There is frequently more than one component to CPP. The experience of pain is affected by physical, psychological and social factors. Possible causes are listed below:

• Gynaecological causes-These include endometriosis, adenomyosis, ovarian pathology, pelvic inflammatory disease (PID), dense vascular adhesions (division of other adhesions confers no benefit)
• Gastrointestinal causes-These include IBS (symptoms can be exacerbated cyclically with menses), constipation (common cause of dyspareunia), inflammatory bowel disease, Coeliac disease
• Urological causes-These include recurrent UTIs, interstitial cystitis
• Musculoskeletal causes-Musculoskeletal abnormality can be a primary source of CPP or an additional component resulting from postural changes. Referral to physiotherapy may be useful.
• Nerve entrapment-Nerve entrapment in scar tissue, fascia or a narrow foramen may cause pain and dysfunction in the distribution of that nerve. Typically this pain is highly localised and exacerbated by particular movements. Incidence of nerve entrapment after one pfannensteil incision is 3.7%
• Psychological and social issues-Depression and sleep disorders are common in women with CPP. For some women childhood sexual or physical abuse may initiate a cascade of events or reactions which make an individual more likely to develop CPP as an adult.

Assessment should aim to identify contributory factors rather than assign causality to a single pathology. Adequate time should be allowed for the woman to explain her symptoms and ideas about her CPP including any specific anxieties she may have regarding possible cause. A favourable initial consultation has been shown to be associated with improved recovery rates. The multi-factorial nature of CPP should be discussed and explored from the start of the consultation.

History

• Nature and pattern of pain
• Association with menstrual cycle, intercourse, movement, posture
• Association with bowel symptoms such as bloating, stool frequency and type, pain on defaecation.
• Association with bladder symptoms such as frequency, dysuria
• Psychological co-morbidity e.g. depression, sleep disorder
• Detailed drug history with particular reference to analgesia (e.g. dose and type), anxiolytics and antidepressants which can exacerbate constipation
• “Red flag” symptoms suggestive of life threatening disease (e.g. rectal bleeding, new bowel symptoms >50 yrs, new onset of pain post-menopause, pelvic mass, excessive weight loss, irregular bleeding >50 yrs, suicidal ideation) should be excluded and managed appropriately.

Examination and Investigation

• Abdominal palpation
• Bimanual vaginal examination
• Screening for STI in particular Chlamydia and gonorrhoea should be offered
• Transvaginal ultrasound scan (TVS), to exclude pelvic pathology e.g. endometriomas, should ideally be carried out at the time of initial vaginal examination. If this resource is unavailable, ultrasound should be carried out as an interval procedure.
• Diagnostic laparoscopy is a second-line investigation if other therapeutic interventions fail and should NOT be used as a first-line investigation in the absence of abnormality on vaginal examination or TVS. A negative laparoscopy has not been shown to positively benefit women’s health beliefs or pain outcome. Laparoscopy should only be performed when there is a high index of suspicion of significant adhesive disease, endometrioma(s) requiring surgical intervention or where endometriosis is suspected in a woman not suitable for hormonal treatment. In these circumstances the laparoscopy should be performed by a surgeon capable of surgically treating these pathologies.

• Cyclical pain or history suggestive of endometriosis in the absence of TVS findings of disease requiring surgery - In women not wishing to conceive, hormonal treatments to suppress ovarian function can be tried – combined hormonal contraception (pills, patches etc.), desogestrel (other POPs do not inhibit ovulation), levonorgestrel-intrauterine system (52mg), medroxyprogesterone acetate 30mg/d for 3-6 months, GnRH analogues (should only be prescribed following discussion with a senior gynaecologist, add-back HRT should be prescribed to reduce side-effects). If conception is desired or hormonal treatment is contraindicated then simple analgesia should be offered and laparoscopy with a view to treatment of endometriosis should be considered.
• Symptoms of IBS/constipation - Dietary advice and a trial of soluble fibre (e.g.Fybogel) plus an anti-spasmodic and/or peppermint oil should be offered.
• Urogenital or bowel symptoms other than IBS - Referral to urology or gastroenterology
• Musculoskeletal symptoms - Referral to physiotherapy
• Nerve entrapment symptoms or pain not manageable with simple analgesia in the absence of TVS or laparoscopic abnormality - Referral to pain management service
• LUNA is ineffective in the management of CPP.