Chronic pelvic pain is defined as cyclic or acyclic pain that emanates from the pelvic area and has been present for 6 months or more. Symptoms include premenstrual pain, dysmenorrhea, dyspareunia, exercise-related pain, cramping, and deep, unilateral, or generalised pain with or without menstrual exacerbation.
In the UK today chronic pelvic pain is one of the most common reasons for referral to a gynaecology clinic and for a woman to see her GP. In fact, it is said to affect 38 in 1,000 women, about the same prevalence as asthma (37/1,000) and chronic back pain (41/1,000) , and it accounts for a fifth of all patient gynaecological referrals. The management of chronic pelvic pain can be frustrating, because the possible cause can be gynecologic or nongynecologic. Symptoms vary, and often do not correlate with laparoscopic findings.
A number of potential causes include: endometrioses, interstitial cystitis, pelvic injury, pelvic inflammatory disease and most often pelvic congestion syndrome. All of these are currently difficult to diagnose and treat because of the complicated design of the pelvis. Currently 61 per cent of women who experience chronic pelvic pain at some time during their lives never receive a specific diagnosis for their symptoms . According to the International Pelvic Pain Society, the personal cost to those suffering from pelvic pain is immense, leaving sufferers’ bed ridden for an average of three days a month.
The First Signs
Chronic pelvic pain is usually first noticed with pain below the bellybutton and near the hips, followed by pressure or heaviness deep within the pelvis. Women may also suffer from intense pain during intercourse, pain while having a bowel movement or even when sitting down. The pain may intensify after standing for long periods and may be relieved when lying down. In some cases chronic pelvic pain can be so intense that sufferers are unable to work, continue their daily routine or exercise. The level of pain can vary from mild to severe and can range from annoying to disabling.
It further presents with a wide range of symptoms, which can include: physical symptoms (pain, trouble sleeping and loss of appetite); psychological symptoms (depression); and changes in behaviour (change in relationships due to physical and psychological problems.)
A woman with chronic pelvic pain must undergo a systematic and thorough investigation to rule out a variety of conditions. These include gynecological, gastrointestinal, urological, neurological, and musculoskeletal diseases. Gynecological conditions that can cause pelvic pain include fibroids, adenomyosis, endometriosis, pelvic inflammatory disease, pelvic adhesions, ovarian diseases (such as a cyst), and fallopian tube diseases. If gynecologic causes have been excluded, gastrointestinal evaluation may be required to rule out such conditions as inflammatory bowel disease, diverticulitis and irritable bowel syndrome. Urological conditions which may cause pelvic pain include bladder infection, urolithiasis (stones in the urinary tract) and urethral inflammation.
Sometimes chronic pelvic pain is psychosomatic. In 50% of women with chronic pelvic pain a history of childhood sexual abuse can be identified. Therefore, when all organic causes of pelvic pain have been ruled out, a psychological evaluation is essential. Occasionally chronic pelvic pain is found to be associated with congestion of the pelvic veins (pelvic varicose veins). The diagnosis of pelvic varicocities requires special imaging studies, such as pelvic venography or ultrasound.
Chronic pelvic pain has been associated with a number of conditions; some of the more common causes of chronic pelvic pain are outlined below.
Endometriosis is a condition in which tissue from the uterine lining (endometrium) grows outside the uterus. The deposits of tissue respond to the menstrual cycle, just as the uterine lining does – thickening, breaking down and bleeding each month as hormone levels rise and fall. Because it happens outside the uterus, the blood and tissue can’t exit the body through the vagina and can become trapped in the abdomen, which can lead to painful cysts and adhesions. Endometrial deposits can also occasionally be found in or on the bowel, in or on the bladder, in scars from operation and in the lungs. Endometriosis is very common affecting about 2 million women in the UK. And one of the main accompanying symptoms of endometriosis is chronic pelvic pain.
Chronic Pelvic Inflammatory Disease (PID) is generally described as an infection and inflammation of the upper genital tract in women. Organs related to reproduction are usually affected including the uterus, fallopian tubes and ovaries. The scarring that usually occurs from PID can lead to infertility, ectopic pregnancy, chronic pelvic pain, abscesses and other similar problems. Particularly at risk are women who have previously suffered from PID and those at risk for sexually transmitted infections (STIs). It is often difficult for women to know whether they are suffering from PID as they might not experience any symptoms. However, many thousands of women are treated for PID every year in the UK.
Pelvic Congestion Syndrome usually presents with symptoms of chronic pelvic pain, congestive dysmenorrhoea, deep dyspareunia and problems related to fluid retention. Pelvic congestion is caused by blood backing up in the veins inside a woman’s pelvis. Patients are known to have excessive cervical secretion which in turn can cause vaginal discharge and women may also complain of lack of libido and failure to achieve orgasm. The chronic pelvic pain associated with pelvic congestion syndrome often worsens when the patient is walking, standing or premenstrual.
Fibroids are known to be the most common growths in a woman’s reproductive system, especially growing in the uterus. Some women may not feel any symptoms, whilst some will suffer from heavy bleeding and pain and also incontinence or fertility. Fibroids are not cancerous and form from muscle fibre; they can vary greatly in size from being as small as a pea to the size of a melon. It is estimated that 20-50 percent of women have, or will have, fibroids at some time in their lives. It is most common in women in their 30s and 40s, and tend to shrink after menopause.
Determining the Source
Determining the source of chronic pelvic pain can be a difficult endeavour and it often involves a process of elimination, since numerous conditions could be responsible.
A Pelvic examination can often reveal signs of infection, abnormal growths and cysts or tense pelvic floor muscles. A thorough pelvic examination might also include the checking of cultures for infection, including sexually transmitted infections.
Laparoscopy is currently the most common procedure of identifying chronic pelvic pain; this is done by way of checking abnormal tissues or signs of infection in the pelvis. The most common indications during a diagnostic laparoscopy include a mass identified by pelvic exam or ultrasound. Other symptoms include: progressive dysmenorrhoea, unresponsive to oral contraception or steroidal anti-inflammatory drugs (NSAIDs), painful irregular vaginal bleeding, and any diagnostic dilemma such as suspected chronic PID or chronic appendicitis.
Transcervical Pelvic Venogram (TPV) Set is designed to diagnose Pelvic Congestion Syndrome, one of the many causes of chronic pelvic pain. The TPV set, developed jointly by Cook Women’s Health and physician members of the International Pelvic Pain Society, is a new breakthrough device to diagnose pelvic congestion syndrome. The TPV set injects a water-soluble contrast medium into the uterine cavity and then into the lining of the uterus to perform a pelvic venography.
This provides physicians with a clear look at what is taking place within the pelvis. The physician can measure the amount of time it takes the fluid to travel through the pelvic veins, if the fluid is slow moving, that indicates a possible congestion. From this point physicians continue to track the amount of time it takes the fluid to travel – the longer this takes the higher the severity of congestion. It allows physicians to fine tune diagnosis and determine the best treatment option for the patient based on the severity of their congestion.
A number of different treatments have proven successful in patients in the past, some of which are outlined below.
General over-the-counter pain relief may provide short-term relief from the painful symptoms associated with chronic pelvic pain. Often hormone treatments are chosen as some pelvic pain is tied to the menstrual cycle and the hormones the body produces. Stopping ovulation by using birth control pills or other hormone medications may help control cyclic pelvic pain. This method usually works if the pain occurs in patients at specific times during the month, linking it to a women’s menstrual cycle.
Often chronic pelvic pain is linked to the nervous system and procedures to control the pain impulses sent to the pelvic region might reduce the pain or stop it altogether. Such procedures, called nerve separation (ablation), will include excising the targeted nerves, injecting a medicine into the nerve to block its sensitivity or using heat or a laser to destroy nerve tissue.
Self-care techniques can often ease at least some of the discomfort. Relaxation, deep breathing, and targeted stretching exercises for the pelvic region can help minimise bouts of pain when they occur. It is also important to receive emotional support. Chronic pain can trigger some intense, negative emotions, such as pain, grief and anger, which can affect a woman’s self-esteem and her relationships with others.
Acknowledging and talking about their feelings is the first step toward emotional health. Stress management can also be an important step to good health.
Surgery is often undertaken as a last resort to correct pelvic adhesions or endometriosis deposits through laparoscopic surgery. A hysterectomy is seen as the very last option and in most cases it is not advised.
It is important to ensure that all women suffering from chronic pelvic pain are informed of the diagnostic and treatment options available to ensure they are able to lead a pain-free and comfortable life.
- 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: 1149-55. [PubMed].