What is Chronic Pelvic Pain?
Background
Chronic pelvic pain is an important issue in women’s health care. It is typically defined as pain involving the pelvis, anterior abdominal wall, lower back, and/or buttocks and lasting greater than 6 months. It is a disorder that can have a significant negative impact on quality of life. There are many accepted causes of chronic pelvic pain in women, but often a definitive diagnosis cannot be made.
The significance of chronic pelvic pain as a medical problem is often underestimated. The prevalence of the condition in reproductive age women is 3.8 percent, similar to the prevalence of asthma (3.7 percent) and back pain (4.1 percent) and higher than that of migraine (2.1 percent).
According to a Gallup Poll, 15 percent of women in the US suffer from chronic pelvic pain. The direct medical costs and lost productivity due to this condition were estimated at $880 million and out of pocket expenses were approaching $2 billion yearly.
Pain
The International Association for the Study of Pain defines pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage. Pelvic pain is a general term and usually refers to pain in the lower abdomen and perineum. Acute pain is typically short-lived, immediate, and severe, often reflecting identifiable tissue damage. Pain that lasts longer than 3-6 months is considered chronic. Clinically significant chronic pelvic pain affects quality of life, the ability to function well physically, and the ability to sleep.
There are many known and suspected causes of chronic pelvic pain. Pain may involve reproductive organs, bowel, bladder, the musculoskeletal system, or the nervous system. Often extensive examinations, diagnostic testing, and referral to multiple specialists are performed to delineate a cause. About 10 percent of all referrals to a gynecologist are for chronic pelvic pain, and it is listed as the indication for 40 percent of laparoscopies and 12 percent of hysterectomies.
Some of these procedures are diagnostic and curative, but many are not. Between 10-55 percent of these women have no visible pathology found during laparoscopy. An estimated 26 percent of women continue to have pain after a hysterectomy. Over 60 percent of women with chronic pelvic pain have no clear-cut diagnosis.
Pain perception, or nociception, occurs in the brain when a signal is transmitted through nerve fibers after a painful stimulus. This occurs in a stepwise fashion through nerves and the spinal cord. There is contact with a stimulus, reception of the stimulus by a nerve ending, transmission of the signal to the central nervous system, and reception of the signal in the brain. Nociception involves different nerve fibers than those that respond to non-painful stimuli like pressure or touch.
Once the pain signal reaches the brain, it is processed and the brain may send signals back to the body. Some of these signals are sent to the musculoskeletal system so that the body can protect itself. Some are sent through the autonomic nervous system and cause and increase in heart rate and blood pressure as well as other symptoms that notify the body of current or potential injury. The descending signals may also influence the pain signals as they ascend (or come up) by blocking some of the pain signals, like a gate. Emotions, memory, age, gender, the environment, and the presence of pain elsewhere in the body can affect both the ascending and descending pain pathways.
When pain becomes chronic, there is progressive sensitization of both the central and peripheral nervous systems. The nervous system is more likely to respond to painful stimuli. Patients with chronic pain may experience lower pain thresholds, pain fields progressing from localized to generalized, increased intensity and prolonged sensations of pain, as well as unexplained spontaneous pain.
This neurologic component may explain some of the coexistent chronic medical conditions that are often associated with chronic pelvic pain. Studies show 40 percent of women diagnosed with chronic pelvic pain have irritable bowel syndrome. Two studies evaluating women with chronic pelvic pain and uterine and bladder tenderness on exam found that 75-76 percent of the patients had endometriosis, 82-89 percent had interstitial cystitis/ painful bladder syndrome, and 65-66 percent had both.
Another evaluation of women diagnosed with interstitial cystitis showed a higher than expected rates of irritable bowel syndrome (39 percent vs. 6 percent in the control population) and fibromyalgia (18 percent vs. 2 percent). Between 25-33 percent of women with fibromyalgia report chronic pelvic pain.
There is also significant interplay between psychologic, physiologic, and behavioral variables in women with chronic pelvic pain. A recent meta-analysis of 23 studies indicated female victims of sexual assault were almost 3 times as likely to experience chronic pelvic pain as the general population. Women with chronic pelvic pain are also more likely to experience anxiety (73 percent) and depression (40 percent) than women without similar symptoms (37 percent and 30 percent respectively).
Symptoms
Women may experience different types of symptoms
- Severe, steady pain
- Intermittent or cyclic pain that comes and goes
- Cramping or aching type pain
- Sharp stabbing pain
- Pressure or heaviness deep in the pelvis
- Pain with sitting for prolonged periods of time
- Pain exacerbated by activity or exercise
- Pain during sexual intercourse
- Pain with voiding or bowel movements
Other associated issues that affect quality of life
- Inability to exercise
- Poor sleep habits
- Interference with relationships-social and personal
- Inability to work in or outside the home
- Problems with intimacy and sexual function
Common Causes
The list of possible causes and conditions associated with pelvic pain is extensive. Many organ systems can be involved including the reproductive or gynecologic system, the urologic system, the gastrointestinal system, the musculoskeletal system, and the neurologic and psychiatric systems.
Some conditions are more common than others:
- Endometriosis or Adenomyosis
- Dysmenorrhea
- Pelvic congestion syndrome
- Cervical stenosis
- Pelvic masses
- Uterine prolapsed
- Irritable bowel syndrome
- Chronic constipation
- Diverticulitis
- Inflammatory bowel disease
- Interstitial cystitis
- Musculoskeletal conditions
- Fibromyalgia
- Pelvic floor dysfunction
- Myofascial trigger points
- Vulvodynia
- Provoked vestibulodynia or vulvar vestibulitis syndrome
Chronic Pelvic Pain Syndrome
Six features patients have in common (from IPPS booklet)
- Pain present for at least 6 months
- Little or no relief from conventional treatment
- Degree of pain perceived is out of proportion to amount of observable tissue damage
- Depressed appearance ( lack of sleep, constipation, decreased appetite, slow motion and slow response)
- Increasingly limited physical activity
- Altered emotional roles in the family or other close relationships
Diagnosis
The diagnosis of CPP involves a physical exam and some testing, but more importantly, it involves a thorough review of medical, family, and personal histories. The onset of pain, how the pain has changed over time, any aggravating or alleviating factors, and associated medical conditions are important. A list of all tests and surgeries used to diagnose or treat pain in the past, medications used, providers seen, and natural or homeopathic remedies used is helpful in the diagnostic process. Questionnaires are also used to help identify types of pain, aggravating factors, and physical, social, and emotional factors that may play a role in the condition.
An extensive physical exam helps direct recommendations for further laboratory and radiologic testing and referral to additional specialists. This exam typically includes a thorough pelvic exam as well as an evaluation of the tissue and muscles that surround the pelvis. Specific areas examined include the external genital tissues with a q-tip, evaluation of the internal and external pelvic muscles and nerves, and an exam of the pelvic organs including the uterus, tubes, ovaries, bladder and urethra, and rectum.
Additional diagnostic tests and referrals to specialists are recommended based on the history and physical exam. This may involve blood tests, radiologic tests such as ultrasounds or MRI’s, tests of the bladder and referral to a urologist or urogynecologist, evaluation of the GI tract and referral to a gastroenterologist.
Approach to Treatment
Pain is a problem within the nervous system. Both the body and mind play a role in the development of chronic pelvic pain. Treatment strategies must address both.
Multiple organ systems may play a role in chronic pelvic pain. Each of these must be evaluated and treated. Often, when pain has become chronic, more than one condition contributes to the overall problem at the same time
Our goal is to help you improve as quickly as possible, but complex issues such as chronic pelvic pain take years to develop. It often takes time to notice a significant reduction in pain.
In most instances, chronic pelvic pain has taken a toll on relationships, families, friends, and work. It is important to understand and address these issues as well. Improvement in quality of life is a priority.
Multidisciplinary Approach
A multidisciplinary team is group whose members have varied but complimentary skills, experience, and qualifications that contribute to the diagnosis and management of a particular condition. Because of the complexities of chronic pelvic pain, it is important to address both the physical and psychosocial aspects of the problem. Members of our team include a gynecologist and nurse practitioners, psychotherapists, physical therapists, nurses, and a secretarial staff devoted to the care of our patients. Communication between team members is crucial, and we meet weekly to review patient concerns, progress, new information about various pelvic pain conditions, and treatment options.
Pain Medication
Pain Medications
Tylenol, Anti-inflammatory medications (ibuprofen, naproxen, etc.), Narcotic pain medication
Different types used based on history, condition and other medications used. Medications are usually used on a schedule. Use of narcotics involves a pain contract.
Hormonal Medications
Oral contraceptives, Progesterone. GnRH analogs, Lupron, GnRH antagonists
Used to suppress ovulation and hormonal fluctuations that may be associated with an increase in pain.
Antibiotics
Various
Generally used only to treat specific infectious conditions
Anti-depressants/ Anti-seizure medications
Amitriptyline, Gabapentin, Lyrica, Cymbalta, Savella
Used to modulate pain that are sent from the body to the brain rather than for their anti-depressant or anti-seizure properties.
Anesthetics
Patches, Cream
Used to treat symptoms of wind-up syndrome and neuropathic pain.
Muscle Relaxants
Oral, Local
Used to treat muscle spasm associated with chronic pain that may often become a pain generator in itself.
Therapy
This may involve physical therapists and/ or psychotherapists depending on conditions noted in a particular patient and treatment options discussed in team meetings.
Physical therapy includes an evaluation of all the musculoskeletal structures of the abdomen, pelvis, and lower extremities. This may include an internal evaluation of the pelvic muscles. Once this evaluation is complete, a physical therapist can recommend various treatment options. Exercises and stretching can help alleviate pain. Manipulation and stretching of the muscles directly by the therapist can also help. Other tools include biofeedback and stimulation of the nerves may be recommended.
Psychotherapy plays an important role in the treatment of patients with chronic pelvic pain. It involves evaluation by a psychotherapist or psychologist to help discuss the affect of chronic pain on relationships and families, how various treatments have affected the patient-both positively and negatively, and the way pain has changed the patient’s quality of life.
Individual psychotherapy is important to allow women to establish trusting relationships in which they can begin to address the way these issues have affected the most important aspects of their lives.
Support groups allow individuals to feels less isolation imposed by a condition that most people don’t understand. It also becomes a place for patients to support each other throughout the phases of their treatment.
There are higher rates of abuse, depression, and anxiety among with chronic pelvic pain. When these issues are addressed through therapy and occasionally with medication, the chance of improving the lives of women with the condition increases tremendously.
Other therapy and procedures
Medical therapy and procedures may be necessary as adjuncts to medications, physical therapy and psychotherapy. Some coexisting conditions respond to more invasive treatment. Interstitial cystitis, endometriosis, and loss of support of genital organs may require additional treatment or surgery.
Trigger point injections have been shown to be very beneficial for myofascial abdominal wall and pelvic floor tenderness. Injections are usually done in the office with a combination of numbing medication and steroids. There is some evidence that Botox may help in the treatment of some chronic pelvic pain conditions as well.
TENS units and nerve stimulators help some conditions associated with chronic pelvic pain, namely interstitial cystitis. More research is being done to evaluate the effectiveness of this therapy on other types of pain
Surgical procedures may be recommended on a case-by-case basis for specific surgical conditions. It is important to remember that a single surgery will rarely improve symptoms of chronic pelvic pain without addressing coexisting conditions.
Resources
International Pelvic Pain Society
National Vulvodynia Association
American College of Obstetrics and Gynecology
Up-to-Date website
References
ACOG Practice bulletin, Chronic Pelvic Pain. No 51, March 2004
Barbieri, Robert L, “Patient information: Chronic Pelvic Pain in Women” Up-to-Date, last update Aug 11, 2010, accessed 1/13/2012
Freudenrich, Craig. How Pain Works. http:science.howstuffworks.com/environmental/life/human-biology/pain
Howard, F, “Causes of chronic Pelvic Pain in women” Up-to-date, accessed 1/13/2012, last updated April 9. 2010.
http://www.iasp-pain.org/Content/NavigationMenu/GeneralResourceLinks/PainDefinitions/default.htm accessed 15 Jan 2011.
International Pelvic Pain Society-patient education pamphlet. Wenoff, Michael and Perry, C Paul, pelvicpain.org, written 1999, accessed Jan 13.2011
Marek, Jantos. Pelviperineology. “Understanding chronic pelvic pain” vol 26, n 2, June 2007. Pelviperineology.org. accessed 1/14/2012
National Institute of Child Health and Human Development. Pelvic Pain. Accessed 15 Jan 2011. http://www.nichd.nih.gov/health/topics/Pelvic_Pain.cfm.
National Vulvodynia Association
Portenoy, RK. “overview of pain” in Merckmanuals.com. last updated April 2007, accessed 1/13/2012
Stones W, Cheong YC, Howard FM. Interventions for treating chronic pelvic pain in women. Cochrane Database of Systematic Reviews 2005, Issue 2. Art. No CD000387.DOI:10.1002/14651858.CD000387., edited and updated with no change to conclusions Issue 1, 2009.
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