Pelvic pain

Pelvic and perineal pain
Micrograph showing endometriosis (H&E stain), a common cause of chronic pelvic pain in women.
Classification and external resources
Specialty
ICD-10	R10.2
ICD-9-CM	625.9, 789.00
Patient UK	Pelvic pain
MeSH	D017699

Pelvic pain is pain in the area of the pelvis. Acute pain is more common than chronic pain. If the pain lasts for more than six months, it is deemed to be chronic pelvic pain. It can affect both women and men.

Common causes in include: endometriosis in women, bowel adhesions, irritable bowel syndrome, and interstitial cystitis. The cause may also be a number of poorly understood conditions that may represent abnormal psychoneuromuscular function.

Female

Most women, at some time in their lives, experience pelvic pain. As girls enter puberty, pelvic or abdominal pain becomes a frequent complaint.

According to the CDC, Chronic pelvic pain (CPP) accounted for approximately 9% of all visits to gynecologists in 2007. In addition, CPP is the reason for 20—30% of all laparoscopies in adults.

Cause

Many different conditions can cause pelvic pain including:

• exaggerated bladder, bowel, or uterine pain sensitivity (also known as visceral pain)
• pelvic girdle pain (SPD or DSP)
• Pudendal nerve entrapment

Gynecologic

• Dysmenorrhea—pain during the menstrual period
• Endometriosis—pain caused by uterine tissue that is outside the uterus. Endometriosis can be visually confirmed by laparoscopy in approximately 75% of adolescent girls with chronic pelvic pain that is resistant to treatment, and in approximately 50% of adolescent in girls with chronic pelvic pain that is not necessarily resistant to treatment.
• Müllerian abnormalities
• Pelvic inflammatory disease—pain caused by damage from infections
• Ovarian cysts—the ovary produces a large, painful cyst, which may rupture
• Ovarian torsion—the ovary is twisted in a way that interferes with its blood supply
• Ectopic pregnancy—a pregnancy implanted outside the uterus

Abdominal

• Loin pain hematuria syndrome
• Proctitis—infection or inflammation of the anus or rectum
• Colitis—infection or inflammation of the colon
• Appendicitis—infection or inflammation of the bowel

Internal hernias are difficult to identify in women, and misdiagnosis with endometriosis or idiopathic chronic pelvic pain is very common. One cause of misdiagnosis that when the woman lies down flat on an examination table, all of the medical signs of the hernia disappear. The hernia can typically only be detected when symptoms are present, so diagnosis requires positioning the woman's body in a way that provokes symptoms.

Workup

The diagnostic workup begins with a careful history and examination, followed by a pregnancy test. Some women may also need bloodwork or additional imaging studies, and a handful may also benefit from having surgical evaluation.

The absence of visible pathology in chronic pain syndromes should not form the basis for either seeking psychological explanations or questioning the reality of the patient’s pain. Instead it is essential to approach the complexity of chronic pain from a psychophysiological perspective which recognises the importance of the mind-body interaction. Some of the mechanisms by which the limbic system impacts on pain, and in particular myofascial pain, have been clarified by research findings in neurology and psychophysiology.

Treatment

Many women will benefit from a consultation with a physical therapist, a trial of anti-inflammatory medications, hormonal therapy, or even neurological agents.

A hysterectomy is sometimes performed.

Spinal cord stimulation has been explored as a potential treatment option for some time, however there remains to be consensus on where the optimal location of the spinal cord this treatment should be aimed. As the innervation of the pelvic region is from the sacral nerve roots, previous treatments have been aimed at this region; results have been mixed. Spinal cord stimulation aimed at the mid- to high-thoracic region of the spinal cord have produced some positive results.

Male

Main article: Chronic prostatitis/chronic pelvic pain syndrome

Chronic pelvic pain in men is referred to as Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS) and is also known as chronic nonbacterial prostatitis. Men in this category have no known infection, but do have extensive pelvic pain lasting more than 3 months. There are no standard diagnostic tests; diagnosis is by exclusion of other disease entities. Multimodal therapy is the most successful treatment option, and includes α-blockers, phytotherapy, and protocols aimed at quieting the pelvic nerves through myofascial trigger point release with psychological re-training for anxiety control. Antibiotics are not recommended.

Differential diagnosis

In men, chronic pelvic pain (category IIIB) is often misdiagnosed as chronic bacterial prostatitis and needlessly treated with antibiotics exposing the patient to inappropriate antibiotic use and unnecessarily to adverse effects with little if any benefit in most cases. Within a Bulgarian study, where by definition all patients had negative microbiological results, a 65% adverse drug reaction rate was found for patients treated with ciprofloxacin in comparison to a 9% rate for the placebo patients. This was combined with a higher cure rate (69% v 53%) found within the placebo group.

Epidemiology

Chronic pelvic pain is a common condition with rate of dysmenorrhoea between 16.8—81%, dyspareunia between 8—21.8%, and noncyclical pain between 2.1—24%.

Social Implications

In the pursuit of better outcomes for patients, numerous problems have been found in current procedures for the treatment of Chronic Pelvic Pain (CPP). These relate primarily with regard to the conceptual dichotomy between an ‘organic’ genesis of pain, where the presence of tissue damage is presumed, and a ‘psychogenic’ origin, where pain occurs despite a lack of damage to tissue. CPP literature in medicine and psychiatry reflects a paradigm where unproblematically observable ‘organic’ processes are causally and sequentially explained, despite evidence in favour of a possible model which accounts for the “complex role played by meaning and consciousness” in the experience of pain. While in the literature of causal mechanisms reference is made to ‘subjective’ aspects of pain, current models do not provide a means through which these aspects may be accessed or understood. Without interpretive or ‘subjective’ approaches to the pain experienced by patients, medical understandings of CPP are fixed within ‘organic’ sequences of the “purely object” body conceptually separated from the patient.

Despite the prevalence of this wider understanding of the biological genesis of pain, alternate diagnosis and treatments of CPP in multidisciplinary settings have shown high success rates for patients for whom ‘organic’ pathology has been unhelpful.

External links

• International Pelvic Pain Society
• American Pain Society
• University of Michigan Pelvic Pain Program
• University of North Carolina Pelvic Pain Program
• Tailbone pain (coccyx pain, coccydynia): Free medical article online at eMedicine
• Pelviperineology The multidisciplinary open access pelvic floor journal