Investigations for Female Chronic Pelvic Pain

Initial Imaging

The American College of Radiology recommends combined transvaginal and transabdominal ultrasound with Doppler as the initial imaging study of choice for evaluating female chronic pelvic pain, as these three modalities are complementary and should be performed together as a single comprehensive examination 1, 2, 3
Transvaginal ultrasound provides superior spatial and contrast resolution for evaluating the uterus, endometrial canal, fallopian tubes, ovaries, and adnexal masses, and should be used in conjunction with transabdominal ultrasound 1
Doppler ultrasound is a standard component that evaluates uterine artery blood flow and assesses for pelvic venous disorders, with low-resistance waveforms associated with chronic pelvic pain 1, 2, 3

The American College of Radiology recommends MRI pelvis with gadolinium contrast as the problem-solving examination of choice when ultrasound findings are nondiagnostic or inconclusive, for evaluating pelvic venous disorders, chronic pelvic inflammatory disease, adhesive disease, pelvic floor dysfunction, and perineal/vulvar/vaginal masses 2, 3, 5
MRI pelvis can demonstrate ovarian vein reflux and engorged periuterine/periovarian veins, and has diagnostic performance comparable to conventional venography for pelvic venous disorders 2, 5

The American College of Radiology states that CT abdomen and pelvis has no established role as a primary imaging modality for chronic pelvic pain, but may be useful when there is poorly localized pain with a broad differential diagnosis or as second-line imaging after equivocal ultrasound 2, 3, 5, 6

A thorough clinical evaluation should include history taking, physical examination, and selective laboratory testing, with consideration of pain characteristics, associated symptoms, red flag symptoms, psychosocial history, and past medical history 4
The American College of Radiology emphasizes the importance of physical examination, including complete pelvic and perineal examination, musculoskeletal examination, and abdominal examination, in the evaluation of chronic pelvic pain 4