Skip to main content

Main menu

  • Home
  • Content
    • Current Issue
    • Ahead of Print
    • Past Issues
    • Supplements
    • Article Type
  • Specialty
    • Articles by Specialty
  • CME/MOC
    • Articles
    • Calendar
  • Info For
    • Manuscript Submission
    • Authors & Reviewers
    • Subscriptions
    • About CCJM
    • Contact Us
    • Media Kit
  • Conversations with Leaders
  • Conference Coverage
    • Kidney Week 2024
    • CHEST 2024
    • ACR Convergence 2023
    • Kidney Week 2023
    • ObesityWeek 2023
    • IDWeek 2023
    • CHEST 2023
    • MDS 2023
    • IAS 2023
    • ACP 2023
    • AAN 2023
    • ACC / WCC 2023
    • AAAAI Meeting 2023
    • ACR Convergence 2022
    • Kidney Week 2022
    • AIDS 2022
  • Other Publications
    • www.clevelandclinic.org

User menu

  • Register
  • Log in

Search

  • Advanced search
Cleveland Clinic Journal of Medicine
  • Other Publications
    • www.clevelandclinic.org
  • Register
  • Log in
Cleveland Clinic Journal of Medicine

Advanced Search

  • Home
  • Content
    • Current Issue
    • Ahead of Print
    • Past Issues
    • Supplements
    • Article Type
  • Specialty
    • Articles by Specialty
  • CME/MOC
    • Articles
    • Calendar
  • Info For
    • Manuscript Submission
    • Authors & Reviewers
    • Subscriptions
    • About CCJM
    • Contact Us
    • Media Kit
  • Conversations with Leaders
  • Conference Coverage
    • Kidney Week 2024
    • CHEST 2024
    • ACR Convergence 2023
    • Kidney Week 2023
    • ObesityWeek 2023
    • IDWeek 2023
    • CHEST 2023
    • MDS 2023
    • IAS 2023
    • ACP 2023
    • AAN 2023
    • ACC / WCC 2023
    • AAAAI Meeting 2023
    • ACR Convergence 2022
    • Kidney Week 2022
    • AIDS 2022
Review

Primary care management of chronic pelvic pain in women

Rachel Bonnema, MD, MS, MEGAN Mcnamara, MD, MSc, Jennifer Harsh, PhD, LMFT and Elizabeth Hopkins, PT, DPT
Cleveland Clinic Journal of Medicine March 2018, 85 (3) 215-223; DOI: https://doi.org/10.3949/ccjm.85a.16038
Rachel Bonnema
Associate Professor of Medicine, Division of General Internal Medicine, University of Nebraska Medical Center, Omaha
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • For correspondence: [email protected]
MEGAN Mcnamara
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Jennifer Harsh
Assistant Professor, Division of General Internal Medicine, University of Nebraska Medical Center, Omaha
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Elizabeth Hopkins
The Nebraska Medical Center, Omaha
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Figures & Data
  • Info & Metrics
  • PDF
Loading

Article Figures & Data

Figures

  • Tables
  • Figure 1
    • Download figure
    • Open in new tab
    • Download powerpoint
    Figure 1

    Pelvic floor anatomy. During the pelvic examination, the levator ani muscles should be directly palpated for tone and tenderness, and the pelvic floor should be evaluated with attention to any tenderness of the bladder and musculoskeletal structures.

Tables

  • Figures
    • View popup
    TABLE 1

    Common causes of chronic pelvic pain and associated findings

    Differential diagnosisAssociated historical featurePhysical examination
    Musculoskeletal
    Pelvic floor dysfunctionComplicated delivery, dyspareuniaVaginismus, point tenderness, or high tone of pelvic floor
    Myofascial pain or fibromyalgiaTender points, chronic somatic painTender points
    Stress fracturesPain with repetitive movements, improved with rest
    Degenerative disk diseaseBurning, paresthesiasRadicular signs, muscle weakness
    Gastrointestinal
    Constipation
    Inflammatory bowel diseaseBowel urgency, hematochezia
    Irritable bowel syndromeBowel symptoms; may increase premenstrually
    Gynecologic (often cyclic with menses)
    AdhesionsSurgical historyImmobile uterus, nodularity
    AdenomyosisMenorrhagia, dysmenorrheaEnlarged, irregular tender uterus on bimanual examination
    Adnexal massLocalized to 1 areaLocalized adnexal mass
    Chronic pelvic inflammatory disease
    DysmenorrheaUterine cramping with menses
    Endometrial or cervical polypIntermenstrual or postcoital bleedingVisual inspection
    EndometritisUterine tenderness on bimanual examination
    EndometriosisDiffuse pelvic pain with menses, deep dyspareuniaFixed or immobile uterus, nodularity
    LeiomyomataMenorrhagia, pressure or heavinessUterine nodularity, enlargement
    Pelvic congestion syndromeMultigravid patient; deep dyspareunia, post-coital pain, worse after prolonged standingVaricosity of labia, uterine tenderness on bimanual examination
    Vulvar vestibulitisVulvodynia, dyspareuniaExquisite localized tenderness
    Urologic
    Interstitial cystitisUrgency, increased frequency of urination
    Urinary tract infectionDysuria
    UrolithiasisLocalized sharp pain
    Radiation cystitisHistory of radiation
    Other
    Psychiatric (depression, somatization)Concurrent mood disorder
    Neurologic (herpes zoster, nerve entrapment)Hot, burning, electric shock-like pain; shingles
    • View popup
    TABLE 2

    Treatment options for chronic pelvic pain in primary care

    Type of therapyExamples or descriptionComments
    Medications
    Simple analgesicsAcetaminophen, nonsteroidal anti- inflammatory drugs (NSAIDs)Avoid prolonged use of NSAIDs due to potential toxicities
    NeuropathicsAmitriptyline, gabapentinGabapentin may be more efficacious than amitriptyline
    Hormonal therapiesOral contraceptives, gonadotropin- releasing hormone (GnRH) analogues, progestogens, danazolGnRH analogues are more effective for pain relief than oral contraceptive pills
    AntispasmodicsDicyclomineMay worsen constipation
    NeuromodulatorsBotulinum toxin AVery effective for pelvic floor spasm
    OtherPentosan polysulfate sodiumFirst-line therapy for interstitial cystitis
    Pelvic physical therapy
    Strengthening (up-training)Contracting the pelvic floor in isolationImproves symptoms of pelvic heaviness and discomfort
    Relaxation (down-training)Stretching, meditation, internal and external manual release of involved muscle groupsImproves symptoms of chronic pelvic pain due to overactive pelvic muscles
    BiofeedbackSurface electromyography in conjunction with strengthening and relaxationAllows visual feedback on muscle control; useful for strengthening or relaxation and treatment of reflexive pelvic floor spasm
    Vaginal dilatorsTool for stretching, pain-free vaginal insertionRestores flexibility and coordination of pelvic floor
    Psychosocial interventions
    Collaborative goal-settingIdentify what has improved patients’ current symptoms to develop goalsVery individualized and specific
    Short-term goals
    Assess progress during each visit and modify goals as needed
    Progressive muscle relaxationSystematic tensing and relaxing of each large muscle group progressing from toes to headEstablish a practice goal (number of practices per week)
    Allows for partner participation
    Can be done with other relaxation techniques (eg, visualization, deep breathing)
    • View popup
    TABLE 3

    Collaborative goal-setting

    IndividualCouple
    My goal is:Our goal is:
    I will:We will:
    When:When:
    I will do this first:We will do this first:
    Challenges that may arise:Challenges that may arise:
    I will handle them by:We will handle them by:
    I will reward myself when:We will reward ourselves when:
    My reward will be:Our reward will be:
PreviousNext
Back to top

In this issue

Cleveland Clinic Journal of Medicine: 85 (3)
Cleveland Clinic Journal of Medicine
Vol. 85, Issue 3
1 Mar 2018
  • Table of Contents
  • Table of Contents (PDF)
  • Index by author
Print
Download PDF
Article Alerts
Sign In to Email Alerts with your Email Address
Email Article

Thank you for your interest in spreading the word on Cleveland Clinic Journal of Medicine.

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Primary care management of chronic pelvic pain in women
(Your Name) has sent you a message from Cleveland Clinic Journal of Medicine
(Your Name) thought you would like to see the Cleveland Clinic Journal of Medicine web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Citation Tools
Primary care management of chronic pelvic pain in women
Rachel Bonnema, MEGAN Mcnamara, Jennifer Harsh, Elizabeth Hopkins
Cleveland Clinic Journal of Medicine Mar 2018, 85 (3) 215-223; DOI: 10.3949/ccjm.85a.16038

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
Share
Primary care management of chronic pelvic pain in women
Rachel Bonnema, MEGAN Mcnamara, Jennifer Harsh, Elizabeth Hopkins
Cleveland Clinic Journal of Medicine Mar 2018, 85 (3) 215-223; DOI: 10.3949/ccjm.85a.16038
Twitter logo Facebook logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Linkedin Share Button

Jump to section

  • Article
    • ABSTRACT
    • COMPREHENSIVE MANAGEMENT LED BY PRIMARY CARE
    • TARGETED EVALUATION
    • GENERAL TREATMENT
    • DISEASE-SPECIFIC TREATMENT
    • PELVIC PHYSICAL THERAPY
    • PSYCHOSOCIAL INTERVENTIONS
    • REFERENCES
  • Figures & Data
  • Info & Metrics
  • PDF

Related Articles

  • No related articles found.
  • PubMed
  • Google Scholar

Cited By...

  • No citing articles found.
  • Google Scholar

More in this TOC Section

  • Alpha-gal syndrome: Recognizing and managing a tick-bite–related meat allergy
  • Managing right ventricular failure in the setting of pulmonary embolism
  • Psychedelics, spirituality, and existential distress in patients at the end of life
Show more Review

Similar Articles

Subjects

  • Gastroenterology
  • Mental Health
  • Pain
  • Women's Health

Navigate

  • Current Issue
  • Past Issues
  • Supplements
  • Article Type
  • Specialty
  • CME/MOC Articles
  • CME/MOC Calendar
  • Media Kit

Authors & Reviewers

  • Manuscript Submission
  • Authors & Reviewers
  • Subscriptions
  • About CCJM
  • Contact Us
  • Cleveland Clinic Center for Continuing Education
  • Consult QD

Share your suggestions!

Copyright © 2025 The Cleveland Clinic Foundation. All rights reserved. The information provided is for educational purposes only. Use of this website is subject to the website terms of use and privacy policy. 

Powered by HighWire