This study assessed the efficacy of conscious pain mapping in diagnosing and treating chronic pelvic pain (CPP) in 43 women over 18-24 months. Conscious pain mapping identified the cause of pain in 35 women (90%), including pelvic pathology in 18 women, pelvic congestion in 13 women, and a normal pelvis in 8 women. Treatment based on conscious pain mapping findings significantly reduced pain scores in most women. The study concluded that conscious pain mapping is a useful additional investigation that can diagnose CPP when laparoscopy findings are negative or conventional treatment has failed.

1. Diagnosis, treatment and follow up of women
undergoing conscious pain mapping for chronic
pelvic pain: a prospective cohort study
A Swanton, L Iyer, PW Reginald
Department of Obstetrics and Gynaecology, Wexham Park Hospital, Slough, Berkshire, UK
Correspondence: Dr PW Reginald, Department of Obstetrics and Gynaecology, Wexham Park Hospital, Wexham Street, Slough, Berkshire SL2 4HL, UK.
Email philip.reginald@hwph-tr.nhs.uk
Accepted 19 April 2006.
Objective To assess the efficacy of conscious pain mapping in
diagnosing and treating chronic pelvic pain (CPP).
Design Prospective cohort study.
Setting Gynaecology Department, UK District General Hospital.
Population Forty-three women diagnosed with CPP.
Methods The cohort was followed up for 18–24 months after
diagnosis and treatment based on conscious pain mapping.
Main outcome measures Improvement of pain assessed by using
visual analogue scale (VAS) pain scores at 6-month follow up.
Results Thirty-nine women had successful conscious pain
mapping. Pelvic pathology was identified in 18, pelvic congestion
in 13 and 8 women had normal pelvic organs. In 35 women
(90%), conscious pain mapping identified the cause of pain. Five
out of eight women (63%) who were judged to have a normal
pelvis had positive findings at pain mapping. VAS scores fell
significantly from pre-treatment to post-treatment values at
6-month follow up (P < 0.01). Overall, 26 women (74%) felt that
their symptoms had improved after treatment based on findings at
pain mapping. However, we concluded that pain mapping only
contributed to the diagnosis and treatment in seven women (27%),
who may not have received appropriate diagnosis and treatment if
they had a laparoscopy under general anaesthetic.
Conclusions Conscious pain mapping is a useful additional
investigation in the management of women with CPP. It can be
employed in women with a negative laparoscopy or with visible
pathology where the conventional treatment has failed.
Keywords Chronic pelvic pain, pain mapping, surgery.
Please cite this paper as: Swanton A, Iyer L, Reginald P. Diagnosis, treatment and follow up of women undergoing conscious pain mapping for chronic pelvic pain:
a prospective cohort study. BJOG 2006; 113:792–796.
Introduction
Chronic pelvic pain (CPP) is a significant problem for both
GPs and gynaecologists. CPP is commonly defined as pain
originating in the lower abdomen or pelvis for duration of
at least 6 months, which is not exclusively cyclical or inter-
course related and not relieved by narcotic analgesics.1
Women who describe symptoms which are solely related to
either menstruation (i.e. dysmenorrhoea) or to sexual inter-
course (i.e. dyspareunia) are usually excluded. The annual
prevalence of CPP in primary care was estimated as 38/1000
in women between 15–73 years of age,2 compared with figures
reported for asthma (37/1000) and back pain (41/1000).
Investigations are often uninformative at eliciting a cause
and unsuccessful surgical intervention is not uncommon. A
diagnostic laparoscopy can be extremely useful in identifying
pathology and up to 40% of laparoscopies performed by
gynaecologists are for CPP.3 No visible pathology is identified
in 35% of women, endometriosis detected in 33% and adhe-
sions in 24% of women, respectively.3,4 Other data have
shown up to 31% incidence of pelvic congestion in women
with CPP.5 The number of negative laparoscopies remains
high and women are often discharged back to primary care
on the basis of this result. However, it is not uncommon for
women to return with recurrence of symptoms and have
further inappropriate surgical intervention.
The identification of pathology at laparoscopy may not
necessarily be the cause of the pain. The poor correlation
between symptoms and extent of endometriosis diagnosed
at laparoscopy is well known,6 and other pathology such as
adhesions may not be the cause of CPP either.7 Symptoms
that are incorrectly attributed to pathology identified at
DOI: 10.1111/j.1471-0528.2006.00976.x
www.blackwellpublishing.com/bjog
General gynaecology
792 ª RCOG 2006 BJOG An International Journal of Obstetrics and Gynaecology

2. laparoscopy can not only label women but also put them at
risk of further unnecessary surgery.
Conscious pain mapping involves a laparoscopy under
local anaesthetic, which is an interactive approach with the
woman in order to elicit the cause of their pain. The tech-
nique could potentially reduce the number of unnecessary
interventions, thereby eliminating inherent risks to the woman,
and subsequently produce a more cost–effective course of
treatment. Laparoscopy under local anaesthesia has been per-
formed for many years.8 First described in 1996, conscious
pain mapping has been practised for a relatively shorter
period9 and the number of studies is limited. Conscious pain
mapping aims to localise areas within the pelvis responsible
for CPP in order to provide specific treatment options.10
A literature search has been performed and there are no
follow-up studies to determine the efficacy of diagnosis at
conscious pain mapping by assessing the response to appro-
priate treatment. The aim of this study was to assess any
symptomatic improvement after treatment, based on the
diagnosis by conscious pain mapping, thereby determining
whether the procedure is a useful diagnostic tool in the man-
agement of CPP.
Methods
Ethical approval was obtained from the East Berkshire Ethics
Committee prior to starting the study. Forty-three women
with CPP were recruited for conscious pain mapping. The
mean age of the women was 33 years (range 24–44 years).
Thirty-one women were parous, having had one or more
children, while the remaining 12 were nulliparous. The dura-
tion of pain ranged from 6 months to 3 years. Prior to con-
scious pain mapping, women were asked to score their
average intensity of pain using a visual analogue scale
(VAS) of 0–10. The aims of the study and procedure were
explained in detail and the women provided informed con-
sent. We provided the choice of conversion to general anaes-
thesia if local anaesthesia was unsuccessful, either during the
same procedure or at a later date.
Contraindications to the technique were the following:
body mass index (BMI) > 30 kg/m2, surgical phobia and
proven psychiatric disorders, including generalised anxiety
disorder. Women with a BMI > 30 kg/m2 were excluded in
order to minimise potential technical difficulties.
The anaesthesia involved a combination of an intravenous
anxiolytic and opioid medication, together with local anaes-
thetic infiltration at the trocar sites. Premedication was not
administered. Alternating doses of midazolam 70 mg/kg and
pethidine 500 mg/kg were administered intravenously and
repeated at 5- to 10-minute intervals if required. Not more
than two doses were required for any of the women in the
study. After infiltrating the skin, the deeper layers of tissue in
the subumbilical area were thoroughly anaesthetised using
20 ml of 0.25% bupivicaine with adrenaline 1:200 000 in a
fan-shaped manner with a spinal needle. A small incision was
made transversely below the umbilicus and the woman was
asked to distend her abdomen and the Verres needle intro-
duced simultaneously. Pneumoperitoneum was achieved by
1.5 l of nitrous oxide. A 10-mm trocar was inserted as the
woman was again asked to distend the abdomen. All laparo-
scopies were performed by the same surgeon (P.W.R.), using
an Olympus 10-mm laparoscope with a 0° lens (A5290A).
Illumination was provided by a 250-W, high-intensity cold
light source and the images were viewed on a high-resolution
colour monitor using a chip camera. The suprapubic area was
infiltrated with 20 ml of 1% lignocaine for insertion of the
second trocar. Adequate infiltration of the peritoneum was
made under direct vision and a second (5-mm) trocar then
introduced.
The operator was blind to the exact side on which the
woman experienced pain. A probe was introduced through
the second port and the pelvic organs and large bowel were
systematically mobilised. Any adhesions identified were
stretched in order to try and reproduce the symptoms. Iden-
tified pathology, such as endometriosis or pelvic varicosities,
was again probed systematically. Women were instructed to
score the pain on probing using a verbal rating score (VRS) of
0–10 and also were asked whether any of the operator’s
manipulations reproduced the pain that she complained.
Pathological findings were probed after the whole pelvis was
systematically screened twice, to try and achieve maximum
consistency. The identified pathology was judged to be the
cause of pain if the probing reproduced the pain that the
woman complained of.
Medical or surgical treatment was started depending on the
diagnosis made at conscious pain mapping. Women were
followed up at 6 months, 12 months and at 18 months or
whenever clinically indicated. Women who underwent sub-
sequent surgical procedures were followed up until 24
months. During the follow up at 6 months, the pain intensity
was scored again using a VAS. A comparison of VAS scores
recorded pre-treatment and at 6 months was analysed using
Wilcoxon signed rank test. Complete resolution of the pain or
a 70% reduction of the VAS was considered to be an improve-
ment. Further improvement of pain, after subsequent medical
or surgical interventions, was recorded at follow-up visits but
not included in the evaluation.
Results
Forty-three women were recruited for conscious pain map-
ping of whom 39 had a successful conscious pain mapping
procedure. Four of the 43 women were excluded from the
initial results. In three women, inadequate anteversion of
the uterus rendered the procedure unsatisfactory and the re-
maining woman did not tolerate insufflation of the peritoneal
Conscious pain mapping for chronic pelvic pain
ª RCOG 2006 BJOG An International Journal of Obstetrics and Gynaecology 793

3. cavity. Twenty-three women had undergone previous diag-
nostic or therapeutic surgical intervention for pelvic pain.
In 35 women (90%), probing of the pelvic organs repro-
duced the pain. In four women (10%), no site of pain was
identified. Three of these women had normal pelvic organs.
The remaining woman had an ovarian cyst, which was not
symptomatic when probed or manipulated. No complications
were recorded, either at the time of the procedure or at
follow up.
Pelvic pathology was identified in 18 women, pelvic con-
gestion in 13 and the eight remaining women were judged to
have normal pelvic organs providing three major categories
(Figure 1). The median pain score (VRS) on probing the
pelvic organs when judged to be responsible for the pain
was 8 (range 7–10), compared with 2 (range 1–4) when the
organ probed was not thought to be the cause of pain.
The pathology group can be further subdivided as follows:
adhesions (n = 5); endometriosis (n = 6); trapped ovary (n =
3); fibroids (n = 2) and ovarian cyst (n = 2). Appropriate
management, either medical or surgical, was implemented
following the diagnosis of symptomatic pelvic pathology.
In 12 out of the 18 (67%) women, the pelvic pathology
identified was judged to be the cause of pain. Of these women,
nine (75%) felt their symptoms had improved following
treatment and this was sustained at follow up. The three
women who did not improve following treatment had three
separate diagnoses made, including adhesions, a uterine
fibroid and endometriosis.
Number of women recruited
n = 43
Successful procedure
n = 39
Site of pain identified
Yes
n = 35
No
n = 4
Pelvic congestion
n = 13
Normal pelvis
n = 8
Pathology
n = 18
Treatment with ovarian
suppression
Site of pain identifiedPathology responsible for pain
Yes
n = 12
No
n = 6
Yes
n = 11
No
n = 2
Yes
n = 5
No
n = 3
Improvement after
treatment at 6 months
Alternate site
identified
Yes
n = 9
No
n = 3
Yes
n = 5
No
n = 1
Improvement after
treatment at 6 months
Improvement after
treatment at 6 months
Yes
n = 10
No
n = 1
Lost to
follow up
n = 1
Declined
treatment
n = 1
Improvement after
treatment at 6 months
Yes
n = 3
No
n = 2
Lost to
follow up
n = 1
Yes
n = 4
Figure 1. Flow diagram representing cohort of women with CPP and clinical outcome after 6-month follow up.
Swanton et al.
794 ª RCOG 2006 BJOG An International Journal of Obstetrics and Gynaecology

4. The pain was not reproduced by probing the area of
pathology observed in 6 of the 18 women (33%). Of these
women, two had adhesions, two had endometriosis, one had
an ovarian cyst and the remaining woman had a trapped
ovary. In five women, an alternative site of pain was identi-
fied. In the woman with the ovarian cyst, no alternative site of
pain was found, and the woman continued to complain of
pain despite aspiration of the cyst at the time of pain map-
ping. The woman with a trapped ovary was lost to follow up.
In the remaining four women, two had tender ovaries and
uterine tenderness was noted in the other two women. Fol-
lowing subsequent treatment, all these four women (80%)
showed improvement.
Thirteen women were diagnosed with pelvic congestion
syndrome based on the findings of a congested uterus with
varicosities in the broad and infundibulopelvic ligaments.
One woman was lost to follow up and one woman declined
the treatment offered. They were both excluded from subse-
quent analysis. In each of the remaining 11 women, medical
ovarian suppression was administered. One woman did not
respond to ovarian suppression and no further treatment was
given. All the remaining ten women (91%) improved at 6
months, but on stopping treatment, symptoms returned in
five women (45%). Surgical management was then recom-
mended, as directed by the initial pain mapping. Pain map-
ping records of these women identified the uterus only to be
tender and reproducing pain in one woman and she had
a total abdominal hysterectomy (TAH). In another woman,
the uterus and both ovaries were tender and we performed
a TAH and bilateral salpingo-oophorectomy (BSO). In the
remaining three women, the uterus and only one ovary was
tender and the treatment was TAH with unilateral ovarian
conservation. All five women were subsequently pain free at
follow up.
In the eight women who were judged to have normal
organs, conscious pain mapping identified the site of pain
in five women (63%). In two women, the site of pain was
interesting. They had both had a TAH with conservation of
the ovaries in the past. Although there was no obvious pathol-
ogy visible at laparoscopy, probing of the vaginal vault repro-
duced the pain. On closer examination, both women had
areas of peritoneal puckering over the vaginal vault measuring
approximately 1 cm in diameter. These areas were infiltrated
with local anaesthetic, and subsequent probing did not repro-
duce the pain. These areas were ablated at a subsequent lap-
aroscopy under general anaesthetic with a carbon dioxide
laser. In the remaining three women, the uterus was found
to be exquisitely tender in one woman, both ovaries in the
second and the left ovary in the third. All these women under-
went ovarian suppression. At 6 months, only one woman who
had bilaterally tender ovaries was pain free. Subsequently, the
woman with the tender uterus underwent a TAH, and we
performed a left salpingo-oophorectomy for the woman with
a tender left ovary. Both women were pain free after
24-month follow up.
No identifiable site of pain was found in three (38%) of the
eight women in this group. One woman was referred to the
gastroenterology team, which diagnosed irritable bowel syn-
drome and the woman’s symptoms improved after treatment.
The second woman was referred to the orthopaedic team,
which diagnosed a musculoskeletal disorder and again the
woman improved following a discectomy. The remaining
woman was lost to follow up.
In summary, the pain was reproduced and the site identi-
fied in 35 of the 39 women (90%) who had a successful lap-
aroscopy. Overall, significant reduction in pain scores was
noted in 26 women (74%). The median pain score before
treatment in women where a site of pain was identified was
8.5 (range 7.0–10.0). The median pain score at 6-month
follow up after treatment was 1.0 (range 0.0–5.0), which is
statistically significant (P < 0.01).
Discussion
Laparoscopy is a widely used investigation in the management
of CPP as it still remains the only tool capable of diagnosing
peritoneal endometriosis and adhesions that are sometimes
responsible for pelvic pain. However, in as many as 50% of
women with CPP, laparoscopic examination under general
anaesthesia does not find a cause, and in some women, the
pathology identified is not necessarily the cause of pain. It is
therefore reasonable to expect that an interactive approach
would enable identification of the actual cause of pain and
thereby appropriate treatment could be initiated.
The validity of the diagnosis is supported by the significant
reduction of pain noted at 6-month follow up after the initial
treatment. Of the 35 women in whom a cause was identified
at conscious pain mapping, 26 reported an improvement of
symptoms at 6 months after the appropriate treatment based
on the diagnosis made at laparoscopy. However, the role of
conscious pain mapping was deemed useful in seven women
as the outcome in the remaining 19 women would have been
the same even if the laparoscopy was performed under general
anaesthesia. Although the possible placebo effect of surgery
can be significant, the authors feel that 6-month follow up is
enough time to negate any effects as a result of this.
Not unexpectedly, this study noted that the observed
pathology was not the cause of pain in 6 of the 18 women
diagnosed in this group. However, an interactive approach
adopted in this study enabled the identification of an alter-
native cause of pain and improvement after treatment in four
of them. Yet, the outcome would not have been any different
in 14 of the 18 women had the laparoscopy been performed
under general anaesthesia.
Pelvic congestion was thought to be the cause of pain in 13
women, with improvement noticed after ovarian suppression
Conscious pain mapping for chronic pelvic pain
ª RCOG 2006 BJOG An International Journal of Obstetrics and Gynaecology 795

5. in 10. The results would likely have been the same even if the
laparoscopy was performed under general anaesthesia. It is
not uncommon for women to have recurrence of pain after
the cessation of ovarian suppression, and in some women
with intractable pain interfering with their quality of life,
abdominal hysterectomy and BSO is successful.11 In our
study, surgical options became necessary in five women
who had significant recurrence of pain and would have been
therefore considered for BSO with hysterectomy. Although
this option may relive pain, it is not optimal in women with
pelvic congestion as they are often young with a mean age of
33 years.12 The identification of the specific organ tenderness
at conscious pain mapping may become useful in conserving
the ovaries in some women. In four of the five women in this
study, pain mapping identified nontender ovaries, which were
therefore conserved, with women continuing to remain pain
free at 24-month follow up. Clearly, this would not have been
possible if laparoscopy was performed under general anaes-
thesia, but the value of this approach needs further evaluation
in future studies.
Conscious pain mapping identified the cause of pain in five
of the eight women with a normal pelvis. In three out of the
five women there was an improvement with appropriate
treatment at 6 months. The remaining two women needed
subsequent surgical intervention which was only possible as
the site of pain was clearly identified through the interactive
procedure. Had the laparoscopy been performed under gen-
eral anaesthesia, no cause of pain would have been identified
in any of them.
It could be argued that the sensation evoked by probing
of the pelvic organs may be not be comparable with the
women’s symptoms. However, this was possibly overcome
by establishing the cause of pain only when probing repro-
duced the pain experienced by the woman. It could be
criticised that the stimulus on probing was variable, but this
possibility was reduced by a single operator and that the
pelvic organs were systematically probed twice in order to
achieve consistency. It is evident from this study that con-
scious pain mapping actually contributed to the diagnosis
and treatment in only 7 of the 26 women (27%) who
improved at 6 months after treatment based on the diagno-
sis. However, identifying the site of pain at conscious pain
mapping subsequently helped to offer appropriate surgical
options in five women in the pelvic congestion group and
two women in the normal pelvis group, all of whom
improved. Perhaps similar results could have been achieved
by identifying and recording the site of pain during a careful
bimanual examination, at least in some cases. This area
needs further evaluation.
Conclusion
This study has confirmed that the observed pathology is not
always the cause of pain and in such cases an alternate site of
pain was identified and treated successfully as a result of this
interactive approach. Furthermore, pain mapping can be
employed as a useful additional tool in women who have
failed to respond to conventional treatments. In cases of
pelvic congestion, conscious pain mapping may provide the
possibility of conserving ovaries in some women who may
require surgical intervention.
An interactive approach enables an individualised and
sometimes limited surgical intervention. It can also be useful
in identifying unusual causes of CPP. However, in order to
further assess the efficacy of conscious pain mapping, large
randomised controlled trials with comparison of long-term
follow up will be necessary. j
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