Pelvic Pain and Sexual Health
What you must know
Chronic pelvic pain is a diagnosis of exclusion with overlapping causes: gynecologic (endometriosis, adenomyosis, pelvic inflammatory disease, adhesions), urologic (interstitial cystitis/bladder pain syndrome), gastrointestinal (irritable bowel syndrome), musculoskeletal (pelvic floor myofascial pain, levator spasm), and neuropathic (pudendal neuralgia). Understand the biopsychosocial model and central sensitization.
Know endometriosis: cyclic pain, dysmenorrhea, dyspareunia, infertility; diagnosis historically laparoscopic, though imaging and empiric therapy are used. Adenomyosis: heavy bleeding, enlarged boggy uterus. Understand vulvodynia (provoked vestibulodynia vs generalized) and its multimodal treatment (topical, pelvic floor PT, psychological support).
Sexual health: dyspareunia (superficial, deep, or introital), genitourinary syndrome of menopause (vaginal dryness, dyspareunia, recurrent UTI; treat with local estrogen, moisturizers, lubricants), and female sexual interest/arousal disorder. Screen for sexual dysfunction and partner violence.
Traps
Attributing pelvic pain to "psychological causes" without evaluating organic disease, or the reverse - ignoring central sensitization. Confusing provoked vestibulodynia with generalized vulvodynia. Missing pudendal neuralgia (pain in the distribution, worse sitting, relief standing).
Rule of thumb
"Map the pain: cyclic → gynecologic; bladder filling → urologic; bowel → GI; sitting/worse with sitting → pudendal or myofascial."
Worked example: A patient with pain worse with sitting, relieved by standing, and pain in the vulvar and perineal distribution. Consider pudendal neuralgia and pelvic floor myofascial pain; refer for pelvic floor physical therapy.