Chronic Pelvic Pain

Chronic pelvic pain is one of the most common and disabling medical problems GPs and gynaecologists see in their practice. It affects nearly 15 percent of women in their reproductive age.  Nearly 25 percent of the women with chronic pelvic pain take 2-3 days per month time off from their work. It can affect their day to day life, sexual life and can cause mood swings. More than half of the women with CPP must cut down on their daily activities one or more days a month, and 90% have pain with intercourse (sex). Almost half of the women with CPP feel sad or depressed some of the time.

Chronic pelvic pain is pain in the area below your bellybutton and between your hips that lasts six months or longer. Chronic pelvic pain can be caused by multiple causes. It can be a condition or may be a symptom of another problem. Many times, the problem that originally caused the pain has lessened or even gone away completely, but the pain continues. This makes it much more difficult for a doctor to find the cause of the pain and to provide treatment. However, in many cases, it’s not possible to identify a single cause for chronic pelvic pain. In that case, the goal of treatment is to reduce your pain and other symptoms and improve your quality of life.

If the strong and persistent pain continues for a long period of time, it can become physically and mentally exhausting. To cope with the pain, an individual may alter her or his emotional and behavioural responses. When pain has continued for so long and to such an extent that the person in pain is changing emotionally and behaving differently to cope with it, this is known as “Chronic Pelvic Pain Syndrome”.

According to International Pelvic Pain Society, Women with this condition will often have experienced the following:

  • Pain present for six months or more.
  • Conventional treatments have not relieved the pain or have given only small relief.
  • The pain is stronger than would be expected from the injury/surgery/condition which initially caused the pain.
  • Difficulty sleeping or sleeping too much, decreased appetite, “slow motion” body movements and reactions, and other symptoms of depression, including feeling blue or tearfulness.
  • Anxiety and helplessness commonly occur.
  • Increasingly less physical activity.
  • Changes in how she relates in their usual roles as spouse, parent, grandparent, and employee.

CPP is a combination of physical symptoms: pain, trouble sleeping, and loss of appetite. Psychological symptoms:  depression, and anxiety. And changes in behaviour:  change in relationships due to the physical and psychological problems.

Pelvic pain affects you as severe and constant pain, crampy pain; pain that comes and goes, dull aching pain which persists all the time, sharp unbearable pain or pressure or heaviness deep within the pelvis. You may have associated pain during intercourse, pain while having a bowel movement or urinating or pain when you sit for long periods of time.

In general, if your pelvic pain disrupts your daily life or if your symptoms seem to be getting worse-see a pelvic pain specialist Melbourne.

Chronic pelvic pain is a complex condition that can have multiple causes. Sometimes, a single disorder may be identified as the cause. In other cases, however, pain may be the result of several medical conditions. Some causes of chronic pelvic pain include:

A variety of gynecologic, gastrointestinal, urologic, musculoskeletal and body-wide disorders can cause chronic pelvic pain.

Gynecologic causes — Gynecologic causes are thought to be the cause of chronic pelvic pain in about 20 percent of women. In some groups of women, gynecologic causes of pelvic pain are even more common. Some of the gynecologic causes of pelvic pain include: Endometriosis – Endometriosis is a condition in which endometrial tissue is also present outside of the uterus. Uterine fibroids — Fibroids, also called leiomyomas, are growths in the uterus. They are not cancerous. While not everyone with fibroids experiences symptoms, some women do have pelvic pain, heavy periods, or fertility problems. Adenomyosis — This is a condition in which endometrial tissue (the tissue that normally lines the inside of the uterus) grows inside the uterine walls. It causes an enlarged uterus and heavy, painful periods, and often affects women who also have endometriosis or uterine fibroids. Pelvic inflammatory disease — Pelvic inflammatory disease is an acute infection usually caused by a sexually transmitted organism. It can involve the uterus, ovaries, and fallopian tubes. .Chronic changes following pelvic inflammatory disease occur in about one-third of women and causes chronic pelvic pain. The reason for this is not clearly known, but is likely because of permanent damage to the uterus, ovaries, and fallopian tubes, and is not because of a chronic infection. Pelvic adhesive disease — Adhesions refer to abnormal tissue that causes internal organs or structures, such as the ovaries and fallopian tubes, to adhere or stick to one another. Adhesions are not scarred tissue, as adhesions are abnormal reactions to surgery, infection, or inflammation, and are not normal healing like scar tissue. It is very controversial whether adhesions cause pelvic pain and medical experts are not in agreement. However, most evidence suggests that surgery for pelvic adhesive disease does not relieve pelvic pain in most women.

Other causes — Non-gynecologic causes of chronic pelvic pain may be related to the digestive system, urinary system, or to pain in the muscles and nerves in the pelvis: Irritable bowel syndrome — Irritable bowel syndrome is a gastrointestinal condition characterized by chronic abdominal pain and altered bowel habits. Painful bladder syndrome and interstitial cystitis — Painful bladder syndrome and interstitial cystitis (PBS/IC) are the terms given to bladder pain that is not caused by infection. Diverticulitis — A diverticulum is a sac-like protrusion that sometimes forms in the muscular wall of the colon (or intestine). Diverticulitis occurs when diverticula become inflamed. This usually causes abdominal pain; nausea and vomiting, constipation, diarrhea, and urinary symptoms can also occur. Pelvic floor pain — Symptoms of pelvic floor dysfunction may include pelvic pain, pain with urination, difficulty urinating, constipation, pain with intercourse, or frequent/urgent urination. Pelvic floor dysfunction can be diagnosed by a clinician feeling the pelvic floor muscles (muscles that support the pelvic organs and hips) through the vagina and/or rectum; muscles that feel tight, tender, or band-like indicate that pelvic floor dysfunction could be contributing to pelvic pain. Abdominal myofascial pain (trigger points) — Pain can originate from the muscles of the abdominal wall due to myofascial pain. This problem usually has small localized areas of abnormal tenderness of the abdominal muscles that are called trigger points. Abdominal myofascial pain is diagnosed by the clinician examining the abdominal muscles for trigger points; often tightening of these muscles while they are examined causes increased pain and assists in diagnosis. Fibromyalgia — Fibromyalgia is one of a group of chronic pain disorders that affect connective tissue structures, including muscles, ligaments, and tendons. It is characterized by widespread muscle pain (or “myalgia”) and tenderness in certain areas of the body. Women with fibromyalgia may also experience fatigue, sleep disturbances, headaches, and mood disturbances such as depression and anxiety.

Endometriosis. This is a condition in which tissue from the lining of your womb (uterus) grows outside your uterus. These deposits of tissue respond to your menstrual cycle, just as your uterine lining does — thickening, breaking down and bleeding each month as your hormone levels rise and fall. Because it’s happening outside your uterus, the blood and tissue can’t exit your body through your vagina. Instead, they remain in your abdomen, where they may lead to painful cysts and fibrous bands of scar tissue (adhesions).

  • Musculoskeletal problems.Conditions affecting your bones, joints and connective tissues (musculoskeletal system) — such as fibromyalgia, pelvic floor muscle tension, inflammation of the pubic joint (pubic symphysis) or a hernia — can lead to recurring pelvic pain.
  • Chronic pelvic inflammatory disease.This can occur if a long-term infection, often sexually transmitted, causes scarring that involves your pelvic organs.
  • Ovarian remnant.After surgical removal of the uterus, ovaries and fallopian tubes, a small piece of the ovary may accidentally be left inside and later develop painful cysts.
  • These noncancerous uterine growths may cause pressure or a feeling of heaviness in your lower abdomen. They rarely cause sharp pain unless they become deprived of a blood supply and begin to die (degenerate).
  • Irritable bowel syndrome.Symptoms associated with irritable bowel syndrome — bloating, constipation or diarrhea — can be a source of pelvic pain and pressure.
  • Painful bladder syndrome (interstitial cystitis).This condition is associated with recurring pain in your bladder and a frequent need to urinate. You may experience pelvic pain as your bladder fills, which may improve temporarily after you empty your bladder.
  • Pelvic congestion syndrome.Some doctors believe enlarged, varicose-type veins around your uterus and ovaries may result in pelvic pain. However, other doctors are much less certain that pelvic congestion syndrome is a cause of pelvic pain because most women with enlarged veins in the pelvis have no associated pain.
  • Psychological factors.Depression, chronic stress or a history of sexual or physical abuse may increase your risk of chronic pelvic pain. Emotional distress makes pain worse, and living with chronic pain contributes to emotional distress. These two factors often become a vicious cycle.

To find out the cause and treatment plan for chronic pelvic pain your doctor will often ask a detailed interview about your pain, your personal health history and your family history and other symptoms. Your doctor will also go examine in detail including pelvic exam. This is to find out if there are any signs of infection, abnormal growths or tense pelvic floor muscles. The gynaecologist will also check for areas of tenderness. If you have any discomfort during examination, let your gynaecologist know especially if the pain is similar to the pain you’ve been experiencing.

Your gynaecologist may also order few lab tests check for infections, such as chlamydia or gonorrhoea. In addition, may order bloodwork to check your blood cell counts and urinalysis to check for a urinary tract infection. Ultrasound may also be needed to detect masses or cysts in the ovaries, uterus or fallopian tubes. Additional investigations; abdominal X-rays, computerized tomography (CT) scans or magnetic resonance imaging (MRI) may be needed.

If the above mentioned investigation cannot find the cause, laparoscopy may be needed to find and treat the cause. The laparoscope allows your gynaecologist to view your pelvic organs and check for abnormal tissues or signs of infection. This procedure is especially useful in detecting endometriosis and chronic pelvic inflammatory disease.

Finding the underlying cause of chronic pelvic pain can be a long process, and in some cases, a clear explanation may never be found. With patience and open discussion, we as a team can develop a treatment plan that helps you live a full life with minimal discomfort.

The main aim of treatment is to reduce symptoms and improve quality of life. If gynaecologist can find a specific cause, treatment will focus on that cause. However, if a cause can’t be identified, the main focus will be how to manage pain and other symptoms.

Depending on the cause, gynaecologist may prescribe a number of medications to treat chronic pelvic pain.

  • Pain relievers.Over-the-counter pain remedies, such as aspirin, neurofen, Panadol may provide partial relief from pelvic pain. Sometimes a prescription pain reliever may be necessary. Pain medication alone, however, rarely solves the problem of chronic pain.
  • Contraceptive pills.Some women find that the days when they have pelvic pain may coincide with a particular phase of their menstrual cycle and the hormonal changes that control ovulation and menstruation. When this is the case, birth control pills or other hormonal medications may help relieve pelvic pain.
  • If an infection is the source of your pain, your doctor may prescribe antibiotics.
  • Some types of antidepressants can be helpful for chronic pain as some seem to have pain-relieving as well as antidepressant effects. They may help improve chronic pelvic pain even in women who don’t have depression.

Other therapies

Your doctor may recommend specific therapies or procedures as a part of your treatment for chronic pelvic pain. These may include:

  • Physical therapy.Stretching exercises, massage and other relaxation techniques may improve your chronic pelvic pain. A physical therapist can assist you with these therapies and help you develop coping strategies for the pain. Sometimes physical therapists target specific points of pain using a medical instrument called transcutaneous electrical nerve stimulation (TENS). TENS delivers electrical impulses to nearby nerve pathways. Physical therapists may also use a psychology technique called biofeedback, which helps you identify areas of tight muscles so that you can learn to relax those areas.
  • Neurostimulation (spinal cord stimulation).This treatment involves implanting a device that blocks nerve pathways so that the pain signal can’t reach the brain. It may be helpful, depending on the cause of your pelvic pain.
  • Trigger point injections.If your doctor finds specific points where you feel pain, you may benefit from having a numbing medicine injected into those painful spots (trigger points). The medicine, usually a long-acting local anesthetic, can block pain and ease discomfort.
  • If your pain could be intertwined with depression, sexual abuse, a personality disorder, a troubled marriage or a family crisis, you may find it helpful to talk with a psychologist or psychiatrist. There are different types of psychotherapy, such as cognitive behavioral therapy and biofeedback. Regardless of the underlying cause of your pain, psychotherapy can help you develop strategies for coping with the pain.

Surgery

To correct an underlying problem that causes chronic pelvic pain, your doctor may recommend a surgical procedure, such as:

  • Laparoscopic surgery.If you have endometriosis, doctors can remove the adhesions or endometrial tissue using laparoscopic surgery. During laparoscopic surgery, your surgeon inserts a slender viewing instrument (laparoscope) through a small incision near your navel and inserts instruments to remove endometrial tissue through one or more additional small incisions.
  • In rare complicated cases, your doctors may recommend removal of your uterus (hysterectomy), fallopian tubes (salpingectomy) or ovaries (oophorectomy). There are important health consequences of having this procedure. Your doctor will discuss the benefits and risks in detail before recommending this option.

Pain rehabilitation programs

You may need to try a combination of treatment approaches before you find what works best for you. If appropriate, you might consider entering a pain rehabilitation program.

These types of programs, such as the Pain clinics typically provide a team approach to treatment, including medical and psychiatric aspects.

Lifestyle and home remedies

Chronic pain can have a major impact on your daily life. When you’re in pain, you may have trouble sleeping, exercising or performing physical tasks.

Chronic pain can also cause anxiety and stress, which in turn may worsen your pain.

Relaxation techniques can help release tension, reduce pain, calm emotions and induce sleep. Many techniques can be learned on your own, such as meditation and deep breathing.

Alternative medicine

Acupuncture

Limited evidence suggests that acupuncture may be helpful for some causes of pelvic pain.

During acupuncture treatment, a practitioner inserts tiny needles into your skin at precise points. Pain relief may come from the release of endorphins, your body’s natural painkillers, but that’s only one of many theories about how acupuncture works. Acupuncture is generally considered a safe treatment.

Talk with your doctor if you’re considering trying a complementary or alternative therapy.

Preparing for your appointment

You’re likely to start by seeing your family doctor or a doctor who specializes in conditions affecting the female reproductive tract (gynecologist).

Depending on the suspected cause of your pain, he or she may refer you to a digestive system specialist (gastroenterologist), a urinary and gynecologic specialist (urogynecologist) or a specialist in musculoskeletal pain (physiatrist or physical therapist).

What you can do

To prepare for your appointment:

  • Make a list of any signs and symptoms you’re experiencing.Include any that may seem unrelated to the reason for your appointment.
  • Make a note of key medical information.Include any major stresses or recent life changes.
  • Make a list of all medications and the doses.Include any prescription and nonprescription drugs, vitamins or other supplements you’re taking.
  • Consider taking a family member or friend along.Sometimes it can be difficult to remember all the information provided during an appointment. Someone who goes with you may remember something that you missed or forgot.
  • Prepare questions.Your time with your doctor is limited, so preparing a list of questions can help you make the most of your time together.

Some basic questions to ask your doctor include:

  • What are the possible causes of my symptoms or condition?
  • What tests do you recommend?
  • If these tests don’t pinpoint the cause of my symptoms, what additional tests might be necessary?
  • What approach will you recommend if we can’t locate an underlying cause?
  • What types of treatments are most likely to improve my symptoms?
  • How long will I need to be treated?
  • How long might it take for me to feel better?
  • Are there any restrictions that I need to follow?
  • Should I see a specialist?
  • Is there a generic alternative to the medicine you’re prescribing?
  • Are there any brochures or other printed material that I can have? What websites do you recommend?

In addition to the questions you’ve prepared in advance, don’t hesitate to ask questions during your appointment at any time that you don’t understand something.

What to expect from your doctor

Your doctor will likely ask you a number of questions. Being ready to answer them may leave extra time to go over any points you’d like to have clarified. Your doctor may ask:

  • When did you first begin experiencing pelvic pain?
  • Has your pain changed or spread over time?
  • How often do you have pelvic pain?
  • How severe is your pain, and how long does it last?
  • Where is your pain located? Does it always occur in one place?
  • How would you describe your pain?
  • Does your pain come in waves or is it constant?
  • Do you feel pain during urination or a bowel movement?
  • Does your menstrual cycle affect your pain?
  • Does anything make your pain better or worse?
  • Does your pain limit your ability to function?
  • Have you recently felt down, depressed or hopeless?
  • Have you ever had pelvic surgery?
  • Have you ever been pregnant?
  • Have you ever been treated for a urinary tract or vaginal infection?
  • Have you ever been touched against your will?
  • What treatments have you tried so far for this condition? How have they worked?
  • Are you currently being treated or have you recently been treated for any other medical conditions?

Understanding long-term (Chronic) Pelvic Pain

When you first develop pain, it is important to see your doctor and check that the pain isn’t due to something that needs medical treatment or it could be dangerous.

Unfortunately, even with the best care, some people still have pain. There may be nothing to find on scans or tests, but the pain persists.

If this is your experience, you may have wondered why your body is so sensitive. Someone may have told you ‘it’s all in your head’ or you may have wondered if you are ‘going crazy’. You don’t need to worry that you are weak, or that the pain is imaginary. It’s real.

There are many differences between short term and long term pains.

Short term pain is the normal way our body tells us something is wrong and we should take action to protect ourselves. The pain you have when touching a hot pan, or pricking your finger with a pin tells you to protect yourself and move away. The pain you feel after an operation tells you to rest more and allow your body to heal. These are short term pains that usually go away over time.

Long term (chronic) pain is when pain doesn’t go away. The original cause of the pain may no longer be present. There is nothing that needs medical attention straight away and you are in no danger. Yet there is still a pain. Tests may be normal and there may be no abnormality to see. Yet still, there is a pain.

Anyone who has a pain of some kind on most days for more than three to six months is usually considered to have Chronic Pain. Other words used to describe this problem include Central Sensitisation or the Chronic Pain Condition or sometimes Neuropathic Pain. 

Once nerve pathways change the pain often becomes more complicated. In the beginning, there may have been one type of pain. Now the pain is more complicated, with a mix of pain problems and often a sense of being tired and generally unwell.

No matter how your pain started, if you have had pain in the pelvis on most days for more than three to six months, then it is likely you have chronic pain. You may still have conditions in the pelvis that have not been fully treated, so sensitisation of pain pathways may not be your only problem, but is it likely that your pain pathways are part of the pain.

Why me?

No one knows why some people develop chronic pain and others do not. Two people may have the same pelvic condition or injury; with one person recovering completely, while the other develops chronic pain. This is an area of research in many areas of medicine, not just pelvic pain, and it is hoped that more will be known about this over time.

It is possible that particular conditions, including endometriosis, may be particularly likely to result in chronic pain. It is also known that repeated episodes of severe pain (such as severe period pain every month) are more likely to lead to chronic pain than a single severe pain episode.

To understand long term, chronic pain, it is useful to think about how pain pathways work, and the effect of long term pain on our muscles, nerve pathways and emotions.

How pain pathways work

Our brain receives messages from all over our body all the time. Much of the information sent to the brain is unimportant, and we are never aware that the information has been collected. The brain filters this information and decides if it wants us to take action.

For example, parts of our brain are constantly collecting information on how much urine is in our bladder. The brain usually allows us to continue our normal activities and be unaware of our bladder until it is full. As the bladder fills, more and more messages are sent to the brain. When full, the brain makes us aware of the need to go to the toilet. If we don’t go the toilet and the bladder continues to fill, we will start feeling pain. Once the bladder is empty again, we are again allowed to continue our normal activities without noticing our bladder – until it becomes full again.

Different situations can affect how this system works.

If there is a painful bladder condition or bladder infection, then more pain messages than usual are sent to the brain and we feel the need to empty our bladder more often.

If we are anxious about our bladder function, then the brain focuses more on pain messages from the bladder and we also feel the need to empty our bladder more often.

The effect of long term pain on muscles

Muscles change when they are injured or when we are in pain – they tense up. Ever had a spasm in the back? – it sure stops you moving and bending! This is a normal protective reaction to prevent more damage to the injured part. Pelvic floor muscles behave like this too when there is something painful in the pelvis. They tighten up.

Muscles aren’t meant to be tight all the time and after a while, they start hurting and adding to the pain. Humans are designed to move, so sitting or lying down a lot due to pain can make the pain even worse. Muscles that become even tighter can spasm, causing sudden, stabbing or crampy pains.

The effect of long term pain on nerve pathways

When something painful happens to us, the nerves in that area send pain signals to the spinal cord and then up to our brain. It is when the brain notices the pain that we feel it.

With long term pain, the pain pathways from the pelvis to the brain change. This is called Central Sensitisation and once this happens, pain becomes more complex.

Things that were mildly painful become more painful. For example, intercourse may have been uncomfortable but is now painful.

Things that weren’t painful before become painful. For example, wearing tight jeans or your partner’s hand on your abdomen may feel unpleasant.

Pain can spread to a wider area. For example, the pain used to be in the lower abdomen but is now felt all over the abdomen, in the back and in the thighs. This does not mean that the back or thighs are abnormal. The pain impulses have spread to our spinal cord and brain and we feel pain in a larger area.

Pain can spread to other pelvic organs. For example, you may have had bad period pain or prostate pain before, but now also have an irritable bowel or overactive painful bladder.

Central sensitisation is also common after sporting injuries, shingles, or really any condition with long term pain. The pain that is felt long after a badly injured leg is amputated (Phantom Limb Pain) is another type of Central Sensitisation.

The effect of long term pain on our emotions

Thoughts and emotions can also affect pain. Feeling tense and anxious about family, work or relationships can make pain worse. Feeling under ‘stress’ from too many responsibilities and life events leads to tight tense muscles. For women with painful sex, just thinking about intercourse can be enough to make their pelvic floor muscles tighten without them realizing. Guilt, worrying about the pain or relationship issues complicates things further. For men with an overactive bladder, just worrying about where a toilet will be when leaving the house can cause the pelvic           floor muscles to tense and pain to worsen.

The effect of long term pain on wellbeing

When pain becomes chronic our immune, endocrine and sympathetic nervous systems all get switched on to help us cope. The whole body gets involved. This may help in the short term, but when pain continues, these systems just don’t function well. And neither do we. Our energy levels, sleep, bowels, concentration, resistance to infection – and lots more – are affected and life becomes even more challenging.

It is common for anyone with chronic pain to have problems with poor sleep, fatigue, anxiety, low mood, nausea, sweating, dizziness or faint feelings.

The Good News – How to manage chronic Pain

Once pain has become chronic, it is unlikely that any one treatment will make it go away completely. However, you can feel positive about the future. There are many ways to manage this pain and make it a much smaller part of your life.

We all want a cure for pain, preferably one that is quick and easy. It’s understandable. One day there may well be such a treatment.

For now, the best treatment for chronic pain involves:

  • learning more about your mix of pains – this site has information to get you started on each of your pains
  • working with a physiotherapist who understands pelvic muscle pain to keep your body moving and muscles comfortable
  • using medications for central sensitisation of nerve pathways, if appropriate – while minimising the use of regular narcotic (opioid) medications
  • keeping active and involved in activities you enjoy – and learning positive ways to manage your pain

The pages on this site will help you with many of these things. Our Facebook site will help you keep up with new treatments and ideas. Our events calendar includes activities you may be able to attend.

Further reading on Chronic Pain

  • Endometriosis and Pelvic Pain – Dr. Susan Evans and Deborah Bush, QSM – A book for girls and women available from www.pelvicpainsa.com.au
  • Painful Yarns – Professor Lorimer Moseley (2004) – A selection of stories that help the understanding of Chronic Pain from any kind – available Amazon
  • Explain Pain – David Butler and Lorimer Moseley (2013) – Further explanation on Chronic Pain in general – available from www.noigroup.com
  • Why do I hurt? – Adriaan Louw (2013) – Amazon

CHRONIC PELVIC PAIN DEFINITION

Chronic pelvic pain is defined as pain that occurs below the umbilicus (belly button) that lasts for at least six months. It may or may not be associated with menstrual periods. Chronic pelvic pain may be a symptom caused by one or more different conditions, but in many cases is a chronic condition due to abnormal function of the nervous system (often called “neuropathic pain”).

CAUSES OF CHRONIC PELVIC PAIN

A variety of gynecologic, gastrointestinal, urologic, musculoskeletal and body-wide disorders can cause chronic pelvic pain.

Gynecologic causes — Gynecologic causes are thought to be the cause of chronic pelvic pain in about 20 percent of women. In some groups of women, gynecologic causes of pelvic pain are even more common. Some of the gynecologic causes of pelvic pain include:

Endometriosis — The tissue lining the inside of the uterus is called the endometrium (figure 1). Endometriosis is a condition in which endometrial tissue is also present outside of the uterus. Some women with endometriosis have no symptoms, while others experience marked discomfort and pain and may have problems with fertility. (See “Patient education: Endometriosis (Beyond the Basics)” and “Patient education: Evaluation of the infertile couple (Beyond the Basics)”.)

Uterine fibroids — Fibroids, also called leiomyomas, are growths in the uterus. They are not cancerous. While not everyone with fibroids experiences symptoms, some women do have pelvic pain, heavy periods, or fertility problems. (See “Patient education: Uterine fibroids (Beyond the Basics)”.)

Adenomyosis — This is a condition in which endometrial tissue (the tissue that normally lines the inside of the uterus) grows inside the uterine walls. It causes an enlarged uterus and heavy, painful periods, and often affects women who also have endometriosis or uterine fibroids. (See ‘Endometriosis’ above and ‘Uterine fibroids’ above.)

Pelvic inflammatory disease — Pelvic inflammatory disease is an acute infection usually caused by a sexually transmitted organism. Occasionally, it is caused by a ruptured appendix, tuberculosis, or diverticulitis. It can involve the uterus, ovaries, and fallopian tubes (which link the ovaries and uterus) (figure 1). Chronic changes following pelvic inflammatory disease occur in about one-third of women and cause chronic pelvic pain. The reason for this is not clearly known, but is likely because of permanent damage to the uterus, ovaries, and fallopian tubes, and is not because of a chronic infection. (See “Patient education: Gonorrhea (Beyond the Basics)” and “Patient education: Chlamydia (Beyond the Basics)”.)

Pelvic adhesive disease — Adhesions refer to abnormal tissue that causes internal organs or structures, such as the ovaries and fallopian tubes, to adhere or stick to one another. Adhesions are not scarred tissue, as adhesions are abnormal reactions to surgery, infection, or inflammation, and are not normal healing like scar tissue. It is very controversial whether adhesions cause pelvic pain and medical experts are not in agreement. However, most evidence suggests that surgery for pelvic adhesive disease does not relieve pelvic pain in most women.

Other causes — Non-gynecologic causes of chronic pelvic pain may be related to the digestive system, urinary system, or to pain in the muscles and nerves in the pelvis:

Irritable bowel syndrome — Irritable bowel syndrome is a gastrointestinal condition characterized by chronic abdominal pain and altered bowel habits (such as loose stools, more frequent bowel movements with the onset of pain, and pain relieved by defecation) in the absence of any specific cause. (See “Patient education: Irritable bowel syndrome (Beyond the Basics)”.)

Painful bladder syndrome and interstitial cystitis — Painful bladder syndrome and interstitial cystitis (PBS/IC) are the terms given to bladder pain that is not caused by infection. Symptoms usually include the need to urinate frequently (frequency) and a feeling of urgently needing to urinate (urgency). Some women with painful bladder syndrome have lower abdominal or pelvic pain in addition to urinary tract symptoms. A separate topic review is available that discusses PBS/IC. (See “Patient education: Diagnosis of interstitial cystitis/bladder pain syndrome (Beyond the Basics)”.)

Diverticulitis — A diverticulum is a sac-like protrusion that sometimes forms in the muscular wall of the colon (or intestine). Diverticulitis occurs when diverticula become inflamed. This usually causes abdominal pain; nausea and vomiting, constipation, diarrhea, and urinary symptoms can also occur. Diverticulitis most often causes acute abdominopelvic pain and is not a common cause of chronic pain. (See “Patient education: Diverticular disease (Beyond the Basics)”.)

Pelvic floor pain — Symptoms of pelvic floor dysfunction may include pelvic pain, pain with urination, difficulty urinating, constipation, pain with intercourse, or frequent/urgent urination. Pelvic floor dysfunction can be diagnosed by a clinician feeling the pelvic floor muscles (muscles that support the pelvic organs and hips) through the vagina and/or rectum; muscles that feel tight, tender, or band-like indicate that pelvic floor dysfunction could be contributing to pelvic pain.

Abdominal myofascial pain (trigger points) — Pain can originate from the muscles of the abdominal wall due to myofascial pain. This problem usually has small localized areas of abnormal tenderness of the abdominal muscles that are called trigger points. Abdominal myofascial pain is diagnosed by the clinician examining the abdominal muscles for trigger points; often tightening of these muscles while they are examined causes increased pain and assists in diagnosis.

Fibromyalgia — Fibromyalgia is one of a group of chronic pain disorders that affect connective tissue structures, including muscles, ligaments, and tendons. It is characterized by widespread muscle pain (or “myalgia”) and tenderness in certain areas of the body. Women with fibromyalgia may also experience fatigue, sleep disturbances, headaches, and mood disturbances such as depression and anxiety. (See “Patient education: Fibromyalgia (Beyond the Basics)”.)

Physical, sexual, or mental abuse — Patients with chronic pain, in general, appear to have a higher incidence of prior physical or sexual abuse, and the same appears to be true for women who experience chronic pelvic pain. Do not be afraid to tell your health care provider if you have ever been, or are currently being, hurt by someone, or if you feel unsafe.

DIAGNOSIS OF THE CAUSE OF CHRONIC PELVIC PAIN

Because a number of different conditions can cause chronic pelvic pain, it is sometimes difficult to pinpoint the specific cause.

History and physical examination — A thorough history and a physical examination of the abdomen and pelvis are essential components of the work-up for women with pelvic pain. In particular, the examination should include the lower back, abdomen, hips, and pelvis (internal examination).

Laboratory tests, including a white blood cell count, urinalysis, tests for sexually transmitted infections, and a pregnancy test may be recommended, depending upon the results of the physical examination.

Pelvic ultrasound — Some diagnostic procedures may also be helpful in identifying the cause of chronic pelvic pain. As an example, a pelvic ultrasound examination is accurate in detecting pelvic masses, including ovarian cysts (sometimes caused by ovarian endometriosis) and uterine fibroids. However, ultrasound is not helpful in the diagnosis of irritable bowel syndrome, diverticulitis, or painful bladder syndrome.

Laparoscopy — A surgical procedure called a laparoscopy may be helpful in diagnosing some causes of chronic pelvic pain such as endometriosis and chronic pelvic inflammatory disease. Laparoscopy is a procedure that is often done as a day surgery. Most women are given general anesthesia to induce sleep and prevent pain. A thin telescope with a camera is inserted through a small incision just below the navel. Through the telescope, the surgeon can see the contents of the abdomen, especially the reproductive organs. If the laparoscopy is normal, the physician can then focus the diagnostic and treatment efforts on non-gynecologic causes of pelvic pain.

If the laparoscopy is abnormal (example:- areas of endometriosis or abnormal tissue are seen) these areas may be treated or biopsied during the procedure.

COPING WITH CHRONIC PELVIC PAIN

Psychological counseling may be offered to help women manage their pelvic pain. There are several types of psychosocial support:

  • Psychotherapy involves meeting with a psychologist, psychiatrist, or social worker to discuss emotional responses to living with chronic pain, treatment successes or failures, and/or personal relationships. Psychotherapy called cognitive behavioural therapy has been found to be helpful for many people with chronic pain.
  • Group psychotherapy allows people to compare their experiences with chronic pelvic pain, overcome the tendency to withdraw and become isolated in pain, and support one another’s attempts at more effective management.
  • Online or local support groups that deal with chronic pain may also be helpful, such as the American Chronic Pain Association (theacpa.org) and the American Academy of Pain Management (www.aapainmanage.org/links/Links.php).
  • Relaxation techniques can relieve musculoskeletal tension and may include meditation, progressive muscle relaxation, self-hypnosis, or biofeedback.

CHRONIC PELVIC PAIN TREATMENT

Chronic pelvic pain has multiple possible treatments that can be combined if needed.

Medical treatment

  • One approach to managing women with chronic pelvic pain is to prescribe sequential drug treatments for disorders that are the most likely causes of the patient’s pain. As an example, endometriosis is the most common gynecological cause of chronic pelvic pain. If endometriosis seems a likely diagnosis based upon the history and physical examination, then a medical therapy for endometriosis is given for a trial period. If this is not successful, then a trial of another medical therapy is initiated. If one of these treatments relieves the pelvic pain, then the likelihood that endometriosis is the cause of pain increases. However, it is important to note that improvement in symptoms is not an absolute confirmation of a diagnosis since the treatment effects are often not specific. As an example, hormonal treatment of endometriosis may also improve pelvic congestion syndrome, irritable bowel syndrome, or interstitial cystitis/painful bladder syndrome
  • A different approach is to use intensive diagnostic testing in an attempt to identify the specific cause of the patient’s pain, if possible, before starting specific therapy. Although therapy targeted specifically to the patient’s diagnosis might appear ideal, arriving at a diagnosis may involve costly laboratory and imaging tests, and often requires exploratory surgery.
  • A third option is a treatment directed at pain, rather than at a specific diagnosis. Nonsteroidal anti-inflammatory drugs, antidepressants, and anticonvulsive medications are often used.

Physical therapy — Pelvic floor physical therapy (PT) is often helpful for women with abdominal myofascial pain and with pelvic floor pain. This type of PT aims to release the tightness in these muscles by manually “releasing” the tightness; treatment is directed to the muscles in the abdomen, vagina, hips, thighs, and lower back. Physical therapists who perform this type of PT must be specially trained. (See “Patient education: Treatment of interstitial cystitis/bladder pain syndrome (Beyond the Basics)”.)

Pain management clinics — If medications are not effective in treating the pain, a woman may be referred to a medical practice specializing in pain management. Pain services utilize multiple treatment modalities including

  • Acupuncture
  • Biofeedback and relaxation therapies
  • Nerve stimulation devices
  • Injection of tender sites with a local anesthetic (eg, lidocaine, Marcaine)

Pain services can help women who are on opioids or narcotics for pain management.

Surgical treatment — A few causes of gynecologic pelvic pain can be treated surgically. For example, some women benefit from surgical removal of their endometriosis.

Hysterectomy may alleviate chronic pelvic pain, especially when it is due to uterine disorders such as adenomyosis or fibroids. However, pain can persist even after hysterectomy, particularly in younger women (those less than 30) and in women with a history of chronic pelvic inflammatory disease or pelvic floor dysfunction. Hysterectomy is not a good choice for the management of chronic pelvic pain in women who have not completed their family. (See “Patient education: Abdominal hysterectomy (Beyond the Basics)” and “Patient education: Vaginal hysterectomy (Beyond the Basics)”.)

Surgery to cut some of the nerves in the pelvis (presacral neurectomy) has also been studied as a treatment for chronic pelvic pain. However, this approach has shown effectiveness mostly for endometriosis pain and has additional surgical risks, so it is not recommended for most women.

WHERE TO GET MORE INFORMATION

Your healthcare provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our website (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

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