{"paper_id":"6c9804df-dbf4-4781-ab24-46914644ccc3","body_text":"Copyright © 2024 The Author(s); Published by Nickan Research Institute . This is an open-access article distributed under the terms of \nthe Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and \nreproduction in any medium, provided the original work is properly cited.\nImmunopathol Persa. 2024;10(2):e40637                                                                                                                                       Original\nImproving chronic pelvic pain diagnosis; the role of \nclinical assessment and symptom evaluation\nMitra Alizadeh1 ID\n, Reihaneh Hosseini1* ID\n, Zahra Asgari2 ID\n \n1Department of Obstetrics and Gynecology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran \n2Departments of Minimally Invasive Gynecologic Surgery, Arash Women’s Hospital, Tehran University of Medical Sciences, Tehran, Iran \n Immunopathologia Persa \nhttp immunopathol.com\n*Correspondence to\nReihaneh Hosseini, \nEmail: rayh_h@yahoo.com, \nhosseini.r@tums.ac.ir \nReceived 3 Mar. 2024\nAccepted 6 May 2024\nePublished 26 May 2024\nKeywords: Physical \nexamination, Pelvic pain, \nEndometriosis\nIntroduction: Chronic pelvic pain (CPP) is primarily caused by several problems such as endometriosis, adhesions, \nirritable bowel syndrome (IBS), infection, interstitial cystitis, psychological issues. There is an estimation that fifty \npercent of CPP cases remain undiagnosed. \nObjectives:  In the present study, we tried to improve the CPP diagnosis rate by clinical assessment and symptom \nevaluation using a standard questionnaire. \nPatients and Methods: We enrolled 70 women with CPP. Clinical examination was done using a questionnaire, \nnamely pelvic pain assessment form from The International Pelvic Pain Society, to gather the data. Participants \nwere requested for suitable paraclinical tests, and if they were suspected of non- gynaecological diseases, they \nwere referred to related specialists. Patients were followed up 6 months after the visit and the final diagnosis was \nmade at the end of follow-up. \nResults: Endometriosis was the most prevalent diagnosis (n=13). Around 11 patients with musculoskeletal \nsymptoms, 22 patients with gastrointestinal symptoms and one patient with psychological symptoms were \nreferred to appropriate clinics. Among women who were suspected for gynaecological, gastrointestinal, and \nmusculoskeletal diseases, 76.1%, 76.2%, and 68.8% patients reported improvements in their symptoms. The \nkappa coefficient for gynaecological, gastrointestinal, and musculoskeletal symptoms were estimated 0.65, 0.78, \nand 0.77, respectively. The accuracy of gynaecological, gastrointestinal, and musculoskeletal symptoms was 0.82, \n0.91, and 0.93, respectively.\nConclusion: Physical examination findings and symptoms in the structure of pelvic pain assessment form can be \nvaluable tools for diagnosis and treatment of CPP and will improve the diagnosis rate.\nAbstract\nCitation: Alizadeh M, \nHosseini R, Asgari Z. \nImproving chronic pelvic \npain diagnosis; the role \nof clinical assessment \nand symptom evaluation. \nImmunopathol Persa. \n2024;10(2):e40637. \nDOI:10.34172/\nipp.2024.40637.\nIntroduction\nChronic pelvic pain (CPP), defined as \npersistent disabling pain located in the minor \npelvis lasting for more than six months, affects \napproximately 15% (ranging from 5.7% to \n26.6%) of women annually in the US (1). Pain \nlevels are quantified as severe enough to cause \ndisability and necessitate medical care, yet \nthey often remain unresponsive to treatment \n(2). Several well-known gynecological and \nextra-gynecological causes contribute to CPP , \nincluding adhesions, endometriosis, irritable \nbowel syndrome (IBS), infection, interstitial \ncystitis, psychological issues, and urethral \nsyndrome (3,4). Notably, endometriosis is the \nmost prevalent cause of CPP (5).\nCPP can arise from one or more organ \nsystems and is frequently associated with \npsychological disturbances (such as depression \nand anxiety), a history of sexual and physical \nabuse, and a variety of somatic complaints. \nThis complexity makes evaluating, diagnosing, \nKey point \n- Chronic pelvic pain could be associated with \npsychological disturbances \n- Pelvic pain assessment form is a valuable tool for \ndiagnosis and treatment of chronic pelvic pain \nand treating patients with CPP challenging \n(6).\nThe etiology of CPP is multifaceted, \nnecessitating several diagnostic procedures \nfor accurate diagnosis. History-taking and \nphysical examinations serve as the initial \nsteps. It is crucial to inquire about factors \nthat trigger or intensify the pain, assess \nthe impact of pain on patients’ quality \nof life, and understand how patients are \ncoping with the pain. Additionally, imaging \ntests, including transvaginal sonography, \ncomputer tomography (CT), and magnetic \nresonance imaging (MRI), play a valuable \nrole in CPP diagnosis (7-9). Furthermore, \nDOI:10.34172/ipp.2024.40637\n\n\nAlizadeh M et al\n Immunopathologia Persa  Volume 10, Issue 2, 2024\n2\nlaparoscopy is a precious diagnostic procedure, performed \nin approximately 40% of CPP patients (10).\nGiven the limited data on the importance of history-\ntaking and physical examinations in patients with CPP , \nwe conducted a cross-sectional study to evaluate the \nvalue of these assessments using a standardized form in \nidentifying the etiology of CPP . Additionally, we reported \nthe prevalence of CPP etiologies.\nObjectives\nIn the present study, we tried to improve the CPP diagnosis \nrate by clinical assessment and symptom evaluation using \na standard questionnaire.\nPatients and Methods\nStudy design \nThis cross-sectional study was conducted at our academic \noutpatient clinic for CPP . Between 2020 and 2022, we \nenrolled all patients who were referred to the Arash \nHospital Clinic in Tehran, Iran, for CPP . All subjects were \ninformed about the study’s goals, and signed informed \nconsent was collected. We defined CPP as pelvic pain \nand/or lower abdominal pain unrelated to menstruation \nor coitus, persisting for over six months. We excluded \nindividuals with chronic medical conditions such as heart \ndisease, kidney disease, connective tissue disease, diabetes, \nand pregnant women.\nTo gather data, we used the pelvic pain assessment form, \na questionnaire developed by the international pelvic pain \nsociety. This questionnaire covers socio-demographic \nfeatures, patients’ pain (duration, cause, visual analogue \nscale score, drugs, and pain distribution maps), past \nand recent surgical history, eating habits, sexual abuse, \nand information related to urinary, reproductive, \nand gastrointestinal systems. The questionnaire was \nadministered to women awaiting their clinic visit. \nResearchers conducted face-to-face interviews to complete \nthe form (11). Subsequently, physical examinations were \nperformed, and diagnoses were based on the history and \nphysical assessments. Patients were also requested to \nundergo suitable paraclinical tests. If non-gynecological \ndiseases were suspected, they were referred to relevant \nspecialists. Follow-up occurred 6 months after the initial \nvisit, and the final diagnosis was determined at that time.\nStatistical analysis\nData analysis was performed using the Statistical Package \nfor the Social Sciences (SPSS) statistical program, version 16 \n(IBM Corp., Armonk, NY , USA). We applied the Shapiro–\nWilk test to evaluate the normality of data distribution. \nBaseline characteristics of the study population were \npresented as frequencies (%) for categorical variables and \nas mean (standard deviation: SD) values for continuous \nvariables. To assess the agreement between symptoms and \nthe final diagnosis, we calculated kappa coefficients. The \nstatistical significance level was considered to be ≤ 0.05.\nResults\nBasic demographics of patients \nThe baseline characteristics of the participants are \npresented in Table 1. All 70 subjects were followed until \nthe end of the research. The mean age of participants was \n42.48 ± 8.33 years. Among the study population, 90% \n(n = 63) were married, and 97.2% (n = 68) were housewives. \nThe mean age at menarche for participants was 12.9 ± 1.5 \nyears. Additionally, 18.6% (n = 13) were nulliparous, while \n81.4% (n = 57) were multiparous.\nBaseline complications of participants\nAll participants underwent interview and their \nexamination results presented in Table 2. The majority \nof our participants complain about vomiting as a \nTable 1. The baseline characteristics of the study population\nVariable No. (%)\nAge (years), mean (SD) 42.4 (8.3)\nMenarche age (y), mean (SD) 12.9 (1.5)\nHistory of C-section, n (%) 25 (35.7)\nFamilial history of pelvic pain, n (%) 2 (2.8)\nPositive medical history, n (%) 18 (25.7)\nGravid, n (%)\n0 13 (18.6)\n≥1 57 (81.4)\nEmployment status, n (%)\nHousewife 68 (97.2)\nEmployed 2 (2.8)\nMarital status, n (%)\nMarried 63 (90)\nSingle 7 (10)\nEducational status, n (%)\nPrimary 51 (72.9)\nTertiary 18 (27.1)\nMedical history\nNatural delivery  45 (64.2)\nCaesarean 25 (35.7)\nMenstruation \nDysmenorrhea 37 (52.8)\nRegular 37 (52.8)\nClotting 23 (32.8)\nBirth control\nNot use any birth control 33(47.1)\nWithdrawal 19 (27.1)\nCondoms 7 (10)\nUndergone tubal ligation 4 (5.7)\nOCP 3 (4.3)\nIUD 2 (2.9)\nHysterectomy 1 (1.4)\nCoffee consumption\n1 to 3 times a day 30 (42.8)\n4 to 6 times a day 7 (10)\n>6 times a day 4 (4.3)\nNot consume coffee 29 (41.4)\nAlcohol usage 2 (2.9)\nDrug abuse 2 (2.9)\nHistory of abuse and \nviolence\nSexual abuse 0\nPhysical violence before age 13 6 (8.6)\nPhysical violence after age 13 2 (2.9) \nIUD, Intrauterine devices; OCP, Oral contraceptive pill.\n\n                                           Immunopathologia Persa  Volume 10, Issue 2, 2024 3\nChronic pelvic pain diagnosis\ngastrointestinal sign (24.3%), the do not work out as \nphysical activity (67.1%), having right adnexal tenderness \nin abdominal and pelvic tenderness (21.4%), having pelvic \ntenderness by speculum examination (15.7%), and pain \nduring or after sexual intercourse (15.7%). \nDiagnosis\nEndometriosis was the most prevalent diagnosis (n = 13, \n18.57%). Other diagnoses included fibroma (n = 7, 10%), \novary cyst (n = 6, 8.57%), pelvic inflammatory disease \n(PID) (n = 5, 7.1%), urinary tract infection (UTI) (n = 2, \n2.85%), atrophic vaginitis (n = 1, 1.42%).\nInterventions \nAbout 11 (15.71%) patients with musculoskeletal \nsymptoms were referred to the physical medicine clinic, \n22 (31.4%) patients with gastrointestinal symptoms \nwere referred to the gastrointestinal clinic, one patient \n(1.42%) with psychological symptoms was referred to \nthe psychological clinic, one patient (1.42%) remained \nwithout a specific diagnosis, two patients with suspected \nfibroma and musculoskeletal symptoms were referred to \nthe physical medicine clinic, five and two patients with \nendometriosis were referred to the gastrointestinal clinic \nand physical medicine clinic, respectively.\nAfter six months follow-up \nTable 3 presents the agreement between clinical findings \nand the final diagnosis. At the end of the follow-up \nperiod. Among 46 suspected women for gynaecological \ndiseases, 35 (76.1%) patients reported improvement in \ntheir symptoms, 11 (23.9%) patients did not report any \nimprovements. In the gastrointestinal complications, \n16 (76.2%) patients reported improvements in their \nsymptoms, six cases (23.8%) did not report any \nimprovement. By physical medicine clinic, 11 (68.8%) \npatients reported improvements in their symptoms.\nThe diagnosis was considered correct if their symptoms \nimproved. The kappa coefficients for gynecological, \ngastrointestinal, and musculoskeletal symptoms were \nestimated as 0.65, 0.78, and 0.77, respectively. Moreover, \nthe accuracy of gynecological, gastrointestinal, and \nmusculoskeletal symptom diagnoses was 0.82, 0.91, and \n0.93, respectively.\nDiscussion\nChronic pelvic pain is a prevalent and crucial disorder that \naffect both men and women and can reduce health-related \nquality of life remarkably (12). It has been estimated that \napproximately 15% of women experience CPP at least for \nonce throughout their life. CPP impose a great direct and \nindirect costs on the healthcare systems. Direct costs are \nattributed to dysfunctions of organ systems and indirect \ncosts are absenteeism, productivity loss, and missed wages \n(13). Y early direct costs were estimated to be about 2.8 \nbillion dollars (14). The main aetiology of CPP in men \nis primarily chronic prostatitis (15), while a variety of \netiologist in women have been identified so far. Of note, \nthere is a chance that the reason behind CPP in women \ncannot be recognized (16). A number of pathologies related \nto urological, psychoneurological, gastrointestinal, and \nmusculoskeletal systems were shown to be associated with \nCPP . In most cases, one of these pathologies is detected \nand treatments usually can cure them. More often the pain \nis associated with a number of pathologies and several \netiologies should be taken into account, and in such cases, \nfrequent treatment is not curative (17).\nIn the present study, we found that endometriosis was \nthe most frequent diagnosis, followed by fibroma, ovary \ncyst, PID, UTI, and atrophic vaginitis. A cross-sectional \nTable 2. Baseline examination results of all participants (n=70)\nExaminations Variable  No. (%)\nGastrointestinal \nsymptoms\nVomiting 17 (24.3)\nPain after eating 13 (18.6)\nChange in bowel habits 12 (17.1)\nEating disorders 8 (11.4)\nMelena  7 (10)\nPhysical activity \nNot exercising 47 (67.1)\n1-2 times a week 14 (20)\n3-5 times a week 2 (2.9)\nDaily exercise 1 (1.4)\nAbdominal and \npelvic tenderness\nRight adnexal tenderness 15 (21.4)\nLeft adnexal tenderness 14 (20)\nSpeculum \nexamination\nPelvic tenderness 11 (15.7) \nLarge uterus 9 (12.9) \nAbdominal tenderness 8 (11) \nVaginal discharge 6 (8.6)\nPelvic pain\nDyspareunia (pain during sexual \nintercourse) 11 (15.7) \nPain following sexual intercourse 11 (15.7) \nPain after exercise 7 (10) \nPain after lying down 3 (4.3) \nSudden pelvic pain 2 (2.9)\nPelvic pain during movement 1 (1.4)\nTable 3. Agreement between clinical findings and final diagnosis\nVariable Symptoms improved\nNo. (%)\nSymptoms not improved\nNo. (%) Kappa Accuracy\nGynaecological suspicion 35 (76.1) 11 (23.9) 0.65 0.82\nGastrointestinal suspicion 16 (72.7) 6 (27.3) 0.78 0.91\nMusculoskeletal suspicion 11 (68.8) 5 (31.3) 0.77 0.93\n\nAlizadeh M et al\n Immunopathologia Persa  Volume 10, Issue 2, 2024\n4\nresearch among 656 women who were referred to a tertiary \ncenter of endometriosis and CPP in Canada demonstrated \nthat 373 (57%), 350 (53%), and 281 of women were \ndiagnosed with endometriosis, IBS, and painful bladder \nsyndrome (PBS), respectively (18). Pelvic congestion is \nanother major cause of CPP . In a previous study, Jurga-\nKarwacka et al found pelvic congestion in near 12% of \npatients suffering from CPP (19). A prospective cohort \nstudy demonstrated that 40%, 20%, and 18% of CPP \npatients had adhesions, pelvic congestion syndrome, \nand endometriosis, respectively, in the laparoscopic \nassessment (20). In the present study, the prevalence of \nendometriosis among CPP patients was slightly lower than \nother studies. The reason for this difference is that in those \nstudies, the diagnostic method was laparoscopic, which is \nmore accurate. However, this small difference indicates \nthat the accuracy of this questionnaire in diagnose of \ngynaecological causes is acceptable.\nIn our study, 17% of patients presented with \nmusculoskeletal symptoms and the accuracy of history \nand physical examination to diagnose musculoskeletal \ndisorders was 93%. Mieritz et al performed a cross-sectional \nstudy to evaluate the prevalence of musculoskeletal \ndisorders in 94 patients with CPP and found that over \nhalf of patients showed musculoskeletal symptoms in \nthe lumbar/pelvic region (21). King et al examined the \nefficacy of physical therapy treatments in 132 patients \nwomen with CPP and the majority of patients experienced \nremarkable or complete improvements in their symptoms \n(22). A systematic review sought to study studies reporting \nassociation between CPP and musculoskeletal disorders. \nThey failed to show the association between CPP and \nmusculoskeletal disorders since validity and use of terms in \nthe relevant studies were inconsistent (23). In the current \nstudy, multiple items of the assessment questionnaire were \nrelated to musculoskeletal disorders; therefore, we reached \na high accuracy for the diagnosis of musculoskeletal \ndisorders.\nWe found that approximately 30% of patients presented \nwith gastrointestinal symptoms as the cause of CPP and the \naccuracy of questionnaire to diagnose GI causes was 91%. \nTachawiwat et al reported that the prevalence of IBS in the \nmild-moderate and severe patients was about 20% and \n19%, respectively. The prevalence of IBS in both groups \nwas significantly higher relative to the control group; \nnevertheless, the prevalence of IBS was not significantly \ndifferent between patients of mil-moderate and severe \nCPP patients (24).\nIn our study, only one patient was referred to a \npsychiatrist clinic. Siqueira-Campos et al designed a cross-\nsectional study to examine the prevalence of anxiety and \ndepression among women with CPP . They found that 66%, \n63%, and 54% of CPP women were suffering from anxiety, \ndepression, and mixed anxiety and depressive disorder, \nrespectively (25). In the study conducted by Siqueira-\nCampos et al, the prevalence of anxiety, depression and \nmixed anxiety and depressive disorder was higher in \nwomen with CPP compared to the pain-free controls. \nMixed anxiety and depressive disorder was present in \n54% of the CPP group and in 28% of the controls (25). \nTherefore, it can be concluded that the assessment form in \nour study alone is not sufficient to screen for psychiatric \ndisorders as a cause of CPP .\nIn the current study, none of the participants mentioned \na history of sexual abuse and 8.6 % and 2.8% of participants \nexperienced physical violence in childhood and adulthood, \nrespectively. In the study by Riedl et al, on 1480 individuals, \nthe prevalence of physical violence was estimated at 38% \nin childhood and 16%in adulthood (26). Chiang et al \nfound 67% physical violence in childhood, 33% sexual \nviolence in childhood, in 566 Kenyan women (27). In our \nstudy, the information was gathered by the interviewer; \nhowever, Riedl et al collected the data from the patients’ \nfile information, which can explain the difference between \nthe findings of these two studies since women are prone \nto the concealment of physical injuries (26). Additionally, \nthe study by As-Sanie et al found that adolescent or adult \nsexual abuse was associated with greater pain-related \ndisability among women with CPP (28). A history of \nphysical abuse or sexual abuse appears to hold a stronger \nrelationship with current depressive symptoms than the \npain experienced by women with CPP (28).\nIn our study, we found the co-existence of gynecological, \nand gastrointestinal, and  musculoskeletal symptoms.  A \nsystematic review of nine studies with 1016 CPP patients \nreported that the prevalence of endometriosis and PBS, \nand the co-existence of endometriosis and PBS was 70%, \n61%, and 48%, respectively (29).  Since our study had a \nlimited number of patients, performing further studies \nwith larger populations is merited. \nConclusion\nThe findings of the present study suggest that 1) the most \nprevalent diagnosis of women referred to CPP clinic is \nrelated to gynecological diseases, 2) gastrointestinal and \nmusculoskeletal issues are prevalent among women with \nCPP , 3) physical examination findings and symptoms can \nbe valuable tools for diagnosis of the aetiology of CPP and \nas a result, will improve patients’ outcomes.\n \nLimitations of the study \nThe study is limited by the small sample size, as it was \nconducted at a single center and had a relatively short \n6-month follow-up period. \nAuthors’ contribution  \nConceptualization: Reihaneh Hosseini. \nData curation: Mitra Alizadeh, Zahra Asgari. \nFormal analysis: Mitra Alizadeh, Zahra Asgari. \nFunding acquisition: Reihaneh Hosseini. \nInvestigation: Mitra Alizadeh. \nMethodology: Reihaneh Hosseini, Zahra Asgari. \nProject administration: Reihaneh Hosseini. \n\n                                           Immunopathologia Persa  Volume 10, Issue 2, 2024 5\nChronic pelvic pain diagnosis\nResources: Reihaneh Hosseini. \nSoftware: Mitra Alizadeh. \nSupervision: Reihaneh Hosseini. \nValidation: Zahra Asgari. \nVisualization: Mitra Alizadeh. \nWriting–original draft: Mitra Alizadeh. \nWriting–review & editing: Zahra Asgari. \nConflicts of interest\nThe authors declare that they have no competing interests. \nEthical issues\nThe research conducted in this study adhered to the principles \noutlined in the Declaration of Helsinki and was approved by the \nEthics Committee of Tehran University of Medical Sciences (Ethical \ncode # IR.TUMS.MEDICINE.REC.398.280). Prior to any intervention, \nall participants provided written informed consent. The study was \nextracted from Mitra Alizadeh thesis in the department of obstetrics \nand gynecology at this university (Thesis code#9611220018). The \nauthors have fully complied with ethical issues, such as plagiarism, \ndata fabrication, and double publication.\nFunding/Support\nThe study supported as a grant project in the Tehran University of \nMedical Sciences, Tehran, Iran (Grant# 9611220018).\nReferences\n1. Dydyk AM, Gupta N. Chronic Pelvic Pain. Treasure Island (FL): \nStatPearls Publishing; 2023.\n2. Dydyk AM, Hameed S. Lumbosacral Plexopathy. 2023 Jul \n16. In: StatPearls [Internet]. Treasure Island (FL): StatPearls \nPublishing; 2024 Jan. \n3. Wozniak S. Chronic pelvic pain. Ann Agric Environ Med. 2016 \nJun 2;23:223-6. doi: 10.5604/12321966.1203880. \n4. Zondervan K, Barlow DH. 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Am J \nObstet Gynecol. 2014;210:317.e1-317.e8. doi: 10.1016/j.\najog.2013.12.048. \n29. Tirlapur SA, Kuhrt K, Chaliha C, Ball E, Meads C, Khan KS. \nThe ‘evil twin syndrome’ in chronic pelvic pain: a systematic \nreview of prevalence studies of bladder pain syndrome and \nendometriosis. Int J Surg. 2013;11:233-7. doi: 10.1016/j.\nijsu.2013.02.003.","source_license":"CC0","license_restricted":false}