Chronic pelvic pain: gynaecological
and non-gynaecological causes
and considerations for nursing care
S¸ule G ¨okyıldız and Nezihe Kızılkaya Beji
ABSTRACT
Chronic pelvic pain (CPP) is one of the most difficult problems encountered by health professionals, and it is a very common gynaecological complaint in women of reproductive age. Any structure in the abdomen and/or pelvis could have a role in aetiology of CPP. The aetiology, however, is often unclear and the origin seems can be multifactorial. A multidisciplinary team can offer simultaneous assessment and management of somatic, behavioural and psychosocial components of the pain, and the nurse as an integral member of the healthcare team has an important role to play in ensuring effective care provision. The purpose of this review is to present comprehensive and contemporary information about the gynaecological and non-gynaecological causes of CPP alongside an examination of the role of the nurse in caring for women who experience this problem.
Key words: Chronic pelvic pain• Gynaecological causes • Non-gynaecological causes • Nursing approach
INTRODUCTION
A number of different definitions of chronic pelvic pain (CPP) can be found within the literature. The Royal College of Obstetricians and Gynaecologists (RCOG) define CPP as ’intermittent or constant pain in the lower abdomen or pelvis of at least 6 months duration, not occurring exclusively with menstruation or intercourse and not associated with pregnancy’ (Kennedy and Moore, 2005). Other definitions are narrower. For instance, CPP has been defined as non-cyclical pain of more than 6 months duration and is of sufficient severity to cause functional disability or medical care (Farquhar and Latthe, 2006). Mind-ful of the RCOG definition above, it has also been suggested that where no organic pathology can be demonstrated through gynaecological exam and labo-ratory test, then the complaint has been termed defined as CPP syndrome(Beard, 1998). CPP is acknowledged as a widespread condition affecting many women
Authors: S¸ G ¨okyıldız, PhD, Adana Health High School, Cukurova
University, Balcali Kampusu 01330, Saricam, Adana, Turkey; Prof. Dr N Kizilkaya Beji, Faculty of Nursing, Istanbul University, Abide-i Hurriyet cad. 34381, Sisli, Istanbul, Turkey
Address for correspondence: S¸ G ¨okyıldız, Adana Health High School,
Cukurova University, Balcali Kampusu 01330, Saricam, Adana, Turkey
E-mail: sgokyildiz@cu.edu.tr
worldwide. CPP can be a confusing and complicated problem and has been reported as confounding both health professionals and patients (Collett et al., 2000; McGowan et al., 2010).
Numerous studies conducted in primary health care centres have detected CPP prevalence in women. Among these studies, the most comprehensive one, collecting data through telephone interviews with 5263 women, was conducted by Mathias et al. (1996). In this study, the CPP prevalence was stated as being 14·7%. Availing of a much smaller sample, Jamieson and Steege (1996) conducted interviews with 581 women (aged between 18 and 45) in the waiting rooms of gynaecology and family practice departments and found that 39% of them had CPP Zondervan et al. (1999) aimed to identify the CPP prevalence and incidence in their study conducted with women who consulted to the primary health care units in Eng-land and found that when all the other diseases that can be seen among women aged between 15 and 73 were taken into consideration, with a percentage of 3·8, CPP was even more frequently encountered than migraine (2·1%) and asthma (3·7%). In their community-based study conducted in England, Zon-dervan et al. (2001) identified that the CPP prevalence in women (n= 2304) aged between 18 and 49 was
24% and 1/3 of these women started having pain more than 5 years ago.
CPP affects women’s daily activities and life quality as well as causing negative effects on mental, physical and sexual functions (Zondervan et al., 1999, Goky-ildiz, 2008). In their study with 1160 women, Grace and Zondervan (2006) found that CPP had negative effects on women’s general health status. Women with CPP were found to have more sleeping problems, more than half reported that pain affected their activi-ties (52·7%), and 12·2% stated that they were unable to do any activities without taking analgesics or relax-ing with 14·3% claimrelax-ing that they had to limit their movements such as walking or moving.
Patients with CPP often lack either a demonstrable organic injury or disease that may account for their pain or have organic pathologies with an uncertain relation to the pain. Therefore, instead of looking for a cause, a useful approach maybe to evaluate the pain itself as a diagnosis, consider several organic contrib-utors and approaching patients with CPP holistically systematically addressing their biopsychosocial needs (Howard, 1997).
The aetiology of CPP is often unclear and the ori-gin seems to be multifactorial(Peters and Van den Tillaart, 2007) with any structure in the abdomen and/or pelvis potentially having a role in the aetiology of CPP(Gunter, 2003; Kroon and Reginald, 2005). The reproductive, urinary, gastrointestinal, musculoskele-tal, peripheral and central nervous systems should be taken into consideration in the evaluation. CPP can be caused by many diseases related to these organ systems some examples being endometrio-sis, interstitial cystitis, irritable bowel syndrome (IBS) and pelvic floor dysfunction(Gunter, 2003; Kroon and Reginald, 2005).
The causes of CPP can broadly be analysed in two parts: gynaecological and non-gynaecological causes (Howard, 1997).
GYNAECOLOGICAL CAUSES Endometriosis
Endometriosis is the development of endometrial tis-sue in areas outside the uterus. The lesions usually occur in the lower abdomen, around the genitouri-nary system. However, they can be found in many other parts of the body such as lung and liver (Denny, 2004; Huntington and Gilmour, 2005; Selam, 2005). Although many theories have been developed to address the issue, the pathophysiology of endometrio-sis remains unknown. It has been proposed that retrograde menstruation, the immune system, and environmental (e.g. dioxin, nitrogen oxides, pesticides,
preservatives) and genetic factors can all have roles to play (Selam, 2005; Szendei et al., 2005; Bloski and Pierson, 2008).
The symptoms of endometriosis vary in their presentation and severity; however, the most common symptom is pelvic pain. The pain may be described as crampy, dull or sharp and usually begins 1 or 2 d before expected menstruation, may be unilateral or bilateral, and lasts until the end of menses (Bloski and Pierson, 2008; Schenken, 2008). The quality of life can be affected by the pain (Huntington and Gilmour, 2005; Oehmke et al., 2009). The study of Oehmke et al. (2009) demonstrates that pain is a major cause of physical, psychosocial, emotional and profes-sional or work-related impairment among women with endometriosis. Curiously, the severity of pain does not correlate well with severity of the condition and, there-fore, severe disease may go undiagnosed. Women with endometriosis may also experience a variety of other symptoms including dyspareunia, dysmenor-rhoea, dyschezia, dysuria, gastrointestinal complaints, rectal bleeding with significant bowel involvement, menstrual dysfunction such as oligomenorrhoea or hypermenorrhea, low back pain and infertility (Bloski and Pierson, 2008; Schenken, 2008).
Symptoms emerge as a result of the inflammations, scar and adhesions caused by the cyclic bleedings in the surrounding tissues. The lesions can be active or inactive, colourless or white, red, blue-black pigmented (Selam, 2005). Prevalence estimates of the disease are 2–18% in women undergoing tubal ligation, 5–50% in infertile patients, 50% in adolescents with intense dysmenorrhoeal or pelvic pain and 5–21% in patients hospitalized due to the complaint of pelvic pain (Missmer and Cramer, 2003).
Pelvic inflammatory disease
Pelvic inflammatory disease (PID) is the inflammation of the uterus, fallopian tubes and ovaries as it progresses to scar formation with adhesions to nearby tissues and organs. PID can emerge acutely and the problem can be solved with treatment; alternatively, the infection happens repeatedly and leads to the development of various complications including CPP. CPP is a prominent consequence of PID and repeated infections are very common (Cody and Ascher, 2000; Swanton and Reginald, 2004; Haggerty et al., 2005; Kroon and Reginald, 2005). Approximately, 20% of the women with laparoscopy-confirmed PID complain of CPP. However, the incidence of CPP rises to 67% in women with three or more episodes of PID (Swanton and Reginald, 2004; Kroon and Reginald, 2005). The exact reason of the development of CPP following
PID is not clear. However, the majority of women with CPP have morphological changes of fallopian tubes or ovaries, and CPP has a high correlation with the presence of adhesions. It is likely that pain is caused by chronic inflammation, often precipitated by recurrent infection (Ghaly and Chien, 2000; Swanton and Reginald, 2004; Kroon and Reginald, 2005).
The organisms most commonly implicated are the sexually transmitted clamydia trachomatis and niesse-ria gonorrhoeae, but other identified causes include gardnerella vaginalis, mycoplasma genitalium and anaerobic infection. A true diagnosis and a complete antibiotic-based treatment regimen can diminish poten-tial problems. Any delay in receiving treatment, along with recurrent episodes of infection, increases the risks of complications significantly (Swanton and Reginald, 2004; Kroon and Reginald, 2005).
Adhesions
Adhesions are abnormal fibrous structures found pre-dominantly in the abdominal cavity(Peters and Van den Tillaart, 2007). In a meta-analysis with over 5000 women, 36% of patients with CPP and 15% of patients in the control group were found to have adhesions (Cheong and Stones, 2006). In Hammoud et al.’s (2004) review on the relationship between adhesions and pelvic pain and the effects of adhesiolysis, the results of the laparoscopy performed due to CPP showed that 24% had adhesions, 33% had endometrio-sis and 35% did not have any pathology (Ham-moud et al., 2004)Risk factors for the development of pelvic adhesions include previous surgery, infections, endometriosis, inflammatory bowel diseases, PID, per-forated appendix and radiotherapy(Peters and Van den Tillaart, 2007). Although they do not cause any prob-lems in most cases, intra abdominal adhesions can cause CPP in some cases. As mentioned above, the relationship between adhesions and CPP is not fully understood or clearly proven (Peters and Van den Tillaart, 2007).
Pelvic relaxation
Relaxation of the pelvic floor with development of cystocele, rectocele, enterocele or uterine descensus may cause pelvic and perineal pain. However, the pain is usually not severe and is in the form of pressure (Howard, 1997).
Pelvic congestion syndrome
Pelvic congestion syndrome describes a collection of symptoms including a dull, aching pain, aggravated by
movement and sexual intercourse, which is associated with pelvic varicosities and congestion. It is common in multiparous women of reproductive age (Cody and Ascher, 2000; Swanton and Reginald, 2004). Common symptoms are vague and nonspecific obtuse pelvic pain, congestive dysmenorrhoea, backache, excessive vaginal discharge, pelvic pressure, deep dyspareunia, urinary symptoms and exacerbation of pain after prolonged standing and sexual intercourse. Lying down may help to reduce pain (Howard, 1997; Cody and Ascher, 2000; Cheong and Stones, 2006).
Adenomyosis
Adenomyosis is the presence of stroma and other tissues belonging to the endrometrium within the uter-ine myometrium. It usually reveals itself with the menometroragia, dysmenorrhoea, dyspareunia and pelvis pain findings. Other symptoms may include chronic pain and deep dyspareunia. On examination, the uterus is often bulky and bimanual palpation is tender (Howard, 1997; Swanton and Reginald, 2004; Kroon and Reginald, 2005).
NON-GYNAECOLOGICAL CAUSES Gastrointestinal causes
The cervix, uterus and adnexa share the same vis-ceral innervation with the lower ileum, sigmoid colon and rectum. Therefore, finding the source of the pain might require an advanced investigation through a detailed anamnesis. Advanced investigation is essen-tial if patients have pain changes associated with diet, nausea, vomiting, loss of weight, diarrhoea and consti-pation, mucus and/or blood in stool (Rapkin and Mayer, 1993). There are a number of conditions that may result in chronic lower abdominal pain including constipation, diverticular disease, inflammatory bowel disease and adhesions. However, IBS is the most common gas-trointestinally based reason for the pelvic pain (Swan-ton and Reginald, 2004; Kroon and Reginald, 2005).
Irritable bowel syndrome
IBS is common in young women. The symptoms are abdominal pain, bloating feeling, bowel dysfunction in the form of constipation, diarrhoea (or a combination of both), pain before bowel movement with the pain resolving following defecation. Other symptoms are abdominal distention, fatigue, headache and irritability. Dyspareunia, menorrhagia and intermenstrual bleed-ing has been found to be common in women with IBS. IBS symptoms often worsen during menstruation. Hence, symptoms should be evaluated carefully (Gel-baya and El-Halwagy, 2001; Swanton and Reginald,
2004; Kroon and Reginald, 2005; Longstreth et al., 2006). Criteria aimed at diagnosing IBS was devel-oped by Manning et al. in 1978. The criteria were modified by an international research team in 1992 and named ‘Rome I’ criteria. With another revision in 1998, it was changed as ‘Rome II’. The team finally revised the Rome II diagnostic criteria for the func-tional bowel disorders, and updated diagnosis and treatment recommendations and determined Rome III criteria. According to this criteria, at least 3 days per month in the last 3 months, the patient must experi-ence abdominal pain or discomfort with 2 or more of the following symptoms: Improvement with defecation, onset associated with a change in frequency of stool, onset associated with a change in form (appearance) of stool.
Urological causes
Due to the close relationship between the common embryological origin and the pelvic organs in the pain transmission, urological causes should be definitely considered as a differential diagnosis in the aetiology of the CPP.
Interstitial cystitis (IC)
IC is a urinary bladder disease of unknown cause characterized by urinary frequency, urgency, nocturia and suprapubic pain. Although the syndrome emerges differently in many patients, CPP and disruption of daily life activities are the routine findings of the disease. The aetiology of the condition still remains unclear despite the existence of a number of theories. Theories as to causation include: bladder wall defects, auto-immune disorder, viral and/or bacterial infection, toxin exposure, pelvic floor dysfunction and inflammatory response (Lukban et al., 2001; Newsome, 2003; Nordling, 2004; Swanton and Reginald, 2004; Atug and Canoruc, 2005; Clemens et al., 2005; Kroon and Reginald, 2005; Tincello and Walker, 2005).
Ninety per cent of patients with IC are female and the symptoms typically start between the ages of 30 and 50. Patients with IC frequently complaining about urinating patterns that are too frequent and too sudden. When the bladder is full, there is an increasing suprapubic pain and when it is empty, there is a fading pelvic discomfort feeling. Almost all the patients experienced nocturia. Feeling pain during sexual intercourse can also be counted among the other symptoms of the disease. In general and somewhat alrmingly, patients with interstitial cystitis experience these uncomfortable feelings for 3–7 years before having a true diagnosis (Swanton and Reginald, 2004; Atug and Canoruc, 2005; Kroon and Reginald, 2005).
The first systematic effort to define IC arose from a workshop sponsored by the National Institute of Arthritis, Diabetes, Digestive and Kidney Diseases (NIDDK) in 1987. The criteria promulgated by the NIDDK are useful for research purposes, but it could be argued that they are restrictive when applied in the clinical setting. Therefore, modified criteria for diag-nosing IC has been advocated by many clinicians. For diagnosing interstitial cystitis the patient must expe-rience pain associated with bladder filling or urinary urgency (endoscopic evidence of Hunner’s ulcerations or glomerulations may or may not be present). If one of the following exists interstitial cystitis is ruled out: Blad-der capacity >350 mL on urodynamic testing (filling cystometrogram), absence of intense urge to void with 150 mL of water during filling cystometrogram using fill rate of 30 to 100 mL/min, detrusor instability on filling cystometrogram, diurnal urinary frequency less then 8 episodes per day, active genital herpes, cyclophos-phamide or any type of chemical cystitis, bacterial or tubercular cystitis, radiation cystitis, benign or malig-nant bladder tumors. These less stringent criteria avoid the extensive diagnostic evaluation demanded by NIDDK standards, and they include many patients who have the symptoms characteristics of IC and who clearly benefit from similar treatments (Gray, et al., 2002).
Musculoskeletal causes Mechanical pelvic pain
Pregnancy or trauma may lead to skeletal mal-alignment, such as separation of the symphisis pubis or sacroiliac dysfunction. Pain may arise from the joints themselves perceived either locally or in a referred site (e.g. pain arising in the sacroiliac joints may be felt high in the ipsilateral iliac fossa) – or from asso-ciated muscle spasm. Usually, the patient is aware that her symptoms began following a particular event, but sometimes the original event occurred many years previously, and it comes to light only when an addi-tional factor arises – such as reduced exercise or the need to carry around a new baby. Poor posture or factors such as leg length discrepancy, may lead to persistent strain on joint capsules, ligaments or muscles (Moore and Kennedy, 2000). Pain arising from the musculoskeletal system varies characteristi-cally with movement and posture, and may get worse towards the end of the day. Confusingly, pain may vary with the menstrual cycle, perhaps partly because of the effect of hormones on joint laxity. Dyspareunia may occur in some positions, especially when couples use the male superior position for intercourse. (Moore and Kennedy, 2000; Steege and Zolnoun, 2009). Pain
can usually be elicited by manoeuvres that stress the affected joints or ligaments, such as straight leg rais-ing, standing on one leg or touching toes (Moore and Kennedy, 2000).
Muscle pain
Pelvic pain can arise from muscles of the pelvic floor as well as muscles of the abdominal wall, back, hips and upper thighs. There is increasing recognition that spasms of these muscles can be primary or secondary causes of pelvic pain (Won and Abbott, 2010). There may be imbalance between muscle groups, perhaps secondary to poor posture, allowing over stretching of one group and chronic contraction of the opposing group. The existence of myofascial trigger points (a hyper-irritable spot, within a taut band of muscle or fascia) is a subject of some controversy, but increasing emphasis is being placed on their role in the genesis of chronic pain syndromes (Moore and Kennedy, 2000). Slocumb (1990) suggests that up to 71% of patients with unexplained CPP may have myofascial trigger points in the abdominal wall (Slocumb, 1990). Pelvic pain posture
Some patients with CPP have an abnormal posture. This may be a secondary adaptation, trying to ease pain arising from another source, or it may be a primary event, born of a sedentary lifestyle. Whatever the origin is, it may lead to chronic muscle tension and strain on joints and ligaments, which then becomes a source of pain itself. In a review of 132 patients with CPP referred to a physical therapist, 75% were found to have this abnormal posture. Seventy per cent of them reported significant or complete relief of symptoms with treatment (Moore and Kennedy, 2000).
Pyschosocial factors
Studies detected a relationship between CPP and sexual/physical abuse (Walling et al., 1994a; Fry
et al., 1997; Collett et al., 1998; Lampe et al., 2003;
Leserman, 2005; Haugstad et al., 2006; Randolph and Reddy, 2006). In Walling et al.’s (1994b) study aiming to compare the frequencies of sexual and physical abuse in the childhood of the women with CPP, when compared with women without CPP (chronic headache) and those with no pain, it was found that the women with CPP had higher sexual abuse compared to the women in other groups. In Collet et al.’s (1998) study comparing women with and without the complaint of CPP, it was found that the frequency of sexual abuse was higher in the group consisting of the women with CPP. In the study conducted by Meltzer-Brody et al. (2007), it was reported that approximately 50% of the
women had a history of sexual or physical abuse and almost 1/3 of them had post-traumatic stress disorder.
Psychological problems have also been found to be related to the chronic nature of pain. It has been reported that more than 60% of women with CPP were found to have psychological problems and the most commonly encountered problem was depression (25–50%) (Reiter, 1998; Slade and Cordle, 2005).
From the literature, it would seem clear that the identification of depression, anxiety, sexual and physi-cal abuse and personality disorders is important in the management of CPP. Women with CPP have more tendency to develop depression, anxiety, substance dependence, somatization and sexual function dis-orders. Hence, their relationships with their spouses can come under great strain, potentially increasing their risk of relationship breakdown and divorce and decreasing their social support structures (Savidge and Slade, 1997). In a meta-analysis of 22 different research-based papers where women with and with-out CPP were compared, it was found that the levels of depression, anxiety, neurotism and psychopathol-ogy were higher in women with CPP. The results also showed similarity with the women who had a different chronic pain syndrome (McGowan et al., 1998). In a study carried out by Kaya et al. (2006), 19 women with CPP and 25 healthy women were compared. A relationship was detected between depression, anxiety and sexual functional disorder. The findings showed that women with CPP had higher depression and anx-iety levels, less satisfaction and more avoidance of sexual life.
NURSING CONSIDERATIONS IN CARING FOR PEOPLE WITH CHRONIC PELVIC PAIN With its physical, social, psychological and economic effects, CPP is a common problem among women. A multidisciplinary team can offer simultaneous assess-ment and manageassess-ment of somatic, behavioural and psychosocial components of the pain. Princi-pal team members have been suggested as being a gynaecologist, a nurse, psychologist, anaesthetist with expertise in pain management, physiotherapist, gastroenterologist, urologist, orthopaedist and a psy-chiatrist (Collett et al., 2000). The goals of the CPP team are directed towards improving quality of life. As such they include confirming any diagnosable disease, addressing pain, identifying any physical or psychoso-cial problem and outlining a care plan to address the problems, providing explanation for any symptoms and problems experienced, reducing anxiety and support-ing patients when the diagnosis is difficult to pinpoint
or the treatment fails. The purpose might be relieving pain when possible, but reducing physical and psycho-logical dysfunction is equally important in improving quality of life. Nurses are in a prime position to support and drive this type of initiative (Collett, et al., 2000; Aslan and Badir, 2005). In all these areas nurses have a pivotal role to play both in the coordination of the teams activities and through direct patient care.
Nurses additionally have a crucial role in pain management in that they spend more time with patients when compared to the other team members, they have information about the patients’ previous experience of pain and pain management. In addition, nurses can play an important role through the provision of planned health education programme intervention as well as teaching pain management methods. Nurses also can act as empathetic patient guides during the implementation of treatment and in assisting patients to evaluate treatment results (Aslan and Badir, 2005).
Price et al. (2006) conducted a study with a view to identifying ways of finding out the views of patients with pelvic pain attending a gynaecology clinic. Using a semi-structured questionnaire, they interviewed 22 women with CPP. Findings suggested a number of principal themes reflecting the desires and experiences of women: non-individualized care, an understanding of their pain and being taken seriously; being informed about the available treatment options, and being comforted about their worries.
Painful sexual activity is a common complaint in women with CPP and forms a key aspect of experience that can be assessed by nurses. Patients can be edu-cated about a host of issues that can increase their abil-ity to have a fulfilling sex life. Education can take place on issues such as the adopting of more comfortable sexual positions, the use of lubricant, and in assisting the woman to identify the location, duration and inten-sity of location pain that may occur before, during or after sexual activity (Denny, 2004; Pearce and Curtis, 2007). In addition, the nurse can also address a topic that is too often overlooked or ignored when discussing sexual experience – orgasm. The nurse is perfectly placed to discuss the issue of orgasm with the woman and to assist her to holistically explore issues that may inhibit achieving orgasm as a result of sexual activity.
In their study investigating the frequency of depression and anxiety in women with CPP and its effects on their life quality, Romao et al. (2009) worked with 52 women with CPP and 54 women without pain. The results of the study revealed that the prevalence of anxiety was 73 and 37% in the CPP and control groups, respectively, and the prevalence of depression was 40 and 30%, respectively. Significant differences between groups were observed in the physical, psychological
and social domains. Patients with higher anxiety and depression scores display lower quality of life scores.
Educational guidance programmes about diet, pain reduction, emotional stress reduction and sexual issues should be organized for patients. Preparing edu-cational brochures can also be useful as they provide another method of communicating important health issues to women. The importance of properly prepared educational input is highlighted when one considers the issue of defecation and CPP. Women should grasp the importance of regular defecation in the management of CPP. Tenderness in the pelvic muscles, the inability to take sufficient dietary fibrous nutrients and liquids and the lack of physical activity may cause constipation, and as discussed above this may well lead to increased pelvic pain. Consuming a fibre rich diet, taking suffi-cient liquids and avoiding foods that can irritate the bladder (such as tea, coffee, chocolate, vinegar, may-onnaise, alcohol, apple, apricot, aged cheese, onion, banana, soybeans, grapes, tomato, spicy foods, aspar-tame, saccharin) are all important. In order to adapt to the diet, patients may add irritants first, and then they may add them one by one to determine the effect of the bladder pain and sub urinary system symptoms (Gray et al., 2002; Moldwin and Sant, 2002; Newsome, 2003; Rosamilia and Dwyer, 2003; Pearce and Curtis, 2007). The International Cystitis Association recom-mends limiting food that are known to cause symptoms in the interstitial patients (Gray et al., 2002).
Nurses carry out the role of a coordinator and can ensure that accurate and consistent communication and cooperation between the patient, their families, and the health care team is evident. Many patients with pelvic pain complain of a long-term pain and no full recovery. Self-help or national and local support groups may be a source of help for the patients. Nurses provide the connection between these groups and the health care professionals (Collett et al., 2000). All these nursing activities can play a central role in ensuring that the negative themes identified by women in Price et al.’s study (2006) such as non-individualized care, failure to understand their care, not being taken seriously and needing to be comforted are addressed head on and eliminated.
CONCLUSION
CPP is a common problem affecting the life quality of many women substantially. Due to its complicated and multifactorial aetiology, CPP requires a multidisci-plinary team approach and it is essential that nurses take their place in this team acting as practitioner, educator, coordinator, counsellor and researcher.
WHAT IS KNOWN ABOUT THIS TOPIC
• CPP can be a perplexing and complex problem, frustrating for both clinicians and patients. CPP is a common problem causing physical, social, psychological and economical effects. Every structure in the abdomen and/or pelvis could have a role in aetiology of CPP. Reproductive system, urinary system, gastrointestinal system, musculoskeletal system, peripheral and central nervous system should be taken into consideration in the evaluation. A multidisciplinary team can offer simultaneous assessment and management of somatic, behavioural and psychosocial components of the pain, and nurses have important roles.
WHAT THIS PAPER ADDS
• An overview of the disparate but extensive literature related to gynaecological and non-gynaecological causes and nursing approach of CPP.
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