, peritoneal thickening, hydrosalpinx, pyosalpinx, and tubo-ovarian abscess 1

Plain Radiography: Not Indicated

There is no evidence to support the use of plain radiography (abdomen and pelvis X-rays) for evaluating chronic pelvic pain. 1

Clinical Evaluation Components

History Taking

• Pain characteristics: Duration (≥6 months defines chronic pain), location (deep pelvis vs. perineum/vulva/vagina), intensity, cyclical vs. non-cyclical pattern 2, 3, 4
• Associated symptoms: Dysmenorrhea, dyspareunia, abdominal bloating, low back pain, bladder symptoms, bowel symptoms 2, 4, 5
• Red flag symptoms: Systemic illness, fever, hemodynamic instability 2
• Psychosocial history: Screen for depression, anxiety, posttraumatic stress disorder, physical and sexual abuse due to their strong association with chronic pelvic pain 4, 6
• Past medical history: Inflammatory bowel disease, immunosuppression, diabetes, prior anorecal surgery, trauma 2

Physical Examination

• Complete pelvic and perineal examination: External inspection, digital rectal examination, internal pelvic examination 2
• Musculoskeletal examination: Assess for myofascial pain and pelvic floor dysfunction 4
• Abdominal examination: Evaluate for masses, organomegaly, tenderness 4

Laboratory Testing

• Selective use: Laboratory studies (complete blood count, inflammatory markers, metabolic panel) are not routinely required but should be guided by clinical findings suggesting systemic illness 2
• Pregnancy testing: Consider in women of childbearing age 2

Common Pitfalls to Avoid

• Do not perform ultrasound components separately: Transvaginal, transabdominal, and Doppler imaging should always be performed together as they are complementary 1
• Do not skip physical examination: Physical examination is the foundation of clinical evaluation, particularly for perineal, vulvar, or vaginal pain 1, 2
• Do not order CT as first-line imaging: CT has limited diagnostic value for chronic pelvic pain and exposes patients to unnecessary radiation 1
• Do not overlook non-gynecologic causes: Chronic pelvic pain requires evaluation of gastrointestinal, urologic, musculoskeletal, and psychoneurological systems 3, 4, 7

Differential Diagnoses to Consider

• Gynecologic: Endometriosis, pelvic venous disorders (pelvic congestion syndrome), chronic pelvic inflammatory disease, adhesions, hydrosalpinx, cervical stenosis 1, 3, 4
• Urologic: Interstitial cystitis/bladder pain syndrome 4, 6, 5
• Gastrointestinal: Irritable bowel syndrome 3, 4, 6
• Musculoskeletal: Pelvic myofascial pain, pelvic floor dysfunction 1, 4, 6
• Perineal/vulvar: Vaginal atrophy, vaginismus, vaginal or vulvar cysts, vulvodynia 1