Gynecologic Pain

Gynecologic pain has numerous and diverse causes. The uterus, cervix, and adnexa share the same visceral innervation as the lower ileum, sigmoid colon, and rectum. Signals travel via the sympathetic nerves to spinal cord segments T10 through L1. Because of this shared pathway, distinguishing between pain of gynecologic and gastrointestinal origin is often difficult. ^{[1, 2]}

The following summary lists many of the causes of gynecologic pain.

Acute pelvic pain

The following complications of pregnancy can cause acute pelvic pain:

• Ectopic pregnancy, ruptured or unruptured

• Abortion

• Degenerating fibroid

Acute infections that can result in pelvic pain include the following:

• Endometritis

• Acute pelvic inflammatory disease

• Tubo-ovarian abscess

• Pelvic thrombophlebitis

• Ovarian vein thrombosis

The following types of adnexal masses can cause acute pelvic pain:

• Corpus luteum hematoma

• Ovarian torsion

• Ruptured ovarian cyst

• Paratubal cyst

• Endometriosis

• Ovarian hyperstimulation syndrome

Recurrent pelvic pain

Gynecologic causes of recurrent pelvic pain are listed below:

• Mittelschmerz

• Primary or secondary dysmenorrhea

The following gastrointestinal conditions can cause recurrent pelvic pain:

• Bacterial or viral gastroenteritis

• Appendicitis

• Bowel obstruction

• Diverticulitis

• Inflammatory bowel disease

• Irritable bowel syndrome

• Mesenteric ischemia

Urologic causes of recurrent pelvic pain are listed below:

• Cystitis

• Acute pyelonephritis

• Ureteric calculus

The following potential causes of recurrent pelvic pain involve the abdominal wall:

• Hematoma

• Strangulated or incarcerated hernia

Miscellaneous causes of recurrent pelvic pain include the following:

• Acute porphyria

• Pelvic thrombophlebitis

• Abdominal aneurysm

• Abdominal angina

Chronic pelvic pain

The following are gynecologic causes of chronic pelvic pain:

• Adhesions

• Chronic ectopic pregnancy

• Chronic pelvic inflammatory disease

• Endometriosis

• Ovarian remnant syndrome

• Inflammatory, neuromuscular, and infectious vulvovaginal conditions

• Adenomyosis

• Chronic endometritis

• Fibroids

• Intrauterine device

• Pelvic congestion

• Pelvic support defects

• Polyps

Urologic causes of chronic pelvic pain are listed below:

• Chronic urinary tract infection

• Overactive bladder

• Interstitial cystitis

• Bladder stones

• Suburethral diverticulitis

• Urethral syndrome

• Trigonitis

The following gastrointestinal conditions can cause chronic pelvic pain:

• Constipation (very common in elderly persons)

• Diverticular disease

• Inflammatory bowel disease

• Enterocolitis

• Irritable bowel syndrome

• Neoplasia

• Chronic appendicitis

• Cholelithiasis

Musculoskeletal conditions that can result in chronic pelvic pain are listed below:

• Coccydynia

• Disk problems

• Degenerative joint disease

• Fibromyositis

• Hernia

• Herpes zoster

• Low back pain

• Levator ani syndrome (pelvic floor spasm)

• Myofascial pain

• Nerve entrapment syndromes

• Osteoporosis

• Posture-related pain

• Scoliosis, lordosis, kyphosis

• Strains, sprains

Other conditions that can cause chronic pelvic pain include the following:

• Physical or sexual abuse, prior or current

• Lead or mercury toxicity

• Hyperparathyroidism

• Porphyria

• Somatization disorders

• Substance abuse (ie, cocaine)

• Sickle cell disease

• Sympathetic dystrophy

• Tabes dorsalis

Associated symptoms and differentiation

Acute pain due to ischemia or injury to a viscus is accompanied by autonomic reflex responses such as nausea, vomiting, restlessness, and sweating. The following is a discussion of some of the important gynecologic causes of acute abdominal pain.

Culdocentesis can still be a useful diagnostic aid for differentiating the cause of acute gynecologic pain. In the absence of a positive pregnancy test result, fresh blood suggests a corpus luteum hemorrhage, old blood suggests a ruptured endometrioma (chocolate cyst), purulent fluid suggests acute pelvic inflammatory disease (PID), and sebaceous fluid indicates a dermoid cyst. However, culdocentesis has largely been superseded by imaging modalities such as ultrasonography.

Ectopic pregnancy

Because of its life-threatening nature, ectopic pregnancy must be ruled out when a woman of reproductive age presents with pelvic pain and a positive pregnancy test. An unruptured ectopic pregnancy produces localized pain due to dilatation of the fallopian tube. Once the ectopic pregnancy is ruptured, the pain tends to be generalized owing to peritoneal irritation. Symptoms of rectal urgency caused by a mass in the pouch of Douglas may also be present. Syncope, dizziness, and orthostatic changes in blood pressure are sensitive signs of hypovolemia in such patients.

Abdominal examination findings include tenderness and guarding in the lower quadrants. Once hemoperitoneum has occurred, distension, rebound tenderness, and sluggish bowel sounds may develop.

Pelvic examination may reveal cervical motion tenderness that is exaggerated on the side of the tubal ectopia.

Initially, a sensitive serum or urine pregnancy test should be performed. Transvaginal ultrasonography should be performed. If an intrauterine gestational sac with a fetal pole is identified, the chances of a coexisting ectopic pregnancy are remote. Such a heterotopic gestation should be considered in patients taking ovulation-inducing drugs.

Serial serum beta-human chorionic gonadotropin (hCG) estimations are often helpful in making the diagnosis. In early intrauterine gestations, the doubling time for hCG is usually 48 hours. Only 15% of cases are exceptions to this rule. In the absence of the availability of ultrasonography or in an emergency setting, culdocentesis can be of value to detect unclotted blood. A hematocrit of less than 16% (in the peritoneal blood) excludes hemoperitoneum.

Laparoscopy should be attempted if the patient is hemodynamically stable, a high index of suspicion remains, or the patient complains of increasing pain despite adequate analgesia.

Treatment options for an unruptured ectopic pregnancy include salpingostomy and salpingectomy. These may be performed laparoscopically or by open procedure. Laparoscopic salpingostomy has been found to be less successful than open surgery because of a higher persistent trophoblastic rate. Methotrexate, a folic acid antagonist, is also used for the treatment of unruptured ectopic pregnancy, with a variable dose regimen being more successful than a single dose regimen. ^[3] A ruptured ectopic pregnancy requires a laparotomy with removal of blood clots, although it can be performed via the laparoscopic route in experienced hands.

Adnexal masses

Corpus luteum hematoma

This condition develops in the luteal phase of the menstrual cycle. Slow leakage produces minimal pain. Frank hemorrhage can lead to hemoperitoneum and hypovolemic shock. Generalized abdominal pain and syncope are features of such a presentation. Treatment includes laparoscopy or laparotomy, evacuation of clots, and control of ovarian bleeding.

Ovarian cyst

The most common causes are dermoid cyst, cystadenoma, and endometrioma. Because the amount of blood loss is usually minimal, hypovolemia does not supervene. Peritoneal irritation due to leakage of cyst fluid can lead to significant tenderness, rebound tenderness, abdominal distension, and hypoperistalsis. Treatment involves cyst removal.

Ovarian torsion

Changes in ovarian axial morphology, which are typically secondary to ovarian cysts (most commonly dermoids), can undergo torsion around the ovarian pedicle. Frequently, torsion resolves spontaneously, and the only presenting symptom is lower abdominal pain. Persistent torsion progresses to occlusion of the venous drainage of the ovary, which leads to congestion, ovarian enlargement, thickening of the ovarian capsule, and subsequent infarction. Pain is typically colicky and eventually becomes severe and is accompanied by nausea, vomiting, and restlessness. Infarction also leads to fever and mild leukocytosis. On pelvic examination, a tender unilateral mass in the anterior pelvis may be palpable.

If the ovary appears viable based on laparoscopic examination findings, the pedicle may be untwisted and the cyst removed. An infarcted ovary must be removed.

For more information, see Adnexal Tumors.

Acute pelvic inflammatory disease

Acute salpingo-oophoritis is a polymicrobial infection that is transmitted sexually. Neisseria gonorrhoeae and Chlamydia trachomatis are usually identified in patients with PID, and both organisms often coexist in the same patient. Gonococcal disease tends to have a rapid onset, while chlamydial infection has a more insidious onset.

The US Centers for Disease Control and Prevention (CDC) has recommended strict diagnostic and management guidelines for the treatment of PID in an effort to reduce serious preventable sequelae such as adhesions and infertility. See the following treatment guidelines:

• 2015 Sexually Transmitted Diseases Treatment Guidelines ^[4]

• Update to CDC’s Sexually Transmitted Diseases Treatment 2010 Guidelines: Oral Cephalosporins No Longer a Recommended Treatment for Gonococcal Infections ^[5]

• Cephalosporin-Resistant Neisseria Gonorrhoeae Public Health Response Plan ^[6]

Diagnostic criteria for PID

All of the following criteria must be present:

• Lower abdominal tenderness

• Cervical motion tenderness

• Adnexal tenderness

The diagnosis may also be supported by any of the following criteria:

• Temperature greater than 101°F (38.3°C)

• Abnormal cervical or vaginal discharge

• Laboratory evidence of C trachomatis or N gonorrhoeae

• Elevated erythrocyte sedimentation rate or elevated C-reactive protein value

Definitive criteria for diagnosis include the following:

• Positive findings on transvaginal ultrasound or other imaging technique demonstrating thickened fluid-filled tubes with or without tubo-ovarian abscess or free pelvic fluid

• Positive endometrial biopsy findings

• Positive laparoscopy findings

Outpatient management of PID

Regimen B includes ceftriaxone at 250 mg intramuscularly (IM), cefoxitin at 2 g IM plus probenecid at 1 g orally (PO), or another parenteral third-generation cephalosporin. Add doxycycline at 100 mg PO bid for 14 days to whichever of these regimens is chosen. Metronidazole 500 mg bid may be added for 14 days.

Oral cephalosporins and quinolones are no longer recommended for the treatment of gonococcal infections because of the emergence of resistant strains. ^{[4, 5, 6, 7]}

Inpatient management of PID

Inpatient regimens for PID are listed below:

• Regimen A includes cefotetan at 2 g intravenously (IV) q12h or cefoxitin at 2 g IV q6h. Add doxycycline at 100 mg IV/PO q12h to the chosen regimen.

• Regimen B includes clindamycin at 900 mg IV q8h plus gentamicin at 2 mg/kg IV/IM loading dose followed by 1.5 mg/kg q8h as a maintenance dose.

• An alternative regimen is ampicillin/sulbactam 3 g IV q6h, plus doxycycline 100 mg IV/PO q12h.

Admission criteria for PID

Hospitalization should be considered for patients with the following conditions:

• Pregnancy

• Inability to exclude surgical emergencies such as appendicitis

• Immunosuppression (including human immunodeficiency virus [HIV] infection with a low CD4 count)

• Confirmed or possible pelvic abscess

• Intrauterine device in situ

• High fever or severe nausea and vomiting

• Inability to comply with an outpatient regimen

• Failed outpatient therapy

• Adolescence

• Significant fertility issues

For more information, see Pelvic Inflammatory Disease.

Tubo-ovarian abscess

A ruptured abscess can lead to gram-negative endotoxic shock; therefore, this condition is a surgical emergency. The most common presentation is bilateral, palpable, fixed, tender masses. Patients often present with generalized abdominal pain and rebound tenderness caused by peritoneal inflammation. In such cases, the infected tissue must be surgically removed under broad-spectrum antibiotic coverage. Preoperative antibiotic coverage for 24-48 hours is recommended if the patient is stable.

Fibroids

Fibroids are benign fibromuscular tumors of the uterine wall that can grow under hormonal influence and can achieve the size of an advanced gestation uterus. They frequently involute after menopause. In the interim, they can be associated with pelvic pain, abnormal (and frequently heavy) bleeding, and symptoms related to pelvic pressure from the mass effect. They are the most common indication for hysterectomy in women of reproductive age.

Degenerating fibroid

This may occur during pregnancy when rapid growth of the tumor outstrips its blood supply. This condition is conservatively managed as much as possible.

Twisted subserous fibroid

A pedunculated subserous fibroid may twist and undergo necrosis, causing acute abdominal pain. It may be removed by laparoscopy or an open procedure.

Submucous fibroid

A pedunculated submucous fibroid may present with cramping pain and vaginal bleeding. Hysteroscopic resection is the treatment of choice.

Medical management

Oral ulipristal acetate, a progesterone receptor modulator in the same class as mifepristone, was as effective as leuprolide acetate in controlling bleeding with fewer side effects. Fibroid shrinkage was less marked, but the effect was longer lasting. Long-term changes in the endometrium have not yet been established. ^[8]

 

Mittelschmerz

Mittelschmerz is midcycle abdominal pain due to leakage of prostaglandin-containing follicular fluid at the time of ovulation. It is self-limited, and a theoretical concern is treatment of pain with prostaglandin synthetase inhibitors, which could prevent ovulation.

Endometriosis

Pain associated with endometriosis may worsen premenstrually or during menses. Patients experience generalized lower abdominal tenderness, and associated complaints include dysmenorrhea, dyschezia, and dyspareunia. Endometriotic deposits in both the uterosacral ligaments and rectovaginal septum contribute to pain during intercourse. Painful defecation is due to infiltration of the bowel wall by endometriotic deposits.

Importantly, remember that the pain associated with endometriosis is not correlated with the presence or amount of visible endometriotic tissue. In fact, the prevalence of endometriosis is the same in women with and without pain. ^{[9, 10]} Rather, pain is related to the chemical mediators of inflammation and neural infiltration.

Ovulation suppression using different drugs has been tried in order to reduce the pain associated with endometriosis. Overall, no difference appears to exist in the efficacy of danazol, gestrinone, oral contraceptives, depot medroxyprogesterone acetate, and gonadotropin-releasing hormone (GnRH) analogs in placebo-controlled trials. However, dydrogesterone was found to be less effective. According to a Cochrane review, ovulation suppression provides no benefit in subfertile women with endometriosis who wish to conceive. ^[11]

The absolute benefit for women undergoing surgical ablation of endometriosis is 30-40% over women having only diagnostic laparoscopy, in the short term. This benefit reduced over time, and the reoperation rate is as high as 50%. ^[12] In cases of rectovaginal endometriosis, significant short-term pain relief was reported by up to 80%, but at 1-year follow-up, 50% required analgesics or hormones for pain relief.

During postoperative treatment, GnRH analogs resulted in significantly reduced pain scores in women who received treatment for 6 months. The evidence for hormone replacement therapy in women with postsurgical menopause for treatment of endometriosis is unclear at present. ^[13]

Laparoscopic cystectomy of an endometrioma was found to be superior to simple drainage for treatment of recurring pain; it has been shown to result in lower recurrence of signs and symptoms of endometriomas and higher cumulative pregnancy rates. ^{[14, 15]}

GnRH agonists were used for 6 months as the only treatment in patients with documented endometriosis. At 5 years, more than half the patients were symptom-free. The best responses were obtained in patients with mild or moderate disease. Among those with persistent or recurrent pain, an increasing correlation existed with the severity of the endometriosis. ^[16]

For more information, see Endometriosis.

Primary dysmenorrhea

By definition, primary dysmenorrhea is menstrual pain associated with ovulatory cycles in the absence of structural pathology. It usually manifests in younger women, and a study on the natural course of dysmenorrhea found that most women are affected throughout the menstrual years. Improvement is more likely in women who bear children. ^[17]

Patients experience suprapubic cramping pain that may radiate to the anterior thigh or sacral region. Pain may be accompanied by autonomic symptoms such as nausea, vomiting, and syncope. The onset of primary dysmenorrhea is a few hours prior to the onset of menses, and pain usually lasts up to 72 hours.

More than 80% of patients have an excellent response to treatment with prostaglandin synthetase inhibitors. Oral contraceptives may be used with equal effectiveness in patients who desire simultaneous fertility control.

Smoking was associated with a higher relative risk of severe dysmenorrhea. In a systematic review, naproxen, ibuprofen, and mefenamic acid were more effective than placebo for pain relief. The Cochrane reviews have analyzed various studies and found high-frequency transcutaneous electrical nerve stimulation (TENS) and acupuncture to be effective for dysmenorrhea. ^[18] Laparoscopic uterine nerve ablation (LUNA) is shown to be effective for women with dysmenorrhea without endometriosis. ^[19] Other drugs that have been reported with some success include nitroglycerin, terbutaline, and guaifenesin.

Secondary dysmenorrhea

Secondary dysmenorrhea is cyclic menstrual pain associated with structural pathology. The most common causes are endometriosis, adenomyosis, and the presence of an intrauterine device. Pain starts 1-2 weeks prior to the onset of menses and persists for a few days after cessation of flow. Hypertonic uterine activity coupled with an excess of prostaglandins is postulated to be the cause of secondary dysmenorrhea.

Patients are somewhat less responsive to nonsteroidal anti-inflammatory drugs (NSAIDs) and combination oral contraceptives compared with patients with primary dysmenorrhea. Presacral neurectomy (PSN) has been shown in a single randomized trial to improve severe dysmenorrhea due to endometriosis. ^[20] A Cochrane review found PSN to provide better pain control in the long term than LUNA, albeit with adverse effects such as constipation. ^[21]

Adenomyosis

Adenomyosis typically manifests in women in their 40s and is essentially a clinical diagnosis. It coexists with endometriosis and fibroids, and a study found that prior uterine surgery was significantly associated with an increased risk of adenomyosis. ^[22] Dysmenorrhea is associated with dyspareunia, dyschezia, and acyclical uterine bleeding. The uterus is soft and tender, especially around the time of menstruation.

Magnetic resonance imaging shows an enlarged junctional zone and myometrial cysts, whereas ultrasonography shows heterogenous abnormal myometrial echogenicity in patients with adenomyosis. Histopathologic correlation with the clinical diagnosis can be found in only half of cases.

For reproductive-aged women, treatment includes NSAIDs, combination oral contraceptives, progesterone-only pills, levonorgestrel intrauterine contraceptive devices, and GnRH agonists. Hysterectomy is a last resort.

Definition and differentiation

The American College of Obstetricians and Gynecologists (ACOG) defines chronic pelvic pain (CPP) as continuous or noncyclical pelvic pain of longer than 6 months' duration that localizes to the anatomic pelvis, abdominal wall at or below the umbilicus, lumbosacral back, or the buttocks and is of sufficient severity to cause functional disability or lead to medical care. ^[23] Nearly 4% of women are thought to have ongoing CPP. It forms the indication for 18% of all hysterectomies and 40% of gynecologic laparoscopies. ^[24]  The relationship of recurrent pain to menstruation or the presence of dyspareunia is only suggestive. ^[23]

Annually, 400,000 laparoscopies are performed on patients with endometriosis and chronic pelvic pain. Negative laparoscopic findings occur in 40% of patients. ^[24]

Important nongynecologic causes that must be considered in the differential diagnosis include irritable bowel syndrome (IBS), interstitial cystitis (IC), and pelvic floor myofascial syndrome. Importantly, rule out abdominal wall etiologies that are aggravated by raising of the head or raising of straightened legs while supine.

For more information, see Chronic Pelvic Pain in Women.

Dyspareunia as a significant factor

Patients with deep, internal, or thrust dyspareunia often express a feeling that some sort of internal collision is occurring during sexual activity. Any pelvic pathology may be responsible for this discomfort, but abnormalities such as endometriosis, pelvic adhesions, pelvic relaxation, malposition (retroversion), adnexal pathology or prolapse, and uterine fibroids are the most likely causes. IC may cause dyspareunia before it proceeds to chronic unremitting pain. IBS may also cause dyspareunia and pain at the apex of the vagina.

Adhesions

A study using conscious pain mapping during awake laparoscopy found that peritoneal adhesions and filmy adhesions that allowed for movement between 2 structures had the highest pain scores, while dense, fixed adhesions caused less pain. ^[25] Pain is acyclical and not accompanied by vaginal bleeding. Dyspareunia and symptoms suggestive of intermittent subacute bowel obstruction may be associated with adhesions. Adhesiolysis should be recommended with realistic expectations, and a multidisciplinary approach in a pain clinic may be worthwhile prior to attempting surgery. In one study, cure or improvement was reported in two thirds of patients with chronic pelvic pain and nearly half of those with dysmenorrhea. ^[26]

In a randomized study, patients with severe adhesions involving the intestinal tract were shown to benefit from adhesiolysis. ^[27] A study found adhesions deflecting the sigmoid colon to the pelvic sidewall in 38% of patients with chronic pelvic pain. Among patients without detectable endometriosis, 80% had a significant reduction in symptoms after adhesiolysis on an 18-month follow-up. ^[28] Various agents have been reported to reduce adhesion formation, but none have gained universal acceptance. A small randomized study of 25 patients found a significant improvement in right-sided pain in women who underwent paracolic adhesiolysis. ^[29]

The issue of prevention of adhesions after pelvic surgery has been an important one. In a Cochrane review, ^[30] the authors found that Interceed adhesion barrier was the only agent that prevented new adhesion formation and reformation following laparoscopic surgery or laparotomy. However, its use did not lead to an improvement in pregnancy rates.

Chronic pelvic inflammatory disease

Pain is thought to be due to infection or adhesions that exacerbate the baseline condition. However, an animal study failed to show adhesions following direct bacterial inoculation. ^[31] Chronic PID may be accompanied by fever, leukocytosis, and gonococcal or chlamydial infection. Laparoscopy and peritoneal fluid cultures help confirm the diagnosis in most cases. Empiric treatment with antibiotics should be commenced prior to laparoscopy.

Ovarian remnant syndrome

Following a total abdominal hysterectomy and bilateral salpingo-oophorectomy, the ovarian remnant can undergo cystic changes that cause pain. Hormonal suppression with danazol, combined oral contraceptive pills, high-dose progestins, and GnRH agonists are possible treatment options. Diagnosis may be aided by ultrasonography. Finding the ovarian tissue may be challenging. As with all laparoscopic surgery, operator expertise is vital in the success of the procedure, because of the dense adhesions that are often present. Otherwise, a laparotomy maybe indicated.

Irritable bowel syndrome

IBS is one of the most common functional intestinal disorders. It is defined as a group of functional disorders in which abdominal discomfort or pain is associated with defecation or a change in bowel habits. IBS also involves features of disordered defecation.

Rome criteria for IBS

The Rome criteria for IBS require the presence of 2 of the following 3 recurrent symptoms for at least 12 weeks during the preceding year:

• Abdominal pain relieved with defecation

• Onset associated with change in frequency of stool

• Onset associated with change in stool appearance

The following symptoms are supportive of the diagnosis:

• Abnormal stool frequency

• Abnormal stool form

• Abnormal stool passage

• Passage of mucus

• Bloating

History plays an important role in excluding causes such as lactose intolerance, which present with similar symptoms. Upon examination, a tender sigmoid colon is often palpable. Fiber supplementation has not been shown to have significant benefits and should be reserved for patients with hard stools. Patients with recurrent severe abdominal cramps may benefit from antispasmodics such as dicyclomine and hyoscyamine, although this treatment has not been substantiated in controlled studies. Patients with severe IBS need a multifaceted approach that includes psychiatric evaluation because symptoms may be a part of a somatization disorder. ^[32]

Low-dose antidepressants such as amitriptyline and selective serotonin reuptake inhibitors may have an adjunctive role. Alosetron was reintroduced to the US market and is approved for severe chronic diarrhea-predominant IBS, but only after other treatment modalities are unsuccessful, because of the risk of serious adverse gastrointestinal events (eg, ischemic colitis, serious complications of constipation). These adverse effects have resulted in hospitalization, blood transfusion, surgery, and death.

Tegaserod, which is a partial agonist of the 5-hydroxytryptamine receptor that helps symptoms of IBS, alleviates constipation and accelerates intestinal transit. Tegaserod was withdrawn from the US market in March 2007 because of an excess number of serious cardiovascular adverse events, including angina, myocardial infarction, and stroke.

Linaclotide was approved for constipation-predominant IBS and has proven particularly useful in women.

Loperamide was found to be useful for women with painless diarrhea. Fedotozine (investigational in the United States) is a kappa-opioid agonist that decreases intestinal hypersensitivity and may help decrease bloating pain. Substance P antagonists are being evaluated for the treatment of IBS. Patient support groups can also be useful.

Approximately 60% of patients with chronic pelvic pain may have IBS as a primary or coexistent diagnosis. The Rome criteria for diagnosis should be used in routine clinical practice. Early diagnosis allows the formulation of a management plan that includes counseling and nonpharmacologic interventions, which play important roles in alleviating patient symptoms.

Myofascial pain

Myofascial etiologies occur in 15% of patients with chronic pelvic pain. Trigger points should be searched for during a methodical abdominal wall and pelvic examination, as they are hyperirritable spots usually within a taut band of skeletal muscle or in muscle fascia. These are focally painful upon compression and can give rise to characteristic referred pain, tenderness, and autonomic phenomena.

Women may experience pain from trigger points (areas overlying muscles that induce spasm and pain) in the myofascial layers of the pelvic sidewall or pelvic floor. The obturator internus and levator ani are common sites and should be palpated. A study found levator pain in 87% of women with diagnosed IC. ^[33] Coexisting symptoms, such as frequent headaches, nonrestorative sleep, diffuse tender points, and fatigue, may be suggestive of systemic disorders such as fibromyalgia.

Treatment for trigger points usually involves hyperstimulation analgesia (eg, stretching, cold spray), local injection of anesthetic agents, TENS, and acupuncture. All of these treatments act as counterirritants that alter the central gate or threshold control and result in the prolonged response. The action of an injected local anesthetic has the effect of blocking the central response. ^[34] A small study of 18 women found improvement in 72% with trigger point injections combining anesthetic agents and triamcinolone. ^[35] A randomized placebo-controlled trial from Australia found significant improvements in nonmenstrual pelvic pain and pelvic floor spasms in women treated with botulinum toxin type A. ^[36]

Myofascial pain may manifest as focal lower abdominal pain due to entrapment of the genitofemoral or ilioinguinal nerves, which is a sequela of Pfannenstiel incisions. A bupivacaine nerve block is both a diagnostic and therapeutic measure. Cryoneurolysis or surgical removal of the involved nerve should be reserved for recalcitrant cases. Manual therapy of pelvic floor myofascial trigger points is also reported to improve pain in women with IC and in women with frequency-urgency syndrome. ^[37]

Interstitial cystitis

Considerable overlap exists in symptomatology in patients with IC and IBS. Although some authorities believe that the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDKD) criteria for IC are too rigid, the criteria still serve as a useful clinical guide for understanding the complex nature of the problem. ^{[38, 39]}

Required findings

Required findings in the NIDDKD criteria for IC are listed below:

• Hunner ulcer or diffuse glomerulations (ie, small bleeding points on the bladder surface seen after hydrodistension of the bladder)

• Pain associated with the bladder or urinary urgency

Automatic exclusions

Automatic exclusions in the NIDDKD criteria for IC are listed below:

• Age younger than 18 years

• Duration of symptoms less than 9 months

• Urinary frequency fewer than 8 times per day

• Absence of nocturia

• Benign or malignant tumors

• Radiation cystitis

• Vaginitis

• Cyclophosphamide cystitis

• Urethral diverticulum

• Genital cancer

• Active herpes infection

• Bladder or lower ureteric calculi

• Involuntary bladder contractions

• Bladder capacity less than 350 mL while awake

• Symptoms relieved by antibiotics, urinary antiseptics, analgesics, anticholinergics, or muscle relaxants

Cystoscopic evaluation under anesthesia can be particularly useful, although not required for the diagnosis to be made. Bladder distention to anesthetic capacity (volume at which spontaneous fill stops while the patient is under anesthesia) will frequently demonstrate a restricted bladder capacity, and petechiae and glomerulations on the bladder wall upon bladder refill suggest the presence of IC. Biopsy can be performed to identify plasma cells within the bladder wall. Pathologists must be asked to perform a specific Giemsa stain on the specimen in order to identify these cells.

Interestingly, patients frequently report symptom improvement after hydrodilation under anesthesia for a period of up to 6 months. It is thought to be due to interruption of the gap junctions in the bladder wall.

A study found evidence of IC on cystoscopy findings in 38% of patients who underwent laparoscopy for chronic pelvic pain. ^[40] In a longitudinal study of a cohort of IC patients, the most common sites of pain were lower abdominal (80%), urethral (74%), and lower back (65%). ^[41]

Two different etiologic mechanisms have been suggested for IC. The classic or ulcerative variant is inflammatory in origin, and the nonulcer variant is neuropathic in origin. This has implications for choice of therapy. An evidence-based therapeutic algorithm for treatment does not exist. ^[38]

Treatment options

Hydroxyzine is a histamine receptor antagonist with effects on the central and peripheral nervous systems. Hydroxyzine is suggested to have a good clinical effect in patients with IC. The dose is 25-50 mg twice daily (bid) for 14 days.

Amitriptyline is a tricyclic antidepressant that also blocks the H1 histamine receptor. Amitriptyline acts via blockade of acetylcholine receptors, including inhibition of reuptake of released serotonin and norepinephrine. It also has a sedating action via the H1 receptors. A placebo-controlled, randomized trial showed significant improvement in patients with IC who were treated with amitriptyline. ^[42]

Corticosteroids are not widely used because of adverse effects such as fluid retention and osteoporosis. However, a study reported improved pain control and overall satisfaction with oral prednisone in a cohort of women with severe refractory IC. ^[43]

Pentosan polysulfate sodium (PPS) is claimed to restore the depletion in the glycosaminoglycan (GAG) layer. A double-blind placebo-controlled trial revealed subjective improvements in pain, urgency, frequency, and nocturia. Patients also demonstrated objective improvement in average voided volume. However, no improvement was noted in urinary frequency. Another study found that the classic subtype of IC responds better than the nonulcer form. In a placebo-controlled trial, one quarter of patients reported more than 25% improvement. A good response is expected after 4-12 months of treatment, and 50% of patients demonstrate improvement in this time. The dose is 150-200 mg bid between meals. A later study evaluating PPS and hydroxyzine failed to show improvement in most women. ^[44]

Chondroitin sulfate is another drug that replenishes the GAG layer. The dose is 50 mL twice a week, then decreasing to once weekly for 4 weeks. Remission is maintained  with monthly instillations.

Intravesical instillation therapy can be performed using agents that are cytoprotective or cytodestructive. Cytoprotective agents include heparin, which may be given in a dose of 20,000 IU in 10 mL of sterile water. Some authors have used methylprednisolone in combination with heparin. A combination of heparin with alkalinized lidocaine was shown to provide better symptom relief than heparin alone. ^[45]

Cytodestructive agents include dimethyl sulfoxide (DMSO), silver nitrate, and bacille Calmette-Guérin (BCG) vaccine. DMSO is a scavenger for intracellular hydroxy free radicals. It is an anti-inflammatory agent and a local anesthetic. It is instilled twice as 50 mL of 50% solution. It may be given with a cocktail of gentamicin, lidocaine, sodium bicarbonate, and heparin. DMSO provides relief in about two thirds of cases, and it increases bladder compliance and inhibits detrusor contractions. ^[46] BCG is thought to modulate immune responses. It is instilled as 12.5 mg (50 mL) weekly for 4-6 weeks. A placebo-controlled trial failed to show significant benefit with BCG. ^[47]

Capsaicin is another drug that has been successful in patients with IC. Capsaicin is a selective neurotoxin for small myelinated class C afferent neurons. It reflexly inhibits bladder contractions, decreases their amplitude, and increases the residual volume. Patients with urgency and frequency due to idiopathic diabetes insipidus or sensory urgency have not responded as well to capsaicin. Also, 40 mL of 2% lidocaine is given to effect anesthesia from the initial excitation. The dose of capsaicin is 50 mL instilled over a 4-week period. Approximately 44% patients were content with this treatment, and an additional 36% had a decrease in the frequency of urge incontinence. Capsaicin requires reinstallation after 6 months.

Resiniferatoxin is an agent that works on a similar principle; however, a randomized, double-blind, placebo-controlled trial failed to demonstrate its efficacy in patients with IC. ^[48]

A Cochrane review of intravesical treatments for IC found that the evidence was most promising for BCG and oxybutynin. ^[49]

Cystectomy and ileal conduit was the most frequently used major surgical procedure. A review of prescribed treatments in the IC database revealed that cystoscopy with hydrodistension is the most popular treatment. Sacral neuromodulation, hyperbaric oxygen, botulinum toxin (BTX-A), and cyclosporine A are among the newer modalities in the treatment of IC and have been tried with some success. Long-term results are needed before these should be recommended as primary measures.

Urethral syndrome and trigonitis

Patients with urethral syndrome or trigonitis present with classic symptoms of urinary tract infection, but urinary culture results are negative for infection. Symptoms include frequency, urgency, and pressure in the absence of nocturia. Physical examination reveals a tender, ropelike urethra or a focally tender trigone. The clinical course is marked by remissions and exacerbations. Causes include chlamydial infections, mycoplasmal infections, herpes simplex, urethral trauma, atrophy, stenosis, and functional obstruction. Female prostatitis is believed to be due to inflammation of the paraurethral glands and is thought to be a frequent cause of urethral syndrome. The patient typically has a history of an initiating urinary tract infection that has been untreated for a significant period. Clinical examination reveals localization of tenderness to the paraurethral glands. ^[50]

Treatment of urethral syndrome/trigonitis should be tailored to the individual cause. Patients with sterile pyuria respond to a 2- to 3-week course of doxycycline or erythromycin. The course has to be repeated in many patients. All postmenopausal women should also receive a trial of local estrogen therapy. Urethral dilatation and biofeedback have been used for resistant cases.

Posthysterectomy syndrome

Posthysterectomy syndrome is pain due to a low-grade cuff cellulitis, seroma, or hematoma of the cuff, or neuralgia related to transection of the nerve tissue. Resection of a portion of the vaginal cuff occasionally helps relieve the pain. ^[51]

Hysterectomy for chronic pelvic pain

Long-term studies have shown that success with hysterectomy is disappointing when the only indication is pain. If the pain has persisted for more than 6 months, has not responded to analgesics, and is causing significant distress and impairment, then hysterectomy may be considered an option after counseling the patient that the pain may persist after surgery.

Idiopathic pain

Newer treatment modalities such as percutaneous tibial nerve stimulation have shown initial promise. ^[52] Because of their noninvasive nature, they are likely to be tried in women with unexplained pelvic pain.

Vulvar pain can be challenging in both diagnosis and management. This section utilizes the Consensus Terminology and Classification of Persistent Vulvar Pain and Vulvodynia as a basic template. ^[53] Some of the terminology used here is redacted from that scholarly document and others. ^{[53, 54]} The clinician should be aware that there are multiple and diverse etiologies for vulvar pain including vulvodynia; infections; neoplasms; neuropathies; inflammatory dermatoses; and post-traumatic, hormonal, and environmental exposures. Comorbidities are common. One must avoid a premature diagnosis of a psychological, psychosomatic origin.

Dyspareunia

Dyspareunia is a condition caused by vulvar and vaginal atrophy in menopausal women that results in moderate to severe pain. Several palliative treatments can reduce the symptoms, which result from inadequate lubrication and lowered estrogen levels. Topical estrogen cream is one option. Another is ospemifene, an oral estrogen agonist/antagonist that acts like estrogen on the vaginal lining but differs from estrogen in that it has a decreased risk of harmful effects on the endometrial and breast tissues. Disadvantages of this agent include hot flashes and the risk of stroke or blood clots.

The US Food and Drug Administration (FDA) approved intravaginal dehydroepiandrosterone (DHEA) for the management of moderate to severe dyspareunia, a symptom of vulvar and vaginal atrophy caused by menopause. DHEA is an inactive steroid found endogenously that is converted into active androgens and/or estrogens. Intravaginal DHEA, known as prasterone intravaginal, has been found to result in clinically significant reductions in dyspareunia in menopausal women. It represents an alternative therapy for management of dyspareunia. ^{[55, 56]}

Vulvodynia

This is probably the most enigmatic cause of vulvar pain. Defined as persistent vulvar pain for over 3 months with no other discernable cause, it may affect up to 8-9% of women at some point in their lives. ^[57] It can be primary, or secondary to another vulvar disorder, and frequently presents with severe dyspareunia. An erythematous and tender area of the mucosa in the posterior vestibule (fossa navicularis and fourchette) is often noted, but sometimes the affected area appears normal.

Patients often describe their pain as burning, sharp, cutting, and “like broken glass.” Vulvodynia can be localized, generalized, or mixed. Provoked vulvodynia (most often with intercourse or clothing contact) or spontaneous vulvodynia is recognized, and the temporality varies widely (immediately with contact, or delayed). Severity of vulvodynia ranges from mild to disabling.

Vulvodynia is not responsive to corticosteroids. Treatment may include topical or systemic gabapentin or pregabalin, tricyclics such as amitriptyline, and other medications. Physical therapy and biofeedback have shown success with selected cases. In refractory cases, surgery is a viable option with a reported high degree of success. ^[58] Further support, insights, and advice for patients is available through the National Vulvodynia Association.

Clitorodynia is a special situation because of the emotional impact involved. It is essential to avoid dismissing vulvodynia and other causes of vulvar pain as sexual aversion or another psychological disorder without a diligent search for a medical cause. Referral to a colleague familiar with vulvar pain should be employed in cases in which any doubt exists. Sexual phobias are relatively infrequent, and relationships can be destroyed through inaccurate diagnosis.

Infectious causes

Persistent, recurrent, and tissue-invasive candidal infections are the most frequent microbial cause of vulvar pain. In addition to Candida albicans, several other species can be causative. They include Candida glabrata, Candida tropicalis, Candida parapsilosis, and others. Signs and symptoms are different from those associated with C albicans; patients report more burning pain and have no “cottage cheese” discharge. The history and examination can be aided by microscopy and polymerase chain reaction (PCR) testing in making what can be very elusive diagnoses.

Candidal urinary tract infections can occur, and prostatic infection in male partners is a possible, albeit infrequent vector. With emerging fluconazole resistance, other candidacidal agents may be necessary, and probably should be prescribed by an experienced provider.

Herpes simplex (herpes simplex virus type 1 [HSV1] or herpes simplex virus type 2 [HSV2]) is not at all uncommon. At times the evanescent shallow ulcerations (excoriations) may not be recognized by the patient, and episodic pain is the only complaint. The typical evaluation includes a history taking, physical examination during an outbreak, and cultures or PCR testing. Treatment includes acyclovir, famciclovir, and valacyclovir for acute cases and for longer-term prophylaxis. Prevention of secondary infection is also important.

Bacterial infections, including streptococcal and methicillin-resistant Staphylococcus aureus (MRSA) infections, can be quite painful. Colon-based organisms may at times be problematic, especially in patients with fistulae and/or Crohn disease.

Clinicians should also be aware that vaginal infections can result in vulvar pain, secondary to an irritating vaginal discharge. A yellow or greenish hue, especially in a malodorous purulent discharge, is a strong indicator of bacterial infection and/or sexually transmitted disease (STD). Microscopy and pH testing are helpful: excess white blood cells (WBCs) (usually in a similar ratio to epithelial cells) and a high pH suggest bacterial infection. Normal WBC presence with a low pH is more compatible with candidal infection. Cultures and PCR tests are useful but are not absolutely confirmatory. Candida species are seen via microscopy in a varying percentage of cases, but false-negatives are common. As always, clinical judgment is a critical component of diagnosis and treatment.

Bartholin gland infection, with or without abscess, is a relatively common cause of vulvar pain. The tender, often warm, cystic masses occur at 5:00 and 7:00 on the vaginal introitus.

Inflammatory causes

Lichen sclerosus, although infrequent, is a common inflammatory condition seen in vulvar clinics. It can be identified by the thin white tissue seen on vestibular mucosa, as well as on keratinized skin, including the perineum and perianal skin. It sometimes appears red and inflamed.

Lichen sclerosus is highly pruritic. As the disease advances, the pathology worsens, resulting in pain, introital stenosis, and dyspareunia. Lichen sclerosus can be complicated by infection, typically with Candida species. A vulvar malignancy (differentiated vulvar intraepithelial neoplasia [d-VIN]) can develop, usually in chronic, untreated cases. The malignant behavior of d-VIN is more aggressive than the more common human papillomavirus (HPV)-related VIN, and therefore expert evaluation should be sought in any suspicious cases. Biopsy should be considered with or without vulvoscopy.

First-line treatment of lichen sclerosus consists primarily of powerful corticosteroids, ^[59] predominantly clobetasol, in a gradually declining dosage. Estrogen will help if there is coexisting atrophy, but testosterone is not nearly as effective as corticosteroids and is no longer recommended as first-line treatment. ^{[59, 60]}

Lichen planus is a very painful disorder. Findings consist of red sharply marginated lesions, erosions, and sometimes the white lacy patterns known as Wickham striae. In contrast to lichen sclerosus, lichen planus can involve the vagina. With vaginal involvement, wide areas of mucosal ulceration, scarring, and a purulent discharge are common. Lichen planus also can involve other mucocutaneous sites such as gingivae and tongue. Cutaneous forms are seen in multiple skin locations. A history of extragenital lichen planus can facilitate the diagnosis, but when in doubt, biopsy with or without vulvoscopy is called for.

Successful management of lichen planus can be formidably challenging. High-potency topical or intralesional corticosteroids are initial choices, with the calcineurin inhibitors tacrolimus 0.1% or pimecrolimus 0.1% as additional therapy in difficult cases. ^{[59, 60]} Generally, ointments are more effective and better tolerated. In more severe and resistant cases, as well as with multisystem involvement, systemic corticosteroids, methotrexate, azathioprine, and especially the newer biologic agents can be effective. ^[61] Examples are adalimumab and infliximab. Strict attention to hygiene and use of loose fitting clothing are requisite. Common substances such as vegetable oil can be soothing.

Lichen simplex chronicus is a maddeningly pruritic lesion, seen mainly on keratinized skin, much like eczema. It becomes painful only when purposeful or inadvertent scratching causes excoriations that become infected. Other painful vulvar inflammations, such as bullous pemphigoid, pemphigus vulgaris, and plasma cell vulvitis are seen less frequently and can often present very challenging diagnoses. In the absence of a history of extragenital conditions, a biopsy is usually necessary. Assessment and management are augmented by consultation with a dermatologist.

A difficult inflammatory condition, often confused with infection, is hidradenitis suppurativa. It presents in varying degrees (Hurley stages) and results in relapsing painful abscesses and draining sinuses. The etiology is not poor hygiene. Genetic predisposition, obesity, smoking, and androgenic hormonal factors are thought to be contributory. It can also occur in the axillae and other intertriginous areas. This chronic relapsing condition can be devastating to the patient; in later stages, embarrassment and self-consciousness may prevent sexual relations. Management includes reduction of androgenic stimulation, topical and sometimes systemic clindamycin for the anti-inflammatory effects (other antibiotics are usually not employed), zinc, and varying surgical procedures depending on the severity of the disease.

Neurologic and muscular causes

One of the more challenging causes of vulvar pain is postherpetic neuralgia.  The pain is episodic, and a history of herpes zoster in corresponding dermatomes is helpful for diagnosis. This condition is probably more common than has been reported. ^[62] Acute recurrences are usually very painful. Treatment consists of antiviral and antiseizure medications, rest, and loose clothing. Analgesics, including opiates, are often needed.

Lumbosacral spine disorders can cause vulvar pain, especially if the disease involves the 2nd, 3rd, and 4th sacral segments. The mechanism is neuropathic.

Pudendal nerve disorders are relatively common, especially following some form of pelvic trauma, such as mechanical injury and surgery. The pain is more dull and aching than with cutaneous disorders. A history of onset following trauma, increased pain on sitting but less pain when sitting on a commode, as well as tenderness on deep palpation of the region of Alcock’s canal are diagnostic clues. The syndrome usually arises from entrapment and compression in Alcock’s canal or other paths that the nerve travels. Neuromas are far less common.

Magnetic resonance imaging (MRI) scans rarely provide help with diagnosis. In some cases, clinical diagnosis is aided by abnormal perineal electrophysiologic studies, increased sacral evoked potentials latencies with abnormal “wink reflex” (clitoral compression causing anal sphincter reflex contraction), and nerve studies on the pudendal nerve. ^[63]

Treatment can include image-guided pudendal block, which is best administered by a pain management specialist who is specifically familiar with those procedures. Physical therapy can also be helpful. Muscle spasms of the obturator, perianal, and other pelvic muscles are additional causes of vulvar and vaginal pain, and they are best managed by muscle relaxants, warm baths, and physical therapy.

High tone pelvic floor disorders, including vaginismus, are more common types of muscle tonus disorders and demonstrate continuous dull aching pain, which can be debilitating. Vaginismus typically causes a severe deep muscle pain a few centimeters within the introitus. It is provoked by intromission or tampon insertion. Both syndromes can be comorbidities of any source of pelvic pain, especially vulvodynia.

Treatment modalities vary widely and employ physical therapy and administration of compounded vaginal diazepam or baclofen. ^[64]  Botulinum toxin injections have been shown to provide a sustained degree of relief. ^[65] The injections should be given only by experienced clinicians, in part because occasional complications and side effects need to be recognized and managed expertly.

Neoplastic causes

HPV-related VIN, d-VIN, Paget disease, and invasive malignancies of any histopathology can cause vulvar pain. Biopsy is always recommended if malignancy is in the differential diagnosis. The clear methods of treatment are oncologic management along with analgesics.

Traumatic causes

Several neuromuscular problems are secondary to obstetrical, surgical, and personal injury trauma. An additional soft tissue cause of pelvic pain, especially dyspareunia, can be dense scarring. Pulling and stretching of unyielding scars can be fairly simple to recognize, especially in the context of obstetrical trauma, surgical procedures, or personal injury. In this category, one may include radiation damage, for it is indeed a type of trauma. In cases of gynecologic, intestinal, and anal cancers, post-radiation atrophy, sclerosis, and scarring are very symptomatic. Dyspareunia is prominent. Treatment is difficult and may include vaginal dilators, emollient skin moisturizers, physical therapy, and counseling.

Environmental causes

Innumerable soaps, bath salts, laundry detergents, fabric softeners, and similar products can result in irritant contact dermatitis. ^[66] Diagnosis of the erythematous and often painful skin lesions can be elusive because they may closely resemble other inflammatory and infectious causes of vulvar pain. An exhaustive search for the offending substance is sometimes needed, and that search may be best handled by an allergist.

Urinary incontinence, sometimes unreported, can also be responsible for contact dermatitis. A detailed history along with a 1- to 2-day phenazopyridine test can be employed, looking for orange staining of a sanitary pad. Management strategies are correction of incontinence, along with warm rinsing and a skin protectant.

Diaper dermatitis can develop in a remarkably short time when skin is exposed to fecal material. Discussion can be awkward but should not be deferred.

Allergic dermatitis(eg, latex) may also occur with attendant itching and pain. Again, consultation with an allergist is important.

Behavioral and psychological causes

Behavioral and psychological causes of vulvar pain require careful, appropriate questioning, perhaps with the assistance of a clinical psychologist. High tone pelvic floor disorders are frequently associated with sexual dysfunction. Neuroses include obsessive/compulsive washing, often with harsh soaps not intended for delicate tissues, trichotillomania, and confabulation. Psychiatric patients may tell delusional stories.

Sexual dysfunction can be either primary or secondary to most of the previously discussed pelvic pain diagnoses. Pain can result from sexual activity in the face of sexual aversion and phobia. Those dysfunctions can be attributable to aberrant childhood raising, dysmorphic body imaging, and physical/sexual abuse in childhood and/or adult life. Patient safety must be assured because abuse may be ongoing. Post-abuse may be regarded as a type of post-traumatic stress disorder (PTSD).

These “hot-button topics” require extreme sensitivity, as well as experience. Placement of brochures and questionnaires in women’s bathrooms is a good tool. Clinical sex counselors and therapists, psychologists, and psychiatrists are essential members of the team in this context.

Be cautious about making a diagnosis of sexual dysfunction until all possible organic causes of pelvic pain have been ruled out. Because sexual aversions may be secondary to organic disorders, it is imperative to be vigilant for comorbidities.

Conclusion

Vulvar pain has many widely diverse etiologies. Comorbidities are common. Many conditions closely resemble others; thus, careful evaluation is advised. Biopsy should be employed in uncertain cases and if malignancy is suspected. Other healthcare professionals should be part of the team, including psychologists, marriage counselors, physical therapists, neurologists, pain management specialists, allergists, dermatologists, urologists, oncologists, and infectious disease specialists.

A special cause of vulvar pain is vulvodynia, a complex condition that lacks any uniformly successful treatment. Although sexual dysfunction can be a primary cause of pain, the diagnosis should be reserved for clear-cut cases in the absence of a purely organic cause. Consultation with specialists expertly familiar with vulvar disorders is recommended if the practitioner is not fully comfortable with these disorders.

Thermal bowel injury is a serious complication of surgery. It occurs in 0.5-3.2 per 1000 cases, and symptoms may not develop for days or weeks. The patient presentation includes bilateral lower quadrant pain, tenderness, fever, leukocytosis, and peritonitis. Ileus or free gas under the diaphragm may be noted on a plain abdominal radiograph.

Peritonitis may occur as a consequence of undetected bowel perforations. Other complications include abscess, enterocutaneous fistula, and septic shock.

Thermal injury to the bladder or ureter may manifest up to 14 days postoperatively with abdominal or flank pain, fever, and peritonitis. Findings from an intervenous pyelogram demonstrate extravasation of urine or urinoma. Patients with mechanical obstruction may present in 1 week with a similar clinical picture.

Incisional hernias rarely become incarcerated. Patients present with abdominal pain and signs of bowel obstruction or perforation.

Hysteroscopy can result in uterine perforation, especially in elderly women, which may involve the bowel. Such a possibility should be kept in mind when evaluating a patient.

Following a vaginal hysterectomy, patients may present with pelvic pain due to vaginal cuff hematoma, cellulitis, or ovarian abscess. Wound complications such as dehiscence, renal angle pain due to ureteric injury, and retention should be considered.

Osteitis pubis is a possibility in patients who undergo a Marshall-Marchetti-Krantz procedure. Operations for vaginal prolapse and urinary incontinence that use synthetic mesh can lead to the development of pelvic pain due to mesh infection, exposure through the vaginal mucosa, and/or contraction and band formation during the healing process. These complications have led to the removal of many mesh products from the market, but patients may present with symptoms many years after mesh implantation. Removal of the mesh can be performed with meticulous dissection to avoid bladder or rectal trauma, and most frequently results in improvement or resolution of the pain.