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As with many pain conditions, chronic pelvic pain (CPP) can be difficult to diagnose. For one thing there is no screening test. For another, because symptoms may be variable, it can be difficult for a woman to define and localize her pain. Finally, there are all those possible causes and associated conditions to investigate.

Conditions that can cause pelvic pain may be divided into seven categories:

Gynecologic conditions

• Endometriosis is a condition in which tissue that makes up the lining of the uterus (endometrium), exits the uterus and attaches to the ovaries, fallopian tubes, bowels or other organs in the abdomen. Because endometrial tissue responds to hormonal changes during a woman's menstrual cycle, the abnormally located tissue swells and bleeds, sometimes causing pain.

  Endometriosis pain is not always restricted to the menstrual cycle. Many women with endometriosis have pain at other times of the month. Endometriosis can also scar and bind organs together, cause tubal (ectopic) pregnancies and lead to infertility, although these outcomes are unusual.

• Fibroids are benign (non-cancerous) tumors or clumps of abnormal tissue that can grow inside, in the wall of or outside the uterus. Many women don't know they have fibroids since often they have no symptoms. However, depending on their location and size, fibroids may cause pelvic pain, backaches, heavy menstrual bleeding, pain during intercourse and such urinary problems as incontinence, frequent urination and repeated urinary tract infections (UTIs). They can interfere with fertility or pregnancy if they distort the shape of the inside of the uterus, but this is unusual. Pain with fibroids is uncommon; heavy bleeding is more common.

• Adenomyosis, like endometriosis, involves the abnormal growth of cells from the uterine lining. In this case the cells grow into the wall of the uterus, pressing against the muscle fibers there. The result is painful cramps and heavy menstrual bleeding.

• Adhesions are fibrous bands of scar tissue that form after surgery or a condition that causes inflammation. When these bands tie organs and tissues together inappropriately, even normal movements and sex may stretch the scar tissue and cause pain. When adhesions block the fallopian tubes or ovaries, infertility can result. If they wrap around the bowel, they can result in bowel obstruction.

• Pelvic inflammatory disease (PID) includes any infection or inflammation of the fallopian tubes, uterine lining and ovaries. It often begins as a sexually transmitted infection. Many women with PID have no symptoms or only mild symptoms (abnormal vaginal bleeding or discharge, or pain with intercourse) and may not seek treatment. However, left untreated, PID may cause scar tissue to form that can lead to chronic pelvic pain, abscesses, tubal pregnancies and infertility.

Urinary Tract Disorders

• Interstitial cystitis (IC) is an inflammatory condition in which the bladder wall becomes irritated, scarred and stiff. The lining of the bladder that protects the wall from irritation seems to break down. The resulting discomfort can range from tenderness to intense pain in the bladder and surrounding area. Symptoms include more urgent and frequent need to urinate. Ninety percent of those with IC are women, whose symptoms may get worse during menstruation. Pain may also intensify during intercourse.

• Chronic urethritis is inflammation and irritation of the urethra (the tube through which urine is eliminated from the bladder) caused by either an infection or a narrowing of the tube.

Intestinal disorders

• Irritable bowel syndrome (IBS) is characterized by abdominal discomfort or painful cramping, bloating and gas and constipation or diarrhea (or bouts of both). Stress and depression can increase the symptoms, as can particular foods and beverages. Women are three times more likely to have IBS than men and their symptoms are often worse during their periods. For more information on IBS, visit the "IBS" topic at this Web site.

• Diverticulosis occurs when small pockets develop in the wall of the large intestine. When these pockets get plugged with undigested food, an infection can develop in the bowel wall causing diverticulitis. Usual symptoms are pain in the lower left abdomen, fever and constipation.

Muscular disorders

Skeletal disorders

• Scoliosis (curvature of the spine), herniated disks in the lower region of the back and other disorders of the bones in the pelvic region can result in chronic pelvic pain.

Psychological disorders

• Depression is a common and treatable illness; chronic pain can be one symptom of depression.

Other conditions

• Hernias, which occur when the intestine pushes through the abdominal wall can cause pelvic pain.

• After abdominal surgery, nerves may get entrapped by re-grown tissue, causing pain. Pelvic pain can also develop from a nerve disorder similar to phantom limb pain. In this case, the discomfort remains even after the pelvic organ has been removed.

Diagnostic Tests for Pelvic Pain

When you first seek medical help for pelvic pain, you may see either your internist (primary care physician) or gynecologist. In either case, your health care professional should consider each possible source of pain. Each may require different diagnostic tests and distinct treatments. If you have more than one diagnosis, each can be diagnosed and treated accordingly. Depending on the problem and the training of your primary care provider, you may need to see other specialists.

Your health care professional will begin by asking you specific questions about your past and present health, your menstrual cycle, sexual history, previous abdominal surgeries and your symptoms. You may be asked to describe the kind and severity of your pain (aching, burning, stabbing), where it is and how it affects your life.

You should tell your health care professional if the pain is constant or intermittent, related to your period, or worse during urination, bowel movements or sex. Also discuss any urinary or intestinal problems you may be having. Do you have constipation or diarrhea? Can you associate the start of your pain with a bladder infection or backache? All information about your pain and other symptoms can help your health care professional with his or her diagnosis. Keep a pain diary with detailed information about the pain and associated symptoms. This strategy can provide important clues.

Because pelvic pain appears to run in families, your health care professional will also ask you about related illnesses and problems in your parents and siblings, especially your mother and sisters. Finally, the health care professional may ask you about any treatments and therapies you've already used for the pain and what the outcomes were.

Following the medical history, your health care professional will conduct a general physical examination, including a pelvic and rectal exam to determine areas of tenderness and find such potential problems as fibroids, masses and hernias. If you have muscle pain, skeletal problems or backache, your health care professional may check your posture and gait and look for relations between those problems and your pelvic pain.

Depending on what he or she finds, these simple, standard tests may be ordered:

• blood tests to check for infection (complete blood count or CBC) and inflammation (sedimentation rate or ESR)

• urinalysis and other urinary tests

• tests for sexually transmitted diseases

If certain conditions are suspected, more tests may be recommended. These include:

• laparoscopy

• pelvic ultrasound

• pregnancy test

• MRI