There is no question that chronic abdominal/pelvic pain can be caused by gastrointestinal disorders that have clear organic origins. These include inflammatory bowel disease, gastroesophageal reflux disease, and ulcer disease, among others. While psychosocial factors can affect the symptoms of and the course of these illnesses, there is a clearly demonstrable structural, physiologic, or biochemical abnormality present in each of them. Constipation fits in this category as well, and one must remember that chronic constipation is defined as chronic retention of stool irrespective of the stooling pattern. The patient can report daily bowel movements and still be constipated if there is incomplete emptying of rectal contents. Suffice it to say for this gynecology text that a detailed history, a meticulous physical examination, and supportive laboratory and imaging studies will reveal these causes of chronic pain fairly readily.

Where the diagnostic process may become more difficult is when no clear organic cause is found. However, current thought and standards have been developed which make the diagnostic process much easier.

A group of international pediatric and adult gastroenterology and mental health specialists met and developed symptom-based diagnostic criteria for what have been termed functional disorders that cause RAP. The disorders for which there are patterns to the symptoms, for which no specific diagnostic tests exist, and in which the diagnostic evaluation rules out disorders with similar presentations are called functional disorders of a recognized symptom pattern. The two disorders most commonly found are functional dyspepsia, not usually an issue in girls with CPP, and IBS. The third type of disorder has no detectable organic cause and no recognizable pattern of symptoms; this is called functional abdominal pain (

table 1). Analogously, pain can emanate from pelvic organs in no specific pattern as well.

In the functional syndromes, whether IBS, functional dyspepsia, or functional abdominal or pelvic pain, symptoms may result from an alteration in transmission of neural impulses between the enteric nervous system and the central nervous system leading to visceral (intestinal or uterine) hypersensitivity.

The emotional state of the patient and the psychosocial situation of the patient then modify the patient’s perception of these sensations. What this means is that under the right psychosocial conditions a patient with functional pain is sensitive to bowel distention or to uterine contractions of an intensity that would not be perceived by a person who does not have these syndromes.

Obviously, stress can play a significant role in contributing to functional pain syndromes in adolescents. While some would think that adolescents have a relatively idyllic life with little stress, that is not the case (

table 2).