From the Guidelines
The workup for pelvic pain should begin with a thorough history and physical examination to identify potential causes, followed by initial laboratory tests and imaging studies, with a pelvic ultrasound being the initial imaging modality of choice, as recommended by the American College of Radiology Appropriateness Criteria 1.
Key Components of the Workup
- A thorough history and physical examination to identify potential causes of pelvic pain
- Initial laboratory tests, including:
- Complete blood count
- Urinalysis
- Pregnancy test for women of reproductive age
- Testing for sexually transmitted infections
- Imaging studies, starting with a pelvic ultrasound to evaluate for structural abnormalities like ovarian cysts, fibroids, or ectopic pregnancy
Specialized Tests and Examinations
- For women, a gynecological examination with cervical cultures to rule out conditions like pelvic inflammatory disease
- For men, a genital examination and prostate assessment
- Additional specialized tests, such as:
- Cystoscopy for suspected bladder issues
- Colonoscopy for gastrointestinal causes
- Laparoscopy for direct visualization of pelvic organs
Importance of a Comprehensive Approach
Pelvic pain can stem from reproductive, urinary, gastrointestinal, musculoskeletal, or neurological origins, and proper diagnosis is crucial for effective treatment. A multidisciplinary approach involving gynecologists, urologists, gastroenterologists, and pain specialists may be necessary for chronic pelvic pain, as noted in the guidelines 1.
Recent Guidelines and Recommendations
The most recent guidelines from the American College of Radiology Appropriateness Criteria 1 emphasize the importance of a thorough history and physical examination, followed by initial laboratory tests and imaging studies, with a pelvic ultrasound being the initial imaging modality of choice. These guidelines also highlight the need for a multidisciplinary approach to managing chronic pelvic pain.
From the Research
Pelvic Pain Workup
The workup for pelvic pain involves a comprehensive approach, including a thorough history and physical examination. The following are key components of the workup:
- A comprehensive history, including questioning regarding the patient's pain complaint and a thorough review of any body system that may be involved, such as neuromusculoskeletal, obstetric, gynecologic, gastrointestinal, urologic, dermatologic, infectious, oncologic, and psychiatric 2
- A physical examination that follows a focused systems-based approach, including examination of gastrointestinal, dermatologic, neurologic, and musculoskeletal systems, and the pelvic floor (internal and external examination, including neuromuscular anatomy) 2
- Evaluation of chronic pelvic pain requires obtaining a careful history, including not only obstetrical and gynecologic information but also screening for gastrointestinal, urologic, musculoskeletal, and neurological disorders 3
- A detailed physical examination is also necessary, and management of chronic pelvic pain depends largely on the cause 3
Diagnostic Considerations
The diagnosis of pelvic pain can be challenging due to the broad differential diagnosis and nonspecific signs and symptoms. The following are common diagnoses to consider:
- Idiopathic pelvic pain, pelvic inflammatory disease, acute appendicitis, ovarian cysts, ectopic pregnancy, and endometriosis in reproductive-aged women 4
- Cancer must be considered in postmenopausal women 4
- Laboratory testing and imaging, such as ultrasonography or computed tomography, can help confirm the diagnosis 4
Treatment Approach
The treatment approach for pelvic pain is often multimodal and requires an interdisciplinary team of clinicians. The following are key considerations:
- A comprehensive approach to chronic pelvic pain includes consideration of multiple organ systems, with empiric therapy appropriate after a thorough history and physical examination 5
- Patient involvement, shared decision-making, functional goal setting, and a discussion of expectations for long-term care are important parts of the evaluation process 6
- Training in trauma-informed care and pelvic musculoskeletal examination are essential to reduce patient anxiety associated with the examination and to avoid missing the origin of myofascial pain 6