Chronic pelvic pain — structured SAQ (15 marks)

(a) Definition and duration threshold (2 marks)

• Definition: chronic pelvic pain is non-cyclic pain localised to the pelvis, anterior abdominal wall at or below the umbilicus, lumbosacral back or buttocks, of sufficient severity to cause functional disability or warrant medical care. ^[1]
• Duration threshold: at least six months. (1 mark for each.)^[1]

(b) The five-system biopsychosocial model (5 marks)

One mark for each system correctly listed with one example cause, plus one mark for the principle that more than one cause usually coexists. ^[1][4]

• Gynaecological — endometriosis, adenomyosis (this woman's history and dyspareunia fit).
• Urological — bladder pain syndrome / interstitial cystitis (her urinary frequency fits).
• Gastrointestinal — irritable bowel syndrome, inflammatory bowel disease.
• Musculoskeletal — pelvic floor myofascial pain, pudendal neuralgia.
• Psychological — depression, anxiety, central sensitisation (her low mood fits).^[1][4]

(c) Structured assessment (5 marks)

• History — pain map (onset, location, character, radiation, severity 0-10, cyclical vs continuous, exacerbating/relieving); screen each of the five systems; psychosocial history including impact on work, sleep, mood, sex and a trauma-informed screen for abuse. ^[1]
• Examination — abdominal palpation (scars, masses, trigger points); speculum (visualise cervix, take cervical screen/swabs); bimanual (uterine size, mobility, tenderness, adnexa, pouch of Douglas, uterosacral ligament nodularity); focused pelvic floor and musculoskeletal assessment (hypertonic pelvic floor, trigger points reproducing the pain).^[4]
• Investigations — FBC, ESR/CRP, urinalysis and culture, pregnancy test; transvaginal ultrasound first-line; pelvic MRI for suspected deep infiltrating endometriosis; refer to urology for cystoscopy and to gastroenterology for endoscopy where symptoms warrant. A normal TVUS does not exclude significant pathology.^[4]
• Recognise that a diagnostic laparoscopy is not mandatory and that a normal laparoscopy (in up to one-third) does not invalidate the symptom.^[1][4]
• State explicitly that the assessment screens every system because more than one cause usually coexists.^[1]

(d) Management options and evidence (3 marks)

One mark per option with a correct evidence statement. ^[4]

• NSAID or hormonal suppression for the nociceptive and cyclical component — empirical hormonal therapy before laparoscopy is acceptable for cyclical pain without red flags (ESHRE).^[4]
• Pelvic floor physiotherapy for the musculoskeletal/myofascial component — often the single most effective intervention in women with trigger points.
• Cognitive behavioural therapy for the biopsychosocial component — the systematic review of psychological therapies for chronic pelvic pain shows improvement in functioning and depression scores.^[3]
• Laparoscopic excision of endometriosis for surgically treatable disease — but state explicitly that LUNA is not effective (JAMA RCT and IPD meta-analysis).^[2]

Common errors that lose marks

• Calling episodic acute pain "chronic pelvic pain" (the 6-month threshold is the bedrock).
• Listing only gynaecological causes — the five-system model is the point of the question.
• Offering LUNA as a surgical option — it is not effective.
• Recommending chronic opioids — they have no role and worsen central sensitisation.
• Saying a normal laparoscopy "rules out" chronic pelvic pain — it does not.^[1][4]

Examiner notes

A high-scoring candidate defends the biopsychosocial model, screens every system, and knows the LUNA evidence. The chronic-pelvic-pain clinic is the organisational answer to the multifactorial model and earns a mark when mentioned. ^[1][4]