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Pain in the pelvic cavity and the perineum (the skin and muscles between the vagina and rectum in women and the scrotum and rectum in men) is one of the most common causes of pain in women. It also is one of the most difficult to diagnose and manage. Researchers estimate that 12 percent to 20 percent of women have chronic pelvic pain, and up to 33 percent of women will have pelvic pain during their lifetime. Unfortunately, 61 percent of women with chronic pelvic pain remain undiagnosed. Patients with pelvic pain may be seen by gynecologists, family physicians, nurse practitioners, internists, urologists, neurologists, and even pain specialists, physical therapists, or sexual counselors, but often do not receive relief from their pain. Diagnosing the cause of pelvic pain is often confused by the myth that most pelvic pain is due to diseases in the ovaries, fallopian tubes or the uterus. It also is confused by the complex relationship between pelvic pain and sexual abuse in some cases.
When a woman has gynecological pain, an obstetrician/gynecologist tends to look for diseases in the uterus, fallopian tubes or ovaries. By the same token, if she goes to a pain medicine specialist, it's highly unlikely the doctor will perform a pelvic examination and or even be familiar with the pelvis. These stumbling blocks are compounded by the fact that patients are often embarrassed about pain in the perineal or pelvic area and frequently delay seeing a physician until the pain becomes intolerable.
It's not surprising that many patients with chronic pelvic and lower abdominal pain go undiagnosed. This section on pelvic pain takes a practical approach to these problems, discussing different diagnoses and various physical and psychological causes to help relieve your anxiety about previous misdiagnoses. The discussion is divided into areas where your primary care doctor can help and where and when a specialist in chronic pelvic pain may be helpful to you.
Doctors define chronic pelvic pain as any pelvic pain that lasts for more than six months. Chronic pain differs from acute (recent) pain in that acute pain may indicate a specific injury to the body. In chronic pelvic pain, the initial injury or problem may have disappeared. The pain continues because of changes in the nervous system, tissues or muscles.
Typically, chronic pelvic pain is characterized by:
· Pain that lasts for six months or longer
· Presence of depression
· Limited physical activity
· Limited activities of daily living and changes in roles (e.g., inability to work, inability to care for children)
· The fact that conventional methods for treating the pain have failed
Chronic pelvic pain, like most other chronic pain conditions, affects your physical and psychological well-being. Your best chance of functional recovery is finding a physician who specializes in treating chronic pelvic pain and uses a multidisciplinary approach to treating all aspects of pain, including the physical and psychological aspects.
Determining the cause of your chronic pelvic pain may be a process of elimination. It's important to track when your pain occurs, how long it lasts, what type of pain you're experiencing (e.g., ache, sharp pain, stinging, burning), and what makes the pain better or worse. Providing this information to your doctor will help him or her determine what tests to perform.
If you're like most people with chronic pelvic pain, you have provided this information to multiple health care providers. It may be frustrating to repeat this information again, but it's important to provide your doctor with as much information as possible.
The National Pain Foundation has a Personal Pain Inventory, where you can record all the details of your particular pain history, including where you hurt, when the pain began, and the types of treatment you have tried. Completing the Personal Pain Inventory can help you and your health care provider design an effective pain management plan. The National Pain Foundation also provides a Personal Pain Journal, where you can record your day-to-day experiences with pain and pain management. The Personal Pain Journal can help you keep track of when you hurt least and when you hurt most; what activities control your pain; and what treatments work best. By keeping a Personal Pain Journal you gain the valuable information you need to communicate with your health care provider and effectively manage your pain condition.
Tests that may be performed to determine the cause of your pain include:
· Pelvic examination
· Cultures
· Laparoscopy, cystoscopy or sigmoidoscopy (surgical procedures during which lighted telescopes placed into different body cavities of the pelvis)
· X-ray, ultrasound, CT scan, magnetic resonance imagery or MRI
· Tests of bladder and rectal function
A pelvic exam helps your doctor determine if there's an infection, abnormal growths or tension in the pelvic floor muscles. He or she also will check for changes in sensation in your skin and any areas of tenderness. For cultures, your doctor will take samples of cells from your cervix, vagina and bladder to check for infection. Laparoscopy, cystoscopy and sigmoidoscopy are surgical procedures during which your doctor looks for abnormal tissues or growths or signs of infection with lighted cameras. Imaging studies, such as ultrasound, CT scans and MRI, may help your doctor determine if your anatomy is normal or if there are any growths. Tests of the bladder include cystoscopy and urodynamics, while sigmoidoscopy and anal manometry are used to study bowel function. Nerve testing also may be helpful.