Evaluation and Treatment of Chronic Pelvic Pain in Children and Adolescents
By Sabrina Carrié, MD, FRCPC1 and Susan Sager, MD, FAAP2
1Chronic Pain Service
Montreal Children’s Hospital
Mcgill University Health Center
Montreal, Quebec, Canada
2Division of Pain Medicine
Boston Children’s Hospital
Harvard Medical School
Boston, Massachusetts
Introduction
Pain due to pelvic pathology can be referred to viscera in the abdominal cavity, the low back, abdominal wall, hips, pelvic floor, and upper thighs, reflecting a broad viscero-viscero and viscero-somatic distribution of the sensory and sympathetic afferent neurons of the lumbosacral plexus. For many young patients, the distinction between pelvic and abdominal pain is not well appreciated and descriptions of pain symptoms due to pelvic pathology can be highly variable. It is not uncommon for adolescents to describe pain due to pelvic pathology as ‘stomach ache,’ and also report symptoms of nausea, gastroesophageal reflux, constipation, and bloating (Sager & Laufer, 2014). Not surprisingly, many young adolescents with these non-specific symptoms are evaluated first by gastroenterologists and are referred to the pain specialist with a diagnosis of irritable bowel syndrome (IBS) or functional abdominal pain (FAP) prior to identifying other pelvic pathology.
The differential diagnosis of pelvic pain is extensive and includes orthopedic, neurologic, gastrointestinal, gynecological, urological, traumatic, infectious, and neoplastic causes. Frequently, chronic pelvic pain (CPP) is multifactorial and involves components of myofascial dysfunction, neuropathic pain, and central sensitization (Levesque & Riant, 2018). A careful history will help direct the evaluation. Chronic pelvic pain in males is rare before puberty, and most commonly associated with urologic symptoms and pelvic floor dysfunction. The most common causes of chronic pelvic pain in females are dysmenorrhea and constipation.
Dysmenorrhea
Dysmenorrhea is a syndrome characterized by recurrent, crampy, lower abdominal pain during menses, and enhanced sensitivity to pain (Iacovides, 2015). Pain is often accompanied by nausea, vomiting, diarrhea, headaches, and muscular cramps, and frequently co-occurs with other chronic pain conditions, including migraine, IBS, and fibromyalgia (Padamsee, 2015) (Costantini, 2017). Dysmenorrhea affects up to 90% of post-menarchal adolescents, with 9% to 33% of adolescent females ages 15-22 years reporting pain as severe or affecting daily function (Suvitie, 2016) (Smorgick & As-Sanie, 2018). Although dysmenorrhea is the leading reason for missed school days and work in adolescent girls (Schroeder & Sanfilippo, 1999), dysmenorrhea is rarely reported by adolescents and a menstrual history is often omitted by clinicians. The resulting “don’t ask/don’t tell” paradox creates a knowledge gap in the diagnostic process, and pelvic pathology as a cause of chronic pain can be missed and remain untreated for years.
As with many repetitive painful events, dysmenorrhea can lead to central sensitization of pain pathways. Studies in adults with primary dysmenorrhea have demonstrated peripheral and central nervous system changes similar to those seen in other chronic pain conditions. Neuronal changes that persist throughout the menstrual cycle (Vincent, 2011), and alterations in metabolic, morphologic, and functional connectivity between pain-related regions of the brain are present in women with dysmenorrhea (Tu, 2013) (Wei, 2016) (Liu, 2017).These studies and others support the growing understanding of dysmenorrhea as one of a group of overlapping chronic pain syndromes with central sensitization as a unifying feature (Sager & Laufer, 2018, second edition not yet in print). The importance of early identification and treatment of dysmenorrhea in adolescents is underscored in a recent adult study demonstrating improvement of IBS and fibromyalgia symptoms after treating dysmenorrhea (Costantini et al., 2017). A menstrual history should thus be obtained on any female adolescent with chronic pain.
Dysmenorrhea is initially treated with non-steroidal anti-inflammatory drugs (NSAIDs). If pain persists then cyclic hormonal therapy is used to lighten periods and decrease pain. If pain resolves with the use of NSAIDs and cyclic hormonal therapy, then no further evaluation is usually needed. If pain does not resolve, laparoscopic evaluation may be warranted to evaluate for endometriosis (ACOG Committee Opinion No. 760: Dysmenorrhea and Endometriosis in the Adolescent, 2018). In fact, nearly all patients with persistent pain after three months of cyclic hormonal therapy will be diagnosed with endometriosis (Laufer, 2011).
Endometriosis
Endometriosis is a painful chronic inflammatory condition defined as the presence of uterine tissue outside the uterus; it is the most common cause of secondary dysmenorrhea in adolescents. Although commonly understood to be a disease of adult women, endometriosis occurs in adolescents and in pre-menarchal girls as early as eight years of age (Marsh, 2005). Endometriosis is an estrogen-dependent disease, and therefore should be considered in the differential diagnosis of all females with abdominal or pelvic pain once the benchmark of thelarche has been met (Economy, 1999). More typically, women are diagnosed during their childbearing years when they seek medical treatment for infertility. However, data show that two-thirds of adult women with endometriosis reported onset of symptoms during adolescence, with 38% reporting symptom onset before age 15 years (Ballweg, 2004 ).
Adolescent endometriosis can be a challenging diagnosis as signs and symptoms are often non-specific for gynaecological pathology and can differ from those reported by adults. On average there is a delay of seven years from onset of symptoms to diagnosis of endometriosis, with longer delays (8–10 years) diagnosing adolescents compared to women in their 30s (<2 years) (Noaham, 2011). Instead of identifying and treating endometriosis, adolescents will be referred to pain physicians for treatment of FAP, chronic back pain, migraines, fibromyalgia, and other chronic pain syndromes. A high index of suspicion is needed to accurately diagnose and treat adolescents with pelvic pain due to endometriosis.
In adolescents, endometriosis symptoms can be cyclical, but more often pain is present throughout the menstrual cycle and associated with a preponderance of gastrointestinal symptoms due to CNS sensitization and development of visceral hyperalgesia. Endometriosis pain in adolescents can worsen with bowel movement or urination, and can be associated with painful tampon insertion, or dyspareunia in sexually active adolescents (Smorgick & As-Sanie, 2018). The appearance of endometriosis at laparoscopy can differ from adults as well, and can be missed if the gynecologist is unfamiliar with the clear and pink lesions seen in adolescent endometriosis. Referral to an adolescent gynecologist is warranted for accurate diagnosis.
Myofascial
Musculoskeletal pain arising from pelvic floor myalgias, pelvic floor dysfunction (PFD), trigger points, neuralgias, and nerve entrapment are common in children and adolescents (Powell, 2014). The pathophysiology of PFD is complex as it occurs as a primary cause of chronic pelvic pain, a response to pain or injury originating elsewhere in the pelvis, or as an associated symptom of a chronic pain syndrome. Primary causes include chronic overuse injuries and biomechanical stress such as poor posture, heels, leg-length discrepancy, heavy backpacks, muscle strain, and trauma (Powell, 2014). In children and adolescents, PFD most commonly is associated with voiding or elimination dysfunction.
Vulvodynia is defined as vulvar discomfort, most commonly described as a burning pain without visible findings and without a specific clinical disorder. This diagnosis typically affects postpartum women between 20 and 50 years old, but can also occur in adolescents. Chronic vulvar pain in younger children can occur after trauma, or associated with an underlying diagnosis such as lichen sclerosis, vulvovaginitis, psoriasis, nevi, infections, ulceration, and immunobullous diseases (Clare & Yeh, 2011). CPP syndromes such as vulvodynia, vestibulodynia or coccydynia represent various presentations of CNS sensitization and often respond well to pelvic floor physical therapy. Adolescents with cancer represent a special population that may have pain due to tumor burden, post-surgical pain or from radiation and chemotherapy with nerve involvement.
Infection
CPP can also stem from prior PID. The risk of CPP is five times more likely in adolescents with previous infections due to sexually transmitted diseases; that’s about 40% of adolescents with prior PID (Trent & Bass, 2011). Adolescents with high risk behaviors are at increased risk for these infections and therefore a pain physician should screen for these behaviors as well as substance abuse in this population.
Non-gynecologic
Non-gynecologic etiology associated with adolescent CPP include, but are not limited to, Interstitial Cystitis/Bladder Pain Syndrome, IBS, chronic constipation, and other GI conditions that may lead to recurrent abdominal or pelvic pain in children and adolescents (Table 1). Both IC and IBS are thought of as neurogenic disorders with visceral hyperalgesia that can present as CPP. If a concurrent GI disorder is suspected or if there is associated weight loss, blood in the stool, fever, a referral to a GI specialist is warranted (Powell, 2014).
Table 1. Differential Diagnosis of Chronic Pelvic Pain in Adolescents (Powell, 2014)
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Approach to Evaluation
A focused pelvic pain history should attempt to identify presence of dysmenorrhea, pelvic floor myalgias, or PFD – all conditions that can maintain CNS sensitization if left untreated. A detailed menstrual history includes onset of menarche, presence of pain with menstruation, regularity and timing of menses, efficacy of hormonal therapy, and presence of breakthrough bleeding. Presence of pain during or after bowel movements or urination, shooting pain to the vagina or urethra, spasm, pain with clenching or squeezing, pain with tampon insertion or intercourse are indicative of pelvic floor involvement (Smorgick & As-Sanie, 2018). A private conversation with all adolescents with CPP is warranted for sensitive questions especially pertaining to sexual activity, abuse, drugs, mood and anxiety. Of note, a history of sexual assault or abuse can be associated with CPP but should not be presumed to be causative of CPP.
The physical exam includes a general exam with special attention to the abdominal wall, pelvis, and back and it should include a sensory, motor and gait exam. Hypersensitivity to light touch, cold or prick of the abdomen, groin, thighs, or low back can identify dermatomes related to most nerves supplying the pelvic area. Allodynia in a non-dermatomal distribution indicates referred visceral pain and sensitization of the abdominal wall (Powell, 2014). Hypersensitivity in a dermatomal distribution is indicative of a specific neuralgia and possible nerve entrapment. Anterior cutaneous nerve entrapment syndrome (ACNES) is identified by a positive Carnett’s sign, typically at the lateral border of the rectus muscle where the nerve branch exits through a fibrous tunnel anteriorly. ACNES can mimic pelvic pain when it involves the subcostal nerves. Various trigger points can identify a myofascial etiology as well.
A back and hip exam should be done for possible radicular symptoms; the sacroiliac joint as well should be examined along with the various muscles around the pelvis including iliopsoas, piriformis, and quadratus lumborum.
A pelvic exam in children and adolescents should be performed by a gynecologist. Bimanual and speculum exams are rarely needed in adolescents, and most exams can be done in the knee chest position. A history of vulvar or pelvic hypersensitivity can be confirmed with a limited external genital exam. Although transvaginal ultrasound exams are common in adults, a transabdominal ultrasound is sufficient to detect anomalies of the reproductive tract in children and adolescents. Labs and imaging are rarely required especially when patients have been referred after extensive investigations. Regardless of the extent of the exam, a discussion should take place with the adolescents to assess level of comfort and if they would like a parent or friend to be present. Part of the exam can be left for a follow-up visit when rapport has been built.
Treatment
Similar to other chronic pain conditions, managing chronic pelvic pain is a multidisciplinary endeavor, and communication among clinicians across disciplines is essential for good pain treatment outcomes. Acute exacerbations in endometriosis pain may be surgical or non-surgical and an effort should be made to identify the cause of an acute increase in pain. Non-surgical causes include missed or delayed OCP, change in absorption of OCP therapy due to medications, and changeover in hormonal therapy. Suspected ovarian torsion, tubal, or ovarian cysts, and adhesions require surgical evaluation. Close communication with the patient’s gynecologist is important for understanding the etiology of episodic pain flares, and to inform pain management.
Medications targeting neuropathic pain, including anticonvulsants such as gabapentin or pregabalin, and antidepressants such as amitriptyline, can be considered although there are no studies in adolescents to provide evidence for their use in CPP. Choice of medication ultimately comes down to side effect profile until further studies are conducted. Topical medications such as lidocaine creams or neuropathic analgesic compounded creams containing ketamine, amitriptyline, lidocaine and/or ketoprofen can be trialed for specific areas of hypersensitivity and allodynia (Lynch & Clark , 2005). When CPP is associated with endometriosis or dysmenorrhea, NSAIDs, and rarely opioids, can be used short term for acute pain due to active disease, e.g. breakthrough bleeding or menstruation.
Pelvic floor physical therapy is one of the most effective treatment modalities for CPP (Prather & Spitznagle, 2007). In a study of 9- to 20-year olds with unexplained CPP or pain associated with IBS, interstitial cystitis, or endometriosis not responding to usual therapy, 80% had improvement of pain with physical therapy (Schroeder & Sanfilippo, 2000). Pelvic floor relaxation therapy, trigger point release, and biofeedback can reduce pain and medication use, and improve quality of life in adolescents with CPP and pelvic floor myalgias (Li, 2006) (Anderson, 2015). Pelvic floor physical therapy and biofeedback can also improve pelvic floor tone, and develop awareness of pelvic floor muscles and the sensation of a full bladder or rectum, thereby decreasing dysfunctional voiding and constipation in children and adolescents (Van Engelenburg-Van Lonkhuyzen, 2017) (Mckenna, 1999). When indicated, neural blockade can help differentiate visceral pain from pain due musculoskeletal causes such as nerve entrapment. There is little data to support routine use of ganglion impar blocks except for treatment of coccydynia.
Complicating the treatment of CPP is the observation that many adolescents with endometriosis and persistent pain have symptoms of anxiety and/or depression. Pain catastrophizing was identified as an independent variable for higher pain scores in adults, and a treatment objective specific for CPP (Allaire, 2018). Cognitive behavioral therapy, including guided imagery and biofeedback, has been shown to be beneficial with increasing evidence for CPP (Till & As-Sanie, 2019) (Arnouk & De, 2017).
Complimentary treatments are generally safe to trial. Acupuncture has been shown to reduce pain from dysmenorrhea (Zhu, 2011), PFD (Arnouk et al., 2017), male CPP (Qin, 2016) and in combination with psychotherapy for endometriosis (Meissner, 2016). Other treatments proposed include yoga and therapeutic massage; however, more research is needed especially for children and adolescents (Arnouk & De, 2017) (Sung & Sung, 2017) (Taa & Buen, 2018).
Conclusion
Chronic pelvic pain in children and adolescents is often overlooked and frequently overshadowed by a preponderance of gastrointestinal symptoms. The most common cause of CPP in adolescents is dysmenorrhea associated with endometriosis. Pain physicians can be especially helpful with identifying co-occurring musculoskeletal disorders. We advocate for a multidisciplinary approach to the care of children and adolescents with CPP with multimodal pharmacologic and non-pharmacologic treatments including physical therapy, psychotherapy and complimentary therapies with early referral to appropriate specialists such as an adolescent gynecologist when warranted.
References
- ACOG Committee Opinion No. 760: Dysmenorrhea and Endometriosis in the Adolescent. (2018). Obstet Gynecol, 132(6):e249-e258.
- Ahangari, A. (2014). Prevalence of chronic pelvic pain among women: an updated review. Pain Physician, 17(02):E141–E147.
- Anderson, r. u. (2015). chronic pelvic pain syndrome: reduction of medication use after pelvic floor physical therapy with an internal myofascial trigger point wand. appl psychophysiol biofeedback, 40, 45-52.
- Arnouk, A., & De, E. (2017). Physical, Complementary, and Alternative Medicine in the Treatment of Pelvic Floor Disorders. Current Urology Reports, 18:47.
- Ballweg, m. l. ( 2004 ). Impact of endometriosis on women's health: comparative historical data show that the earlier the onset, the more severe the disease. Best Pract Res Clin Obstet Gynaecol, 18, 201-18.
- Clare , C., & Yeh , J. (2011). Vulvodynia in Adolescence: Childhood Vulvar Pain Syndromes. Journal of Pediatric and Adolescent Gynecology, Volume 24, Issue 3, Pages 110-115.
- Costantini, r. a. (2017). visceral pain as a triggering factor for fibromyalgia symptoms in comorbid patients. Pain, 158, 1925-1937.
Economy, k. &. (1999). Pelvic pain. Adolesc Med, 10, 291-304. - Hicks, C., & Rome, E. (2012). Chronic Pelvic Pain in the Adolescent. Endocr Dev, 22:230-50.
- Iacovides, S. e. (2015). What we know about primary dysmenorrhea today: a critical review. Hum Reprod Update.
- Kives, S., & Kirkham, Y. (2012). Ovarian cysts in adolescents: medical and surgical management. Adolesc Med State Art Rev, 23(01): 178–191, xii.
- Laufer , M., & Goitein , L. (1997). Prevalence of endometriosis in adolescent girls with chronic pelvic pain not responding to conventional therapy. J Pediatr Adolesc Gynecol, 10(4):199–202.
- Levesque, A., & Riant, T. (2018). Clinical Criteria of Central Sensitization in Chronic Pelvic and Perineal Pain (Convergences PP Criteria): Elaboration of a Clinical Evaluation Tool Based on Formal Expert Consensus. Pain Medicine, Volume 19, Issue 10: 2009–2015.
- LI, Y. Q. (2006). Chronic prostatitis during puberty. BJU Int, 98, 818-21.
- Liu, j. l. (2017). altered white matter microarchitecture in the cingulum bundle in women with primary dysmenorrhea: a tract-based analysis study. Hum Brain Mapp, 38, 4430-4443.
- Lynch , M., & Clark , A. (2005). Topical amitriptyline and ketamine in neuropathic pain syndromes: an open-label study. J Pain, 6(10):644-9.
- Marsh, e. e. (2005). endometriosis in premenarcheal girls who do not have an associated obstructive anomaly. Fertil Steril, 83, 758-60.
- Nnoaham, k. e. (2011). impact of endometriosis on quality of life and work productivity: a multicenter study across ten countries. Fertil Steril, 96, 366-373.
- Padamsee, S. &. (2015). Menstrual-Cycle and Menstruation Disorders in Episodic vs Chronic Migraine: An Exploratory Study. \. Pain Med, 16, 1426-32.
- Powell, J. (2014). The Approach to Chronic Pelvic Pain in the Adolescent. Obstetrics and Gynecology Clinics of North America V, Volume 41, Issue 3, 343-355 .
- Prather, H., & Spitznagle, T. (2007). Recognizing and Treating Pelvic Pain and Pelvic Floor Dysfunction. Physical Medicine and Rehabilitation Clinics of North America, Vol 18, Issue 3, 477-496.
- Sager, S., & Laufer, M. (2014). Chronic pelvic pain in chidlren and adolescents. Oxford Textbook of Paediatric Pain.
- Schroeder , B., & Sanfilippo , J. (2000). Musculoskeletal pelvic pain in a pediatric and adolescent gynecology practice. J Pediatr Adolesc Gynecol, 13(2):90.
- Smorgick, N., & As-Sanie, S. (2018). Pelvic Pain in Adolescents. Semin Reprod Med, 36:116–122.
- Sung, S.-H., & Sung, A. (2017). Acupuncture Treatment for Chronic Pelvic Pain in Women: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Evid Based Complement Alternat Med, Volume 2018.
- Suvitie, p. a. (2016). prevalence of pain symptoms suggestive of endometriosis among finnish adolescent girls (teenmaps study). J Pediatr Adolesc Gynecol, 29, 97-103.
- Taa , M., & Buen, M. (2018). Systematic review and meta-analysis of complementary treatments for women with symptomatic endometriosis. Int J Gynaecol Obstet, 43(1):2-9.
- Till, S., & As-Sanie, S. (2019). Psychology of Chronic Pelvic Pain: Prevalence, Neurobiological Vulnerabilities, and Treatment. Clinical Obstetrics and Gynecology, 2(1):22–36.
- Trent , M., & Bass , D. (2011). Recurrent PID, subsequent STI, and reproductive health outcomes: findings from the PID evaluation and clinical health (PEACH) study. Sex Transm Dis, 38(09):879–881.
- Tu, c. h. (2013). Menstrual pain is associated with rapid structural alterations in the brain. Pain, 154, 1718-24.
- Vincent, k. w. (2011). Dysmenorrhoea is associated with central changes in otherwise healthy women. Pain, 152, 1966-75.
- Wei, s. y. (2016). Changes in functional connectivity of pain modulatory systems in women with primary dysmenorrhea. Pain, 157, 92-102.
