Chronic pelvic pain — structured oral station (12 minutes)

Opening prompt — "How do you frame this woman's presentation?"

Model response — the definition plus the model: ^[1][3]

• "This is chronic pelvic pain by the standard definition — non-cyclic pelvic pain of at least six months' duration causing functional disability."
• "I frame it through the multifactorial biopsychosocial model: gynaecological, urological, gastrointestinal, musculoskeletal and psychological. More than one cause usually coexists."
• "Her deep dyspareunia and urinary frequency point to a gynaecological cause (endometriosis, adenomyosis) and a urological cause (bladder pain syndrome) respectively — I will assess both."^[1][3]

Probe 1 — "Describe your structured assessment."

• "A pain map; a structured history of every system; a psychosocial history including impact on work, sleep, mood, sex and a trauma-informed screen for abuse." ^[1]
• "Examination: abdominal, speculum, bimanual — including uterosacral ligament nodularity — and a focused pelvic floor and musculoskeletal assessment to reproduce the pain." ^[3]
• "Investigations: FBC, ESR/CRP, urinalysis and culture, pregnancy test; transvaginal ultrasound first-line; pelvic MRI if deep infiltrating endometriosis is suspected; cystoscopy and lower GI endoscopy by referral where symptoms warrant."^[3]

Probe 2 — "Her pelvic MRI shows deep infiltrating endometriosis involving the uterosacral ligaments. What is your management plan?"

• "A multidisciplinary stepped-care approach: education and validation; NSAIDs and hormonal suppression (continuous COCP or a progestin, or the LNG-IUS); pelvic floor physiotherapy for any myofascial component; psychological support." ^[3][4]
• "For the deep infiltrating disease: a multidisciplinary surgical team (gynaecology, colorectal, urology), shared decision-making about the extent of surgery, and conservative resection where possible." ^[3]
• "I would not offer LUNA — the JAMA RCT and IPD meta-analysis show it is not effective for chronic pelvic pain." ^[2]

Probe 3 — "She is already on escalating oral morphine from a previous clinician. What do you do?"

• "Chronic opioids have no role in chronic pelvic pain — they worsen central sensitisation and carry dependence and overdose risk. I would refer her to a pain specialist for a structured opioid deprescribing pathway and apply a biopsychosocial multidisciplinary plan."^[1][4]

Probe 4 — Communication: "How do you explain a normal laparoscopy to a woman who is in pain?"

• "I would say: 'Your pain is real. The scope did not show a structural cause, but that is a recognised outcome in up to one-third of women with chronic pelvic pain, and it does not mean the pain is imaginary. We now know to look at the other systems — the bladder, the bowel, the muscles of the pelvic floor, and how your nervous system is processing pain — and treat those.' This validates the pain and reframes the plan." ^[1]