Chronic pelvic pain in women

DEFINITION — Chronic pelvic pain is defined as pain that occurs below the umbilicus (belly button) that lasts for at least six months. It may or may not be associated with menstrual periods. Chronic pelvic pain is not a disease, rather, it is a symptom that can be caused by several different conditions.

CAUSES — A variety of gynecologic, gastrointestinal, and systemic disorders, can cause chronic pelvic pain.

Gynecologic causes — Gynecologic causes are thought to be the cause of chronic pelvic pain in about 20 percent of women. Some of the gynecologic causes of pelvic pain include:

Endometriosis — The tissue lining the inside of the uterus is called the endometrium (show figure 1). Endometriosis is a condition in which endometrial tissue is also present outside of the uterus. Some women with endometriosis have no symptoms, while others experience marked discomfort and pain and may have problems with fertility. (See "Patient information: Endometriosis" and see "Patient information: Evaluation of the infertile couple").

Chronic pelvic inflammatory disease — Pelvic inflammatory disease is an infection caused by a sexually transmitted organism. Occasionally, it is caused by a previous ruptured appendix or scarring resulting from previous pelvic surgery. It can involve the uterus, ovaries, and fallopian tubes (which link the ovaries and uterus) (show figure 1). Pelvic inflammatory disease can cause pain, abnormal uterine bleeding, and symptoms of infection such as fever and chills.

Other causes — Non-gynecologic causes of chronic pelvic pain may be related to the digestive system, urinary system, or to pain in the muscles and nerves in the pelvis:

Irritable bowel syndrome — Irritable bowel syndrome is a gastrointestinal condition characterized by chronic abdominal pain and altered bowel habits (such as loose stools, more frequent bowel movements with onset of pain, and pain relieved by defecation) in the absence of any specific cause. (See "Patient information: Irritable bowel syndrome").

Painful bladder syndrome and interstitial cystitis — Painful bladder syndrome and interstitial cystitis are the terms given to inflammation of tissues in the bladder and surrounding nerves and muscles that is not caused by infection. Symptoms usually include the need to urinate frequently (frequency) and a feeling of urgently needing to urinate (urgency). Some women with painful bladder syndrome have lower abdominal or pelvic pain in addition to urinary tract symptoms.

Diverticulitis — A diverticulum is a sac-like protrusion that sometimes forms in the muscular wall of the colon (or intestine). Diverticulitis occurs when diverticula become inflamed. This usually causes abdominal pain; nausea and vomiting, constipation, diarrhea, and urinary symptoms can also occur. (See "Patient information: Diverticular disease").

Pelvic floor pain — The muscles of the pelvic floor can sometimes become shortened, tight and tender; this is called pelvic floor dysfunction. The pelvic floor includes muscles that attach to the pelvic bones and sacrum (lower part of the spine). Normally, these muscles function to support the hips and pelvic organs. It is not clear why this problem develops, but symptoms may include pelvic pain, pain with urination, constipation, pain with intercourse, or frequent/urgent urination. Pelvic floor dysfunction can be diagnosed by a clinician by applying pressure to the muscles in the vagina and/or rectum; muscles that feel tight, tender, or band-like indicate that pelvic floor dysfunction could be contributing to pelvic pain.

Fibromyalgia — Fibromyalgia is one of a group of chronic pain disorders that affect connective tissue structures, including muscles, ligaments, and tendons. It is characterized by widespread muscle pain (or "myalgia") and tenderness in certain areas of the body. Women with fibromyalgia may also experience fatigue, sleep disturbances, headaches, and mood disturbances such as depression and anxiety. (See "Patient information: Fibromyalgia").

DIAGNOSIS — Because a number of different conditions can cause chronic pelvic pain, it is sometimes difficult to pinpoint the specific cause.

History and physical examination — A thorough history and a physical examination of the abdomen and pelvis are essential components of the work-up for women with pelvic pain. In particular, the examination should include the lower back, abdomen, hips, and pelvis (internal examination).

Laboratory tests, including a white blood cell count, urine analysis, tests for sexually transmitted infections, and a pregnancy test may be recommended, depending upon the results of the physical examination.

Pelvic ultrasound — Some diagnostic procedures may also be helpful in identifying the cause of chronic pelvic pain. As an example, a pelvic ultrasound examination is accurate in detecting pelvic masses, including ovarian cysts (sometimes caused by ovarian endometriosis) and uterine fibroids. However, ultrasound is not helpful in the diagnosis of irritable bowel syndrome, diverticulitis, or painful bladder syndrome.

Laparoscopy — A surgical procedure called a laparoscopy may be helpful in diagnosing some causes of chronic pelvic pain such as endometriosis and chronic pelvic inflammatory disease. Laparoscopy is a procedure that is often done as a day surgery. Most women are given general anesthesia to induce sleep and prevent pain. A thin telescope with a camera is inserted through a small incision just below the navel. Through the telescope, the surgeon can see the contents of the abdomen, especially the reproductive organs. If the laparoscopy is normal, the physician can then focus the diagnostic and treatment efforts on non-gynecologic causes of pelvic pain.

If the laparoscopy is abnormal (eg, areas of endometriosis or abnormal tissue are seen) these areas may be treated or biopsied during the procedure.

TREATMENT — Chronic pelvic pain due to a gynecologic condition is often treated medically. In some cases, however, surgery may be the treatment of choice.

Medical treatment — Medication may be prescribed once laboratory and imaging tests suggest the pain is due to a gynecologic condition. Drugs that may be used include: Nonsteroidal anti-inflammatory medications such as ibuprofen Oral contraceptive pills prescribed as monthly cycles or as "long cycles." When prescribed as long cycles, a woman takes the active pill continuously for three to four months followed by one week off the pill. Doxycycline, an antibiotic used to treat some causes of pelvic inflammatory disease. Medications called gonadotropin releasing hormone (GnRH) agonist analogues used to treat endometriosis.

Physical therapy — Pelvic floor physical therapy (PT) is often helpful for women with tight and tender pelvic muscles. This type of PT aims to release the tightness in these muscles by manually "releasing" the tightness; treatment is directed to the muscles in the vagina, hips, thighs, and lower back. Physical therapists who perform this type of PT must be specially trained.

Pain management clinics — If medications are not effective in treating the pain, a woman may be referred to a medical practice specializing in pain management. Pain services utilize multiple treatment modalities including Acupuncture Biofeedback and relaxation therapies Nerve stimulation devices Injection of tender sites with local anesthesia medication

Psychological counseling may be offered to help women manage the pain. Pain services can help women who have become dependent on narcotics for pain management.

Surgical treatment — A few causes of gynecologic pelvic pain can be treated surgically. For example, some women benefit from surgical removal of their endometriosis.

Hysterectomy may alleviate chronic pelvic pain, especially when it is due to uterine disorders such as adenomyosis or fibroids. However, pain can persist even after hysterectomy, particularly in younger women (those less than 30) and in women with a history of chronic pelvic inflammatory disease or pelvic floor dysfunction. Hysterectomy is not a good choice for the management of chronic pelvic pain in women who have not completed their family. (See "Patient information: Abdominal hysterectomy" and see "Patient information: Vaginal hysterectomy").

Surgery to cut some of the nerves in the pelvis has also been studied as a treatment for chronic pelvic pain. However, this approach has not proven to be effective for most women.

WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.

This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.

A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine

(www.nlm.nih.gov/medlineplus/healthtopics.html)
The International Pelvic Pain Society

(www.pelvicpain.org)
The Mayo Clinic

(www.mayoclinic.com)
U.S. Department of Health and Social Services

(www.4woman.gov, search for pelvic pain)


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Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Mathias, SD, Kuppermann, M, Liberman, RF et al. Chronic pelvic pain: prevalence, health-related quality of life, and economic correlates. Obstet Gynecol 1996; 87:321.
2. Scialli, AR. Evaluating chronic pelvic pain. A consensus recommendation. Pelvic Pain Expert Working Group. J Reprod Med 1999; 44:945.
3. Flor, H, Fydrich, T, Turk, DC. Efficacy of multidisciplinary pain treatment centers: a meta-analytic review. Pain 1992; 49:221.