Pelvic pain - chronic

After a daylong hard work, sometime you might feel severe back pain, which usually vanishes after a short nap or rest. But if you are suffering from pain in the pelvic region, which is the area below your belly and above your hip, for the past 6 months or more, than is could be something called as Chronic Pelvic Pain (CPP).

Understanding Chronic Pelvic Pain

CPP may be a continuous pain or it may ebb and flow. You might feel mild or severe pain in the pelvic region. When asked to spot your pain, you might sweep your hand all around the pelvic region rather than spotting a specific area.

A chronic pelvic pain may be a symptom of other underlying cause or it might be a disease in itself. CPP is common among female adolescents. It is estimated that about 25% of women with CPP are forced to spend 2-3 days on bed each month, more than half of women with CPP are restrained from their daily activity, and 90% of them suffer pain during intercourse. Despite such suffering caused by CPP many times doctors are not able to come up with a diagnosis or treatment to help these women.

Pain in the pelvic region is caused either by gynecological problems or due to other medical conditions.

Gynecological causes

  • Endometriosis: Endometrium is the tissue lining of your uterus and endometriosis is a disease of endometrium. In endometriosis the tissue from uterus lining invades the fallopian tube, ovaries, pelvis, bladder and other regions. During normal menstrual cycle these tissues swell and bleed like your uterus, as this happens outside the uterus the blood and tissue cannot find its way out through the vagina, they get collected in the abdomen resulting in painful cyst
  • Pelvic inflammatory disease: Infection in uterus, fallopian tube, and ovaries
  • Fibroids: Non-cancerous muscle growth in the wall of uterus
  • Ovarian remnant: During surgical removal of uterus and ovaries called hysterectomy, small part of the ovaries might be left behind, which later develops into a painful cyst
  • Ectopic pregnancy: Pregnancy outside the uterus

Non-gynecological causes

  • Gastro-intestinal causes: Irritable bowel syndrome which means problem in the intestine, where the food is pushed too fast or too slow through intestine. Other gastro-intestinal problems that cause CPP are – appendicitis, constipation, gastroenteritis (inflammation of the stomach and intestine), hernia (protrusion of organ or tissue), and inflammatory bowel disease
  • Interstitial cystitis: Inflamed and irritated bladder wall resulting in stiff, non-expandable bladder. Other urological problems are kidney stones, urethral syndrome, urinary tract infection
  • Musculoskeletal: Joint pain, posture problem, spinal injury, and inflammation
  • Psycho-social issues: Depression, sexual abuse, eating disorder, and substance abuse

There are a few chronic pelvic pain symptoms mentioned below. They are:

  • Severe and steady pain
  • Dull aching
  • Cramps
  • Sharp pains
  • Pressure or heaviness deep within the pelvis
  • Pain during intercourse
  • Pain while urinating
  • Pain while sitting for a long time

Diagnosis of CPP begins with detail examination of your previous medical history. Your doctor would enquire you about the duration and frequency of your symptoms, severity and location of pain, situations that increase or decrease pain, and previous medicines and treatments that you have undergone. Your doctor would also ask you about any health related issue in your family. He would also want to know information like

  • Is your pain related to bowel movement or menstrual cycle or both?
  • Does it pain during sexual activity and urination
  • Your previous pelvic surgeries
  • Previous infections

As CPP is caused due to variety of sources it is important that during a physical examination your doctor give attention to screen for musculoskeletal cause your doctor will examine your posture, palpate (diagnosis by touch) your upper and lower back, check your leg-length, and ask you whether you often stand on one-leg. He will ask you to lie down on your back and palpate your abdomen with your legs and head raised.

Physical examination will also focus on urological and gynecological causes. He will palpate your urethra and bladder for detecting specific tenderness or mass.

A rectal examination will be done if gastrointestinal cause of CPP is suspected.

Laboratory tests include a complete blood picture and erythrocyte sedimentation rate; urine analysis and urine culture; human chorionic gonodotropin hormone will be measured in sexually active individuals. A plain film of the abdomen will be taken if constipation is suspected.

An ultrasound examination of abdomen, vagina, and rectum will be done in patients with abnormal results of physical examination.

Performing a safe and minimal invasive laparoscopy in patients detect with abnormal physical examinations has become an important diagnostic tool in assessing CPP. Laparoscopic examination is done when

  • CPP doesn’t respond to oral contraceptives and anti-inflammatory drugs
  • Chronic pelvic inflammatory disease or appendicitis is suspected
  • Identifying a pelvic mass
  • Irregular, painful vaginal bleeding
  • Progressive dysmenorrhea (painful periods)

The underlying cause of CPP will dictate the pelvic treatment procedure, it varies for each patients. CPP is not a single cause disease, it is caused by various factors interacting together therefore you will need several treatments procedure for all these problems. Few treatment options are

  • Hormone therapy for patient with endometriosis and heavy menstrual bleeding
  • Stopping ovulation (periods) with birth control pills or injections
  • Non-steroid anti-inflammatory medicine for relieving pain
  • Antibiotics in case of infection
  • Relaxation exercise, physical therapy and biofeedback (controlling emotional state using electric shocks) for people with connective tissue or muscle pain
  • Abdominal trigger point injection: giving shots in the trigger point region, in the lower wall of abdomen, where the pain originates, actually subsides the pain
  • Psychological counseling with or without anti-depressant medicines
  • Meditation, yoga, breath-work for mind and body relaxation
  • Rarely, surgery for patient with adhesion or remnant or endometriosis