Chronic Pelvic Pain: Causes, Diagnosis, and Treatment Options

In short: Chronic pelvic pain is pain below the navel and between the hips that lasts for months. Causes include endometriosis, chronic pelvic infection, fibroids, irritable bowel, muscle and bone problems and psychological factors. Treatment includes painkillers, hormones, antibiotics and psychological support, with laparoscopy in some cases. See the doctor if the pain continues or does not respond to painkillers.

Chronic pelvic pain is a complex topic because so many different conditions and diseases can cause it. If you have been living with ongoing pelvic discomfort, understanding the possible causes is an important first step toward finding relief.

WHAT DEFINES CHRONIC PELVIC PAIN?

Chronic pelvic pain is pain in the lower abdomen lasting at least six months, severe enough to affect your quality of life or require treatment.

HOW COMMON IS CHRONIC PELVIC PAIN?

Chronic pelvic pain is more common than many women realise: about 15% of women report it, and 4% say the pain is severe enough to miss work. It is the reason for about 40% of gynecologic laparoscopies and about 10 to 15% of hysterectomies.

WHAT ARE THE GYNECOLOGIC CAUSES OF CHRONIC PELVIC PAIN?

Gynecologic causes include:

• Endometriosis: the presence of endometrial-like tissue outside the uterine cavity. This is one of the most common gynecologic causes and is found in about one third of women with chronic pelvic pain who have a laparoscopy.
• Pelvic Inflammatory Disease (PID): an infection of the upper genital tract (tubes, ovaries, and uterus) caused by an untreated sexually transmitted infection. 30% of women with PID will develop chronic pelvic pain due to scar tissue from the infection.
• Pelvic adhesions: dense fibrous bands from infection, endometriosis, or prior surgery can cause chronic pelvic pain. Mild adhesions may not be the cause of the pain. Adhesions involving the bowel can cause abdominal bloating, constipation, and pain. Adhesions involving the uterus and bladder are often found in patients with multiple cesarean deliveries.
• Pelvic Congestion Syndrome: dilated uterine and ovarian veins found on a pelvic ultrasound or pelvic MRI. Dilated veins can also be found in women without symptoms.
• Adenomyosis: the presence of endometrial glands in the myometrium, often linked to increased parity, causing heavy bleeding and pain with menstruation. Pain is due to bleeding and enlargement of endometrial glands in the uterine muscle.
• Pelvic Mass: pain can be caused by torsion or pressure of the mass on adjacent organs.
• Fibroids: fibroids can cause pressure symptoms. Acute pain can occur due to degeneration, twisting, or expulsion of the fibroid through the cervix.

WHAT ARE THE UROLOGIC CAUSES OF CHRONIC PELVIC PAIN?

Interstitial cystitis / painful bladder syndrome

Recurrent urinary tract infection

Urethral diverticulum

Bladder cancer.

WHAT ARE THE GASTROINTESTINAL CAUSES OF CHRONIC PELVIC PAIN?

• Irritable Bowel Syndrome (IBS): characterized by chronic or intermittent abdominal pain associated with bowel function or dysfunction. About 10% of the general population has symptoms compatible with IBS; women are diagnosed more than twice as often as men.
• Inflammatory Bowel Disease:

Crohn’s disease and ulcerative colitis cause fatigue, diarrhea, abdominal cramps, weight loss, fever, and rectal bleeding.

• Diverticulitis
• Colon cancer

Chronic constipation

Celiac disease.

WHAT ARE THE MUSCULOSKELETAL CAUSES OF PELVIC PAIN?

• Fibromyalgia: a disorder of widespread pain in many areas of the body for at least 3 months, often with tiredness, poor sleep and poor concentration.
• Pelvic floor muscle spasms
• Chronic abdominal wall pain
• Inflammation of the pubic bone
• Hip joint and muscle tendon abnormalities.

WHAT MENTAL HEALTH ISSUES CAN CONTRIBUTE TO CHRONIC PELVIC PAIN?

Drug seeking and opiate dependency

Physical and sexual abuse experience

Depression and somatization disorders.

SYMPTOMS of Chronic Pelvic Pain

The nature of pelvic pain can be acute (sudden), chronic, intermittent, or cyclic.

Cyclical pain is usually associated with the menstrual period.

Pain can also be associated with voiding, bowel motion, physical activity, or intercourse.

DIAGNOSIS of Chronic Pelvic Pain

Medical history

Physical examination

Psychological assessment and counseling.

WHAT RADIOLOGIC IMAGING IS USED FOR DIAGNOSIS OF PELVIC PAIN?

Pelvic ultrasound detects pelvic masses and fibroids.

In experienced hands, transvaginal ultrasound is the first test used to tell whether an ovarian mass looks benign or suspicious, and it can also detect adenomyosis, endometriomas and deep endometriosis.

MRI is better for identifying pelvic masses and diagnosing adenomyosis.

CT scan can detect diverticular disease and pelvic masses.

WHAT LABORATORY STUDIES ARE USED FOR DIAGNOSIS OF PELVIC PAIN?

Blood test

Urine test

Cervical swab to check for Chlamydia and gonorrhea infection when infection is suspected

A pregnancy test should be done in any woman who could be pregnant, to rule out ectopic pregnancy.

WHY IS LAPAROSCOPIC SURGERY USED FOR PELVIC PAIN?

Our article on keyhole surgery in gynecology describes how this examination of the pelvis is performed.

To diagnose pelvic adhesions and endometriosis.

[Laparoscopy can diagnose and treat conditions such as endometriosis and adhesions at the same time, but it is no longer the first step: it is usually offered when ultrasound or MRI and medical treatment have not explained or controlled the pain, or when surgery is needed. One large study revealed the following findings during laparoscopy in women with chronic pelvic pain:

35% had no visible abnormalities, 33% had endometriosis, 24% had adhesions, 5% had PID, and 3% had ovarian cysts.

WHEN WOULD ADDITIONAL SURGERY BE NECESSARY?

There is a chance of recurrence in cases of endometriosis, pelvic adhesions, ovarian cysts, and fibroids, so patients may experience recurrent pelvic pain requiring a repeat laparoscopy for treatment.

WHAT IF LAPAROSCOPY DOES NOT SHOW ANY ABNORMALITIES?

If no abnormality is detected by laparoscopy, cystoscopy or colonoscopy may be advised when there are bladder or bowel symptoms, to rule out urologic and gastrointestinal causes; many women benefit from a multidisciplinary pain-management approach.

Cystoscopy: this procedure helps detect a bladder tumor and interstitial cystitis. Colonoscopy: this procedure helps detect colon tumors and inflammatory bowel disease.

• TREATMENT of Chronic Pelvic Pain

IS TREATMENT BEFORE DIAGNOSIS (EMPIRIC TREATMENT) APPROPRIATE?

Empiric treatment can be used in cases of suspected endometriosis, especially if the patient prefers to avoid a surgical procedure, but a satisfactory response does not confirm the diagnosis.

Prolonged treatment may be necessary to evaluate improvement in symptoms.

It may not be effective in cases of moderate and severe endometriosis.

WHAT CONDITIONS ARE TREATED WITH MEDICATIONS?

• PID: treated with a combination of broad-spectrum antibiotics. In some instances, hospital admission is needed for IV antibiotics.
• UTI: oral antibiotics. Simple cystitis can be treated in three to five days. Recurrent cystitis sometimes requires daily antibiotic therapy for suppression. Hospitalization and IV antibiotic therapy are required in cases of complicated renal infections.
• Irritable Bowel Syndrome: modifications in diet, behavioral changes, medications, and psychotherapy are used.
• Interstitial Cystitis/Painful Bladder Syndrome: no curative therapy exists. Ongoing physical and pharmacologic therapies are used to control symptoms.
• Pelvic Congestion Syndrome: this diagnosis is controversial; progesterone injections have shown effectiveness for some patients.

WHAT CONDITIONS ARE TREATED WITH SURGERY?

• Adhesions: laparoscopic adhesiolysis is most effective in patients with dense adhesions and adhesions involving the bowel. * Adenomyosis: medical treatment such as a hormonal IUD (Mirena) or progestogen tablets is usually tried first; hysterectomy, usually laparoscopic, is the definitive treatment for women who have completed their family and whose symptoms persist.
• Endometriosis: laparoscopic resection of endometriosis implants. In cases of severe endometriosis, for women who have completed childbearing, hysterectomy with removal of all visible endometriosis is an option; whether to remove the ovaries as well depends on age and should be discussed carefully.
• Pelvic/Ovarian Mass: this includes removal of the mass with or without removal of the ovary. Preservation of the ovary depends on several factors.
• Pelvic congestion syndrome: surgical treatment options include hysterectomy and oophorectomy, embolization of the ovarian veins, sclerotherapy, and surgical ligation of the ovarian veins.
• Fibroids: myomectomy or hysterectomy are surgical treatment options.

LAPAROSCOPIC UTEROSACRAL NERVE ABLATION (LUNA)

LUNA involves resection of about a 2 cm segment of the uterosacral ligament to destroy the uterine nerve fibers located there. However, large studies have shown that LUNA does not improve chronic pelvic pain, and current guidelines no longer recommend it.

LAPAROSCOPIC PRESACRAL NEURECTOMY (LPSN)

LPSN is removal of the presacral nerve (superior hypogastric plexus), which carries pain signals from the uterus. This is a more delicate procedure because of the presence of large vessels and ureters near the area of dissection. It can be effective for central pelvic pain and menstrual pain, though success rates decline over many years.

ALTERNATIVE TREATMENT OPTIONS FOR CHRONIC PELVIC PAIN

Physical therapy

Trigger-point injections

Local anesthetic patches

Acupuncture

Psychotherapy

Behavioral and relaxation feedback therapies

Nerve stimulation

If chronic pelvic pain is affecting your daily life, you don’t have to manage it alone. Dr. Najeeb Layyous and his team welcome patients seeking a careful, thorough evaluation to better understand their symptoms and explore suitable next steps.

Dr Najeeb Layyous F.R.C.O.G

Consultant Obstetrician, Gynecologist and Infertility Specialist