Differential diagnosis of chronic pelvic pain in women: the urologist's approach

Chronic pelvic pain in women is a challenging clinical entity that is frequently encountered by urologists. The diagnostic process can be laborious, and often requires multidisciplinary collaboration. In this Review, the authors discuss the key issues in the diagnosis of this disorder, highlighting the importance of a thorough patient history to direct subsequent investigations. Chronic pelvic pain in women can be caused by a host of gynecological, gastrointestinal, musculoskeletal, neurologic, as well as urologic disorders. An initial broad differential diagnosis is essential. At times, overlapping symptoms and vague physical findings necessitate a multidisciplinary diagnostic approach. A thorough history, which is careful to characterize all aspects of the patient's symptoms, can usually direct the differential toward the bladder when this organ is the source of the pain. Interstitial cystitis/painful bladder syndrome (IC/PBS) should be included in the differential diagnosis, but it should not be used as an expeditious diagnosis when pain coexists with frequency and urgency. Multiple other urologic conditions such as overactive bladder, urinary tract infection, urethral diverticulum, periurethral masses (Skene gland cyst or abscess), and even urethral stricture disease, have overlapping symptom complexes with IC/PBS, and they must not be overlooked as they are much more easily diagnosed and treated. By using a stepwise approach and an evidence-based thought process, the obscurity of chronic bladder and urethral pain can evolve into a progressively narrowing differential. Key Points Chronic pelvic pain (CPP) is a challenging clinical entity that is an important issue in the health care of women The differential diagnosis for CPP of urologic etiology includes urinary tract infection, urethral diverticulum, periurethral masses, urethral stricture disease, pelvic floor dysfunction, interstitial cystitis and painful bladder syndrome Voiding symptoms of urgency, frequency and nocturia are commonly reported in patients who are complaining of bladder or urethral pain No one particular diagnostic technique can be used to evaluate CPP; of paramount importance is the patient's history, which can substantially narrow the differential diagnosis and initiate appropriate referral Using a stepwise approach and an evidence-based thought process can help guide the history, physical examination, and ancillary testing in the best interests of the patient