Geri D. Hewitt, MD

Chronic pelvic pain, a common complaint in female adolescents, is defined as cyclic or 	noncyclic, intermittent or constant discomfort in the pelvic region for at least 6 months. It often frustrates 	the patient, her parents, and her physician, and it can lead to major functional problems such as changes in family 	dynamics or school absenteeism.

As time passes between symptom onset and diagnosis (and symptom relief), patient frustration may grow, possibly 	leading to "doctor shopping" and use of opioid analgesics. Thus, the physician should promptly address 	all of the female adolescent's pain symptoms and pain-related concerns. While searching for the source of the patient's 	chronic pelvic pain, the physician should investigate both organic and nonorganic factors. Thus, the work-up should 	include both a thorough physical exam and consideration of various psychological issues.


 According to this model, the patient's perception of pain arises from a combination of nociceptive stimuli, her 	emotional state, and concomitant social determinants. This model explains the phenomenon of symptom shifting in 	patients with chronic pain syndromes: When nociceptive stimuli are removed without adequate attention paid to the 	patient's underlying psychological or social concerns, new symptoms arise at an alternate site. For example, a 	patient with chronic pelvic pain who undergoes surgery that alleviates her symptoms may go on to develop disabling 	headaches because her underlying emotional problems have not been adequately addressed.

As somatic, psychological, and social factors--either alone or in combination--usually play a role in chronic 	pain syndromes, each should be investigated from the outset. If the physician delays psychological evaluation until 	after ruling out organic disease, patients and their families are less likely to accept any potential nonorganic 	causes.

 In a prospective, randomized trial, Peters and colleagues compared two 	groups of patients: those evaluated for psychosocial as well as organic causes of pain beginning with the first 	visit, and those evaluated for psychosocial causes only after organic pathology had been ruled out.

 	Patients in the former group had better responses to therapy and better long-term outcomes.


 The cause of chronic pelvic pain in an adolescent may be organic, nonorganic, or multifactorial (Table 1).


 These include endometriosis with or without Mllerian anomalies; adnexal lesions, such as ovarian masses or 	chronic ectopic pregnancy; infectious causes, such as pelvic inflammatory disease (PID) or tubo-ovarian abscesses; 	and pelvic adhesive disease.


 The most common urologic cause of chronic pelvic pain in adolescents is urinary tract infection. Although much 	less likely, kidney stones, interstitial cystitis, and urethral syndrome may also be responsible for the pain.


 Diseases of the lower gastrointestinal (GI) tract may present as chronic pelvic pain because the organs of the 	pelvis and lower GI tract share the same visceral innervation. Some of these disease processes may be revealed 	by the history and physical examination, whereas others may require radiologic or endoscopic evaluation. Constipation, 	which is often caused by poor diet or bowel habits and thus is common in adolescents, can be readily diagnosed 	with examination and abdominal films, and then corrected with hydration, dietary changes, and pharmacologic intervention 	if necessary. A careful dietary history may lead to the diagnosis of lactose intolerance or irritable bowel syndrome 	(IBS). Patients who suffer from IBS-related chronic pelvic pain are particularly prone to somatization, depression, 	and anxiety. Other GI-related causes of chronic pelvic pain are peptic ulcer disease, gastroenteritis, inflammatory 	bowel disease, chronic appendicitis, and hernias. The two lattermost conditions will require surgical consultation.


 Conditions of the musculoskeletal system that involve an increase in muscle tone (e.g., leg-length discrepancy, 	trigger points) can lead to chronic pelvic pain. In addition, structural abnormalities, injuries, or diseases of 	the lumbar spine, hip, or various muscles (e.g., abdominals, iliopsoas, quadratus lumborum, piriformis, obturator 	internus and externus) may cause pain that is referred to the lower abdomen or anterior thigh. This pain may fluctuate 	in severity over the course of the menstrual cycle because of the effect of varying levels of progesterone and 	relaxin on these tissues. Pain consistent with a musculoskeletal cause often changes in intensity and location 	with variations in posture or with specific activities. Poor posture or leg-length discrepancy can lead to chronic 	pelvic pain because of mechanical stress on joint capsules, ligaments, and muscles.


 Chronic pelvic pain can also be psychosomatic in origin. Because her body is changing more rapidly than at any 	other time in her life, the female adolescent typically experiences a heightened awareness of bodily functions 	and sensations. In addition, the adolescent has a unique set of temporary stressors (e.g., school grades, social 	pressures, awakening sexuality) that can cause physical symptoms. More permanent stressors to which she may be 	exposed (e.g., parental divorce, past or present sexual abuse) may also produce troublesome physical symptoms, 	particularly if she cannot cope with these issues in a healthy fashion because of her temperament or because of 	the circumstances themselves.

Coping style may also play an important role in the development of psychosomatic symptoms.

 	Some adolescents cope actively with stress; if their home situation becomes intolerable, for example, they simply 	run away. Others cope passively, without exhibiting any overt reaction; they internalize their stress and develop 	chronic pain symptoms or fatigue.

Other factors that affect an adolescent's ability to cope with stress include lifestyle and major life events.

 A pattern of regularity-- the same meal schedule every day, regular exercise, the same 	wake-up time and bedtime every day--will likely help her cope more effectively with stress. In contrast, a chaotic 	schedule is likely to cause or aggravate problems. Major life events (e.g., death of a relative, moving, parental 	divorce, natural disaster) may also threaten an adolescent's ability to cope. Occurrence of two or more of these 	events within a short period of time substantially increases the risk of maladaptive coping and inducement of psychosomatic 	symptoms.


 Assessment of a patient with chronic pelvic pain begins with a thorough history that emphasizes duration and frequency 	of symptoms, location and severity of the pain, situations that exacerbate or relieve the pain, and past medications 	and therapies. The physician should inquire about whether other family members have similar symptoms; the patient's 	response to painful stimuli may be influenced by her observations of how other family members respond to pain. 	This symptom modeling is a well-known phenomenon of psychosomatic disease.

A prospective pain calendar may be useful in obtaining this information; the patient should also record information 	regarding her menses to reveal any cyclic component.

The history should focus on these specific areas:

Gynecologic: age at menarche, sexual activity, exposure to sexually transmitted diseases, menstrual irregularities, 		pregnancy history

Urologic: frequency of urination, dysuria, hematuria

Gastrointestinal: dietary history, nausea or vomiting, bowel habits

Psychosocial: history of depression, eating disorders, substance abuse; number of missed school days; coping 		style; presence or absence of major life changes.

In addition, past illnesses and surgeries, along with current medications, should be reviewed. The physician 	should also inquire about a family history of endometriosis; girls whose first-degree relatives have or have had 	the disease face an increased risk for developing it.


 Chronic pelvic pain may arise from a variety of sources. To screen for musculoskeletal causes, the physician should 	examine the patient's posture for evidence of lordosis, one-legged standing, or leg-length discrepancy. The upper 	and lower back should be palpated while the patient is sitting. Once the patient is supine, leg flexion and head 	and leg raises should be done with abdominal-wall palpation. The physician should ask the patient to point to the 	area of greatest pain; typically, an adolescent whose pain is psychosomatic will have difficulty isolating a small 	area of pain origin.

The pelvic exam should focus on possible urologic and gynecologic causes. The physician should palpate the urethra 	and bladder base for specific tenderness, and the vaginal fornices for tenderness or masses. The uterus and adnexa 	can be evaluated on bimanual exam. The physician should also perform a rectal exam, particularly if a GI source 	or endometriosis is suspected. Detection of a large mass of soft stool or a wide rectal vault might suggest a diagnosis 	of constipation.


 These should include a complete blood cell count with differential, urinalysis, urine culture and sensitivity, 	and erythrocyte sedimentation rate. Cervical cultures and a b-human chorionic gonadotropin measurement should be 	performed in sexually active patients. Considering the history and physical findings, the clinician may order other 	diagnostic tests. For example, a plain film of the abdomen is helpful if constipation is suspected. Transabdominal, 	transvaginal, or transrectal pelvic ultrasonography may be useful in patients with abnormal or equivocal findings 	on the physical exam.

In adolescents with chronic pelvic pain, an abnormal finding on pelvic ultrasound has a 92.4% predictive value 	in confirming the abnormality at the time of laparoscopy (even though the abnormality may not be the source or 	cause of the pelvic pain).

 Abnormalities most commonly identified by ultrasound 	include adnexal masses (e.g., ovarian cysts, tubo-ovarian abscesses) or Mllerian abnormalities (e.g., bicornuate 	uterus). A normal finding on pelvic ultrasound is much less predictive (60%) of a normal pelvis at the time of 	diagnostic laparoscopy in the same patient population.

 As pelvic ultrasound cannot 	diagnose endometriosis, PID, or pelvic adhesive disease, a normal finding should not necessarily be the endpoint 	in the work-up.

Safe and minimally invasive in adolescents, laparoscopy has become an important diagnostic tool in evaluating chronic 	pelvic pain in this patient population.

 The most common indications for a diagnostic 	laparoscopy include a mass identified by pelvic exam or ultrasound, progressive dysmenorrhea, chronic pelvic pain 	unresponsive to oral contraceptives or nonsteroidal anti-inflammatory drugs (NSAIDs), painful irregular vaginal 	bleeding, and any diagnostic dilemma such as suspected chronic PID or chronic appendicitis (Table 2).

Prevalence of identifiable pathology at diagnostic laparoscopy has ranged from 56% to 94% (Table 3).

 More recent studies report a higher prevalence of pathology--particularly endometriosis--which 	is most likely due to increased recognition of the appearance of this disease in adolescents, as well as more selective 	indications for laparoscopy. Other pathologic findings identified at diagnostic laparoscopy include pelvic adhesive 	disease, ovarian masses, ovarian torsion, appendicitis, Mllerian anomalies, chronic ectopic pregnancy, paratubal 	cysts, and PID.

Articles

Chronic pelvic pain, a common complaint in female adolescents, is defined as cyclic or noncyclic, intermittent or constant discomfort in the pelvic region for at least 6 months. It often frustrates the patient, her parents, and her physician, and it can lead to major functional problems such as changes in family dynamics or school absenteeism.

Geri D. Hewitt, MD

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Chronic Pelvic Pain in the Adolescent Differential Diagnosis and Evaluation