Chronic Pelvic Pain

CHRONIC PELVIC PAIN

Surveys estimate that 1 in 3 women reports experiencing pelvic pain at some point in her life and about 9 million women suffer from chronic pelvic pain. Symptoms are sometimes very straight forward and a diagnosis easy to obtain. In other cases, a diagnosis is only reached after several options have been ruled out, or treatments have been less than effective. Unfortunately this takes time, while the pain remains. According to the International Pelvic Pain Society, nearly 15% of all American women ages 18-50 suffer from chronic pelvic pain, yet 61% still have no diagnosis. Why is a diagnosis so hard to find?

When pain changes from acute (less than 6 months in duration) to chronic, sometimes the initial injury or assault to the body has lessened or even disappeared, but the pain remains due to changes in the nervous system, muscles or other tissues. Sometimes the pain starts in one area, but ends up somewhere else. Have you ever hurt one ankle, only to develop pain in the other leg or foot? You were protecting the injured foot, only to strain the other. Or have you experienced a pinched nerve that caused pain down the arm or leg, not just at the place where the nerve was pinched? This is simplistic, but gives you an idea of how the systems in the body interact. It then becomes difficult to sort out the origin of the pain to determine an accurate diagnosis and effective treatment. Treatments must be aimed not only at the original problem, but the other systems that are now involved in causing the symptoms. As previously mentioned, some diagnoses are only reached after other diagnoses have been ruled out – either because the diagnostic tests didn’t support the diagnosis or the treatment(s) for that diagnosis didn’t help.

Prior to your appointment, spend some time organizing your history, symptoms and chronology of the problem. By that we mean: when did it start, does anything make it better or worse, what seems to affect it (menstrual cycle, constipation, sleep, or activity), what treatment and/or medication have you tried? Try to decide what concerns you most about your pain and how the pain most impacts your life. The answers to these questions will help you and your physician decide on a course of action.

Common causes of chronic pelvic pain:

Endometriosis causes chronic pelvic pain, particularly before or during periods as well as during or after intercourse. Endometriosis occurs when tissues that line the uterus grow outside the uterus, usually on the surfaces of organs in the pelvic and abdominal areas. When bleeding during menstruation occurs, these endometrial implants bleed into the pelvic region causing pain and inflammation. The most common symptoms of endometriosis are painful cramps or periods, heavy periods, chronic pelvic pain, intestinal pain, pain during or after intercourse, and infertility. Common treatments include medication, hormone therapy and surgery.

Pelvic adhesions are bands of fibrous scar tissue that can form in the abdomen and pelvis after surgery. Because adhesions connect organs and tissue that normally are separated, they can lead to a variety of complications including pelvic pain, infertility and bowel obstruction. The most common treatment for adhesions is surgery. Unfortunately, adhesions typically return after surgery because abraded surgical surfaces are created that lead to new adhesion formation.

A third cause of chronic pelvic pain is pelvic inflammatory disease (PID). This is a general term that refers to infection of the uterus (womb), fallopian tubes (tubes that carry eggs from the ovaries to the uterus) and other reproductive organs. PID occurs when bacteria move upward from a woman's vagina or cervix (opening to the uterus) into her reproductive organs. It can damage the fallopian tubes and tissues in and near the uterus and ovaries. Many different organisms can cause PID, but many cases are associated with gonorrhea and chlamydia, two very common sexually transmitted bacterial diseases. A prior episode of PID increases the risk of another episode because the reproductive organs may be damaged during the initial bout of infection. Untreated PID can lead to serious consequences including infertility, ectopic pregnancy (a pregnancy in the fallopian tube or elsewhere outside of the womb), abscess formation, and chronic pelvic pain. PID can be cured with several types of antibiotics.

Irritable bowel syndrome and chronic constipation can affect the lower urinary tract and cause chronic pelvic pain. Pelvic floor dyssynergia (abnormal activity of the pelvic floor) can also cause chronic pelvic pain. Studies suggest that up to 26% of women who have had a hysterectomy continue to experience persistent pelvic pain.

Vulvodynia is chronic itching, burning, stinging, stabbing, irritation or rawness of the area around the opening of the vagina. Pain may come and go, and may occur during intercourse, attempts to insert a tampon, or pelvic examination. It may also occur without any provocation. Often there is no redness or sign of irritation in the area. Unfortunately, some physicians are unaware of this condition, and may mistakenly suggest to patients that this is a psychological condition. The true cause has yet to be identified, however possible causes may be injury or irritation of the nerves to that area, genetic factors, localized hypersensitivity, or spasms of the muscles that support the pelvic organs. Since each woman’s symptoms are unique, no single treatment works all the time for everyone. It frequently takes time to find the treatment or combination of treatments that will decrease the symptoms. There are a variety of treatments including local anesthetics, medication, nerve blocks, creams, dietary changes, discontinuing possible irritants, biofeedback, physical therapy, and surgery.

The urgency and frequency associated with overactive bladder and recurrent urinary tract infections can cause chronic pelvic pain. Treatment is available for both of these conditions. Failure to respond to treatment may indicate another cause for these symptoms.

Urgency and frequency are lower urinary tract symptoms that can present as chronic pelvic pain. Interstitial cystitis (IC) is a chronic condition resulting in discomfort or pain in the bladder and the surrounding pelvic region. Symptoms vary and may include mild discomfort, pressure, tenderness, or intense pain in the bladder and pelvic area, that increases in severity during a woman’s period. Symptoms include urgency and frequency, with pain that intensifies as the bladder fills with urine or during sexual intercourse. Sometimes the act of urination relieves the bladder pain associated with filling. Although the symptoms resemble those of a urinary tract infection, there is no infection present, and antibiotics are not useful. Many women treated for recurrent urinary tract infections actually are suffering from IC. It is no surprise that the symptoms do not go away with antibiotic treatment. The cause of IC is unknown, although some women associate the onset of symptoms with a specific UTI, catheterization, or bladder or pelvic surgery. It is believed that the protective lining of the bladder breaks down and allows harmful substances in the urine to reach the nerves located in bladder wall. This causes inflammation and pain localized to the bladder. Diagnosis is made after other conditions are ruled out. There is no cure, so treatment is aimed at relieving symptoms. Treatments include bladder distention, bladder instillation (“bladder bath” or medication placed in the bladder for a specific amount of time then removed), and medication taken by mouth, electrical stimulation, changes in diet, bladder training, quitting smoking, and exercise.

The journey for women with chronic pelvic pain is frequently lonely and frustrating, and many women have difficulty finding a physician who listens to or believes them. We will do our best to work with you to discover the basis of your pain. If we feel it is indicated, we will refer you to other specialists, including those who specialize in chronic pain issues.

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