Patient information: Chronic pelvic pain in women

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 not a disease, rather, it is a symptom that can be caused by several different conditions.

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 (picture 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" and "Patient information: Evaluation of the infertile couple".)

Chronic pelvic inflammatory disease — Pelvic inflammatory disease is an infection caused by a sexually transmitted organism. Occasionally, it is caused by a previous ruptured appendix or scarring resulting from previous pelvic surgery. It can involve the uterus, ovaries, and fallopian tubes (which link the ovaries and uterus) (picture 1). Pelvic inflammatory disease can cause pain, abnormal uterine bleeding, and symptoms of infection such as fever and chills. (See "Patient information: Gonorrhea" and "Patient information: Chlamydia".)

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".)

Painful bladder syndrome and interstitial cystitis — Painful bladder syndrome and interstitial cystitis (PBS/IC) are the terms given to pain in the tissues in the bladder and surrounding nerves and muscles 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: Painful bladder syndrome and interstitial cystitis".)

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".)

Pelvic floor pain — The muscles of the pelvic floor can sometimes become shortened, tight and tender; this is called pelvic floor dysfunction. The pelvic floor includes muscles that attach to the pelvic bones and sacrum (lower part of the spine). Normally, these muscles function to support the hips and pelvic organs. It is not clear why this problem develops.

Symptoms may include pelvic pain, pain with urination, constipation, pain with intercourse, or frequent/urgent urination. Pelvic floor dysfunction can be diagnosed by a clinician feeling the muscles in the vagina and/or rectum; muscles that feel tight, tender, or band-like indicate that pelvic floor dysfunction could be contributing to pelvic pain.

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".)

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, urine analysis, 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 — Medication may be prescribed once laboratory and imaging tests suggest the pain is due to a gynecologic condition. Drugs that may be used include:

• Nonsteroidal anti-inflammatory medications such as ibuprofen

• Hormonal birth control methods (eg, pill, patch, vaginal ring) may be taken so that the woman has a monthly menstrual period or so that the woman only has a period every three to four months. (See "Patient information: Hormonal methods of birth control".)

• Doxycycline, an antibiotic used to treat some causes of pelvic inflammatory disease.
• Medications called gonadotropin releasing hormone (GnRH) agonist analogues used to treat endometriosis. (See "Patient information: Endometriosis".)

Physical therapy — Pelvic floor physical therapy (PT) is often helpful for women with tight and tender pelvic muscles. 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 vagina, hips, thighs, and lower back. Physical therapists who perform this type of PT must be specially trained. (See "Patient information: Treatment of painful bladder syndrome and interstitial cystitis".)

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 have become dependent on 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" and "Patient information: Vaginal hysterectomy".)

Surgery to cut some of the nerves in the pelvis has also been studied as a treatment for chronic pelvic pain. However, this approach has not proven to be effective 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. Because no two people are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.

This discussion will be updated as needed every four months on our web site (www.uptodate.com/patients). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.

Some of the most pertinent include:

Patient Level Information:
Patient information: Endometriosis
Patient information: Evaluation of the infertile couple
Patient information: Gonorrhea
Patient information: Chlamydia
Patient information: Irritable bowel syndrome
Patient information: Painful bladder syndrome and interstitial cystitis
Patient information: Diverticular disease
Patient information: Fibromyalgia
Patient information: Hormonal methods of birth control
Patient information: Treatment of painful bladder syndrome and interstitial cystitis
Patient information: Abdominal hysterectomy
Patient information: Vaginal hysterectomy

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

A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable.

• National Library of Medicine

      (www.nlm.nih.gov/medlineplus/healthtopics.html)

• The International Pelvic Pain Society

      (www.pelvicpain.org)

• The Mayo Clinic

       (www.mayoclinic.com)

• US Department of Health and Social Services

      (www.4woman.gov, search for pelvic pain)

[1-3]