Chronic pelvic pain

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1], Associate Editor(s)-in-Chief: Roghayeh Marandi, M.D.

Synonyms and keywords:

Overview

Chronic pelvic pain is a symptom, not a diagnosis, and is defined as persistent or recurrent pelvic pain of either men or women for longer than three to six months. It can be classified into two subgroups: specific disease-associated pelvic pain that there is a pathology to explain the pain such as pelvic inflammatory disease, infections, adnexal pathologies, endometriosis, etc., and chronic pelvic pain syndrome (CPPS), which its diagnosis often based on the history and physical examinations and imaging and laboratory findings are often inconclusive in diagnosing it, and usually, no specific etiology can be found. It is likely represents an abnormal neurological function and is a form of centralized pain, where the body develops a low threshold for pain, often a result of chronic pain. For example, the acute pain associated with endometriosis could become centralized ( Peripheral sensitization may lead to central sensitization) during a three to six months duration, as the pain becomes chronic Sensoryry neurons' chemistry in the central nervous system is altered with central sensitization, changing how pain signals are processed. As a result, neurons in the central nervous system's pain pathways remain in a persistent state of high reactivity, resulting in heightened pain perceptions. In centralized pain, the previous mild to moderate pain is experienced as severe pain (hyperalgesia), or tactile sensations can be interpreted as painful (allodynia). Also, chronic pelvic pain has a strong association with previous physical or emotional trauma, so the etiology of chronic pelvic pain could be related to functional somatic pain syndrome. Treatment of chronic pelvic pain is often complicated and is usually focused on the suspected etiology of the chronic pelvic pain, such as treating a comorbid mood disorder, neuropathy, or uterine dysfunction, which can exacerbate chronic pain.

Historical Perspective

Systemic approach to chronic pelvic pain was first described by Kresch, who developed a series of forms to obtain information from the pelvic pain patient.

Classification

• Chronic pelvic pain may be classified into two subgroups based on existing pathology that explains the pelvic pain.

• 1-specific disease-associated pelvic pain with pathology to explains the pain
  • Pelvic inflammatory disease
  • Adenxal pathologies
  • Uterine pathologies
  • Pelvic organ prolapse
  • Iatrogenic causes
• 2-Chronic pelvic pain syndrome( CPPS) without pathology to explain the pain. If the pain can be localized to an organ, then a more specific term may be used such as:
  • Painful bladder syndrome
  • Vulvodynia: Vestibular pain syndrome, Clitoral pain syndrome
  • Generalised vulvar pain syndrome
  • Rectal pain syndrome
  • Irritable bowel syndrome
  • Proctalgia fugax
  • Coccydynia
  • Pelvic floor muscle pain syndrome
  • Endometriosis- associated pain syndrome (pain remains even after endometriosis treatment)
  • Chronic prostatitis/chronic pelvic pain syndrome
  • Orchalgia
  • Perineal pain syndrome
  • Epididymal pain syndrome
  • Penile pain syndrome
  • Urethral pain syndrome
  • Post-vasectomy pain syndrome
  • Dysmenorrhea
    • Pain with menstruation that is not associated with well-defined pathology. Dysmenorrhoea needs to be considered as a chronic pain syndrome if it is persistent and associated with negative cognitive, behavioral, sexual, or emotional consequences.
  • If the pain is localized to multiple organs, then the syndrome is a Complex regional pain syndrome which is considered as CRPS.

Pathophysiology

• Pathophysiology could be related to somatic structure or viscera pathologies, central sensitization of pain, or both.
• Central sensitization mechanisms:
  • With central sensitization, the chemistry of sensory neurons in the central nervous system is altered, changing how pain signals are processed. As a result, neurons in the pain pathway in the central nervous system remain in a persistent state of high reactivity, resulting in heightened perceptions of pain. For example, the cyclical pain in endometriosis is due to recurrent bleeding in the endometriotic implants, or pain in pelvic congestion syndrome is due to engorged and dilated pelvic veins causing the decreased venous washout.As one organ system becomes dysfunctional, such as in interstitial cystitis, another organ can also develop pathology, such as irritable bowel syndrome. As comorbidities develop, the chronic nature of symptoms leads to centralized pain, only enhancing pain. Collectively, persistent and increased sensitivity to pain becomes chronic pelvic pain.
• Recurrent trauma, infection or ongoing inflammation or muscle tenderness
• Psychological mechanisms
  • More common with history of prior abuse (childhood: 64% vs 23%). Laparoscopic findings may not correlated with pains.
  • Emotional, cognitive, behavioral, and sexual responses also could involve in chronic pelvic pain.
• Nerve damage
• Vascular hypothesis
  • Pain arises from dilated pelvic veins in which blood flow is markedly reduced (citation needed)

Causes

Gender-specific causes classification

Women

Infection, Endometriosis, Dysmenorrhea, Dysparunia, Myofascial Pain Syndrome, Vulvodynia, Vulvitis, Cystitis, bladder pain syndrome, Ovarian Remnant Congestion, Sympathetically Mediated Pain, Pelvic Congestion, Pelvic Fibrosis, Pelvis Neurodystonica, Irritable Bowel Syndrome, Sexual abuse/Physical abuse, Cancer, Psychiatric Disorders, Surgical Procedures(adhesions), Pelvic floor muscle pain syndrome, Vulvodynia,Vestibular pain syndrome,Endometriosis- associated pain syndrome

Men

Prostatitis, Chronic Orchalgia, Prostadynia, Interstitial Cystitis, Ureteral Obstruction, Irritable Bowel Syndrome, bladder pain syndromeSexual/Physical Abuse, Cancer,Psychiatric Disorders, Proctalgia fugax, Radiation proctitis, Surgical Procedures (adhesions), Rectal pain syndrome,Pelvic floor muscle pain syndrome,Prostatic pain syndrome, Scrotal pain syndrome, Testicular pain syndrome, Epididymal pain syndrome, Penile pain syndrome, Urethral pain syndrome, Post-vasectomy scrotal pain syndrome

Causes by Organ System

Cardiovascular	Pelvic vein thrombosis
Gastroenterologic	Anal fissure, Appendicitis, Colitis, Colonic polyps, Constipation, Diarrhea, Diverticulitis, Gastrointestinal cancers, Hemorrhoids, Internal hernia, Irritable bowel syndrome, Proctitis, Reproductive tract cancers, Strangulated hernia, Ulcerative colitis,Abdominal epilepsy, Proctalgia fugax, Radiation proctitis, Surgical Procedures (adhesions)
Hematologic	Porphyria
Iatrogenic	Ovarian remnant
Infectious Disease	UTI
Musculoskeletal / Ortho	Coccydynia, Low back pain, Muscle spasm, Pelvic girdle malrotation, Tension in the pelvic floor muscles, Degenerative joint disease. Disc herniation
Neurologic	Nerve entrapment in pelvis(surgical scar in the lower part of theabdomen), Peripheral neuropathy in pelvis, Post herpetic neuralgia, Post infectious neurological hypersensitivity, Pudendal nerve neuralgia, iliohypogastric, ilioingiunal, genitofemoral, lateral femoral cutaneous nerve, shingles (herpes zoster infection), spine-related nerve compressions
Obstetric/Gynecologic	Adenomyosis, Adhesions in the pelvic area, Cervical polyps, Chronic vulvovaginitis, Dysmenorrhea, Ectopic pregnancy, Endometrial polyps, Endometriosis, Fibroids, Miscarriage, Mittelschmerz pain, Mullerian abnormalities, Ovarian cysts, Ovarian torsion, Pelvic congestion syndrome, Pelvic inflammatory disease, Pelvic relaxation, Placental abruption, Retroverted uterus, Uterine leiomyoma, Vulvodynia,Dyspareunia
Oncologic	Colon cancer, Neuromas, Pelvic tumor, Testicular tumors
Psychiatric	Chronic stress, Depression, drug addiction, dependence,family problems, Somatotisation disorders
Renal / Electrolyte	Loin pain hematuria syndrome
Rheum / Immune / Allergy	Fibromyalgia
Sexual	Clitorodynia, Epididymo-orchitis, Sexual abuse, sexual dysfunction
Trauma	Physical abuse
Urologic	Chronic bacterial prostatitis, Chronic bladder irritation, Chronic non bacterial prostatitis, Chronic pelvic pain syndrome, Chronic urethritis, Epididymal cysts, Hydrocele, Interstitial cystitis, Urinary tract calculi, Varicocele

Common Causes

Commonly proposed etiologies of chronic pelvic pain(CCP) include:

• Endometriosis (very controversial) Deeply Infiltrative Endometriosis may be more important
• Infection or post-infectious neurological hypersensitivity
• Exaggerated bladder, bowel, or uterine pain sensitivity (also known as visceral pain)
• Ovarian cysts, uterine leiomyoma - often found in asymptomatic patients as well
• Less common emergencies: ovarian torsion, appendicitis, ectopic pregnancy
• Pelvic girdle pain (Pubic Symphysis Dysfunction, SPD or DSP)

Differentiating chronic pelvic pain from other Diseases

Differential diagnosis by organ system:

• Gynecological - Endometriosis, pelvic inflammatory disease, pelvic adhesion disease, recurrent ovarian cysts, leiomyoma, adenomyosis, hydrosalpinx, and post-tubal ligation pain syndrome
• Gastroenterological - Irritable bowel syndrome, celiac disease, inflammatory bowel disease, colorectal carcinoma, and hernias
• Urological - Interstitial cystitis (painful bladder syndrome), recurrent cystitis, Radiation cystitis, chronic urolithiasis, bladder cancer, and urethral syndrome
• Musculoskeletal - Abdominal wall myofascial pain, fibromyalgia, coccygodynia, pelvic floor tension myalgia, piriformis syndrome
• Neurological/vascular - ilioinguinal nerve entrapment, iliohypogastric nerve entrapment, pudendal neuralgia, spinal cord injury, pelvic congestion syndrome, peripheral neuropathy, and vulvar varicosities

Epidemiology and Demographics

• Chronic pelvic pain affects one in seven women in the United States.
• No adequate data on incidence were found.

Age

Chronic pelvic pain is more commonly observed among women aged 18-50 years old.

Gender

• Chronic pelvic pain affects one in seven women in the United States.
• Ninety-nine percent of all cases of chronic pelvic pain are female.

Race

• African-American women are more likely to develop endometriosis.

Risk Factors

Common risk factors in the development of chronic pelvic syndrome are genetic, psychological state, recurrent somatic trauma, and endocrine factors.

Natural History, Complications and Prognosis

• The patient's pain is located within the pelvis and has lasted greater than six months duration.
• Common complications are having pain even after hysterectomy, dependency on opioids, infection, and bleeding after laparoscopy.
• Prognosis is generally poor in patients with chronic pelvic pain, similar to other chronic pain syndromes.

Diagnosis

Diagnostic Criteria

• It is a symptom, not a diagnosis, pain is an intermittent or constant pain in the lower abdomen or pelvis, lumbosacral back, buttocks being for at least 6 months.

Symptoms

• Symptoms of chronic pelvic pain may include the following:

• persistent non-cyclical or cyclical pelvic pain which is like paresthesia, numbness, burning, or lancinating pain, in the pelvis, anus, and/or genitals

• The systemic approach should be used to identify the source of pain.

• Gynecological:
  • Painful periods, painful ovulation, painful intercourse, heavy bleeding with periods, irregular periods, vaginal discharge, pain during ejaculation
• Gastrointestinal:
  • Painful bowel movement with menses, the urgency with bowel movement, bloating, diarrhea, nausea, vomiting
• Musculoskeletal:
  • Low back pain, pain with certain movements
• Urinary tract:
  • Dysuria, polyuria
• Psychological:
  • Stress, depression, anxiety, anger

• Be careful about the symptoms that suggest life-threatening conditions such as :
  • unexplained weight loss, new bowel symptoms over 50, new pain after the menopause, pelvic mass, bleeding per rectum, irregular vaginal bleeding over 40, post-coital bleeding
  • Rule out malignancy or serious systemic disease.

Physical Examination

• As well as a local examination, a full clinical examination should be done.
  • Abdominal and pelvic examination to exclude gross pelvic pathology (focal tenderness, enlargement, distortion on abdominal examination, suprapubic tenderness)
  • Examination of external and internal genitalia, Q tip test: cotton-tipped applicator can trigger pain in vulvar pain syndrome, vulvodynia
  • Clinical pelvic examination ( Traditional bimanual examination to examine the uterus, adnexa, anorectal)
  • Rectal examination, looking for fecal incontinence, tender puborectal muscles, anal or rectal prolapse,...
  • Musculoskeletal examination: Tender sacroiliac joints are suggestive of a musculoskeletal origin to the pain
  • Full clinical examination of the spinal, muscular, nervous, and urogenital systems to detect any pathology

Laboratory Findings

There are no specific laboratory findings associated with making the diagnosis of the chronic pelvic syndrome. They might be useful in the diagnosis of comorbid conditions responsible for the development of chronic pelvic pain. To rule out the pregnancy, chronic inflammation, or infection as the source of chronic pelvic pain, a complete blood count with differential, urine pregnancy test, erythrocyte sedimentation rate, urinalysis, chlamydia, and gonorrhea, CA-125, ESR, pap smear are often ordered.

Electrocardiogram

There are no ECG findings associated with chronic pelvic pain.

X-ray

An x-ray may be helpful in the diagnosis of co-morbidities associated with chronic pelvic pain.

Echocardiography or Ultrasound

There are no ultrasound findings associated with chronic pelvic pain. However, an ultrasound may be helpful in the diagnosis of comorbid conditions responsible for the development of chronic pelvic pain such as cysts, masses, and adenomyosis, hydrosalpinx which is an indicator of pelvic inflammatory disease; comorbidity is often seen in chronic pelvic pain, and rule out anatomic abnormalities.

CT scan

CT scan may be helpful in the diagnosis of pelvic congestion syndrome, uterine or adnexal or other pathologies as the cause of pelvic pain.

MRI

MRI may be helpful in the diagnosis of comorbidities responsible for chronic pelvic pain such as adhesions, adenomyosis, endometriosis, fibroids, and it is usually ordered following an ultrasound if abnormalities are seen.

Other Imaging Findings

• Hysteroscopy may be helpful in the diagnosis and resection of uterine fibroids.
• Pelvic venography for diagnosis of pelvic congestion syndrome

Other Diagnostic Studies

• Laparoscopy is used for diagnosis and treatment of endometriosis, adhesions
• Colonoscopy
• Diagnostic nerve blocks may help the patient with chronic pelvic pain complains of symptoms of neuropathic pain. The sacral nerve root is numbed from a nerve block. If the patient's pain is eliminated, this helps confirm the chronic pelvic pain secondary to peripheral nerve dysfunction.

Treatment

where the origin of the pain is known, the underlying disease should be treated. However, if the source of the pain is unknown, it is recommended for the patient to undergo further evaluation to find the underlying disease. Treatment may include:

• Pain management: Usually, the first step in the treatment of CPP is analgesic drugs.
• Behavioral therapy
• Pelvic floor physical therapy
  • If the cause of chronic pelvic pain is pelvic floor muscle dysfunction
• Medications
• Surgery

Treatment of specific disease-associated pelvic pain:

• Treat the underlying pathology; for example, in endometriosis, there are therapeutic options, including pharmacotherapy and surgery are available
• All other gynecological conditions (including dysmenorrhea, obstetric injury, pelvic organ prolapse, and gynecological malignancy) can be treated effectively using pharmacotherapy or surgery.

Treatment of chronic pelvic pain syndrome

• There are different types of therapeutic options, psychological treatment such as CBT and surgery available to treat chronic pelvic pain syndromes.

• In general
  • Treatment of a patient with chronic pelvic pain syndromes( without any pathologies responsible for pain) is over-the-counter analgesic(acetaminophen, NSAIDs).
  • If OTC is inadequate for pain relief and the pain is cyclical, oral contraceptive pills, depot medroxyprogesterone, or an intrauterine device is recommended if the pain is cyclical.
  • If hormonal treatment is ineffective, or the pain not cyclical, or pelvic pain is suspected to be neuropathic, it is essential to evaluate the patient for an underlying mood disorder.
  • If there is a mood disorder, antidepressant therapy (SSRI) is recommended.
  • If a patient with suspected chronic pelvic pain secondary to neuropathic pain does not have an underlying mood disorder, various treatment options exist, such as antidepressants (TCAs), pregabalin, gabapentin, or SNRIs such as venlafaxine or duloxetine.
  • If pain is uncontrolled with those various treatment options, it is recommended to refer to a Pain Medicine specialist and possibly start a trial of opioid analgesics.
  • Local steroid injection can be considered in sacral nerve injury.
  • Adjunct, non-pharmacological treatments such as pelvic floor therapy for chronic pain with the musculoskeletal origin, cognitive behavioral therapy, nutrition counseling, neuromodulatory procedures are also be offered.

Surgery

• The surgical procedure can only be performed for patients experiencing severe, uncontrolled pain, or there is a concern for acute abdomen, and the patient should be referred for laparoscopic surgery or sent to the emergency department. If laparoscopic surgery is inconclusive, the patient's pain is likely secondary to chronic regional pain syndrome.
• Peripheral nerve blocks and neuromodulation of sacral nerves may also be necessary in severe cases.
• Hysterectomy sometimes can be considered in chronic pelvic pain secondary to the uterine origin.

Prevention

The measures that are thought to reduce the risk of some diseases responsible for chronic pelvic pain could be considered primary prevention of chronic pelvic pain.

Additional Resources

• Milburn A, Reiter R, Rhomberg A: Multi-disciplinary approach to chronic pain. Obstet Gynecol Clin 1993;20:643 - 661.
• Stovall DW: Endometriosis associated pelvic pain: Evidence for an association between the stage of disease and a history of chronic pelvic pain. Fertil Steril 1997;68:13 - 17.
• Schroeder B, Sanfillippo JS: Chronic Pelvic Pain and Recurrent Abdominal Pain in Female Adolescents. Pediatr Clin North Am 1999;46:566 - 567.
• Elisabeth Thibaud, Hyams JS: Clinical aspects of recurrent abdominal pain. Pediatric and Adolescent GynecologyPediatr Ann 2001;30:17–21.
• Jantos M.: Understanding Chronic Pelvic Pain. Pelviperineology Vol. 26 N.2 June 2007 66-68

Related Chapters

• Abdominal adhesions
• Coccydynia (coccyx pain, tailbone pain)

External Links

• International Pelvic Pain Society
• Pelvic Floor Digest: Free Selected medical abstracts on pelvic pain. Updated
• American Pain Society
• Endometriosis Research Center
• endometriosis.org
• Endometriosis Association
• Pelviperineology The multidisciplinary open access pelvic floor journal

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