Chronic Pelvic Pain
Chronic pelvic pain may be a steady pain or a pain that comes and goes, perhaps with a woman's menstrual cycle. The pain may be bad enough to interfere with normal daily activities. Chronic pelvic pain is defined as pelvic pain that lasts for more than 6 months.
Pelvic pain and pelvic masses are common symptoms experienced by women and can be due to several causes. Both can be described as acute or chronic, cyclic or non cyclic, localized of generalized, or a combination. Specific characteristics vary with the muse. It's important to note that sudden, severe pain with mass indicates a serious disorder such as an ectopic pregnancy, and requires immediate evaluation and treatment.
Ten percent of all outpatient visits to a gynecologist are for pelvic pain, a lid in the United States, chronic pelvic pain has a prevalence of 3% (approximately 9.2 million women). It affects women of reproductive age and older.
What causes Pelvic Pain ?
Many gynecologic conditions cause pelvic pain and pelvic masses:
- Several types of infections can lead to pelvic pain, such as vaginitis, urinary tract infection, and pelvic inflammatory disease (PID). Bacteria enter via the genitourinary tract and cause inflammation.
- Pelvic pain may occur early in pregnancy, especially in the right lower quadrant, due to the dextrorotation of the uterus as it grows. It's sometimes referred to as round ligament pain.
- Spontaneous abortion, whether missed, threatened, incomplete, or complete, can induce pelvic pain.
- Ectopic pregnancy, the implantation of the fertilized ovum in a place other than the uterus (most commonly one of the fallopian tubes), can produce lower abdominal pain (commonly unilateral) with a tender mass.
- Endometriosis, the presence of endometrial tissue outside of the endometrium, may cause pelvic pain with dyspareunia (difficult or painful sexual intercourse). Uterosacral nodules may be felt during physical examination.
- An endometrial polyp is a mass of tissue holding on to the surface of the endometrium by a pedicle. It isn't commonly associated with pain.
- Fibroids are masses of smooth muscle and fibrous connective tissue in the uterus.
- One symptom of premenstrual syndrome (PMS) is described as pelvic heaviness or pressure and is most commonly felt 7 to 10 days before menses.
- Mittelschmerz can cause pain in the middle of the menstrual cycle due to ovulation.
- Dysmenorrhea is pain that occurs during menses.
- Ovarian cysts are masses, which are usually benign sacs that contain fluid or semisolid material. They may cause unilateral adnexal pain. Severe pain occurs with rupture or torsion.
- Adhesions from prior surgeries can cause pain as well as masses.
- Pelvic malignancy can present as a mass but isn't commonly associated with pelvic pain.
Pelvic pain may also be caused by non gynecologic conditions, such as:
- GI disorders, such as appendicitis, irritable bowel syndrome, spastic colon, chronic constipation, diverticulitis, and inflammatory bowel disease.
- musculoskeletal problems
- prior physical or sexual abuse.
Signs and symptoms of Pelvic Pain
Pelvic pain may be described in many ways, such as cramping, bloating, discomfort, pressure. stabbing, or aching. Pelvic masses can be small,large,localized to a single mass, or consist of multiple masses. Pelvic masses themselves may cause pain. Many associated signs and symptoms may occur with pelvic pain and masses, including:
- dyspareunia, or pain with deep thrusting during sexual intercourse.
- cervical motion tenderness
- vaginal fornix pain
- adnexal tenderness
- enlarged, bulky uterus
- uterosacral nodules
- nausea and vomiting
- severe pain with rupture of ovarian cysts, adnexal torsion, or hemorrhage
- leukocytosis (increased white blood cell count)
- cervical discharge
- adnexal enlargement
- back pain
- leg pain.
Diagnostic tests used to identify the cause of pelvic pain or masses depend on the suspected cause. Tests may include:
- specimen cultures
- serum or urine pregnancy test
- complete blood count to rule out anemia if bleeding is present
- erythrocyte sedimentation rate or C-reactive protein, to identify inflammatory or infectious process
- computed tomography scan
- magnetic resonance imaging
- laparoscopy, if the client is in severe pain and the diagnosis is unclear, pathology is suspected, or there's minimal or no response to therapy
- laparoscopic pain mapping
- ultrasound, sigmoidoscopy, colonoscopy, or barium enema if a GI problem is suspected
- urinalysis, cystourethroscopy, or urodynamic studies if infection of the urinary tract is suspected.
When evaluating for chronic pelvic pain, it's absolutely necessary to perlonn laparoscopy and cystoscopy because chronic pelvic pain can be caused by endometriosis, interstitial cystitis, or both.
Treatment of Pelvic Pain
Treatment of pelvic pain and masses should be directed to the cause of the pain. However, a cause isn't always identified, and although treatment of symptoms is commonly attempted, pain isn't always relieved. In fact, it may worsen with treatment. Treatments may include:
- nonsteroidal anti-inflammatory drugs
- gonadotropin-releasing hormone agonists
- hormonal contraceptives
- embolization of fibroids
- surgical removal of fibroids, cysts, or endometrial growths
- laparoscopic laser surgery
- uterosacral nerve ablation for central pelvic pain or dysmenorrhea unresponsive to medical therapy
- Relaxation exercises, biofeedback (treatment to control emotional states using electronic devices) and physical therapy.
- presacral neurectomy
- nerve block or transection
Special considerations and Prevention
- Encourage the woman to keep a "diary" of the pain, which may help the client and clinician identify possible causes.
- Provide nutritional counseling to the client with a GI problem, such as constipation, that may contribute to pelvic pain.
- Rest regularly by sitting reasonably upright with your back well supported.
- Educate the client about diagnostic procedures and treatment.
- Encourage good hygiene practices if an infectious cause is suspected or determined.
- Make appropriate referrals for counseling, surgery, or other specialists.
- Deep breathing and targeted stretching exercises for your pelvic region could help minimize bouts of pain when they occur. Ask your doctor for advice or seek the assistance of a physical therapist to learn relaxation techniques you can practice at home.
- Supportive care is crucial in caring for these clients. Many women suffering chronic pelvic pain are frustrated by the lack of a diagnosis, lack of relief, or both.