What is chronic pelvic pain?
Chronic pelvic pain is pain felt in the lower abdomen or pelvis which has been experienced constantly or intermittently for at least six months and occurs at other times other than during menstruation and/or sexual intercourse.
What causes chronic pelvic pain?
Persistent pelvic pain is thought to affect 1 in 5 women and 1 in 12 men in Australia. Long term pelvic pain is not a diagnosis in itself but rather a description of symptoms. In many cases a doctor will not be able to identify a reason for ongoing pelvic pain or give a clear diagnosis however they will be able to rule out any serious medical condition.
Ongoing pelvic pain is thought to be a combination of physical, psychological and/or social factors rather than one single underlying condition. These can include:
- Endometriosis: a condition where the lining of the womb (the endometrium) is found outside the body (usually in the pelvis)
- Adenomyosis: a condition where the endometrium is in pockets within the muscle wall of the uterus (womb)
- Interstitial Cystitis: recurrent bladder infections
- Pelvic Inflammatory Disease (PID): an infection of the uterus, fallopian tubes and/or pelvis
- Irritable Bowel Syndrome (IBS): a long-term condition affecting the digestive system where pain is the dominant symptom
- adhesions (scar tissue): this may be a result of previous surgery, infection or endometriosis
- musculoskeletal pain: pain in joints, muscles ligaments and bones
- depression (including postnatal depression)
- previous or ongoing traumatic experiences such as sexual abuse
- Prostatitis
- Hernia
- Urethral stricture
- Benign prostatic hyperplasia (BPH)
Symptoms associated with chronic pelvic pain
- difficulty sleeping
- constipation
- decreased appetite
- depression or feelings of sadness
- a loss of daily function
- continuous or nearly continuous pain that lasts for six months or longer
- conventional treatments such as over the counter pain medications have not helped the pain
Both women and men with persistent pelvic pain may find that they feel symptoms in other parts of their body. They may find that the muscles in the pelvis cause tension which may affect bladder and bowel function. Others may notice pain and stiffness of their lower back and legs with pain that is more troublesome than the pelvic pain.
Diagnosis of chronic pelvic pain
A doctor will take a full and detailed history including questions such as what makes the pain worse/better and if it is related to any other symptoms such as bladder or bowel function or intercourse. They will also carry out a physical examination.
Investigations that may be offered are an ultrasound scan to look at the pelvis and its organs and screening tests for sexually transmitted diseases (STDs) as these can cause pelvic inflammatory diseases and/or chronic pelvic pain.
If the pelvic pain is related to bladder and bowel function or symptoms then a referral to a specialist in this field may be made (for example, to a gastroenterologist for investigation for IBS or urologist).
If the pain occurs on a regular basis at a specific time such as the menstrual cycle then a woman may be offered drugs to suppress menstruation for a few months. This may assist a doctor in making a diagnosis.
Treatment
Treatment for chronic pelvic pain may include a combination of treatment including drugs which may help with the physical pain and psychological treatment.
Occasionally pelvic pain can be helped by undergoing a surgical procedure: some women find that the pain is improved if their endometriosis is surgically removed.
Analgesia (pain medication) may be prescribed. The pain may initially respond to over-the-counter medication such as paracetamol or ibuprofen however if these are not effective then prescription drugs may need to be taken. A tricyclic antidepressant drug such as Amitriptyline may partly help with persistent pelvic pain and assist with sleep. This medication may cause side effects such as a dry mouth, drowsiness, constipation or nausea. It is usually started at a low dose and increased slowly so that side effects can be minimised. Alternatively, another type of antidepressant called selective serotonin reuptake inhibitors (SSRIs) may be used. These may cause side effects such as agitation, sleep disturbances, vivid dreams and diarrhoea.
Physical therapy may include referral to a physiotherapist who can advise on positioning or stretching exercises and who may carry out treatment such as massage, ultrasound or trial a TENS machine. A TENS machine is a small machine that can be attached to a belt or waistband. Small electrodes are attached to the skin of the lower abdomen with sticky pads and the machine delivers small electrical impulses via these electrodes. This is thought to help the pain in two ways: a low electrical pulse encourages the body to produce more endorphins (the body’s own pain relieving chemical) while a high electrical pulse can override the pain messages, blocking them and preventing them from reaching the brain. They may also recommend pelvic floor training. This aims to reduce the tightness and tenderness in the pelvic floor muscles. The treatment is directed towards the vagina, hips, thighs and lower back.
Psychological treatment includes education, reassurance, counselling, relaxation therapy and stress management techniques. Pain management programs and cognitive behavioural therapy (CBT) may also be effective in helping women to better self-manage chronic pelvic pain.
Chronic Pain Australia offers support and advice to people and their families with persistent pain (chronicpainaustralia.org.au), as does Pelvic Pain Foundation (Pelvic Pain Foundation)
