What Causes Chronic Pelvic Pain?

Causes of chronic pelvic pain

Gynaecologic causes

Urological causes

Gastrointestinal causes

Musculoskeletal causes

TREATMENT OF CHRONIC PELVIC PAIN

PATIENTS WITH CHRONIC PELVIC PAIN NEED NOT SUFFER IN SILENCE

Pelvic pain is a common disabling problem that affects up to 1 in 5 women and is the commonest cause of days off work in women of reproductive age.

Chronic pelvic pain in women aged 18 to 50 years accounts for direct medical costs of approximately $881.5 million per year in the United States.

Chronic pelvic pain is pain that occurs below the navel, lasts for at least six months and may not be related to menstrual periods. Unfortunately, the cause of chronic pelvic pain is often difficult to diagnose as many different conditions involving the uterus, ovaries, bladder, bowel or pelvic floor muscles and nerves can cause this problem.

Many patients may also have associated problems such as depression, anxiety, and sexual dysfunction. Hence, it is important that a multidisciplinary approach is used to deal with chronic pelvic pain. Dr Cherylin Fu, Senior Consultant from the Department of Colorectal Surgery at Singapore General Hospital, a member of the SingHealth group, shares more.

Causes of chronic pelvic pain

A wide variety of conditions can cause chronic pelvic pain. Some of the more common causes include:

Gynaecologic causes

Chronic pelvic pain is thought to be caused by gynaecologic issues in about 20 percent of women.

Endometriosis - One of the most common gynaecologic causes is endometriosis, a condition where the tissue normally lining the inside of the uterus can also be found outside of the uterus. Women with this condition may experience severe menstrual cramps or pain since their early teens or twenties, painful intercourse or difficulty getting pregnant.

Pelvic inflammatory disease - This acute infection is usually sexually transmitted. It can affect the uterus, ovaries, and fallopian tubes. About a third of women suffer from complications which may cause chronic pelvic pain.

Pelvic adhesions - Adhesions is the term for abnormal tissue that makes internal organs or structures, such as the ovaries and fallopian tubes, stick to one another. Surgery, infection, or inflammation can lead to the development of such abnormal tissue. Whether adhesions cause pelvic pain and whether surgery for pelvic adhesions actually relieves pelvic pain for most women remain controversial.

Urological causes

Painful bladder syndrome and interstitial cystitis - Painful bladder syndrome (PBS) and interstitial cystitis (IC) are terms used to describe bladder pain not caused by infection. Typical symptoms include the need to urinate frequently or urgently.

Gastrointestinal causes

Irritable bowel syndrome - Irritable bowel syndrome (IBS) is a gastrointestinal condition characterised by chronic abdominal pain, cramps, bloating 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.

Musculoskeletal causes

Levator ani syndrome, proctalgia fugax (anorectal pain) and coccygodynia (pain at the coccyx) - These are examples of “functional” pelvic floor disorders that cause chronic pelvic pain. Patients may experience recurrent episodes of pain in the region of the pelvis, rectus, anus or tailbone, which may occur suddenly at night, lasting for more than 20 minutes before disappearing.

The cause is unknown, but thought to be related to abnormal tightening or overactivity of the pelvic floor muscles. During examination, the doctor may feel the pelvic floor muscles through the rectum or vagina as a tight band that is tender when pressing on it.

Pudendal nerve entrapment (Alcock’s canal syndrome) - The pudendal nerve is responsible for sensation around the anus, the base of the scrotum (in males) and vagina (in females). Rarely, it may get compressed, resulting in pain, numbness or burning sensation around the perineum on one side. These symptoms may occur in the sitting position and worsen with bicycle riding. Treatment involves injection of local anaesthetic or steroids.

Apart from a detailed history taking and physical examination, some common tests may be performed.

TESTS FOR CHRONIC PELVIC PAIN

Blood tests
Pregnancy test
Ultrasound of the pelvis - to look for growths such as ovarian cysts and uterine fibroids
Computed Tomography scan - A CT scan can provide detailed high-resolution scan of the abdomen and pelvis to look for abnormal masses or tumours
MRI of the pelvis - A magnetic resonance imaging scan (better known as an MRI scan) of the pelvis will be used to look for pelvic floor abnormalities such as pelvic organ prolapse
Endoanal ultrasound - ultrasound scan of the anal sphincter muscles and pelvic floor muscles to exclude abscesses or fistulas
Laparoscopy - a surgical procedure done under general anaesthetic which may be helpful in diagnosing some causes of chronic pelvic pain such as endometriosis and chronic pelvic inflammatory disease

The telescope allows the surgeon to see inside the abdomen, especially the reproductive organs. If the findings are normal, the physician can then further investigate non-gynaecologic causes of pelvic pain.

If the laparoscopy reveals areas of endometriosis or abnormal tissue, they may be treated or biopsied on the spot.

TREATMENT OF CHRONIC PELVIC PAIN

Treatment of chronic pelvic pain often involves different specialists including surgeons, physiotherapists, pain specialists and even psychologists. If a specific cause is found, treatment will be directed accordingly. For example, patients with gynaecologic conditions such as endometriosis will often need medications such as hormonal therapy. In some cases, surgery may be required.

After thorough investigation, no physical abnormality or disease may be found. In such cases, dysfunctional pelvic floor muscle states as interstitial cystitis or levator ani syndrome may be the cause. Physical therapy may then help to relax and normalise pelvic floor function and to alleviate pain.

Treatment options available to chronic pelvic floor patients include:

Biofeedback therapy with surface electromyography - More than just pelvic floor exercises, biofeedback aims to teach patients to identify, relax or contract the various muscle groups in the pelvis. It is safe, non-invasive and often highly effective when used appropriately.

Myofascial therapy - This type of therapy aims to relieve specific muscle tightness through digital massage of acutely painful “trigger points” located in the abdomen, vagina, hips, thighs, and lower back.

A physiotherapist can also teach various muscle relaxation and digital massage techniques that patients can do on their own at home.

In some instances, psychological counselling may also be offered to help patients manage their pelvic pain. There are several types of psychosocial support and psychotherapies which may involve meeting with a psychologist, psychiatrist and/or social worker.

If medications are not effective in relieving the pain, patients may be referred to see an anaesthetist specialised in pain management.

PATIENTS WITH CHRONIC PELVIC PAIN NEED NOT SUFFER IN SILENCE

If you have pelvic pain that seems more complicated than just period pain, do seek medical attention and visit your doctor or GP. It may take more than one health professional to help you. Management of chronic pelvic pain requires a multidisciplinary pelvic floor team that may include a gynaecologist, urologist, colorectal surgeon, pain specialist, psychologist, specialist pelvic physiotherapist and nursing professionals, among others.

Ref: R14

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