Medical and surgical management of chronic pelvic pain

Chronic pelvic pain (CPP) is a common debilitating condition affecting 4–25% of women in the reproductive age group. Endometriosis is the commonest cause. Other gynaecological and non-gynaecological causes include adenomyosis, pelvic inflammatory disease, uterine fibroids, irritable bowel syndrome and interstitial cystitis. Other causes can be musculoskeletal, neurological or psychological. Investigations are of limited value in the diagnosis of CPP. Laparoscopy remains the gold standard in diagnosis. This article explores the various medical and surgical management options of CPP based on recent evidence available. A multidisciplinary approach should be undertaken in women with more severe problems. First line medical management options include nonsteroidal anti-inflammatory drugs, oral contraceptive pills and progestogens. Other medications like androgenic agents and gonadotropin-releasing hormone (GnRH) analogues have been used with various side effect profiles. For those patients who need to be treated surgically, a maximum effort must be made to resect all endometriosis, restore normal pelvic anatomy, resect nerve fibres and treat surgically accessible disease.