Chronic Pelvic Pain in Women

Back

Background

Chronic pelvic pain (CPP) is a common problem and presents a major challenge to health care providers because of its unclear etiology, complex natural history, and poor response to therapy.

Chronic pelvic pain is poorly understood and, consequently, poorly managed. This condition is best managed using a multidisciplinary approach. Management requires good integration and knowledge of all pelvic organ systems and other systems including musculoskeletal, neurologic, and psychiatric systems.

A significant number of these patients may have various associated problems, including bladder or bowel dysfunction, sexual dysfunction, and other systemic or constitutional symptoms. Other associated problems, such as depression, anxiety, and drug addiction, may also coexist.

In the United States, estimated direct medical costs for outpatient visits for chronic pelvic pain (women aged 18-50 y) is approximately $881.5 million per year.[1]

Pathophysiology

The pathophysiology of chronic pelvic pain is complex and multifactorial. It remains unclear.

Epidemiology

Frequency

United States

Chronic pelvic pain is a common problem. It affects approximately 1 in 7 women.[1] In one study of reproductive-aged women in primary care practices, the reported prevalence rate of pelvic pain was 39%.[2] Of all referrals to gynecologists, 10% are for pelvic pain.[3]

International

A similar prevalence of chronic pelvic pain has been described in other countries.[4]

Mortality/Morbidity

As with other chronic pain, chronic pelvic pain may lead to prolonged suffering, marital and family problems, loss of employment or disability, and various adverse medical reactions from lifelong therapy.

Race

In one study, blacks had a higher incidence of pelvic pain.[2]

Sex

Chronic pelvic pain is most common among reproductive-aged women. Common causes of chronic pelvic pain in men include chronic (nonbacterial) prostatitis, chronic orchalgia, and prostatodynia.

Age

Chronic pelvic pain is most common among reproductive-aged women, especially those aged 26-30 years.[2]

History

The proposed definition of chronic pelvic pain (CPP) is nonmenstrual pain of 3 months duration or longer that localizes to the anatomic pelvis and is severe enough to cause functional disability and require medical or surgical treatment. Most authorities agree that patients should be diagnosed with chronic pelvic pain if they have pain primarily located in the pelvis for more than 3-6 months duration.

Patient history is important in cases of chronic pelvic pain. Because of the complex etiology and, often, the presence of associated disorders, a general approach with a thorough history that directs further evaluation and appropriate consultations is needed.[5] Perform a detailed review of systems, including reproductive, GI, musculoskeletal, urologic, and neuropsychiatric. As needed, ask specific questions, especially if the patient has an associated disorder. A thorough past history is also important to avoid repeating invasive and expensive procedures.

Physical

Good rapport, tolerance, and an open-minded approach are important in the evaluation of any patient with chronic pain. A thorough systematic examination usually suggests an appropriate diagnosis and therapy.

Causes

Various reproductive, GI, urologic, and neuromuscular disorders may cause or contribute to chronic pelvic pain. Sometimes, multiple contributing factors may exist in a single patient.

Laboratory Studies

The decision to perform laboratory or imaging evaluations in patients with chronic pelvic pain (CPP) is based on the need for confirmation of the diagnosis and to help rule out other potentially life-threatening illnesses. Certain investigations sometimes are needed to provide appropriate and safe medical or surgical treatment.

Imaging Studies

Other Tests

Medical Care

Treatment of chronic pelvic pain (CPP) is complex in patients with multiple problems.[11, 12] It usually requires specific treatment and simultaneous psychological and physical therapy. A good relationship should be established between the clinician and the patient. Treatment of chronic pelvic pain must be tailored for the individual patient.

The goals of treatment must be realistic. They should be focused toward restoration of normal function (minimal disability), better quality of life, and prevention of relapse of chronic symptoms.

Surgical Care

Consultations

Medication Summary

Pharmacotherapy in chronic pelvic pain (CPP) consists of symptomatic abortive therapy to stop or reduce the severity of acute exacerbation of pain and long-term therapy for chronic pain.

Acetaminophen (Tylenol)

Clinical Context:  First choice for pain, especially during pregnancy and breastfeeding.

Ibuprofen (Advil, Motrin)

Clinical Context:  Inhibits inflammatory reactions and pain by decreasing activity of cyclooxygenase, which is responsible for prostaglandin synthesis.

Naproxen (Aleve, Naprosyn, Naprelan)

Clinical Context:  For relief of mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing activity of cyclooxygenase, which results in a decrease of prostaglandin synthesis.

Class Summary

These agents are generally used in mild-to-moderate pain; however, they may also be effective for severe pain.

Fentanyl (Duragesic patch)

Clinical Context:  Potent narcotic analgesic with much shorter half-life than morphine sulfate. DOC for conscious sedation analgesia. Ideal for analgesic action of short duration during anesthesia and immediate postoperative period. Excellent choice for pain management and sedation; short duration (30-60 min) and easy to titrate.

Easily and quickly reversed by naloxone. When using transdermal dosage form, most patients are controlled with 72-h dosing intervals.

However, some patients require dosing intervals of 48 h.

Available in 12, 25, 50, 75, and 100 mcg doses.

Class Summary

These agents are commonly used for many pain syndromes.

Gabapentin (Neurontin)

Clinical Context:  Has anticonvulsant properties and antineuralgic effects; however, exact mechanism of action is unknown.

Structurally related to GABA but does not interact with GABA receptors.

Pregabalin (Lyrica)

Clinical Context:  Structural derivative of GABA. Mechanism of action unknown. Binds with high affinity to alpha2 -delta site (a calcium channel subunit). In vitro, reduces calcium-dependent release of several neurotransmitters, possibly by modulating calcium channel function. FDA approved for neuropathic pain associated with diabetic peripheral neuropathy or postherpetic neuralgia and as adjunctive therapy in partial-onset seizures.

Class Summary

Certain antiepileptic drugs (eg, the GABA analogue gabapentin and pregabulin [Lyrica]) have proven helpful in some cases of neuropathic pain. Other anticonvulsant agents (eg, clonazepam, topiramate, lamotrigine, zonisamide, tiagabine) have also been tried in chronic pelvic pain (CPP).

Nortriptyline (Pamelor)

Clinical Context:  Demonstrated effectiveness in the treatment of chronic pain.

Amitriptyline (Elavil)

Clinical Context:  Analgesic for certain chronic and neuropathic pain.

Class Summary

These agents increase synaptic concentration of serotonin and/or norepinephrine in the CNS by inhibiting reuptake by the presynaptic neuronal membrane (eg, duloxetine [Cymbalta], venlafaxine [Effexor]).

Fluoxetine (Prozac)

Clinical Context:  Considered an alternative to TCAs, with fewer adverse anticholinergic and cardiovascular effects.

Sertraline (Zoloft)

Clinical Context:  Considered an alternative to TCAs, with fewer adverse anticholinergic and cardiovascular effects.

Paroxetine (Paxil)

Clinical Context:  Considered an alternative to TCAs, with fewer adverse anticholinergic and cardiovascular effects.

Class Summary

These agents selectively inhibit presynaptic serotonin reuptake with minimal or no effect in the reuptake of norepinephrine or dopamine. SSRIs can be used in second-line or third-line treatment of painful diabetic neuropathy. They are used in patients who are already depressed.

Further Inpatient Care

Hospitalization is not usually required for patients with chronic pelvic pain (CPP); however, the need for hospitalization depends on the invasiveness of the treatment choice for pain control and on the severity of the case.

Further Outpatient Care

Patients with chronic pelvic pain are generally treated in an outpatient setting and require a variety of health care professionals to optimally manage their condition.

Complications

Like other chronic pain, chronic pelvic pain may lead to prolonged suffering, marital or family problems, loss of employment, disability, and various adverse medical reactions from lifelong therapy.

Author

Manish K Singh, MD, Assistant Professor, Department of Neurology, Teaching Faculty for Pain Management and Neurology Residency Program, Hahnemann University Hospital, Drexel College of Medicine; Medical Director, Neurology and Pain Management, Jersey Institute of Neuroscience

Disclosure: Nothing to disclose.

Coauthor(s)

Elizabeth E Puscheck, MD, Professor, Department of Obstetrics and Gynecology, Wayne State University School of Medicine; In Vitro Fertilization Director, Gynecologic Ultrasound Director, Clinical Endocrine Laboratory Consultant, Department of Obstetrics and Gynecology, University Women's Care

Disclosure: Wyeth Grant/research funds Other

Jashvant Patel, MD, Medical Director, Department of Pain Medicine and Comprehensive Rehabilitation, Medical College of Pennsylvania Hahnemann University

Disclosure: Nothing to disclose.

Specialty Editors

Suzanne R Trupin, MD, FACOG, Clinical Professor, Department of Obstetrics and Gynecology, University of Illinois College of Medicine at Urbana-Champaign; CEO and Owner, Women's Health Practice; CEO and Owner, Hada Cosmetic Medicine and Midwest Surgical Center

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

A David Barnes, MD, PhD, MPH, FACOG, Consulting Staff, Department of Obstetrics and Gynecology, Mammoth Hospital (Mammoth Lakes, California), Pioneer Valley Hospital (Salt Lake City, Utah), Warren General Hospital (Warren, Pennsylvania), and Mountain West Hospital (Tooele, Utah)

Disclosure: Nothing to disclose.

Frederick B Gaupp, MD, Consulting Staff, Department of Family Practice, Hancock Medical Center

Disclosure: Nothing to disclose.

Chief Editor

Michel E Rivlin, MD, Professor, Department of Obstetrics and Gynecology, University of Mississippi School of Medicine

Disclosure: Nothing to disclose.

References

  1. Mathias SD, Kuppermann M, Liberman RF, et al. Chronic pelvic pain: prevalence, health-related quality of life, and economic correlates. Obstet Gynecol. Mar 1996;87(3):321-7. [View Abstract]
  2. Jamieson DJ, Steege JF. The prevalence of dysmenorrhea, dyspareunia, pelvic pain, and irritable bowel syndrome in primary care practices. Obstet Gynecol. Jan 1996;87(1):55-8. [View Abstract]
  3. Reiter RC. A profile of women with chronic pelvic pain. Clin Obstet Gynecol. Mar 1990;33(1):130-6. [View Abstract]
  4. Zondervan KT, Yudkin PL, Vessey MP, et al. Prevalence and incidence of chronic pelvic pain in primary care: evidence from a national general practice database. Br J Obstet Gynaecol. Nov 1999;106(11):1149-55. [View Abstract]
  5. Neis KJ, Neis F. Chronic pelvic pain: cause, diagnosis and therapy from a gynaecologist's and an endoscopist's point of view. Gynecol Endocrinol. Nov 2009;25(11):757-61. [View Abstract]
  6. Taran FA, Weaver AL, Coddington CC, Stewart EA. Understanding adenomyosis: a case control study. Fertil Steril. Sep 2010;94(4):1223-8. [View Abstract]
  7. Weijenborg PT, Ter Kuile MM, Stones W. A cognitive behavioural based assessment of women with chronic pelvic pain. J Psychosom Obstet Gynaecol. Dec 2009;30(4):262-8. [View Abstract]
  8. Lampe A, Solder E, Ennemoser A, et al. Chronic pelvic pain and previous sexual abuse. Obstet Gynecol. Dec 2000;96(6):929-33. [View Abstract]
  9. Jacoby K, Rowbotham RK. Double balloon positive pressure urethrography is a more sensitive test than voiding cystourethrography for diagnosing urethral diverticulum in women. J Urol. Dec 1999;162(6):2066-9. [View Abstract]
  10. Howard FM, Perry PC, Carter JE, eds. Pelvic Pain: Diagnosis and Management. Baltimore, Md: Lippincott Williams & Wilkins; 2000.
  11. [Guideline] American College of Obstetricians and Gynecologists (ACOG). Chronic pelvic pain. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 2004 Mar. 17 p. (ACOG practice bulletin; no. 51).
  12. [Guideline] Chronic pelvic pain. In: Fall M, Baranowski AP, Elneil S, Engeler D, Hughes J, Messelink EJ, Oberpenning F, Williams AC. Guidelines on chronic pelvic pain. Arnhem, The Netherlands: European Association of Urology (EAU); 2008 Mar. p. 8-62.
  13. Everaert K, Devulder J, De Muynck M, et al. The pain cycle: implications for the diagnosis and treatment of pelvic pain syndromes. Int Urogynecol J Pelvic Floor Dysfunct. 2001;12(1):9-14. [View Abstract]
  14. George JW, Skaggs CD, Thompson PA, Nelson DM, Gavard JA, Gross GA. A randomized controlled trial comparing a multimodal intervention and standard obstetrics care for low back and pelvic pain in pregnancy. Am J Obstet Gynecol. Oct 23 2012;[View Abstract]
  15. Suskind AM, Berry SH, Ewing BA, Elliott MN, Suttorp MJ, Clemens JQ. The Prevalence and Overlap of Interstitial Cystitis/Bladder Pain Syndrome and Chronic Prostatitis/Chronic Pelvic Pain Syndrome in Men: Results of the RAND Interstitial Cystitis Epidemiology Male Study. J Urol. Nov 16 2012;[View Abstract]
  16. Baker PK. Musculoskeletal origins of chronic pelvic pain. Diagnosis and treatment. Obstet Gynecol Clin North Am. Dec 1993;20(4):719-42. [View Abstract]
  17. Ben-David B, Friedman M. Gabapentin therapy for vulvodynia. Anesth Analg. Dec 1999;89(6):1459-60. [View Abstract]
  18. Benes J, Nadvornik P, Dolezel J. Abdominoinguinal pain syndrome treated by centrocentral anastomosis. Acta Neurochir (Wien). 2000;142(8):887-91. [View Abstract]
  19. Bergqvist A. Current drug therapy recommendations for the treatment of endometriosis. Drugs. Jul 1999;58(1):39-50. [View Abstract]
  20. Bodden-Heidrich R, Küppers V, Beckmann MW, Rechenberger I, Bender HG. Chronic pelvic pain syndrome (CPPS) and chronic vulvar pain syndrome (CVPS): evaluation of psychosomatic aspects. J Psychosom Obstet Gynaecol. Sep 1999;20(3):145-51. [View Abstract]
  21. Bost BW. Deflecting sigmoid adhesions: an anatomic cause of chronic pelvic pain and irritable bowel syndrome. Obstet Gynecol. Apr 2001;97(4 Suppl 1):S27.
  22. Braverman PK. Sexually transmitted diseases in adolescents. Med Clin North Am. Jul 2000;84(4):869-89, vi-vii. [View Abstract]
  23. Carter JE. A systematic history for the patient with chronic pelvic pain. JSLS. Oct-Dec 1999;3(4):245-52. [View Abstract]
  24. Carter JE. Surgical treatment for chronic pelvic pain. J Soc Laparoendosc Surg. Apr-Jun 1998;2(2):129-39. [View Abstract]
  25. Clemons JL, Arya LA, Myers DL. Diagnosing interstitial cystitis in women with chronic pelvic pain. Obstet Gynecol. Aug 2002;100(2):337-41. [View Abstract]
  26. Cody RF Jr, Ascher SM. Diagnostic value of radiological tests in chronic pelvic pain. Baillieres Best Pract Res Clin Obstet Gynaecol. Jun 2000;14(3):433-66. [View Abstract]
  27. Demco LA. Pain referral patterns in the pelvis. J Am Assoc Gynecol Laparosc. May 2000;7(2):181-3. [View Abstract]
  28. Dwarakanath LS, Persad PS, Khan KS. Role of laparoscopy in the management of chronic pelvic pain. Hosp Med. Aug 1998;59(8):627-31. [View Abstract]
  29. Economy KE, Laufer MR. Pelvic pain. Adolesc Med. Jun 1999;10(2):291-304. [View Abstract]
  30. Ehlert U, Heim C, Hellhammer DH. Chronic pelvic pain as a somatoform disorder. Psychother Psychosom. Mar-Apr 1999;68(2):87-94. [View Abstract]
  31. [Best Evidence] Finnerup NB, Otto M, McQuay HJ, et al. Algorithm for neuropathic pain treatment: an evidence based proposal. Pain. Dec 5 2005;118(3):289-305. [View Abstract]
  32. Ghaly AF, Chien PF. Chronic pelvic pain: clinical dilemma or clinician's nightmare. Sex Transm Infect. Dec 2000;76(6):419-25. [View Abstract]
  33. Grace VM. Pitfalls of the medical paradigm in chronic pelvic pain. Baillieres Best Pract Res Clin Obstet Gynaecol. Jun 2000;14(3):525-39. [View Abstract]
  34. Gurel H, Atar Gurel S. Dyspareunia, back pain and chronic pelvic pain: the importance of this pain complex in gynecological practice and its relation with grand multiparity and pelvic relaxation. Gynecol Obstet Invest. 1999;48(2):119-22. [View Abstract]
  35. Hewitt GD, Brown RT. Acute and chronic pelvic pain in female adolescents. Med Clin North Am. Jul 2000;84(4):1009-25. [View Abstract]
  36. Holley RL, Richter HE, Wang L. Neurologic disease presenting as chronic pelvic pain. South Med J. Nov 1999;92(11):1105-7. [View Abstract]
  37. Howard FM. Abuse history and chronic pain in women: I. Prevalences of sexual abuse and physical abuse. Obstet Gynecol. Jan 1995;85(1):158-9. [View Abstract]
  38. Howard FM. An evidence-based medicine approach to the treatment of endometriosis- associated chronic pelvic pain: placebo-controlled studies. J Am Assoc Gynecol Laparosc. Nov 2000;7(4):477-88. [View Abstract]
  39. Howard FM. Laparoscopic evaluation and treatment of women with chronic pelvic pain. J Am Assoc Gynecol Laparosc. Aug 1994;1(4 Pt 1):325-31. [View Abstract]
  40. Howard FM. The role of laparoscopy as a diagnostic tool in chronic pelvic pain. Baillieres Best Pract Res Clin Obstet Gynaecol. Jun 2000;14(3):467-94. [View Abstract]
  41. Howard FM. The role of laparoscopy in chronic pelvic pain: promise and pitfalls. Obstet Gynecol Surv. Jun 1993;48(6):357-87. [View Abstract]
  42. Howard FM. The role of laparoscopy in the evaluation of chronic pelvic pain: pitfalls with a negative laparoscopy. J Am Assoc Gynecol Laparosc. Nov 1996;4(1):85-94. [View Abstract]
  43. Howard FM, El-Minawi AM, Sanchez RA. Conscious pain mapping by laparoscopy in women with chronic pelvic pain. Obstet Gynecol. Dec 2000;96(6):934-9. [View Abstract]
  44. Jarrell JF. The weight of chronic pelvic pain. J Obstet Gynaecol Can. May 2004;26(5):453-4. [View Abstract]
  45. Justins DM. Management strategies for chronic pain. Ann Rheum Dis. Sep 1996;55(9):588-96. [View Abstract]
  46. Kanazi GE, Perkins FM, Thakur R, Dotson E. New technique for superior hypogastric plexus block. Reg Anesth Pain Med. Sep-Oct 1999;24(5):473-6. [View Abstract]
  47. Kontoravdis A, Hassan E, Hassiakos D, et al. Laparoscopic evaluation and management of chronic pelvic pain during adolescence. Clin Exp Obstet Gynecol. 1999;26(2):76-7. [View Abstract]
  48. Large RG. Psychological aspects of pain. Ann Rheum Dis. Jun 1996;55(6):340-5. [View Abstract]
  49. Luzzi G, O'Leary M. Chronic pelvic pain syndrome. BMJ. May 8 1999;318(7193):1227-8. [View Abstract]
  50. Malik E, Berg C, Meyhofer-Malik A, et al. Subjective evaluation of the therapeutic value of laparoscopic adhesiolysis: a retrospective analysis. Surg Endosc. Jan 2000;14(1):79-81. [View Abstract]
  51. McCrory P, Bell S. Nerve entrapment syndromes as a cause of pain in the hip, groin and buttock. Sports Med. Apr 1999;27(4):261-74. [View Abstract]
  52. McDonald JS. Management of chronic pelvic pain. Obstet Gynecol Clin North Am. Dec 1993;20(4):817-38. [View Abstract]
  53. Moore J, Kennedy S. Causes of chronic pelvic pain. Baillieres Best Pract Res Clin Obstet Gynaecol. Jun 2000;14(3):389-402. [View Abstract]
  54. Morikawa JH. Laparoscopy for chronic pelvic pain. Hawaii Med J. Jan 1999;58(1):22-3. [View Abstract]
  55. Negre E, Chaptal PA, Grolleau-Raoux D, Caporiccio A. [Systemic embolism after closure of an ostium secundum (author's transl)]. Ann Chir Thorac Cardiovasc. Jan 1975;14(1):21-4. [View Abstract]
  56. Nezhat FR, Crystal RA, Nezhat CH, Nezhat CR. Laparoscopic adhesiolysis and relief of chronic pelvic pain. JSLS. Oct-Dec 2000;4(4):281-5. [View Abstract]
  57. Olive DL, Schwartz LB. Endometriosis. N Engl J Med. Jun 17 1993;328(24):1759-69. [View Abstract]
  58. Papathanasiou K, Papageorgiou C, Panidis D, Mantalenakis S. Our experience in laparoscopic diagnosis and management in women with chronic pelvic pain. Clin Exp Obstet Gynecol. 1999;26(3-4):190-2. [View Abstract]
  59. Pashley DH. Dentin permeability and dentin sensitivity. Proc Finn Dent Soc. 1992;88 Suppl 1:31-7. [View Abstract]
  60. Prentice A. Medical management of chronic pelvic pain. Baillieres Best Pract Res Clin Obstet Gynaecol. Jun 2000;14(3):495-9. [View Abstract]
  61. Reiter RC. Evidence-based management of chronic pelvic pain. Clin Obstet Gynecol. Jun 1998;41(2):422-35. [View Abstract]
  62. Richter HE, Holley RL, Chandraiah S, Varner RE. Laparoscopic and psychologic evaluation of women with chronic pelvic pain. Int J Psychiatry Med. 1998;28(2):243-53. [View Abstract]
  63. Rickert VI, Kozlowski KJ. Pelvic pain. A SAFE approach. Obstet Gynecol Clin North Am. Mar 2000;27(1):181-93. [View Abstract]
  64. Robert R, Prat-Pradal D, Labat JJ. Anatomic basis of chronic perineal pain: role of the pudendal nerve. Surg Radiol Anat. 1998;20(2):93-8. [View Abstract]
  65. Sand PK. Chronic pain syndromes of gynecologic origin. J Reprod Med. Mar 2004;49(3 Suppl):230-4. [View Abstract]
  66. Scialli AR. Evaluating chronic pelvic pain. A consensus recommendation. Pelvic Pain Expert Working Group. J Reprod Med. Nov 1999;44(11):945-52. [View Abstract]
  67. Selfe SA, Matthews Z, Stones RW. Factors influencing outcome in consultations for chronic pelvic pain. J Womens Health. Oct 1998;7(8):1041-8. [View Abstract]
  68. Selfe SA, Van Vugt M, Stones RW. Chronic gynaecological pain: an exploration of medical attitudes. Pain. Aug 1998;77(2):215-25. [View Abstract]
  69. Steege JF. Office assessment of chronic pelvic pain. Clin Obstet Gynecol. Sep 1997;40(3):554-63. [View Abstract]
  70. Stewart P, Slade P. Comparative study of pelvic and non-pelvic pain/the prevalence of chronic pelvic pain. Br J Obstet Gynaecol. Dec 1998;105(12):1338-9. [View Abstract]
  71. Stone AR, Kim JH. Pelvic, perineal, and genital pain. In: Gershwin ME, Hamilton ME eds. The Pain Management Handbook: A Concise Guide to Diagnosis and Treatment. Totowa, NJ: Humana Press; 1998:147-63.
  72. Stones RW, Mountfield J. Interventions for treating chronic pelvic pain in women. Cochrane Database Syst Rev. 2000;CD000387. [View Abstract]
  73. Stones RW, Selfe SA, Fransman S, Horn SA. Psychosocial and economic impact of chronic pelvic pain. Baillieres Best Pract Res Clin Obstet Gynaecol. Jun 2000;14(3):415-31. [View Abstract]
  74. Stovall DW. Transvaginal ultrasound findings in women with chronic pelvic pain. Obstet Gynecol. Apr 1 2000;95(4 Suppl 1):S57.
  75. Summitt RL Jr. Urogynecologic causes of chronic pelvic pain. Obstet Gynecol Clin North Am. Dec 1993;20(4):685-98. [View Abstract]
  76. Toozs-Hobson P, Bidmead J, Cardozo L. Chronic pelvic pain. Br J Obstet Gynaecol. Nov 1998;105(11):1238. [View Abstract]
  77. Vercellini P, De Giorgi O, Pisacreta A, et al. Surgical management of endometriosis. Baillieres Best Pract Res Clin Obstet Gynaecol. Jun 2000;14(3):501-23. [View Abstract]
  78. Walker JJ, Irvine G. How should we approach the management of pelvic pain?. Gynecol Obstet Invest. 1998;45 Suppl 1:6-10; discussion 10-1, 35. [View Abstract]
  79. Winkel CA, Scialli AR. Safety of medical and surgical management of chronic pelvic pain and endometriosis. Obstet Gynecol. Apr 2001;97(4 Suppl 1):S28.
  80. Wise TN, Arnold LM, Maletic V. Management of painful physical symptoms associated with depression and mood disorders. CNS Spectr. Dec 2005;10(12 Suppl 19):1-13. [View Abstract]
  81. Zondervan K, Barlow DH. Epidemiology of chronic pelvic pain. Baillieres Best Pract Res Clin Obstet Gynaecol. Jun 2000;14(3):403-14. [View Abstract]

Transabdominal longitudinal view of the female pelvis.

Transabdominal transverse view of the female pelvis: The bladder is rectangular. The ovaries are seen bilaterally in the adnexa.

Transabdominal longitudinal view of the female pelvis.

Transabdominal transverse view of the female pelvis: The bladder is rectangular. The ovaries are seen bilaterally in the adnexa.