Chronic Pelvic Pain and Recurrent Abdominal Pain in Female Adolescents

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 and Recurrent Abdominal Pain in Female Adolescents

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.

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.

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    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.


    A variety of gynecologic, gastrointestinal, urologic, musculoskeletal and body-wide disorders can cause chronic pelvic pain.

    Gynecologic causes - Gynecologic causes are thought to be the cause of chronic pelvic pain in about 20 percent of women. Some of the gynecologic causes of pelvic pain include:

    Endometriosis - The tissue lining the inside of the uterus is called the endometrium. Endometriosis is a condition in which endometrial tissue is also present outside of the uterus. Some women with endometriosis have no symptoms, while others experience marked discomfort and pain and may have problems with fertility.

    Pelvic inflammatory disease - Pelvic inflammatory disease is an acute infection usually caused by a sexually transmitted organism. Occasionally, it is caused by a ruptured appendix, tuberculosis, or diverticulitis. It can involve the uterus, ovaries, and fallopian tubes (which link the ovaries and uterus). Chronic changes following pelvic inflammatory disease occur in about one-third of women and causes chronic pelvic pain. The reason for this is not clearly known, but is likely because of permanent damage to the uterus, ovaries, and fallopian tubes, and is not because of a chronic infection.

    Pelvic adhesive disease - Adhesions refer to abnormal tissue that causes internal organs or structures, such as the ovaries and fallopian tubes, to adhere or stick to one another. Adhesions are not scar tissue, as adhesions are abnormal reactions to surgery, infection, or inflammation, and are not normal healing like scar tissue. It is very controversial whether adhesions cause pelvic pain and medical experts are not in agreement. However, most evidence suggests that surgery for pelvic adhesive disease does not relieve pelvic pain in most women.

    Other causes - Non-gynecologic causes of chronic pelvic pain may be related to the digestive system, urinary system, or to pain in the muscles and nerves in the pelvis:

    Irritable bowel syndrome - Irritable bowel syndrome is a gastrointestinal condition characterized by chronic abdominal pain and altered bowel habits (such as loose stools, more frequent bowel movements with onset of pain, and pain relieved by defecation) in the absence of any specific cause.

    Painful bladder syndrome and interstitial cystitis - Painful bladder syndrome and interstitial cystitis (PBS/IC) are the terms given to bladder pain that is not caused by infection. Symptoms usually include the need to urinate frequently (frequency) and a feeling of urgently needing to urinate (urgency). Some women with painful bladder syndrome have lower abdominal or pelvic pain in addition to urinary tract symptoms. A separate topic review is available that discusses PBS/IC.

    Diverticulitis - A diverticulum is a sac-like protrusion that sometimes forms in the muscular wall of the colon (or intestine). Diverticulitis occurs when diverticula become inflamed. This usually causes abdominal pain; nausea and vomiting, constipation, diarrhea, and urinary symptoms can also occur. Diverticulitis most often causes acute abdominopelvic pain and is not a common cause of chronic pain.

    Pelvic floor pain - Symptoms of pelvic floor dysfunction may include pelvic pain, pain with urination, difficulty urinating, constipation, pain with intercourse, or frequent/urgent urination. Pelvic floor dysfunction can be diagnosed by a clinician feeling the pelvic floor muscles (muscles that support the pelvic organs and hips) through the vagina and/or rectum; muscles that feel tight, tender, or band-like indicate that pelvic floor dysfunction could be contributing to pelvic pain.

    Abdominal myofascial pain (trigger points) - Pain can originate from the muscles of the abdominal wall due to myofascial pain. This problem usually has small localized areas of abnormal tenderness of the abdominal muscles that are called trigger points. Abdominal myofascial pain is diagnosed by the clinician examining the abdominal muscles for trigger points; often tightening of these muscles while they are examined causes increased pain and assists in diagnosis.

    Fibromyalgia - Fibromyalgia is one of a group of chronic pain disorders that affect connective tissue structures, including muscles, ligaments, and tendons. It is characterized by widespread muscle pain (or "myalgia") and tenderness in certain areas of the body. Women with fibromyalgia may also experience fatigue, sleep disturbances, headaches, and mood disturbances such as depression and anxiety.