Chronic Pelvic Pain
What is chronic pelvic pain?
Chronic pelvic pain refers to pain in the lower half of your abdomen, lasting six months or longer. The pain may be in a small specific area or it may be throughout the pelvis. Having long-standing pelvic pain is common, it affects around 1 in 6 women. Long-term pain can be very difficult to live with. It may cause you emotional, social and even economic difficulties. You may experience depression, difficulties in sleeping and a disruption to your daily routine.
Chronic pelvic pain is a complex problem. It is not a disease in itself, it is a symptom which can be caused by many conditions. Often, however, an easily treatable cause is not found, therefore, chronic pelvic pain becomes a condition treated in its own right focusing on symptom relief rather than treating the cause of the pain. Even if no reason can be found for the pain, there are still treatments which will improve the pain and many women find that the quality of their lives improves when they get a better understanding of what is involved.
Chronic pelvic pain is experienced differently by each woman. Pain may be:
Severe and constant
Pain that comes and goes (intermittent)
Sharp pains or cramping
Pressure or heaviness deep within your pelvis
It is often associated with
Pain during sex
Pain when using your bowels
Pain when you sit down
Your discomfort may intensify after standing for long periods and may be relieved when you lie down. The pain may be mild and annoying, or it may be so severe that you miss work, can't sleep and can't exercise.
What causes chronic pelvic pain?
Many conditions can cause chronic pelvic pain. It is often caused by a combination of physical, psychological and/or social factors, rather than a single underlying condition.
Sometimes we don’t find a specific cause. This does not mean that you don’t have real pain, just that a cause is not always easy to find. Gynecologic causes are thought to be the cause of chronic pelvic pain in about 20 percent of women. However, other diseases can cause pelvic pain. In addition, psychological factors may contribute to your pain.
Some causes of chronic pelvic pain include:
Endometriosis - a condition where cells of the lining of the womb (the endometrium) are found elsewhere in the body, usually in the pelvis. These deposits of tissue respond to your hormones, just like your uterine lining does. 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 scar tissue (adhesions).
Adenomyosis - a condition where the endometrium is in pockets within the muscle wall of the womb. This can cause heavy bleeding and pain with your period.
Pelvic inflammatory disease (PID) (an infection of the womb, fallopian tubes and/or pelvis) This can occur if an infection, often sexually transmitted, has caused scarring involving your pelvic organs.
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.
Musculoskeletal pain (pain in your joints, muscles, ligaments and bones) which may be perceived as pain in your pelvis
Irritable bowel syndrome (IBS) - In addition to pain it often causes bloating, constipation and/or diarrhoea in the absence of any other cause
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 – this may cause pelvic pain, pain with urination, difficulty urinating, constipation, pain with intercourse, or frequent/urgent urination. Sometimes this occurs in response to other conditions which have been causing pain. 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 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.
Ovarian remnant – sometimes after a hysterectomy(removal of uterus), ovarian tissue may become trapped beneath scar tissue and later develop painful cysts.
Understandably, all women who suffer from chronic pain regardless of the cause will have some psychological effect from it. Psychological factors, such as depression, chronic stress or a history of sexual or physical abuse may increase your risk of developing chronic pelvic pain. Emotional distress makes pain worse, and living with chronic pain contributes to emotional distress.
Should I See a Doctor?
If pain is bothersome, persistent and not settled with simple over the counter pain medication you should see your doctor.
What happens when I first see the doctor?
At your first appointment, you should have the chance to describe the pain you have experienced and discuss your anxieties. It often requires some extra time so make sure you book a longer appointment with your doctor.
Although at times you may feel you are repeating yourself, your story is important. The way you describe your symptoms is crucial in making a diagnosis. Your doctor will probably ask you a number of questions about:
the pattern of your pain
what makes your pain better or worse(certain sorts of movement, for example)
whether you have noticed other problems that might be linked to the pain (sex, bladder, bowel or psychological symptoms, for instance)
It is therefore, a good idea to start keeping a pain diary before your appointment. This involves noting down when your pain occurs, how severe it is, how long it lasts and the things that seem to affect it. A pain diary will also help you to describe your pain and to become more aware of the ways in which it affects you.
You may be asked about aspects of your everyday life including your sleep patterns, appetite and general wellbeing. You may also be asked about how you are feeling and whether you are feeling depressed or tearful. This is because long-term pain is known to cause depression, which in turn may make your pain worse. If your doctor knows how your pain is affecting you personally, this can be taken into account with your treatment.
Your doctor will then undertake a thorough physical examination. This may include a pelvic and rectal examination. A pelvic examination can reveal signs of infection, abnormal masses or tense pelvic floor muscles. Your doctor will check for areas of tenderness and changes in sensation. Let your doctor know if you feel any pain during this exam, especially if the pain is similar to the discomfort you've been experiencing.
What types of tests might I be offered?
Figuring out what's causing your pain often involves a process of elimination. Possible tests your doctor might suggest include:
Blood tests – to check for signs of infection
Vaginal swabs or urine tests – to check for infections
Ultrasound - This is usually a transvaginal scan (where the probe is gently inserted into your vagina) to look more closely at the uterus, fallopian tubes and ovaries. Usually this is not painful, however, if you have pelvic pain it may cause some tenderness
Other imaging tests. Your doctor may recommend abdominal X-rays, computerized tomography (CT) scans or magnetic resonance imaging (MRI) to help detect abnormal structures or growths.
These tests are usually arranged by your GP. If they have found a cause but are unable to treat it themselves or they have not found the cause they may refer you on to a specialist. This will probably be a gynaecologist, a urologist or bowel doctor depending on what your GP thinks is the most likely cause of your pain. Ask your GP to refer you to a specialist with a special interest in pelvic pain.
What Happens Next?
Your gynaecologist will review your history and examine you again. They may discuss performing a laparoscopy to help diagnose and treat the pain. During laparoscopy, your doctor makes a small incision in your belly button and inserts a thin tube attached to a small camera (laparoscope). The laparoscope allows your doctor to view your pelvic organs and check for abnormal tissues or signs of infection in your pelvis. 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 many cases, a clear explanation may never be found. With patience and open communication, however, you and your doctor can develop a treatment plan that helps you live a full life.
What treatment may help?
If your doctor can pinpoint a specific underlying cause, your treatment will focus on eliminating that particular cause. However, if you're unable to find the cause of your pelvic pain, treatment will focus on managing your pain. Treatment for long-standing pain usually involves multiple therapies and lifestyle changes. We do not have any treatments which will take the pain away instantly or completely. The focus of treatment is to achieve a level of pain that is tolerable enough that you may return to your usual activities.
Medications Depending on the underlying cause, your doctor may recommend a number of medications to treat your condition, including:
Pain relievers. Over-the-counter pain remedies, such as aspirin, ibuprofenor paracetamol may provide partial relief from your pelvic pain. Sometimes a stronger prescription pain reliever may be necessary. Pain medication alone, however, rarely solves the problem of chronic pain.
Hormone treatments. The days when you have pelvic pain may coincide with a particular phase of your menstrual cycle and the hormonal changes that control ovulation and menstruation. Birth control pills or other hormonal medications may help relieve cyclic pelvic pain.
Antibiotics. If an infection is the source of your pain, your doctor may prescribe antibiotics.
Antidepressants. Antidepressants can be helpful for a variety of chronic pain syndromes. Tricyclic antidepressants, such as amitriptyline, nortriptyline (Pamelor) and others, 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.
Therapies Your doctor may recommend specific therapies or procedures as a part of your treatment for chronic pelvic pain. These treatments may include:
Physical therapy and exercise. Applications of heat and cold to your abdomen, stretching exercises, massage and other relaxation techniques may improve your pain. A physiotherapist may recommend exercises to strengthen or relax your pelvic floor muscles. In addition, strength and aerobic exercise will help your feeling of general wellbeing. Your physiotherapist or doctor can advise you on what exercises are appropriate.
Transcutaneous electrical nerve stimulation (TENS). This approach may help improve localized or regional pain. During TENS therapy, electrodes deliver electrical impulses to nearby nerve pathways — which can help control or relieve some types of pain.
Counseling – recognizing the role that psychological factors play in worsening your symptoms is an important element in treating your pain
Trigger point injections. If your doctor finds a specific point where you feel pain, a possible treatment option is the direct injection of a numbing medicine into a painful spot (trigger point). The medicine, usually a long-acting local anesthetic, can block pain and ease discomfort.
Surgery To correct an underlying problem, your doctor may recommend a surgical procedure:
Laparoscopic surgery. In some instances, pelvic adhesions or endometrial tissue can be removed by laparoscopic surgery. During laparoscopic surgery, your surgeon performs an operation through several small incisions in your abdomen, using instruments with an attached camera.
Not all these treatments are appropriate for every woman. You will often need to try a combination of treatment approaches before you find what works best for you.
Are there any risks?
Your doctor or specialist practitioner should give you full detailed information about the risks and benefits of any investigation, surgical procedure and treatment suggested. There are no risks associated with having an ultrasound scan.
Are there any alternatives?
Non-medical therapies play an important role in managing chronic pelvic pain. Depending on your medical history, life situation and test results, your doctor may be able to tell you how likely these alternative therapies are to relieve your symptoms.
Learn strategies for managing stress. Becoming too anxious or stressed over certain situations may exacerbate chronic pain. Effective stress management techniques not only help reduce your stress levels but may also have the indirect effect of easing stress-triggered pain. Try to use relaxation and stress-reduction techniques that have worked for you in the past, such as exercise, yoga, meditation or simple deep breathing.
Acupuncture. 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 isn't safe if you're taking blood thinners or if you have low blood counts.
What might happen if I don’t have treatment?
Your doctor may not be able to predict what might happen for you as an individual.
For many women the pain gets better with time. Most women have no serious or life threatening problem underlying the pain. Many women find that they can cope better with their pain after they have been given a thorough explanation of the nature of the pain, including previous test results and possible causes of the pain. They can also cope better when they feel reassured that there is no serious or life-threatening disease present.
Is there anything else I should know?
You should visit your doctor if you experience any of the following:
bleeding from your rectum
a change in your bowel habits which has lasted for more than six weeks
new pain after you have passed the menopause
any unusual swelling in your abdomen
excessive weight loss
irregular vaginal bleeding, such as bleeding between periods, or vaginal bleeding after the menopause or vaginal bleeding during or after sex.
Chronic pelvic pain is a difficult and complex problem but you are not alone. No treatment will work all the time for everyone but we will find ways to improve your quality of life. You have the right to be fully informed about your health care and have the opportunity to share in making decisions about it. If you are not comfortable with the final diagnosis, you can ask for a second opinion or ask your GP to refer you to a doctor or clinic that specializes in managing chronic pain.
If you have any questions, please contact Dr. Goncalves,
Penticton Obstetrician and Gynecologist.