P-093 - Undiagnosed Neurological Conditions in Chronic Pelvic Pain: More Common Than We Think

Abstract Title: Undiagnosed Neurological Conditions in Chronic Pelvic Pain: More Common Than We Think

Background: Chronic pelvic pain (CPP) refers to the experience of persistent pain perceived to originate from pelvic structures. CPP can be overwhelming to the patient, as the vast differential diagnosis crosses many specialties and the root cause can be difficult to determine. Approximately 80% of CPP is non-gynecological in nature and is associated with a myriad of neurological, visceral, musculoskeletal, sexual, and psychological symptoms.

Purpose/Objectives: Primary management of CPP depends on identifying and addressing its underlying etiologies and contributors. However, there is little literature examining the prevalence of neurological conditions in the setting of CPP. In this study, we actively screened CPP patients within our combined Urology/Urogynecology/Neurology specialty referral pain clinics for CPP associated with neurologic symptoms and, if present, completed a multidisciplinary assessment of the patient. Based upon our previous observations, which demonstrated that small fiber polyneuropathy is prevalent in patients with complex pelvic pain, we hypothesized that a significant proportion of people with CPP who screen positive for neurological symptoms or signs may have an objective neurologic disorder.


Methods: Approval from our Institutional Review Board was obtained prior to study initiation. Participants included CPP patients referred to our multidisciplinary neurology, urology, and gynecology CPP clinic between February 2022 and January 2024. A retrospective review of prospectively collected data was conducted. Study criteria included patients over the age of 18 with CPP who underwent a combined workup with a urologist board certified in urogynecology and reconstructive pelvic surgery (URPS) and a neurologist fellowship-trained in pain management. A standardized, systematic neurological evaluation was provided if the clinical picture suggested a structural or functional nervous system disorder. The subsequent workup was tailored to presenting complaints and neurological examination. Patients were excluded from the study and deemed to have an “incomplete workup” if they did not complete all the evaluations recommended by both the urologist and neuropathic pain specialist at the time of data analysis.


Results: A total of 188 patients initiated combined evaluation, with 126 (67%) completing recommended testing by the time of analysis. Upon examination, 51 (27%) patients had upper motor neuron findings, 17 (9%) lower motor neuron findings, and 105 (58%) a nonfocal examination. Of the 126 who completed evaluation, 92 (73%) were found to have objective evidence of a neurological disorder, 77 (84%) of which were de novo findings. The most common diagnoses included small fiber neuropathy, large fiber neuropathy, lumbosacral radiculopathy, and severe spinal stenosis.

Our findings demonstrate that in patients with CPP who screen positive for neurological symptoms, two thirds have objective evidence of neurological disease. This indicates that those who manage patients with CPP should include a neurological review of systems, akin to those reported in this article during routine evaluation. This is especially important in patients whose pain symptoms have been refractory to first-line therapy. Therefore, we suggest that patients presenting with CPP should be screened for neurological diagnoses and arrange for combined urologic and neurologic management, implementing a multidisciplinary approach to care.

Conclusions/Implications for future research and/or clinical care: Neurologic disease is prevalent in subspecialty CPP patients who screen positive for neurologic symptoms and signs. A vast majority of the diagnoses in this study were de novo and many patients had experienced diagnostic delay. Screening for neurologic symptoms and utilization of multidisciplinary expertise is recommended in patients with CPP in order to facilitate optimal diagnosis, management, and symptom outcome.


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