Robert T. Brown, Geri D. Hewitt
As girls enter gynecologic maturity, pelvic or abdominal pain becomes a frequent complaint. Probably the most common cause of recurrent pelvic pain is menstruation. With dysmenorrhea that is mild to moderate and easily controllable with simple medications, there is little mystery as to cause, and there is little concern as to control. However, when pain is chronic or chronically recurrent, and when it is not treatable with simple medications or other analgesic methods, then investigation is needed to ferret out the cause and to develop an effective treatment plan.
Chronic pelvic pain (CPP) accounts for 10% of all visits to gynecologists. In addition, CPP is the reason for 20 - 30% of all laparoscopies in adults.
Analogously, recurrent abdominal pain (RAP) occurs in 5 - 15% of female children 6 - 19 years old. In a community-based study of middle and high school students, 13 - 17% had weekly abdominal pain. Using criteria for irritable bowel syndrome (IBS), 14% of high school students and 6% of middle school students fit the criteria for adult IBS. As with other difficult to diagnose chronic medical problems, patients with CPP/RAP account for a very large number of office visits and medical resources in proportion to their actual numbers.
Although there are various definitions of chronic pelvic and/or abdominal pain, the accepted pediatric criteria, as stated by Apley and Naish for RAP in children, are three or more bouts of pain severe enough to affect activities over a time period of not less than 3 months. In adults, the diagnosis of CPP requires cyclic or non-cyclic, intermittent or constant discomfort in the pelvic region for at least 6 months.
Chronic Pelvic Pain and Recurrent Abdominal Pain Etiology
There are many etiologies of CPP and of RAP. There are clear organic causes for CPP/RAP and causes that seem to mix organic processes with psychosocial phenomena. Even with endometriosis, a clearly organic cause of pain, it is known that the severity of the symptoms is not correlated with the amount of abnormal tissue seen in the pelvis. The best way to conceptualize chronic pelvic and abdominal pain syndromes is via a biopsychosocial model (BPSM). This model brings together organic factors, psychological factors, and environmental factors into a comprehensive picture that is often needed to explain these symptoms.
In the past, many people with chronic pain syndromes were said to have psychosomatic causes of their pain, but in recent years, it has become clear that such syndromes are not solely caused by psychological processes, or are psychosomatic in origin. While that term might not be accurate if it is understood to mean caused solely by psychological factors, the authors feel that the term still has relevance. The real definition of 'psychosomatic' does fit the BPSM.
According to a current medical dictionary, 'psychosomatic' means 'pertaining to the mind-body relationship'. A psychosomatic disorder is one in which physical symptoms are caused by or exacerbated by psychological factors.
To that we would add that recognition needs to be made of the interplay among all these factors, i.e. the BPSM.
We will first discuss gynecologic etiologies of CPP/RAP, then abdominal etiologies, and finally, management issues.