CHRONIC PELVIC PAIN DEFINITION

Chronic pelvic pain is defined as pain that occurs below the umbilicus (belly button) that lasts for at least six months. It may or may not be associated with menstrual periods. Chronic pelvic pain is often a symptom that can be caused by several different conditions, but is sometimes a chronic condition due to abnormal function of the nervous system (often called “neuropathic pain”).

CAUSES OF CHRONIC PELVIC PAIN

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

Gynecologic causes — Gynecologic causes are thought to be the cause of chronic pelvic pain in about 20 percent of women. Some of the gynecologic causes of pelvic pain include:

Endometriosis — The tissue lining the inside of the uterus is called the endometrium (figure 1). 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. (See "Patient information: Endometriosis (Beyond the Basics)" and "Patient information: Evaluation of the infertile couple (Beyond the Basics)".)

Chronic pelvic inflammatory disease — Pelvic inflammatory disease is an acute infection usually caused by a sexually transmitted organism. Occasionally, it is caused by a ruptured appendix, tuberculosis, or diverticulitis. It can involve the uterus, ovaries, and fallopian tubes (which link the ovaries and uterus) (figure 1). Chronic pelvic inflammatory disease occurs after acute pelvic inflammatory disease in about one-third of women and causes chronic pelvic pain. The reason for this is not clearly known, but is likely because of permanent damage to the uterus, ovaries, and fallopian tubes. (See "Patient information: Gonorrhea (Beyond the Basics)" and "Patient information: Chlamydia (Beyond the Basics)".)

Other causes — Non-gynecologic causes of chronic pelvic pain may be related to the digestive system, urinary system, or to pain in the muscles and nerves in the pelvis:

Irritable bowel syndrome — Irritable bowel syndrome is a gastrointestinal condition characterized by chronic abdominal pain and altered bowel habits (such as loose stools, more frequent bowel movements with onset of pain, and pain relieved by defecation) in the absence of any specific cause. (See "Patient information: Irritable bowel syndrome (Beyond the Basics)".)

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. A separate topic review is available that discusses PBS/IC. (See "Patient information: Diagnosis of interstitial cystitis/bladder pain syndrome (Beyond the Basics)".)

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. (See "Patient information: Diverticular disease (Beyond the Basics)".)

Pelvic floor pain — Symptoms of pelvic floor dysfunction may include pelvic pain, pain with urination, difficulty urinating, constipation, pain with intercourse, or frequent/urgent urination. 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 small 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.

Fibromyalgia — Fibromyalgia is one of a group of chronic pain disorders that affect 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, and mood disturbances such as depression and anxiety. (See "Patient information: Fibromyalgia (Beyond the Basics)".)

DIAGNOSIS OF THE CAUSE OF CHRONIC PELVIC PAIN

Because a number of different conditions can cause chronic pelvic pain, it is sometimes difficult to pinpoint the specific cause.

History and physical examination — A thorough history and a physical examination of the abdomen and pelvis are essential components of the work-up for women with pelvic pain. In particular, the examination should include the lower back, abdomen, hips, and pelvis (internal examination).

Laboratory tests, including a white blood cell count, urinalysis, tests for sexually transmitted infections, and a pregnancy test may be recommended, depending upon the results of the physical examination.

Pelvic ultrasound — Some diagnostic procedures may also be helpful in identifying the cause of chronic pelvic pain. As an example, a pelvic ultrasound examination is accurate in detecting pelvic masses, including ovarian cysts (sometimes caused by ovarian endometriosis) and uterine fibroids. However, ultrasound is not helpful in the diagnosis of irritable bowel syndrome, diverticulitis, or painful bladder syndrome.

Laparoscopy — 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. Laparoscopy is a procedure that is often done as a day surgery. Most women are given general anesthesia to induce sleep and prevent pain. A thin telescope with a camera is inserted through a small incision just below the navel. Through the telescope, the surgeon can see the contents of the abdomen, especially the reproductive organs. If the laparoscopy is normal, the physician can then focus the diagnostic and treatment efforts on non-gynecologic causes of pelvic pain.

If the laparoscopy is abnormal (eg, areas of endometriosis or abnormal tissue are seen) these areas may be treated or biopsied during the procedure.

COPING WITH CHRONIC PELVIC PAIN

Psychological counseling may be offered to help women manage their pelvic pain. There are several types of psychosocial support:

• Psychotherapy involves meeting with a psychologist, psychiatrist, or social worker to discuss emotional responses to living with chronic pain, treatment successes or failures, and/or personal relationships.
• Group psychotherapy allows people to compare their experiences with PBS/IC, overcome the tendency to withdraw and become isolated in pain, and support one another's attempts at more effective management.
• Online or local support groups that deal with chronic pain may also be helpful, such as the American Chronic Pain Society (www.theacpa.org) and the American Academy of Pain Management (www.aapainmanage.org/links/Links.php).
• Relaxation techniques can relieve musculoskeletal tension, and may include meditation, progressive muscle relaxation, self-hypnosis, or biofeedback.

CHRONIC PELVIC PAIN TREATMENT

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

Medical treatment

• One approach to managing women with chronic pelvic pain is to prescribe sequential drug treatments for disorders that are the most likely causes of the patient's pain. As an example, endometriosis is the most common gynecological cause of chronic pelvic pain. If endometriosis seems a likely diagnosis based upon the history and physical examination, then a medical therapy for endometriosis is given for a trial period. If this is not successful, then a trial of another medical therapy is initiated. If one of these treatments relieves the pelvic pain, then the likelihood that endometriosis is the cause of pain increases. However, it is important to note that improvement in symptoms is not absolute confirmation of a diagnosis since treatment effects are often not specific. As an example, hormonal treatment of endometriosis may also improve pelvic congestion syndrome, irritable bowel syndrome, or interstitial cystitis/painful bladder syndrome
• A different approach is to use intensive diagnostic testing in an attempt to identify the specific cause of the patient's pain, if possible, before starting specific therapy. Although therapy targeted specifically to the patient's diagnosis might appear ideal, arriving at a diagnosis may involve costly laboratory and imaging tests, and often requires exploratory surgery.
• A third option is treatment directed at pain, rather than at a specific diagnosis. Nonsteroidal anti-inflammatory drugs, antidepressants, and anticonvulsive medications are often used.

Physical therapy — Pelvic floor physical therapy (PT) is often helpful for women with abdominal myofascial pain and with pelvic floor pain. This type of PT aims to release the tightness in these muscles by manually "releasing" the tightness; treatment is directed to the muscles in the abdomen, vagina, hips, thighs, and lower back. Physical therapists who perform this type of PT must be specially trained. (See "Patient information: Treatment of interstitial cystitis/bladder pain syndrome (Beyond the Basics)".)

Pain management clinics — If medications are not effective in treating the pain, a woman may be referred to a medical practice specializing in pain management. Pain services utilize multiple treatment modalities including

• Acupuncture
• Biofeedback and relaxation therapies
• Nerve stimulation devices
• Injection of tender sites with a local anesthetic (eg, lidocaine, Marcaine)

Pain services can help women who are on opioids or narcotics for pain management.

Surgical treatment — A few causes of gynecologic pelvic pain can be treated surgically. For example, some women benefit from surgical removal of their endometriosis.

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 younger women (those less than 30) and in women with a history of chronic pelvic inflammatory disease or pelvic floor dysfunction. Hysterectomy is not a good choice for the management of chronic pelvic pain in women who have not completed their family. (See "Patient information: Abdominal hysterectomy (Beyond the Basics)" and "Patient information: Vaginal hysterectomy (Beyond the Basics)".)

Surgery to cut some of the nerves in the pelvis (presacral neurectomy) has also been studied as a treatment for chronic pelvic pain. However, this approach has shown effectiveness mostly for endometriosis pain and has additional surgical risks, so it is not recommended for most women.

WHERE TO GET MORE INFORMATION

Your healthcare provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient information: Chronic pelvic pain in women (The Basics)
Patient information: Endometriosis (The Basics)
Patient information: Painful periods (The Basics)
Patient information: Pelvic inflammatory disease (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient information: Endometriosis (Beyond the Basics)
Patient information: Evaluation of the infertile couple (Beyond the Basics)
Patient information: Gonorrhea (Beyond the Basics)
Patient information: Chlamydia (Beyond the Basics)
Patient information: Irritable bowel syndrome (Beyond the Basics)
Patient information: Diagnosis of interstitial cystitis/bladder pain syndrome (Beyond the Basics)
Patient information: Diverticular disease (Beyond the Basics)
Patient information: Fibromyalgia (Beyond the Basics)
Patient information: Hormonal methods of birth control (Beyond the Basics)
Patient information: Treatment of interstitial cystitis/bladder pain syndrome (Beyond the Basics)
Patient information: Abdominal hysterectomy (Beyond the Basics)
Patient information: Vaginal hysterectomy (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Causes of chronic pelvic pain in women
Chronic prostatitis/chronic pelvic pain syndrome
Pathogenesis, clinical features, and diagnosis of interstitial cystitis/bladder pain syndrome
Diagnostic approach to abdominal pain in adults
Differential diagnosis of abdominal pain in adults
Evaluation of chronic pelvic pain in women
Primary dysmenorrhea in adult women: Clinical features and diagnosis
Treatment of chronic pelvic pain in women
Management of interstitial cystitis/bladder pain syndrome
Treatment of primary dysmenorrhea in adult women

The following organizations also provide reliable health information.

• The International Pelvic Pain Society

     (www.pelvicpain.org)

• The Mayo Clinic

      (www.mayoclinic.com)