What is Chronic Pelvic Pain (Longterm pain in the Pelvis)?
Chronic pelvic pain is a long-lasting pain that occurs in the pelvic area of women and can be debilitating. This type of pain is quite common and is often tied to other issues like irritable bowel syndrome, severe depression, or pelvic inflammatory disease. In the United States, one in seven women experiences chronic pelvic pain, making it as common as migraines, asthma, and chronic back pain. This type of persistent pain in a certain region is called a chronic regional pain syndrome.
Usually, doctors diagnose chronic pelvic pain if a woman has been experiencing pelvic pain for three to six months. The diagnosis often relies on the patient’s medical history and physical examinations, and several associated symptoms or triggering factors can help identify the condition. However, imaging tests and lab work may not always be helpful in diagnosing chronic pelvic pain. Instead, these tests are often more useful in diagnosing the other medical conditions associated with the pain. Still, about half of chronic pelvic pain cases remain undiagnosed.
Chronic pelvic pain often becomes a type of centralized pain, whereby the body becomes more sensitive to pain after a period of recurring pain. For instance, if a woman suffers from endometriosis, the acute pain from that condition can become chronic and centralized over a span of three to six months. As a result, even mild previously pain can be experienced as severe, a phenomenon known as hyperalgesia. In some situations, even ordinary touch can be perceived as painful, a condition referred to as allodynia. Chronic pelvic pain is often linked to past physical or emotional trauma and can be related to a somatic pain syndrome, a condition where pain is experienced bodily but has no identifiable physical cause.
Treating chronic pelvic pain can be complicated with limited options backed by research. Typically, treatment strategies focus on addressing the suspected source of the pain, such as treating an associated mood disorder, nerve damage, or uterine dysfunction. Chronic pelvic pain affects an estimated four to sixteen percent of women. This widespread prevalence demands a keen eye from doctors to detect and diagnose it early. Managing this condition calls for a multidisciplinary approach involving different medical specialists that work together to provide adequate pain relief. Treatment can range from psychotherapy and hormone therapy to more intensive procedures like spinal cord stimulation or total hysterectomy.
What Causes Chronic Pelvic Pain (Longterm pain in the Pelvis)?
Chronic pelvic pain is linked with a range of different issues, including irritable bowel syndrome, interstitial cystitis, and unexplained ongoing fatigue. It can also be associated with mental health conditions like post-traumatic stress disorder and major depression. The diagnosis and treatment often focus on any related conditions that may be causing the pain.
More than half of chronic pelvic pain cases come with other conditions like endometriosis, pelvic adhesions, or interstitial cystitis. In fact, it’s common for several of these problems to occur all at once alongside the pelvic pain.
Chronic pelvic pain is a type of reflex dystrophy, which means there are both neurological and psychological components to it. It’s believed that the pain becomes centralized, meaning that patients can develop a heightened sense of pain and sensitivity due to dysfunction in the pelvic floor muscles.
A variety of conditions can lead to this chronic pain, including chronic cystitis, endometriosis, adhesions, or musculoskeletal injuries. Often, women experience this pain for over two years before seeking medical help. The ongoing nature of this pain can alter the central nervous system, making it respond to various stimuli as if they were painful.
It’s also important to mention that chronic pelvic pain can either be widespread or more concentrated. Patients with widespread pain symptoms such as pelvic pain combined with pain in multiple limbs, the spine, and above the diaphragm often have significant psychological conditions like generalized anxiety disorder, major depression, and post-traumatic stress disorder. The mental and emotional state of the patient can influence the amount of visceral pain, including chronic pelvic pain. Patients with such widespread symptoms require a longer duration of treatments compared to patients with more focal pelvic pain.
Finally, individuals suffering from chronic pelvic pain often have higher rates of depression, anxiety, and sleep disorders. This could be the result of past traumatic experiences or childhood sexual abuse. At the same time, changes in the body due to different health issues could also contribute to the development of chronic pelvic pain. Conditions like leiomyomas, nerve root entrapment, sacral cysts, and cauda equina syndrome have all been linked with chronic pelvic pain. Smokers, those in a poor state of mental health, and those who have experienced multiple episodes of pelvic inflammatory disease are also at a greater risk. Unfortunately, in many cases of chronic pelvic pain, irritable bowel syndrome was left undiagnosed or untreated prior to the diagnosis. Similarly, endometriosis has been linked with both chronic pelvic pain and irritable bowel syndrome.
Risk Factors and Frequency for Chronic Pelvic Pain (Longterm pain in the Pelvis)
Chronic pelvic pain is a condition that often occurs with other health issues. It is estimated that 35% of patients with this condition also have irritable bowel syndrome. About 61% of women with bladder pain syndrome, and close to 50% of women with endometriosis, also deal with chronic pelvic pain. This condition is prevalent in about 4 to 16% of women, but only a third of those suffering seek medical care. With chronic pelvic pain, 20% of patients also have gynecological issues.
- Urological and gastrointestinal problems are more common, but endometriosis is the most frequent issue associated with people seeking medical care for pelvic pain.
- Between 20 to 80% of those with chronic pelvic pain who choose to have surgery are diagnosed with endometriosis.
- 70% of patients who were previously diagnosed with endometriosis are then diagnosed with chronic pelvic pain.
- Chronic pelvic pain is found in 99% of female patients.
- People who have had a history of pelvic trauma or surgery are at a significantly increased risk of developing this condition.
- After elective cesarean delivery, 28% of women develop long-lasting pelvic pain, and 20% still have this pain six months after surgery.
- About half of women with chronic pelvic pain report past experiences of sexual or physical abuse.
- One in three patients with both a history of abuse and chronic pelvic pain also have posttraumatic stress disorder.
- Up to 30% of women with a previous history of pelvic inflammatory disease develop chronic pelvic pain.
- About a quarter of patients who undergo a hysterectomy due to chronic pelvic pain from adenomyosis still experience pain after surgery.
Signs and Symptoms of Chronic Pelvic Pain (Longterm pain in the Pelvis)
If you think you might be suffering from chronic pelvic pain, your symptoms might include consistent or recurring pain in your pelvis that has lasted for more than six months. This pain isn’t linked to pregnancy and could be either constant or repeating in cycles. While chronic pelvic pain can sometimes be connected to your menstrual cycle, it can also present alongside other symptoms like problems with digestion, urination, sexual activity, mental health, and menstruation. Sometimes, this pain can also affect your overall quality of life.
To understand what might be causing this pain, your doctor will ask about your medical history, including past sicknesses, surgeries, gynecological issues, childbirths, and any treatment you’ve received in the past. They’ll want to know if your pain is triggered or relieved by certain factors, like menstruating, urinating, having sex, or moving bowels. They’ll also be interested in whether you experience pain in other areas, which might suggest that the pain is actually coming from a non-visceral or non-organ source. It might also be necessary to evaluate for mental health disorders, as these could be connected to your pelvic pain.
Your doctor will also perform a physical examination to check for any telltale signs of an underlying problem. This will include looking at your external genitalia, checking your pelvic floor muscles for any tenderness or tightness, and assessing your abdomen. They’ll also feel for any abnormalities in your uterus or its surroundings, and check for pain in your lower back, sacroiliac joint, and pelvis.
There are a few red flag symptoms to watch out for. If you notice bleeding after sexual activity, bleeding or pain onset after menopause, unexplained weight loss, a pelvic mass, or blood in your urine, this suggests that you might have a systemic disease, and it’s very important to consult a doctor. Women with chronic pelvic pain also have more asymmetry in their iliac crest height and symphyseal levels.
One technique your doctor might use is called the Carnett test. For this test, you’ll lie on your back and raise both your legs off the table. The doctor will then apply pressure to the area where you’re experiencing pain. If the pain increases when your abdominal muscles are contracted as you lift your legs, this suggests that the pain is caused by a problem with your fascia or muscles, not your organs.
A good understanding of your symptoms and history, along with a comprehensive physical examination, will aid your doctor in diagnosing the cause of your chronic pelvic pain.
Testing for Chronic Pelvic Pain (Longterm pain in the Pelvis)
To diagnose chronic pelvic pain, doctors consider your medical history and perform a physical examination. If these indicate a specific cause of your pain, further tests can confirm the diagnosis.
One method involves tapping a cotton swab on your abdomen. This test can determine whether there is a skin-related source of pain, a condition known as cutaneous allodynia. Specifically, this test is quite accurate for patients suffering from chronic pelvic pain.
Evaluating how the pain impacts your life and daily routines is also important. This can be done through a standardized questionnaire.
The starting point in evaluating a patient with suspected chronic pelvic pain involves checking for any red flag symptoms which might point to severe conditions or possible cancer. If there aren’t any, and no clear diagnosis is possible, then further tests like a complete blood count, inflammation marker test, urinalysis, pregnancy test, and tests for gonorrhea and chlamydia can be done. In addition, a pelvic ultrasound can be performed to rule out any physical abnormalities.
Pelvic ultrasound is crucial as it can help identify cysts, lumps, and a condition known as adenomyosis. It can also identify a condition called hydrosalpinx, which can suggest pelvic inflammatory disease, a common issue in patients with chronic pelvic pain.
If the patient is in severe pain, or there’s a chance of an acute abdomen (a sudden, severe abdominal condition), the patient may need laparoscopic surgery or be sent to the emergency department. If no clear cause of pain is found after surgery, the chronic pelvic pain may be due to a syndrome known as chronic regional pain syndrome.
Doctors may also use a diagnostic nerve block to determine if chronic pelvic pain is due to nerve dysfunction. This involves numbing a nerve root in the lower back to see if the pain subsides. Another method used during laparoscopic surgery is pain mapping, where the doctor probes the patient’s tissue to determine the specific area causing the pain.
Treatment Options for Chronic Pelvic Pain (Longterm pain in the Pelvis)
The research on how to best treat long-term pelvic pain is limited. The main goal of treatment for this type of pain, when we don’t know the cause, often focuses on relieving symptoms. The treatment approach should not only address the physical cause of the pain, but also consider any psychological aspects, including any accompanying mental health conditions.
If the source of chronic pelvic pain is known, the treatment will focus on treating the identified disease. However, if the source of the pain isn’t known, further investigation into the cause is recommended.
The first step in treatment often begins with over-the-counter pain relievers, like acetaminophen or nonsteroidal anti-inflammatory drugs. If these relieve the pain, no further pain management may be necessary at the time. However, if the pain doesn’t lessen, and occurs in a cycle, hormonal replacement therapy (like birth control pills or an intrauterine device) might be suggested. If hormones aren’t effective or the pain isn’t cyclical, then the patient might be assessed for a possible mood disorder. Antidepressant therapy may be recommended if a mood disorder is detected.
If the patient’s pain is thought to be neuropathic (related to nerve damage) and they don’t have a mood disorder, several treatment options might be suggested. These could include certain types of antidepressants, or epilepsy medication known to relieve nerve pain, depending on the patient’s individual conditions and preference.
However, if the pain is still not managed with these treatments, a referral to a pain medicine specialist may be necessary, with the consideration of prescribing stronger pain relievers, like opioids.
Physical therapy, especially ones focusing on the pelvic floor, posture, or movement strategies, can also be beneficial for chronic pelvic pain. In addition to physical therapy, cognitive-behavioral therapy performed with a psychologist or psychiatrist can also help reduce pain and stress, and improve how the patient functions day-to-day.
In severe cases, treatments that involve blocking nerve signals or modulating sacral (lower back) nerves may be necessary. Surgery like hysterectomy can be considered in certain conditions causing chronic pelvic pain, but it’s usually the last option.
Other treatment options such as injections with botulinum toxin (Botox) or local steroid can help to decrease pain. Trigger point injections can provide temporary relief and may be diagnostic for certain types of pain. If the injections are beneficial, it might indicate that the patient’s pain is related to tightened, or hypertonic, muscles of the pelvic floor or abdominal wall.
In all cases, patient education about their chronic pelvic pain, along with guidance on the psychological aspects of their pain, can be helpful.
What else can Chronic Pelvic Pain (Longterm pain in the Pelvis) be?
There are various reasons why someone might have long-term pain in the pelvic area, and it’s key to identify which of these might be causing the ailment. If pain persists in this area over time, it becomes chronic pelvic pain.
Several factors can lead to chronic pelvic pain, including:
- Gynecological causes – issues like endometriosis, pelvic infection, scar tissue in the pelvic region, recurring ovarian cysts, fibroids, changes inside the uterus muscles, blocked fallopian tubes or pain after having tubes tied
- Gastroenterological causes – conditions of the digestive system like irritable bowel syndrome, celiac disease (gluten intolerance), inflammatory bowel diseases, bowel cancer, or hernias
- Urological reasons – bladder-related problems like interstitial cystitis (also known as painful bladder syndrome), recurring bladder infections, radiated infection of the bladder, continuous bladder stones, bladder cancer, or pain in the urethra (tube that drains urine from the bladder)
- Musculoskeletal reasons – problems with the muscles or skeletons like pain in the abdominal wall muscles, fibromyalgia, tailbone pain, tension in pelvic floor muscles, or problems with a muscle in the buttocks
- Neurological or vascular problems – issues like trapped nerves in the groin area, pain related to the pudendal nerve in the pelvis, injuries to the spinal cord, pelvic congestion syndrome (varicose veins in the pelvis), nerve damage in the peripheries, or enlarged veins in the vulva
The five most common reasons for chronic pelvic pain are irritable bowel syndrome, musculoskeletal pain in the pelvic floor, painful bladder syndrome, nerve damage in the peripheries, and constant pain disorders of the uterus.
What to expect with Chronic Pelvic Pain (Longterm pain in the Pelvis)
After a gynecologic surgery designed to alleviate chronic pelvic pain, patients reported a 46% improvement in their pain and a 31% reduction in signs of any associated depression. However, the outlook is often not so positive for patients experiencing chronic pelvic pain, mirroring outcomes seen in other chronic pain conditions. The greatest improvements in life quality come from treating the root cause of the pain and any accompanying mood disorders.
Physical therapy, specifically pelvic floor therapy, can be an effective treatment method for chronic pelvic pain. Following completion of therapy, those with chronic pelvic pain used 22% fewer prescription pain medications than those who didn’t undergo therapy. Moreover, patients reported lesser pain and a decrease in the frequency and urgency of urination, particularly in cases where chronic pelvic pain arose from painful bladder syndrome.
In cases where the chronic pelvic pain originated from a gynecological cause, a hysterectomy provided 50% pain relief for 40% of patients. However, up to 40% of patients can expect chronic pelvic pain to continue, with 5% even reporting increased pain following surgery.
Patients with fewer concurrent health issues had a better outcome when dealing with chronic pelvic pain. It’s not yet clear when is the best time for patients with chronic pelvic pain to choose surgery as their treatment option. Adding to these challenges is the lack of long-term research studies on the treatment of chronic pelvic pain, with many studies only examining results over months and not years.
Pain mapping has been shown to reduce pain in approximately half of the patients dealing with chronic pelvic pain.
Possible Complications When Diagnosed with Chronic Pelvic Pain (Longterm pain in the Pelvis)
When talking about long-term pelvic pain, it’s crucial to consider any past trauma. Many women suffering from this consistent pelvic pain have experienced abuse and may also be dealing with post-traumatic stress disorder.
Women who choose to have an elective hysterectomy to address the gynecological causes of their pelvic pain might still feel pain after the operation.
People who use opioid painkillers to manage their pelvic pain may develop a tolerance to these drugs over time. As a result, they may need to take higher doses for the same level of pain relief.
Insomnia, or trouble sleeping, is a common problem for those with centralized pain disorders and needs to be treated appropriately.
Laparoscopic surgery, a minimally invasive surgical procedure, does not find the cause of the patient’s pelvic pain in forty percent of cases. Additionally, this surgery, as well as a hysterectomy, come with several risks, including infection and bleeding.
Preventing Chronic Pelvic Pain (Longterm pain in the Pelvis)
People suffering from chronic pelvic pain need to understand that their condition has multiple causes. To help improve their health, it’s vital for them to get regular exercise, lots of sleep, and maintain a well-balanced diet. It’s also essential that they stay open and communicate promptly with their healthcare professionals, and never skip any prescribed medications or treatments. This will help manage their pain and improve their quality of life.
