Pelvic Pain

Drawing of the female reproductive system. Source: SEER's Training Web Site.

Pelvic pain is a general term to describe pain that occurs in the lower abdomen. It may be steady pain, or pain that comes and goes.

Types

Pelvic pain can be acute or chronic. Acute means the pain comes on suddenly, while chronic means it has been present for a longer period of time.

Causes

Acute pelvic pain

In women, the most common causes of acute pelvic pain are the following:

• Urinary tract infection, an infection of the urinary bladder most commonly caused by bacteria such as E. coli.
• Pelvic inflammatory disease, an infection of the fallopian tubes, ovaries, uterus, and other pelvic structures caused by bacteria, usually chlamydia or gonorrhea. The pelvic organs can be affected by inflammation; abscesses (pockets of pus) can form on the ovaries and fallopian tubes (a tuboovarian abscess).
• Ovarian cysts, which may burst, bleed, degenerate, or twist (a condition called torsion), causing the blood supply to be cut off.
• Uterine fibroids, benign but bulky tumors that may twist on themselves, cutting off blood supply) or degenerate (grow out of their blood supply).
• Endometriosis, a condition in which material from the inside of the uterus is found in other parts of the body, may cause pelvic pain if an endometrioma breaks open. An endometrioma is a large ovarian cyst filled with endometriosis.
• Endometritis, an infection of the uterus.
• Dysmenorrhea, or pain during the menstrual cycle. This can result from endometriosis, fibroids, or primary dysmenorrhea, a kind of menstrual pain which is thought to be caused by chemical substances called prostaglandins.
• Ectopic pregnancy, a pregnancy that forms in the fallopian tube instead of the uterus. Ectopic pregnancies usually rupture (burst open) within the fallopian tube, causing internal bleeding that can be life-threatening.
• Miscarriage,a pregnancy that is lost, usually within the first 13 weeks
• Ovarian hyperstimulation syndrome, a rare disease that occurs in women undergoing fertility treatments. A similar syndrome may be produced by gestational trophoblastic disease.
• Appendicitis,infection of the appendix
• Mesenteric lymphadenitis, an inflammation of certain lymph nodes in the abdomen.
• Diverticular disease, or outpouchings of the intestines that can become inflamed or infected.
• Kidney stones, or stones that form in the urinary tract, may cause pelvic pain, usually by blocking the ureter.

Chronic pelvic pain

Chronic pelvic pain is defined as pain in the pelvis that has been present for at least six months. Causes can be put into the following categories:

1. Gynecologic (female reproductive organs)
2. Urinary tract
3. Intestinal
4. Musculoskeletal
5. Neurologic
6. Psychological

Gynecologic causes:

• Endometriosis can cause chronic pelvic pain; it is especially likely to be during the menstrual period (dysmenorrhea), Pain is typically constant and varies from a dull ache to severe pain. Onset is several days before the period and often improves after the period. It is frequently associated with dyspareunia (pain during intercourse). Pain may radiate to the back and legs.
• Adenomyosis. Symptoms are very similar to endometriosis but are more frequently associated with menorrhagia (heavy menstrual bleeding)
• Fibroids. Non-cancerous growths in the uterus that can cause pressure-type pain. Fibroids can also cause acute pain.
• Ovarian cysts. There are many types of cysts. Pain may be caused by stretching of the cyst's outer capsule, or by its pressing on nearby organs.
• Pelvic adhesions, or scar tissue from prior surgery or infection.
• Pelvic inflammatory disease, an infection of the fallopian tubes, ovaries, uterus, and other pelvic structures caused by bacteria, usually chlamydia or gonorrhea. The pelvic organs can be inflamed, or abscesses (pockets of pus) can form on the ovaries and fallopian tubes.
• Pelvic congestion syndrome, in which enlarged, varicose-type veins around the uterus and ovaries can sometimes cause an ache or pain.
• Ovarian remnant syndrome: Rarely, when the ovaries are surgically removed, a small piece of ovary may be left behind. This ovarian remnant can later develop tiny, painful cysts.
• Retroversion or retroflection of the uterus, in which the uterus is tipped back toward the tailbone.
• Vulvodynia, or chronic pain or discomfort of the vulva (external female genitalia). Vulvodynia can cause burning, stinging, irritation, or rawness of the vulva.

Urinary tract causes:

• Interstitial cystitis, or inflammation of the bladder wall and lining. Often associated with endometriosis.
• Kidney stones.
• Recurrent urinary tract infection (bladder or kidney infection).
• Prostatitis, or inflammation or infection of the prostate gland.

Intestinal causes:

• Constipation.
• Irritable bowel syndrome.
• Diverticulitis. Inflammation of an outpouched area on the intestine.
• Colitis. Inflammation of the colon.
• Bowel obstruction, a condition that may occur if someone has had prior surgery that causes scarring, which can block the intestines. Bowel obstructions can come and go over a long period of time.
• Celiac disease (intolerance to gluten and wheat).

Musculoskeletal causes:

• Pelvic floor muscle spasm: Pelvic muscles form a floor at the base of the pelvis that hold the pelvic organs in place. If these muscles spasm, it can cause pain.
• Hernia.
• Coccyx (tail bone) pain.
• Lower back pain from stressed back muscles.
• Herniated disc in the spinal column can put pressure on nerves and cause pain.
• Fibromyalgia, a condition that causes pain and tenderness in certain tissues and muscles.

Neurologic causes:

• Inflammation or entrapment of a pelvic nerve from childbirth or surgery. Pudendal nerve inflammation is a common example, and it can be treated by a pain specialist.

Psychological causes:

• Post-traumatic stress disorder after sexual assault.
• Depression.
• Stress in general can worsen symptoms of pain.

Associated factors

A review of factors associated with chronic pelvic pain showed that the following made women more likely to develop this symptom:^[1]

• Drug or alcohol abuse
• Miscarriage
• Heavy menstrual flow
• Pelvic inflammatory disease
• Previous cesarean section
• Disease in the pelvis
• History of abuse
• Psychological disease

What Pelvic Pain Could Mean

Pelvic pain is a symptom, not a disease in and of itself. It may be the first sign of a number of different disorders, some of which are minor, and some of which are more serious. Researchers have found that the following are the most common explanations of chronic pelvic pain in women:

• Intestinal disorders such as constipation and irritable bowel syndrome in 50%-80%
• Musculoskeletal disorders in 30%-70%
• Urinary disease in 5%-10%
• Advanced endometriosis or bowel adhesions in less than 5%
• Multiple causes in 30%-50%
• No identifiable medical cause in 5%

In addition, psychological diagnoses are present in up to 60% of women with pelvic pain.^[2]

Diagnosis

History

Some questions that may help make a diagnosis are the following:

• Describe the type of pain (ache, sharp, burning, stabbing, etc.)
• Where is the pain located?
• Does it come and go or is the pain constant?
• Does anything make the pain better or worse?
• Is the pain related to the menstrual cycle?
• Is it related to bowel movements?
• Does it hurt during urination or sexual activity?
• Is there pain in other parts of the body?
• Has there been a recent infection? Are there associated fevers?
• Has the patient had surgery in the pelvic area in the past?

Exams and tests

Many tests may be used to diagnose the cause of pelvic pain. These include the following:

• Pregnancy test to rule out an ectopic pregnancy or a miscarriage
• CBC to check the white blood cell count to see if the body is fighting an infection
• Sedimentation rate, a very nonspecific blood test for inflammation
• Urinalysis to look for an infection or for blood if kidney stones are suspected
• Pelvic exam to see if certain organs are tender when palpated
• Pap smear to look for infection, abnormal cells, and cancer
• Culture of the cervix for chlamydia and gonorrhea to check for a pelvic infection
• Pelvic ultrasound to look for ovarian mass, fibroids, or ectopic pregnancy
• Pelvic CT scan to look for conditions such as appendicitis, ovarian mass, or fibroids
• X-rays to look for kidney stones, air in the abdomen (which suggests a hole in the stomach or intestines), or other problems
• Laparoscopy, an outpatient surgery sometimes required to diagnose acute pelvic pain. It is the only definitive way to diagnose endometriosis.
• Nerve block. A pain specialist can anesthetize the nerve that is thought to cause the pain. If the pain goes away with injection of a particular nerve, the diagnosis of neuropathy can be made.

Treatment

Treatment of pelvic pain depends on its cause. Treatments for specific conditions can include antibiotics for infections; anti-inflammatory medications and birth control pills for primary dysmenorrhea, endometriosis, and fibroid pain; or GnRH agonists (medications that suppress the body's natural hormones) for endometriosis. Narcotic pain medications may be used temporarily to treat the pain of cycle-related ovarian cysts. Laparoscopy is commonly used to search for and treat adhesions, endometriosis and non-gynecologic problems such as appendicitis. Major surgery such as hysterectomy (removal of the uterus) is sometimes necessary.

Patients with chronic pelvic pain due to neurologic or musculoskeletal causes may receive minimally-invasive treatment, in which x-rays are used to guide therapies such as injections of pain medication, steroids, or botulinum toxin.^[3]

A holistic approach to chronic pelvic pain is likely to be beneficial, since the disorder is often due to or complicated by complex physical and psychosocial factors (in particular a history of sexual trauma or abuse).^[4]

Clinical Trials

For a list of U.S. government-sponsored clinical trials on pelvic pain, visit ClinicalTrials.gov.

References

1. ↑ Latthe P, Mignini L, Gray R, Hills R, Khan K. Factors predisposing women to chronic pelvic pain: systematic review. BMJ. 2006 Apr 1;332(7544):749-55. Epub 2006 Feb 16. Abstract | Full Text
2. ↑ Dick ML. Chronic pelvic pain in women: assessment and management. Aust Fam Physician. 2004 Dec;33(12):971-6. Abstract | PDF
3. ↑ Peng PW, Tumber PS. Ultrasound-guided interventional procedures for patients with chronic pelvic pain - a description of techniques and review of literature. Pain Physician. 2008 Mar-Apr;11(2):215-24. Abstract | PDF.
4. ↑ Tettambel MA. Using integrative therapies to treat women with chronic pelvic pain. J Am Osteopath Assoc. 2007 Nov;107(10 Suppl 6):ES17-20. Abstract | Full Text

External Links

American College of Obstetricians and Gynecologists

International Pelvic Pain Society

Prostatitis Blog: On Patients, Prostates, and Pain