Whatever the original cause of the pain, when pain has persisted for any length of time, it is likely that other psychosocial factors are now contributing to the maintenance of the pain. Pain is commonly accompanied by anxiety and depression, and these conditions need to be carefully assessed and treated (2,72,73). In a typical gynecologic setting, referral to a psychologist or psychiatrist for parallel evaluation can evoke resistance. The inference is drawn that the referring physician is ascribing the pain to psychological causes. The patient needs to understand the reason for this referral and to be reassured that it is a routine and necessary part of the evaluation. A psychologist is one of the key personnel in a multidisciplinary pain clinic.
A complete physical examination should be performed, with particular attention directed to the abdominal and lumbosacral areas, vulva, pelvic ﬂoor, and internal organs via vaginal, bimanual, and rectovaginal examination. The examination should include the Carnett test, which is an evaluation of the painful sites on the abdominal wall before and after tensing of the abdominal muscles (head raised off the table or with bilateral straight leg raise) to differentiate abdominal wall and visceral sources of pain. Abdominal wall pain is augmented and visceral pain is diminished with palpating the tender points after these maneuvers (74). While standing, the patient should be examined for hernias, both abdominal (inguinal and femoral) and pelvic (cystocele and enterocele). An attempt should be made to locate by palpation the tissues that reproduce the patient’s pain. If abdominal wall sources of pain are noted, it is useful to block these areas with injection of local anesthetics and then perform the pelvic examination (74). Neuropathic symptoms (sharp or lancinating or electrical pain, burning, or tingling sensations) should be localized to the peripheral nerve subserving the involved area.
Reproductive Tract The most common findings noted at the time of laparoscopy for CPP are endometriosis and adhesions. Patients with other gynecologic pathology, such as benign or malignant ovarian cysts, uterine leiomyomas of size sufficient to encroach on supporting ligaments or other somatic structures, or significant pelvic relaxation should be evaluated and treated in a manner that is appropriate for the underlying condition. Pain associated with these latter conditions is generally not severe, and appropriate surgical management is therapeutic.
Endometriosis See the section on secondary dysmenorrhea above and for a more thorough discussion of the diagnosis and management of endometriosis refer to Chapter 17.
Endometriosis can be demonstrated in 15% to 40% of patients undergoing laparoscopy for chronic pelvic pain. Endometriosis is a surgical diagnosis based on identification and histology of characteristic lesions (75). Endometriosis produces a low-grade inﬂammatory reaction; over time this results in adhesions between conﬂuent pelvic organs (76). However, the cause of the pain is not well established. There is no correlation between the location of disease and pain symptoms (77,78). There appears to be no relationship between the incidence and severity of pain or the stage of the endometriotic lesions, and as many as 30% to 50% of patients have no pain regardless of stage. Similarly, 40% to 60% of patients have no tenderness on examination regardless of stage (78). Deeply infiltrating endometriosis lesions that involve the rectovaginal septum and the bowel, ureters, and bladder are strongly associated with pain (76,79,80). Pelvic adhesions related to endometriosis are a predictor of pelvic pain (81). Vaginal and uterosacral deep lesions are associated with dyspareunia and dyschezia.