Chronic pain is a chief complaint for patients in the primary care practice, with approximately 10–20% reporting chronic pain. Patients reporting chronic pain often experience psychological distress and disability, in addition to pain . Epidemiological data indicate that women are more susceptible than men to chronic pain syndromes; they are more often likely to report multiple pain sites, more frequent pain, and more intense pain than men [2,3].
Definitions of chronic pelvic pain (CPP) vary, but it is usually defined as pain in the lower abdominal region of at least 6 months' duration, and is distinguished from cyclical pelvic pain (dysmenorrhea) or pain associated with sexual intercourse (dyspareunia) .
Diagnosing and treating CPP by general practitioners and gynecologists is not easy. This is mainly because of the wide range of possible diagnoses and often overlapping symptoms . Possible causes for CPP include endometriosis, chronic pelvic inflammatory infections, adhesions, irritable bowel syndrome, interstitial cystitis, urethral syndrome, and pelvic congestion syndrome. In many women, no disease is evident after a wide range of diagnostic procedures. Traditionally, psychological factors have been sought to explain the presence of pain in these women, but recently an integrative approach of both somatic and psychological causes is increasingly accepted .
CPP in women, although widespread, yet has been virtually ignored . It is estimated that one third of all women will experience CPP in their lifetimes . Its prevalence in the general population of women between the ages of 18 and 50 years is high: 14.7% in the United States (1996) , 24% in the UK (2001) , and 25.4% in New Zealand (2004) . In primary care, an annual prevalence of 38 of 1000 in women aged 13–71 years was reported in UK (2001), a rate comparable with that of other chronic conditions such as migraine, asthma, or back pain . Moreover, CPP accounts for 15% of outpatient gynecologic visits in the United States . In most developing countries, comparable data on the prevalence of CPP are lacking but a recent systematic review reported prevalence rates varying from 5.2% in India to 8.8% in Pakistan to 43.2% in Thailand .
From the woman's point of view, CPP is often a debilitating condition that can result in reduced quality of life, including emotional distress, relationship problems, and loss of time at work . Most often, anxiety about the pain is an important troubling aspect [4,5].
Despite being described as a major women's health issue, no data could be traced about the prevalence of CPP or its effect on women's lives in Egypt. This study aimed to estimate the prevalence of three types of pelvic pain (CPP, dysmenorrhea, and dyspareunia) among women attending Family Health Centers (FHCs) in Alexandria, Egypt, and to describe the nature and severity of pain as perceived by women.
Subjects and methods
Study design and setting
This cross-sectional study was carried out in FHCs in the Alexandria governorate, Egypt.
All FHCs in Alexandria city at the time of the study (2008) were included (n=3). Eligible women attending the clinics of these centers included ever-married women aged 18–59 years who were not pregnant and had not been pregnant during the past 12 months. On the basis of a prevalence of 30%  and a precision of 3%, the calculated sample size was 896 participants. This was rounded to 900. Eligible women attending the selected centers during a period of 1 year – starting February 2008 to February 2009 – and who accepted to participate were recruited.
CPP was defined as recurrent or constant pelvic pain of at least 6 months' duration, unrelated to pregnancy, menstruation, or sexual intercourse. Dysmenorrhea was defined as pelvic pain during, shortly before, or shortly after menstruation, whereas dyspareunia was defined as pelvic pain during or in the 24 h after sexual intercourse.
Data collection methods
Data were collected through interview using a precoded structured interview questionnaire. The questionnaire was modeled on that used for the Oxfordshire study . It was tested in a pilot study and some questions were modified to be culturally appropriate. The questionnaire covered a wide range of issues such as personal and demographic data, lower back pain, menstruation, circumcision, pregnancy and childbirth, contraception, sleep, nature of pelvic pain, medical history, and health-seeking behavior for the CPP, including diagnoses received and investigations performed. Severity of pain was assessed using both the verbal rating scale and the visual analogue scale [12,13].
Clients who gave their verbal consent were interviewed in a private setting. Brief explanation of the study objectives and assurance of confidentiality of the data were guaranteed before the beginning of the interview. Every woman was asked if she had other types of pelvic pain (whether related or not to menstruation or sexual intercourse) in the past 12 months. The location of pelvic pain was shown in a picture and described as any type of pain in the lower part of the abdomen. The duration of the interview ranged from 20 to 30 min.
Eligible women sitting in the waiting areas whether coming to be examined or accompanying their children/relatives to the doctor were targeted for the study. The study was approved by the Ethics Committee of the High Institute of Public Health, Alexandria University.
The SPSS program version 16 was used for data analysis  (SPSS, Chicago, Illinois, USA 2007). Differences at a P value of less than 0.05 were considered statistically significant. The χ2 test was used as a test of significance.
The total number of the studied population was 900 women with a mean age of 33.15±7.66 years. They were mostly from urban origin (83.2%), currently married (94.9%), and having less than four children (86.7%). Nearly two thirds of them (68.5%) completed secondary education and the majority (74.4%) were housewives.
Of all the sampled women (n=900) 26.6% had CPP, of those who had periods 55.3% had dysmenorrhea, and of the currently married women 40.5% had dyspareunia Thirty-two percent of this sample reported of not having pelvic pain of any type (Fig. 1). The figure also illustrates the overlap in the prevalence of the three types of pelvic pain among the subgroup of women (n=773) who had periods and were currently married. Women who had pelvic pain and dysmenorrhea or pelvic pain and dyspareunia were 6.6 and 4.4%, respectively. Isolated cases of CPP constituted approximately 2.3% of the sample. Women having both dysmenorrhea and dyspareunia constituted 17% of the sample. In addition, 13.5% of the sample had three types of pelvic pain.
CPP cases had significantly higher rates of dysmenorrhea (χ2=44.13, P<0.001) and dyspareunia (χ2=97.9, P<0.001) than women with no CPP (Fig. 2).
The characteristics of CPP are shown in Table 1. Most women with CPP (92%) had CPP of an intermittent form, whereas 8% of them had continuous CPP. The majority of women with intermittent CPP (64.3%) did not know whether their pain was cyclic or not. Only 9% of them reported midcycle pelvic pain. Nearly half (46.9%) of the women had CPP for more than 1 year (1–5 years). Pain was perceived as severe by a considerable percentage (32.2%). Their mean visual analogue scale for pain severity was 6.5±2.1.
Figure 3 shows the distribution of women with CPP according to the type of pain they had. The most frequently mentioned types of pain encountered were moderate cramping pain and moderate heaviness (40%), followed by the moderate dull aching (31%).
Table 2 shows the distribution of women with CPP according to factors that increase/relieve their pain. Nearly 60% of women with CPP mentioned that having a full bladder increases their pain. Sexual intercourse increases the pain in approximately half of the women (46.4%). Approximately 40% of women with CPP reported ‘1 week before menstruation’ and loaded colon as factors that increase their pain. The least mentioned factors to increase pain were defecation and ‘1 week after menstruation’, which were reported by 7.1 and 9.7% of women with CPP, respectively.
With regard to the relieving factors, nearly half of the women mentioned urination and sleep/rest as pain-relieving factors (46.9 and 46.4%, respectively). Approximately 40% of them used medications to relieve their pain. Pain was relieved by defecation and 1 week after menstruation in 36.4 and 26.5% of the cases, respectively. Both cold foments and ovulation were the least mentioned factors to decrease CPP (1.3%) each.
Table 3 shows the diagnoses women received for CPP in their lifetime. Colon problem was the most common diagnosis (50%). Pain was attributed to pelvic infection and/or intrauterine device-associated inflammation in 32 and 25% of cases, respectively. Urinary tract infection was diagnosed in 14%. Nearly a quarter (26%) of women were never told about the cause of pain. The majority of women (60%) received one diagnosis but a considerable number (39%) also received two and more diagnoses.
This study shows that CPP was a common condition among ever-married women aged 15–49 years attending FHCs in Alexandria, Egypt with a prevalence rate of 26.6%. Lack of consensus on the definition of CPP greatly hinders epidemiological and comparative studies . Comparable local or national Egyptian studies were lacking. Prevalence rates reported in developing countries vary greatly from 5.2% in India to 8.8% in Pakistan to 43.2% in Thailand .
Studies conducted in the primary care practice often report prevalence rates higher than those shown by community-based studies. The prevalence of CPP in this study was slightly higher than the figures reported by population-based studies in the UK (2001) , New Zealand (2004) , and Australia (2008)  (24, 25.4, and 21.5%, respectively). Compared with the rates in primary care, the present rate of CPP was lower than the corresponding rates reported in the United States (1996; 39%)  and Aberdeen, Scotland (1992; 39%) . The higher prevalence in these studies may be attributed to the difference in the operational definition used for CPP, as the first study inquired about any degree of pelvic pain irrespective of the duration, whereas this study asked about CPP of 6-month duration or more. In the second study, the inclusion of infertile women as well as the undefined duration of pain in the group studied in Aberdeen was likely to have accounted for this high prevalence rate, and the estimate could not be related to the general population.
The significance of the high prevalence rate reported by our study is heightened when considering the overlap of CPP with other associated types of pain – that is, dysmenorrhea and dysparunia, as well as the pain severity, duration, and number of episodes [6,11]. For example, types of pelvic pain other than CPP were highly reported (55.3% for dysmenorrhea and 40.5% for dyspareunia, Fig. 1). In addition, 13.5% of women who had periods and were sexually active suffer three types of pelvic pain. Moreover, women had often experienced this pain for long durations (approximately one third of women with CPP reported that they have been suffering for more than 5 years, Table 1).
Reported prevalence rates of dysmenorrhea in the literature varied through different studies ranging from 20 to 90% [17,19]. This variability may be attributed to the population sampled with regard to their age, marital status, and other sociocultural factors. Another reason for this variation is different definitions used for dysmenorrhea in the different studies as there is no universally accepted method of defining dysmenorrhea. The prevalence of dysmenorrhea reported in this study (55.3%, Table 2) was lower than other figures reported by similar studies in UK, New Zealand, and Australia (81, 66.5, and 71.7%, respectively) [4,7,16]. It is also lower than the prevalence of dysmenorrhea reported in many Egyptian studies. Zurayk et al.  reported a 71% prevalence rate among women of reproductive age living in rural villages in the Giza governorate. Another high prevalence rate of dysmenorrhea (75%) among adolescent girls in Mansoura, Egypt, (2005) was also reported .
The association between pelvic infection and dyspareunia and pelvic pain had been previously reported in the literature [22–24]. Women in this study reported a high rate of dyspareunia (41.1%, Fig. 1), which is much higher than the rates reported by other studies (26.2% in New Zealand (2004)  and 14.1% in Australia (2008) ); however, it is similar to that shown in UK by Zondervan et al.  (41%) and in the Dakahlia governorate, Egypt by Elnashar et al.  (31.2%). A recent Egyptian study  found that circumcised women were more likely to suffer sexual problems and dyspareunia than noncircumcised women. Genital mutilation results in various forms and degrees of sexual malfunction. Erection of a partially mutilated clitoris stretches scarred erectile tissue and stimulates damaged clitoral nerve tissues, which can be a painful and mentally inhibiting ordeal . Circumcision also leads to higher rates of episiotomy during delivery, in which the scar of episiotomy may also cause dyspareunia by itself . Most women in this study similar to the vast majority of Egyptian women  were circumcised.
Despite the high prevalence of CPP in this study, less than half of the women with CPP (46%) sought medical advice during the past year. Many of them received two diagnoses or more and a quarter received no diagnosis for their condition during their entire period of suffering (Table 3). This is not surprising, because of the substantial overlap in symptoms between CPP and other abdominal and gynecological symptoms and the need for performing many investigations, which are not available in primary care.
In contrast, the majority of women who received a diagnosis for their condition got one diagnosis (61%) only (Table 3), the most common being colon problems and pelvic infections. Similarly, Zondervan et al.  found that irritable bowel syndrome was the most common diagnosis among women with CPP in UK, but contradicting the present study, Zondervan reported stress to be the second most common diagnosis. Job stress besides home responsibilities might explain the psychosomatic nature of CPP among UK women.
Looking at the multiple diagnoses received, one can observe that the common known causes of CPP (for example, endometriosis, and interstitial cystitis) were not commonly encountered among women seeking care. This means that these types of pains were neither correctly diagnosed nor properly managed which might be reflected (clear) from the continuous suffering of women. Nevertheless, self-reported results are important because they at least represent women's perceptions of diagnoses given for their symptoms.
Conclusion and recommendations
The rates of pelvic pains among women attending FHCs in Alexandria were high. Pain was mostly perceived as moderate and cramping. The majority of women got one diagnosis only, the most common being colon problems and pelvic infections. Pelvic pain should receive greater attention both in public education and clinical practice. The overlap between multiple abdominal and pelvic symptoms, as well as the wide range of possible causes for CPP, provides further support for the requirement of multidisciplinary settings for effective assessment and management of CPP. Primary care physicians should be prepared to initiate pain management to alleviate women's stress and disability.
1. Marcus DA Chronic pain: a primary care guide to practical management. 20092nd ed Totowa, NJ Humana Press
2. Aloisi AMFillingim RB. Sensory effects of gonadal hormones. Sex, gender and pain. 2000 Seattle IASP Press:7–24
3. Unruh AM. Gender variations in clinical pain experience. Pain. 1996;65:123–167
4. Zondervan KT, Yudkin PL, Vessey MP, Dawes MG, Barlow DH, Kennedy SH. Prevalence
and incidence of chronic pelvic pain
in primary care: evidence from a national general practice database. Br J Obstet Gynaecol. 1999;106:1149–1155
5. Moore J, Kennedy S. Causes of chronic pelvic pain
. Baillieres Best Pract Res Clin Obstet Gynaecol. 2000;14:389–402
6. Grace VM, Zondervan KT. Chronic pelvic pain
in New Zealand: prevalence
, pain severity, diagnoses and use of the health services. Aust N Z J Public Health. 2004;28:369–375
7. Zondervan KT, Yudkin PL, Vessey MP, Jenkinson CP, Dawes MG, Barlow DH, et al. The community prevalence
of chronic pelvic pain
in women and associated illness behaviour. Br J Gen Pract. 2001;51:541–547
8. Society of International Radiology (SIR). Fact Sheet: Pelvic congestion syndrome—chronic pelvic pain
in women nonsurgical procedure is effective treatment for painful ovarian varicose veins. 2004; Available at: http://www.sirweb.org/news/newsPDF/facts/Pelvic
9. Mathias SD, Kuppermann M, Liberman RF, Lipschutz RC, Steege JF. Chronic pelvic pain
, health-related quality of life and economic correlates. Obstet Gynecol. 1996;87:321–327
10. Latthe P, Latthe M, Say L, Gulmezoglu M, Khan KS. WHO systematic review of prevalence
of chronic pelvic pain
: a neglected reproductive health morbidity. BMC Public Health. 2006;6:177
11. Prior A, Wilson K, Whorwell PJ, Faragher EB. Irritable bowel syndrome in the gynecological clinic. Survey of 798 new referrals. Dig Dis Sci. 1989;34:1820–1824
12. Gould D, Kelly D, Goldstone L, Gammon J. Examining the validity of pressure ulcer risk assessment scales: developing and using illustrated patient simulations to collect the data. J Clin Nurs. 2001;10:697–706
13. Ohnhaus EE, Adler R. Methodological problems in the measurement of pain: a comparison between the verbal rating scale and the visual analogue scale. Pain. 1975;1:379–384
14. SPSS Inc. SPSS 16.0 for Windows. Release 16.0.0. 2007 Chicago, Illinois SPSS Inc.
15. Dalpiaz O, Kerschbaumer A, Mitterberger M, Pinggera G, Bartsch G, Strasser H. Chronic pelvic pain
in women: still a challeng. BJU Int. 2008;102:1061–1065
16. Pitts MK, Ferris JA, Smith AM, Shelley JM, Richters J. Prevalence
and correlates of three types of pelvic pain in a nationally representative sample of Australian women. Med J Aust. 2008;189:138–143
17. Jamieson DJ, Steege JF. The prevalence
, pelvic pain and irritable bowel syndrome in primary care practices. Obstet Gynecol. 1996;87:55–58
18. Mahmood TA, Templeton AA, Thomson L, Fraser C. Menstrual symptoms in women with pelvic endometriosis. Br J Obstet Gynaecol. 1991;98:558–563
19. Davis AR, Westhoff CL. Primary dysmenorrhea
in adolescent girls and treatment with oral contraceptives. J Pediatr Adolesc Gynecol. 2001;14:3–8
20. Zurayk H, Khattab H, Younis N, El Mouelhy M, Fadle M. Concepts and measures of reproductive morbidity. Health Transit Rev. 1993;3:17–40
21. El Gilany AH, Badawi K, El Fedawy S. Epidemiology of dysmenorrhoea among adolescent students in Mansoura, Egypt. East Mediterr Health J. 2005;11:155–163
22. Heim LJ. Evaluation and differential diagnosis of dyspareunia
. Am Fam Physician. 2001;63:1535–1544
23. Munday PE. Pelvic inflammatory disease--an evidence-based approach to diagnosis. J Infect. 2000;40:31–41
24. Younis N, Khattab H, Zurayk H, El Mouelhy M, Amin MF, Farag AM. A community study of gynecological and related morbidities in rural Egypt. Stud Fam Plann. 1993;24:175–186
25. Elnashar AM, El Dien Ibrahim M, El Desoky MM, Ali OM, El Sayd Mohamed Hassan M. Female sexual dysfunction in Lower Egypt. Int J Obstet Gynaecol. 2007;114:201–206
26. Elnashar A, Abdelhady R. The impact of female genital cutting on health of newly married women. Int J Gynaecol Obstet. 2007;97:238–244
27. World Health Organization (WHO). Female genital mutilation. 1996 Geneva, Switzerland World Health Organization (WHO)
28. Kettle C, Ismail KMK, O'Mahony F. Dyspareunia
following childbirth. Obstet Gynaecol. 2005;7:245–249
29. El Zanaty F and Way A. Egypt Demographic and Health Survey 2008. 2009. El-Zanaty and Associates and Macro International, Ministry of Health, Cairo, Egypt.
30. Zondervan KT, Yudkin PL, Vessey MP, Jenkinson CP, Dawes MG, Barlow DH, et al. Chronic pelvic pain
in the community--symptoms, investigations and diagnoses. Am J Obstet Gynecol. 2001;184:1149–1155
31. Khattab HAS The silent endurance: social conditions of women's reproductive health in rural Egypt. 19922nd ed Amman, Jordan Population Council, Regional Office for West Asia and North Africa