Chronic Pelvic Pain

Endometriosis is a condition in which endometrial tissue (tissue lining the inside of the uterus) is also present outside of the uterus. Each month during a woman’s menstrual cycle this tissue is stimulated by the menstrual cycle hormones and causes bleeding and scarring. Some women with endometriosis have no symptoms, while others experience marked discomfort and pain and may have problems with fertility especially if the endometriosis causes scarring of her fallopian tubes.

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. Chronic pelvic inflammatory disease occurs after acute pelvic inflammatory disease 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.
Other causes include non-gynecological causes of chronic pelvic pain and may be related to the digestive system, urinary system, or to pain in the muscles and nerves in the pelvis.

IBS is a gastrointestinal condition characterized by chronic abdominal and altered bowel habits such as loose stools, more frequent bowel movements with onset of pain, and pain relieved by defecation.

IC/PBS – are the terms given to bladder pain not caused by infection. Symptoms usually include urinary frequency and a feeling of urinary urgency. Some women with painful bladder syndrome have lower abdominal or pelvic pain in addition to urinary tract symptoms.

A diverticulum is a sac-like protrusion that may form in the muscular wall of the colon or intestine. Diverticulitis occurs when the diverticula become inflamed. This causes abdominal pain, nausea, vomiting, constipation, diarrhea, and urinary symptoms.

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.

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 (eg, areas of endometriosis or abnormal tissue are seen) these areas may be treated or biopsied during the procedure.

Chronic pelvic pain due to a gynecologic condition is often treated medically. In some cases, however, surgery may be the treatment of choice.
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 absolute confirmation of a diagnosis since 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 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.

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.

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.

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

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