Chronic Pelvic Pain

Chronic pelvic pain is pain that occurs below the umbilicus (or belly button) that lasts for at least six months. It may be associated with menstruation. Chronic pelvic pain is not a disease, but a symptom that may be caused by several different conditions.

Causes

A variety of gynecologic, gastrointestinal and systemic disorders can cause chronic pelvic pain.

 

Gynecologic Causes

Gynecologic causes of pelvic pain include:

• Endometriosis: Endometriosis is a condition in which endometrial tissue is also present outside of the uterus. Some women with endometriosis have no symptoms, while others experience marked discomfort and pain and may have problems with fertility.
   

• Pelvic inflammatory disease: Pelvic inflammatory disease is an infection typically caused by a sexually transmitted organism. Occasionally, it is caused by a previous ruptured appendix or scarring resulting from pelvic surgery. It can involve the uterus, ovaries and fallopian tubes. Pelvic inflammatory disease can cause pain, abnormal uterine bleeding, and symptoms of infection such as fever and chills.
   

• Adenomyosis: Adenomyosis is the presence of endometrial tissue within the uterine muscle. It can cause an enlarged uterus, pain and abnormal uterine bleeding.
   

• Uterine leiomyomas: Often called fibroids, these are benign (noncancerous) tumors in the uterus that can cause abnormal
  uterine bleeding and pain.
   

Other Causes

Nongynecologic causes of chronic pelvic pain include:

• Irritable bowel syndrome: This gastrointestinal condition is characterized by chronic abdominal pain and altered bowel habits (such as loose stools, more frequent and painful bowel movements) in the absence of any specific cause.
   

• Interstitial cystitis: Interstitial cystitis is inflammation of bladder tissues not due to infection. Symptoms usually include frequent urination and a feeling of urgency. Some women with interstitial cystitis present with lower abdominal pain rather than urinary tract symptoms.
   

• Diverticulitis: A diverticulum is a saclike 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.
   

• Fibromyalgia: Fibromyalgia is a chronic pain disorder that affects connective tissue structures, including muscles, ligaments and tendons. It is characterized by widespread muscle pain (or "myalgia") and tenderness in certain areas of the body. Women with fibromyalgia may also experience fatigue, sleep disturbances, headaches, depression and anxiety.
   

Testing and Diagnosis

Because a number of different conditions can cause chronic pelvic pain, it is sometimes difficult to pinpoint the specific cause. A thorough history and a physical exam of the abdomen and pelvis are essential. Lab tests, including a white blood cell count, urinalysis, tests for sexually transmitted infections and a pregnancy test may be performed.

Some diagnostic procedures may also be helpful in identifying the cause of chronic pelvic pain. For example, a pelvic ultrasound is very good at detecting pelvic masses, including ovarian cysts and uterine fibroids.

A surgical procedure called a laparoscopy may be helpful in diagnosing some causes of chronic pelvic pain such as endometriosis and chronic pelvic inflammatory disease. During a laparoscopy, a flexible tube with a fiber-optic lens is inserted through a small incision just below the belly button. Through the tube, or laparoscope, the surgeon can visualize the contents of the abdomen, especially the reproductive organs. If the laparoscopy reveals a normal pelvis, the physician can then focus the diagnostic and treatment efforts on nongynecologic causes of pelvic pain.
 

Treatment

Chronic pelvic pain due to a gynecologic condition is often treated with medication. In some cases, however, surgery may be the treatment of choice.
 

Medication

Medication may be prescribed once laboratory and imaging tests suggest the pain is due to a gynecologic condition. Medications include:

• Nonsteroidal anti-inflammatory medications such as ibuprofen

• Oral contraceptive pills

• Doxycycline, an antibiotic used to treat some causes of pelvic inflammatory disease

• Medications called gonadotropin releasing hormone (GnRH) agonist analogues used to treat endometriosis

If these medications are not effective in treating the pain, the woman is sometimes referred to a medical practice specializing in pain management. Pain services frequently utilize multiple treatment modalities including acupuncture and behavioral and relaxation feedback therapies. Nerve stimulation devices or injection of tender sites with anesthetic agents may also be used. Psychological counseling may be offered to help women manage the pain. Pain services can also be helpful in treating women who have become dependent on narcotics for pain management.
 

Surgery

A few causes of gynecologic pelvic pain can be treated surgically. For example, some women may benefit from surgical removal of their endometriosis. Uterine fibroids can be excised (a procedure called myomectomy) or removed with hysterectomy (surgical removal of the uterus). For numerous valid reasons, many women are reluctant to have a hysterectomy procedure and prefer to explore options that do not result in removal of the uterus. Your clinician should be sensitive and responsive to these preferences.

Hysterectomy may alleviate chronic pelvic pain, especially when it is due to uterine disorders such as adenomyosis or fibroids. However, pain can persist even after hysterectomy, particularly in women under 30 and those with a history of chronic pelvic inflammatory disease. Hysterectomy is not a good choice for the management of chronic pelvic pain in women who want more children.

Surgery to cut some of the nerves in the pelvis has also been studied as a treatment for chronic pelvic pain. However, the effectiveness of this approach has not yet been demonstrated.
 

Learn More

Your doctor is the best resource for important information related to your particular case. Not all patients with chronic pelvic pain are alike, and it is important that your situation is evaluated by someone who knows you as a whole person.