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Chronic pelvic pain is defined as pain lasting for six months or more. This is the pain that frustrates both patients and doctors. The diagnosis often is elusive and treatment regimens may be unhelpful for the most part. Following are the most common disorders, diseases or conditions that can cause chronic pelvic pain.
Gynecologic Diseases or Disorders
Acute Dysmenorrhea
Acute dysmenorrhea (painful menstruation) is the
most common cause of pelvic pain for women, and is said to be responsible for
the majority of days absent from school or workplace. Most women rely on
over-the-counter pain relievers (ie, analgesics), so those who seek out medical
management suffer from either very severe or repetitive dysmenorrhea that is not
well controlled with over-the-counter medications.
Endometriosis
Endometriosis is the second leading cause of pelvic pain
in women. Endometriosis is a disease where the inside lining of the uterus
(called endometrial tissue) grows outside of the uterus and attaches to the
fallopian tubes, the bladder, intestines and ovaries. This inside lining is the
blood and tissue that is shed with menstruation. Researchers estimate that 90
million women in the world have endometriosis. Symptoms include dysmenorrhea
(painful menses), dyspareunia (painful sex), dysfunctional uterine bleeding, and
infertility. Hormonal treatment (eg, birth control pills) or surgery can relieve
some of the symptoms of endometriosis.
Surgery can be an effective way to control endometriosis. Laparoscopy is a procedure during which a lighted camera is inserted into the abdomen so the surgeon can see the abdominal cavity. Laparoscopy is used to diagnose and treat endometriosis. The surgeon can remove or destroy the endometrial tissue that is outside of the uterus during this type of procedure by inserting lasers or other tools into the abdomen.
Laparotomy is a more invasive procedure during which the surgeon removes the endometriosis or removes the uterus and/or the ovaries and fallopian tubes. This is a last resort treatment as it is considered major abdominal surgery.
Patients usually have intermittent cramping and sharp pain. Pain may begin prior to the onset of menstruation and gradually progresses until it becomes incapacitating. Although many women get relief from over-the-counter, non-steroidal anti-inflammatory agents, progestational drugs are often prescribed to suppress the production of the prostaglandins (potent hormone-like substances) believed to be responsible for the symptoms.
Nerve Disorders
The pelvis itself is the area above the pelvic floor that actually constitutes the lowest portion of the abdomen. Pain in the actual perineum (between the vagina and the rectum) can be due to abnormalities of the pudendal nerve, the genital branch of the genitofemoral nerve, or the posterior femoral cutaneous nerve.1
Some patients with pelvic pain have damage to the pudendal nerve, which is called pudendal neuropathy. The pudendal nerve transmits feelings from the external genitals, the lower rectum, and the perineum to the central nervous system. Patients with pudendal neuropathy have vaginal pain during intercourse, bladder pain during urination, rectal pain during defecation, and sitting pain. Some experts suggest the use of pudendal blocks to relieve pain in these patients.2
Pelvic Neuropathy
The following neuropathies are representative of
some — but certainly not all — of the common conditions for which patients may
consult a physician.
Patients may have ilio-inguinal and ilio-hypogastric nerve disturbances in the lower abdomen. These patients have past histories that often include surgical trauma in the lower abdominal wall. We are not certain of the origin of this pain but suspect it is related to the stretching or cutting of nerves located around the incision line. Pain may develop immediately after the initial trauma or gradually over time, depending on the severity of the injury and possibly the nerve fiber size.
Many patients with this type of pelvic neuropathy have undergone repeated exploratory surgeries because their original physician was convinced the initial intra-abdominal pathology had not been addressed or perhaps that recurrent pain might have been due to abdominal adhesions. This is becoming less common today due to the widespread use of laparoscopy, but the latter procedure itself may cause abdominal neuropathy due to placement of the scope or other surgical tools or because of the entrance points of the laparoscope. The classic example is the patient who has had one or more laparotomies; often the incisions are obvious and the maximal tender points are noted along the skin area marked by the incision scar.
Patients with pelvic neuropathy often benefit from repeated local anesthetic nerve blocks spaced over time. The blocks should not, however, be done too frequently because stimulating the nerve can create a new pain signal. Most patients will see improvement in pain in four to six weeks. Patients who do not respond to nerve blocks can be treated with cryotherapy (freezing) of those nerves still causing problems. When all else fails, you and your doctor can consider a trial of spinal cord stimulation for pain relief.
Genito-femoral nerve disorders are often labeled genitofemoral neuropathies. Patients with this type of disorder have low abdominal pain or even back pain that has migrated to the front of the body and now descends into the genital area. The pain is often incapacitating when it occurs in sharp repeated attacks. Almost all patients experience significant pain relief — usually within minutes of therapy — after individual nerve blocks and maximum trigger point injections. Nerve blocks are procedures in which a surgeon positions a needle — most commonly guided by an X-ray fluoroscope — near a structure (e.g., a nerve) that the surgeon believes is the source of the pain. The surgeon then injects a local anesthetic to numb the nerve or "block" its function. He or she then monitors the effect of the block to determine if a patient achieves pain relief. For trigger point injections, a doctor injects an anesthetic into the trigger point, which eases pain for some patients. Trigger point injections are most helpful when done in conjunction with a chronic pain management program.
There are some treatment failures, and sometimes these allow you to explore an overlooked organic disorder that may have been missed on the first pass. For most patients with pudendal neuropathy who don't respond well to pudendal blocks, however, it's because the therapy fails to deliver medication near enough to the pudendal nerve to relieve pain.
It is also possible that a pudendal block, when performed trans-vaginally via a blind approach, may miss the primary target — the ischial spinous (the bone near the bottom of the pelvis) process. In a study performed earlier, a CT scanner was used to precisely locate the ischial spinous process and, thus, allow more direct needle guidance. Twenty-six female patients with pudendal neuropathy were treated over a several month period. Over time, they received five CT-guided pudendal block treatments.
All 26 patients were asked to score their pain before and after therapy based upon the classic pain scale, with 10 being the worst possible pain imaginable. Sixteen of 26 patients (62 percent) had significant pain reduction after therapy; however, 10 patients (38 percent) did not.
Other Disorders
Gastroenterologic Causes of Chronic Pelvic Pain
Because the
reproductive organs share nerves with parts of the colon and rectum, it can be
difficult to determine if lower abdominal pain is related to female reproductive
organs (gynecologic) or related to the stomach, intestines and other organs of
the digestive system (gastroenterologic). Irritable bowel syndrome (IBS) is a
common cause of lower abdominal pain. Pain is typically intermittent cramping in
the left-lower quadrant in location. Patients may experience changes in bowel
function, such as diarrhea, constipation, bloating and/or flatulence. Pain is
often improved after bowel movements. Symptoms may be worse after eating; during
times of stress, tension, anxiety or depression; during the premenstrual phase
of the cycle; or with intercourse. A doctor diagnoses IBS based on the patient's
history. Other conditions that can cause abdominal pain and should be ruled out
include inflammatory bowel disease, polyps (benign tumors) and malignancy of the
bowel. Treatment of IBS generally consists of dietary alterations, bulk forming
agents, stress and anxiety reduction, anti-colonic and anti-spasmodic
preparations, and low-dose tricyclic anti-depressant.
Urinary Tract Infections
Chronic pain of urologic origin may be due to
recurrent steroid arthritis, urethral syndrome, urethral diverticulite,
interstitial cystitis or infiltrating bladder tumors. Ureteral causes of pelvic
pain can include kidney stones, renal obstruction and endometriosis. Symptoms of
urine frequency or urgency, pelvic pain and pain during intercourse with
negative laboratory studies can be consistent with interstitial cystitis (IC) or
urgency frequency syndrome. Symptoms of interstitial cystitis include pain on
bladder filling and relief upon emptying and pain on suprapubic, pelvic,
urethral or vaginal areas. Symptoms that do not meet IC criteria may be called
urgency frequency syndrome but may just represent an earlier form of
interstitial cystitis or bladder hyperalgesia (over sensitivity). To diagnose
IC, a doctor will insert potassium chloride in the bladder, which will be
exquisitely painful in patients with this disorder. Therapy consists of
increasing water intake and following a bladder diet, intravesical (inside the
bladder) therapy, anti-depressants, anti-histamines, physical therapy,
biofeedback or repeated anesthetic blocks to the uterine, vaginal or nerves of
the pelvis. Medications that help with IC pain include tricyclic
antidepressants, membrane stabilizing agents, nonsteroidal anti-inflammatory
agents, and occasionally opioids.
Pelvic Joint Instability
Persistent pelvic pain and pelvic joint
instability in some females has been associated with early puberty (before age
8) and the use of oral contraceptives before childbirth. Thus, patients who have
pelvic pain in which all diagnostic workups have been normal and who have a
history of early onset of menstruation associated with oral contraceptive use,
may have pelvic joint instability.3
Hematoma
Another possibility to consider in women complaining of
pelvic pain is a hematoma of the piriformis muscle. A hematoma is the abnormal
collection of blood. The piriformis is one of the small muscles deep in the
buttocks that rotate the leg outward. A hematoma of the piriformis muscle is a
rare complication that can cause impingement (restriction) of the sciatic,
inferior gluteal and pudendal nerves. This may result from compression between
the muscle and the iliac spine. In these cases, a CT scan should help confirm
the diagnosis.4
Osteitis Pubis
Active females who present with pubic pain and adductor
pain (pain with squeezing the legs together) may be suffering from osteitis
pubis. In one study of 59 patients, recovery took up to seven months among the
female subjects. This disorder can be managed with a support belt and pain
relievers (analgesics). There was also an associated finding of pelvic
malalignment or sacroiliac dysfunction in these patients.5
References
1. Tong HC, Haig A. Posterior femoral cutaneous nerve mononeuropathy: a case report. Arch Phys Med Rehabil. 2000 Aug;81(8):1117-8
2. Penarrocha M, Bagan JV, Alfaro A, Penarrocha M. Acyclovir treatment in 2 patients with benign trigeminal sensory neuropathy. J Oral Maxillofac Surg. 2001 Apr;59(4):453-6.
3. Hill DA, Lense JJ. Office management of Bartholin gland cysts and abscesses. Am Fam Physician. 1998 Apr 1;57(7):1611-6, 1619-20
4. Mock JN, Orsay EM. Primary mesenteric venous thrombosis: an unusual cause of abdominal pain in a young, healthy woman. Ann Emerg Med. 1994 Feb;23(2):352-5; Termote JL, Baert A, Crolla D, Palmers Y, Bulcke JA. Computed tomography of the normal and pathologic muscular system. Radiology. 1980 Nov;137(2):439-44.
5. Goldberg HI, Gore RM, Margulis AR, Moss AA, Baker EL. Computed tomography in the evaluation of Crohn disease. AJR Am J Roentgenol. 1983 Feb;140(2):277-82; Slipman CW, Jackson HB, Lipetz JS, Chan KT, Lenrow D, Vresilovic EJ. Sacroiliac joint pain referral zones. Arch Phys Med Rehabil. 2000 Mar;81(3):334-8