When evaluating a patient with chronic pelvic pain, the history and physical examination can narrow the differential diagnosis and guide further laboratory and ancillary testing.4 As many as 40 percent of women who present to primary care practices with chronic pelvic pain have more than one diagnosis. Therefore, it is important to investigate all contributing factors related to the pain including psychological, social, and environmental.1,5-7 Women with chronic pelvic pain usually want the following: to receive personalized care from their physicians; to be taken seriously; to receive an explanation for their condition (more so than a cure); and to be reassured.8 Therefore, the physician should schedule several visits to complete the evaluation and provide appropriate counseling. It contains a summary of selected findings on the history, physical examination, and diagnostic tests and their potential significance for the patient. The International Pelvic Pain Society has many helpful resources including history and physical examination forms and patient education materials.

A pelvic pain intake questionnaire facilitates obtaining details of the history. A useful form is available from The International Pelvic Pain Society9 and may be downloaded free of charge. Only a few of the areas of the history that may not be as familiar to most gynecologists are covered in this review, but this is not meant to minimize the importance of the detailed history that is needed in clinical practice to formulate a thorough differential diagnosis.

The physical examination can identify areas of tenderness and the presence of masses or other anatomical findings that aid in the diagnosis. However, a lack of findings during the physical examination does not rule out intra-abdominal pathology because many patients with a normal examination will have pathologic findings on subsequent laparoscopy.1 The physical examination should proceed slowly and gently because both the abdominal and pelvic components of the examination may be painful. Palpation of the outer pelvis and back may reveal trigger points that indicate a myofascial component to the pain. The pelvic examination should begin with a single-digit, one-handed examination. A moistened cotton swab should be used to elicit point tenderness in the vulva and vagina. The patient should be checked for any nodules, masses, or point tenderness along the bladder or other musculoskeletal structures. Once the single-digit, one-handed examination is completed, a bimanual examination should be performed to check again for nodularity, point tenderness, cervical motion tenderness, or lack of mobility of the uterus.17 A rectal examination may show rectal or posterior uterine masses, nodularity, or pelvic floor point tenderness. Testing for Carnett's sign should be performed by placing a finger on the painful, tender area of the patient's abdomen and having the patient raise both legs off the table while lying in the supine position. A positive test occurs when the pain increases during this maneuver and is associated with a myofascial cause of the pain. This may also indicate that the cause of the pain is within the abdominal wall (e.g., fibromyalgia or trigger point). Visceral pain should not worsen during the maneuver.18

Routinely having every woman with chronic pelvic pain have a barium enema and upper gastrointestinal series to "rule out" gastrointestinal disease, an intravenous pyelogram to rule out urinary tract disease, a pelvic ultrasound to rule out infection, and so on is neither efficient nor effective. It seems more appropriate to perform diagnostic tests that are indicated by the history and physical examination, and when the results will change the diagnoses, the further evaluation, or the treatment. A full discussion of these tests is beyond the scope of this article.

Laparoscopy is an important diagnostic study in the evaluation of pelvic pain-over 40% of gynecologic diagnostic laparoscopies are done for chronic pelvic pain. Endometriosis and adhesions account for at least 85% of all laparoscopic diagnoses. It is important to remember that a negative laparoscopy is not synonymous with no diagnosis or no disease and does not mean that a woman has no physical basis for her pain. More discriminative use of laparoscopy, carefully based on the patient's history, physical examination, laboratory, and imaging findings, might decrease the rate of negative laparoscopies from 39% to 4%.19

A new approach to diagnostic laparoscopy, "conscious laparoscopic pain mapping," has been suggested as a way to improve the diagnostic capability of laparoscopy. Conscious laparoscopic pain mapping is a diagnostic laparoscopy under local anesthesia, with or without consicous sedation, directed at the identification of sources of pain.20,21

The technique used with conscious laparoscopic pain mapping is a gentle probing or tractioning of tissues, lesions, and organs with a blunt probe or forceps passed through a secondary trocar site. Diagnosis of an etiological lesion or organ is based on the severity of pain elicited and on replication of the pain that is the patient's presentin gsymptom. Chroinc pelvic pain, however, is a multifaceted and complicated problem, and it is premature to assume that the findings with mechanically elicited tenderness at conscious pain mapping directly translate into cause and cure. For example, data from our center evaluating laparoscopic diagnosis and treatment, comparing a historical cohort of 65 patients treated before the introduction of conscious pain mapping with 50 patients treated after introduction of conscious laparoscopic pain mapping, failed to show any improvement in outcome. A significant difference between the populations in these two groups is that only half of the patients in the traditional laparoscopy group had undergone prior evaluations and treatments for chronic pelvic pain, whereas all of the patients in the consious laparoscopic pain mapping group had. Other published series of conscious laparoscopic pain mapping procedures do not clearly report data on outcomes 6-12 months afterwards. Whether conscious laparoscopic pain mapping improves outcomes in women with chronic pelvic pain, either by decreasing unnecessary surgical interventions or improving pain relief via more specific medical and surgical treatments, needs more study and probably will require a prospective, randomized trial.

Chronic pelvic pain is a serious problem. Women who suffer from chronic pelvic pain are a heterogeneous group, and the possible diagnoses and contributing factors are varied and numerous. Diagnosis can be complex, and the goals of treatment must be realistic. Sometimes these consist only of treatment of one or more specific diseases, such as endometriosis and irritable bowel syndrome, but often must include treatment of pain itself as a diagnosis. Although chronic pain may be difficult for the clinician and her patient to accept as a diagnosis, it is an important concept in the care of chronic pelvic pain. Laboratory and imaging studies should be selectively utilized, as should laparoscopy. Conscious laparoscopic pain mapping has been proposed as a way to improve information derived from laparoscopic evaluations. Finally, it offers hope that with future research the psychoneurological dysfunctions responsible for chronic pelvic pain may be identified, leading to definitive, curative approach.