Chronic pelvic pain is one of the most common reasons women visit a health professional. By Kirsten Braun
Chronic pelvic pain (CPP) is pain experienced in the lower abdomen (below the belly button) and/or the vulva, vagina or perineum (area between the anus and vagina) for at least six months. It is estimated that 15% of women suffer from CPP and many continue suffering for a number of years. Chronic pain caused by CPP can have an enormous impact on a person's life, affecting their appetite, sleep, work and social life. Many women with CPP also have sexual issues such as pain during or after sex, which can impact on relationships. Consequently, women dealing with CPP can also experience psychological issues such as depression and anxiety.
Causes of CPP
There are many possible causes of CPP, which is why it can be difficult for women to get a definitive diagnosis. Some of the more common causes include:
Endometriosis – Endometriosis occurs when the endometrial tissue (the tissue that lines the uterus) grows outside the uterus. The stray tissue swells and bleeds as it would in menstruation but the trapped blood/tissue causes inflammation and irritation. Over time, adhesions can develop which causes pelvic organs to stick together. The pain is often worse before a period. Unfortunately, many women who receive treatment for endometriosis continue to experience CPP.
Irritable bowel syndrome (IBS) – IBS is caused by changes in how the gastrointestinal tract works. Symptoms include abdominal/pelvic pain, constipation, diarrhoea and bloating.
Painful bladder syndrome – Painful bladder syndrome (also known as interstitial cystitis) is a condition in which the walls of the bladder are irritated and inflamed. Women typically experience pain as their bladder fills, finding relief on urination. Consequently they tend to need to urinate more frequently.
Pelvic inflammatory disease (PID) – PID occurs when an infection moves upwards from the vagina to the cervix, uterus and/or fallopian tubes. Many cases result from sexually transmitted infections such as chlamydia or gonorrhoea. It can cause scarring, including in the fallopian tubes which can lead to infertility. Women with PID can go on to develop CPP, even following successful treatment of the condition.
Vulvodynia – This condition is characterised by discomfort, pain, irritation, burning and/or rawness of the vulva. The area is sensitive to touch and activities like penetrative sex, wearing tight clothing or sitting for long periods exacerbate the pain.
Pelvic floor dysfunction – This condition occurs when the pelvic floor muscles are too tense. As the pelvic floor muscles must be relaxed for urination, bowel movements and sexual intercourse, pelvic floor dysfunction can interfere with these functions.
Pelvic congestion syndrome – This condition is similar to having varicose veins in the legs. The valves in the veins do not function properly, allowing blood to pool in the vein causing pressure and bulging. The pain is usually dull, aching and exacerbated by standing for long periods and by sexual intercourse.
For some women, CPP can be caused by the abnormal function of the nervous system which is also referred to as neuropathic pain (see neuropathic pain section).
As CPP is a complex condition and can have many contributing factors it is important that a thorough history is taken. It should include information such as:
• when the pain started
• where the pain is located
• how often the pain is experienced (in waves or constant)
• how the pain could be described (sharp or dull, burning, prickling, cramping, pressure or heaviness)
• what exacerbates the pain (sexual intercourse, urination, bowel movement, menstruation, sitting, standing, exercise, stress)
• what relieves the pain (lying down, hot bath)
• what tests have been carried out so far and their findings
• what treatments have been used to date (if any) and their success (including medications, alternative medicine, physiotherapy)
Information about previous pelvic surgeries, pregnancies, sexually transmitted infections and/or sexual abuse are also of interest.
The physical examination can involve checking the abdomen for any signs of tenderness and/or growths. The pelvic exam may include checking for signs of infection, evaluating areas of pain as well as examining the pelvic floor muscles.
Women may also be referred for a pelvic ultrasound or magnetic resonance imaging (MRI). If a condition such as endometriosis is suspected a laparoscopy may be performed. It involves inserting a small thin tube with a small camera attached (laparoscope) into the abdomen through a small incision.
Unfortunately, many women who suffer from CPP do not obtain a clear diagnosis. Even women who undergo a laparoscopy may not have a diagnosis in many cases. Some women end up on a treadmill of different tests and procedures trying to find an answer for their pain.
Even if a particular cause of pelvic pain is found, treatments may not bring pain relief immediately and/or the pain may persist even following treatments. It is important, therefore, that treatment for CPP includes addressing the chronic pain itself with effective pain management strategies.
Treating the pain
A multi-disciplinary approach has been found to be helpful in treating the pain experienced by women with CPP. This type of approach may include:
Education – Understanding how pain works in the body can be very helpful for women with CPP. A greater awareness of the different processes at work can alleviate fears and sense of helplessness which can exacerbate a person's pain.
Physical therapies – A physiotherapist who specialises in treating pelvic problems can be a useful addition to treating CPP. They typically use massage, stretching exercises and relaxation techniques to provide relief from the pain. They may also work on strengthening and/or relaxing the pelvic floor muscles. Physiotherapists may also use transcutaneous electrical nerve stimulation (TENS). TENS uses a very small electrical current passed through the skin via electrodes to produce a pain relieving effect.
Physical activity – When people are in pain they often fear that physical activity will exacerbate the problem. It is, however, important for people to continue moving as gentle physical activity can be very useful in treating chronic pain. Physical activity produces endorphins which have pain relieving properties and assist in reducing stress, anxiety and depression. The key is to start slowly and increase the amount of physical activity gradually. An exercise physiologist can assist in developing a program that is suitable.
Diet – When the body is suffering from pain a nourishing diet of whole grains, low fat meat and dairy, oily fish, vegetables and fruits and good fats can be beneficial. Reducing the intake of caffeine (coffee, tea, cola, energy drinks) is also worthwhile as caffeine can exacerbate feelings of stress and anxiety. Women suffering from urinary or bowel symptoms may find consulting a dietician helpful as there are foods that appear to worsen these symptoms.
Psychological therapies – Our experience of pain can be influenced by our thought and behaviours. Cognitive behavioural therapy (CBT), therefore, can form an important part of treatment for CPP. CBT can teach women to think differently about their pain and their ability to cope with the pain.
Complementary medicine – There is limited scientific evidence supporting the use of complementary medicine in treating CPP but some studies suggest that acupuncture may be of assistance.
Pain medication – Pain medication can play a role in providing women with pain relief from CPP. Pain medications are best used in conjunction with other treatments and the types of medications and dosages should be reviewed regularly. Non steroidal anti-inflammatory drugs (NSAIDs) are often the first choice for treating CPP. If no relief can be found with NSAIDs, other medications such as antidepressants and anticonvulsants may be prescribed for their pain relieving properties. Caution should be taken with opioid pain medication (codeine, morphine, oxycodone) as women can become dependent on it and there is evidence that long term use can sensitise nerve pathways, even worsening chronic pain.
Pain clinics – Pain clinics specialise in treating people who suffer from chronic pain. They have a multi-disciplinary approach, addressing both the physical and emotional aspects of chronic pain and also help educate people about pain. They often run set programs to help people manage their pain. There are pain clinics in both the public and private sectors but public pain clinics can have long waiting lists.
Pain is an important part of our body's defense mechanism. Pain is experienced when tiny nerve endings in the body send pain messages to the brain. Pain is produced as a way of protecting the body from damage or further damage such as in the case of removing a finger that is being burned on a stove top. Pain also assists the body to heal. The pain experienced from a sprained ankle, for example, makes us rest the area rather than continue to walk on it. In normal situations the threat recedes and so does the body's protective behaviour. In the case of the sprained ankle, for example, the ankle begins to heal and the need to protect it from use diminishes, as does the pain.
In the case of neuropathic pain, the original cause of the pain is no longer present but the brain continues to perceive a threat and so the pain continues. In addition, the nerves that transmit the painful sensations can actually become extra sensitive. When this occurs, pain can occur from a stimulus that would not normally cause pain and/or severe pain can occur from only a mild touch.
It is important to point out that neuropathic pain is not "all in the head". The pain that the person is experiencing is still very real, it is just that the brain has been tricked into thinking that there is more danger/damage than there really is.
Pain can be a frightening experience for many people. People may fear not knowing the origin of the pain, of making the pain worse or having the pain impact on their ability to hold down a job or look after their children. These fears can exacerbate the experience of the pain itself.
Last modified: April 2014
© Women's Health Queensland Wide Inc. This article was written by Kirsten Braun and reviewed by the Women's Health Queensland Wide editorial committee. It was published in Health Journey 2014 Issue 1.
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