Chronic Pelvic Pain Causes and Treatment

Pelvic pain occurs mostly in the lower abdomen area. The pain might be steady, or it might come and go. If the pain is severe, it might get in the way of your daily activities.

If you have chronic pelvic pain, see your GP to find out the cause and to get any necessary treatment.

If you’re a woman, you might feel a dull pain during your period. It could also happen during sex. Pelvic pain can be a sign that there is a problem with one of the organs in your pelvic area, such as the uterus, ovaries, fallopian tubes, cervix or vagina.

Persistent or recurrent pelvic pain

If you’ve had pelvic pain for six months or more that either comes and goes or is continuous, it is known as chronic pelvic pain. Chronic pelvic pain is more intense than ordinary period pain and lasts for longer. It affects around one in six women.

It could also be a symptom of infection, or a problem with the urinary tract, lower intestines, rectum, muscle or bone. If you’re a man, the cause is often a problem with the prostate.

You might have to undergo a lot of medical tests to find the cause of the pain. The treatment will depend on the cause, how bad the pain is and how often it occurs.

Chronic pelvic pain can truly be described as a ‘silent epidemic’.

Around 1 in 5 women have pelvic pain, yet most people in our community think it is rare. Why is this?

Women don’t like to talk about their pelvic pain. It’s a pain others can’t see, in a sensitive area, that men don’t get and that may affect her sexuality or fertility. You can’t tell by looking at her that she has pelvic pain, and when the pain is very severe she stays home. This is why pelvic pain is the commonest cause of days off work in women of reproductive age.

Chronic pelvic pain is a pain that starts young – often in the teens or twenties – with bad period pain over more than 1-2 days a month. Her mother may have had bad periods too, so she may have been told that ‘its normal’, ‘part of being a woman’ or that ‘nothing can be done’.

Not surprisingly, this ‘normalising’ of her pain by family, friends and sometimes health professionals over several years can erode her self-confidence. It also misses the opportunity to manage the pain promptly.

Types of Pelvic pain

There are many types of pelvic pain, but one of the commonest is a medical condition called endometriosis. Women with endometriosis have tissue like the lining of the uterus around the pelvis in places it is not supposed to be. Scans are usually normal, but a laparoscopy (‘keyhole surgery’) will show areas of abnormality.

Common causes of chronic pelvic pain

The most common causes of chronic pelvic pain are:
endometriosis – a long-term condition where small pieces of womb lining are found outside the womb (such as on the ovaries)
chronic pelvic inflammatory disease – a bacterial infection of the womb, fallopian tubes or ovaries, which often follows a chlamydia or gonorrhoea infection and needs immediate treatment with antibiotics
irritable bowel syndrome – a common condition of the digestive system that can cause stomach cramps, bloating, diarrhoea and constipation

Less common reasons for chronic pelvic pain

Less common causes of chronic pelvic pain include:

  • recurrent ovarian cysts – fluid or blood-filled sacs that develop on the ovaries
  • a recurrent urinary tract infection
  • lower back pain
  • prolapse of the womb – the womb slips down from its normal position and usually causes a “dragging” pain
  • adenomyosis – endometriosis that affects the muscle of the womb, causing painful, heavy periods
  • fibroids – non-cancerous tumours that grow in or around the womb
  • chronic interstitial cystitis – long-term inflammation of the bladder
  • inflammatory bowel disease – a term used to describe two chronic diseases, ulcerative colitis and Crohn’s disease, which affect the gut
  • a hernia – where an internal part of the body pushes through a weakness in the surrounding muscle or tissue wall
  • trapped or damaged nerves in the pelvic area – these may cause sharp, stabbing or aching pain in a specific area, which often gets worse with certain movements

The causes of chronic pelvic pain are varied, but are often associated with the presence of ovarian and pelvic varicose veins. Pelvic congestion syndrome is similar to varicose veins in the legs.

In both cases, the valves in the veins that help return blood to the heart against gravity become weakened and don’t close properly, this allows blood to flow backwards and pool in the vein causing pressure and bulging veins.

In the pelvis, varicose veins can cause pain and affect the uterus, ovaries and vulva. Up to 15 percent of women, generally between the ages of 20 and 50, have varicose veins in the pelvis, although not all experience symptoms.

The diagnosis if often missed because women lie down for a pelvic exam, relieving pressure from the ovarian veins, so that the veins no longer bulge with blood as they do while a woman is standing.

Many women with pelvic congestion syndrome, spend many years trying to get an answer to why they have this chronic pelvic pain. Living with chronic pelvic pain is difficult and affects not only the woman directly, but also her interactions with her family, friends, and her general outlook on life.

Because the cause of the pelvic pain is not diagnosed, no therapy is provided even though there is therapy available.

If you have pelvic pain that worsens throughout the day when standing, you may want to seek a second opinion with an interventional radiologist, who can work with your gynecologist.

You can ask for a referral from your doctor, call the radiology department of any hospital and ask for interventional radiology or visit the doctor finder link at the top of this page to locate a doctor near you.

While some women with endometriosis will only ever have painful periods, others develop more complex pain over time including any or all of the following pains:

  • Painful periods (Dysmenorrhoea)
  • Bowel pain, bloating, cramps, and irritable bowel
  • Bladder symptoms of frequent voiding (Frequency), getting up at night (Nocturia), needing to get to a toilet in a hurry (Urgency), or flare ups that feel like a urine infection
  • Pelvic muscle pain causing painful intercourse (Dyspareunia), pain with smear tests or pain using tampons
  • Pain opening bowels (Dyschezia)
  • Sharp or burning pains
  • Frequent headaches or migraines

If you have pelvic pain that has become more complicated than just period pain, it may take more than one health professional to help you be as well as you can be.

A multidisciplinary pelvic pain team might include a gynaecologist, pain specialist, your GP, psychologist, specialist pelvic physiotherapists, and nursing professionals among others.

This team can work with you to provide medical pain management approaches as well as help you develop the knowledge and skills for pain self-management that you can use on a daily basis.

Women with chronic pelvic pain do not fit easily in services for other types of pain targeted at older patients.

Prevalence

  • Women with pelvic congestion syndrome are typically less than 45 years old and in their child-bearing years.
  • Ovarian veins increase in size related to previous pregnancies. Pelvic congestion syndrome is unusual in women who have not been pregnant.
  • Chronic pelvic pain accounts for 15 percent of outpatient gynecologic visits.
  • Studies show 30 percent of patients with chronic pelvic pain have pelvic congestion syndrome (PCS) as a sole cause of their pain and an additional 15 percent have PCS along with another pelvic pathology.

Risk Factors

Two or more pregnancies and hormonal increases

  • Fullness of leg veins
  • Polycystic ovaries
  • Hormonal dysfunction

Symptoms

The chronic pain that is associated with this disease is usually dull and aching. The pain is usually felt in the lower abdomen and lower back. The pain often increases during the following times:

  • Following intercourse
  • Menstrual periods
  • When tired or when standing (worse at end of day)
  • Pregnancy
  • Other symptoms include:
  • Irritable bladder
  • Abnormal menstrual bleeding
  • Vaginal discharge
  • Varicose veins on vulva, buttocks or thigh

Diagnosis and Assessment

Once other abnormalities or inflammation has been ruled out by a thorough pelvic exam, pelvic congestion syndrome can be diagnosed through several minimally invasive methods.

An interventional radiologist, a doctor specially trained in performing minimally invasive treatments using imaging for guidance, will use the following imaging techniques to confirm pelvic varicose veins that could be causing chronic pain.

  • Pelvic venography: Thought to be the most accurate method for diagnosis, a venogram is performed by injecting contract dye in the veins of the pelvic organs to make them visible during an X-ray. To help accuracy of diagnosis, interventional radiologists examine patients on an incline, because the veins decrease in size when a woman is lying flat.
  • MRI: May be the best non-invasive way of diagnosing pelvic congestion syndrome. The exam needs to be done in a way that is specifically adapted for looking at the pelvic blood vessels. A standard MRI may not show the abnormality.
  • Pelvic ultrasound: Usually not very helpful in diagnosing pelvic congestion syndrome unless done is an very specific manner with the patient standing while the study is being done. Ultrasound may be used to exclude other problems that might be causing pelvic pain.
  • Transvaginal ultrasound: This technique is used to see better inside the pelvic cavity. As with a pelvic ultrasound it is not very good at visualizing the pelvic veins unless the woman is standing. However it may be used to exclude other problems.

Treatment Options

Once a diagnosis is made, if the patient is symptomatic, an embolization should be done. Embolization is a minimally invasive procedure performed by interventional radiologists using imaging for guidance.

During the outpatient procedure, the interventional radiologist inserts a thin catheter, about the size of a strand of spaghetti, into the femoral vein in the groin and guides it to the affected vein using X-ray guidance.

To seal the faulty, enlarged vein and relieve painful pressure, an interventional radiologist inserts tiny coils often with a sclerosing agent (the same type of material used to treat varicose veins) to close the vein. After treatment, patients can return to normal activities immediately.

Additional treatments are available depending on the severity of the woman’s symptoms. Analgesics may be prescribed to reduce the pain.

Hormones such birth control pills decrease a woman’s hormone level causing menstruation to stop may be helpful in controlling her symptoms.

Surgical options include a hysterectomy with removal of ovaries, and tying off or removing the veins.

Source and More Info: Society of Interventional Radiology, Australian Pain Management Association and NHS Choices

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