Chronic Pelvic Pain

The pelvic region is the area below the navel and the lowest part of the abdomen. The pain caused by this area is called pelvic pain.

Chronic Pelvic Pain is defined as the pain of the pelvic region that lasts longer than 6 months. It is one of the most common problems among women. 25% of women with chronic pelvic pain spend 2-3 days in bed every month. Approximately half of these women feel the need to interrupt daily activities for 1 day or more every month. 90% of them feel pain during sexual intercourse. Chronic pelvic pain can have many causes. If it is caused by another health problem, treating this cause will be sufficient to relieve the pain.

What is seen in chronic pelvic pain?

Severe pain may continue for a long time. It causes physical, mental and psychological fatigue. The patient goes through emotional and behavioral changes in her daily life to cope with pain. The following conditions can be seen in Chronic Pelvic Pain;

  • Persistence of pain for 6 months or longer
  • Conventional treatments provide little or no relief from pain
  • The patient has difficulty sleeping or sleeps too much, constipation, decreased appetite, sluggish movements or reactions and other symptoms of depression, constant sadness and tearfulness
  • Continuously decreasing physical activity
  • Difficulty in fulfilling her duties as a wife, mother and employee

What are the Most Common Causes of Chronic Pelvic Pain?

Endometriosis: It is the presence of endometrial tissue outside of the uterus. Due to hormonal changes, these tissues thicken, shed and bleed, just like the lining of the uterus (endometrium). However, as in the uterus, these tissues cannot be expelled through the vagina as they do in the uterus, they may cause cysts or adhesions in the pelvis and cause chronic pelvic pain. It can cause very severe adhesions around the ovaries and uterus. Although endometriosis may not cause any complaints at all, it may also present with painful urination, painful defecation and severe pain during menstruation or sexual intercourse.

Painful Pelvic Floor Muscle Spasm: It is the case of involuntary contraction of pelvic floor muscles that support the uterus, bladder, and rectum in the pelvic bone. It is associated with severe pain which is similar to the pain in leg cramps. It can be unilateral or bilateral. The diagnosis is made by gynecologic examination. The examination must be performed by a physician who has a special training on this subject, otherwise the diagnosis can easily be missed.

Pelvic Inflammatory Disease (Chronic): Sexually transmitted diseases can cause long-lasting, persistent infections and severe adhesions around the pelvic organs, ovaries and uterus. Therefore, the patient may experience pain.

Myomas: They are benign tumors of the uterus. They can cause a feeling of fullness and pressure in the pelvis.

Irritable Bowel Syndrome: Symptoms such as bloating, constipation and diarrhea may be associated with irritable bowel syndrome, which can cause pain and feeling of pressure in the pelvic area. 

Painful Bladder Syndrome (Interstitial Cystitis): This condition may be associated with recurrent pain in the bladder and frequent need to urinate. The patient feels pain when the bladder is full and a temporary relief after emptying it. A series of tests including examination of the bladder from the inside with a camera are used for diagnosis.

Pelvic Congestion Syndrome: Enlarged, varicose veins around the uterus and ovaries can cause pain. These patients may also have varicose veins on the legs, calves and perineum.

Anterior abdominal wall pain: Neuropathic pain (similar complaints which are seen in diabetic patients' feet), especially due to previous surgeries, can also be seen in this area. The diagnosis and treatment of this pain are quite different from all the other reasons. 

Psychological factors: depression, chronic stress, or sexual / physical abuse may increase the risk of chronic pelvic pain. Emotional stress worsens the pain, while living with the pain causes emotional stress, and the patient finds herself in a vicious circle.

However in many cases, it is not possible to attribute chronic pelvic pain to a single cause. In such complicated cases, the goal of treatment should be improving the quality of life by reducing pain and other symptoms.

How is Chronic Pelvic Pain Diagnosed?

When your doctor takes your history, it is very important that you describe the problem in detail. You should also inform your doctor about all your medical history, family history and drug history, as well. Gynecological examination, blood tests and imaging methods (ultrasonography, MRI) can be utilized for diagnosis after taking a detailed patient history.

Is Gynecologic Examination in Pelvic Pain Different From General Gynecological Examination?

It is quite different. The entire vaginal wall, uterine suspensory ligaments, pelvic nerves and presence of pain trigger points must be examined carefully. A vaginal pain mapping must be performed and it must be identified if the pain is limited to this area or it has any radiation. Special tests are performed, if pelvic nerve involvement is suspected. Methods that temporarily stop pain can also be used in diagnosis.

Vaginal culture, blood and urinalysis may be ordered to exclude any infections.

Which Imaging Methods Can Be Utilized?

Ultrasonographic examination is used as the standard imaging technique to detect the presence of any cysts or myomas.

Other Imaging Methods: Mainly Magnetic Resonance Imaging (MRI) may provide useful information. Standard MRI protocols may not be sufficient here. The appropriate MRI device should be able to obtain very precise images and have special equipment to improve the image quality during shooting. These features are available only in a very limited number of imaging centers. In addition, it is very important that the images be reviewed by a radiologist who is experienced on these subjects.

Is Laparoscopy Used in Diagnosis?

Today, Laparoscopy is generally used for treatment rather than diagnosis. In this surgical method, a small camera is inserted in your belly through a small incision and pelvic organs are examined for any abnormal tissue or signs of infection. This method is especially important for the diagnosis of endometriosis and chronic pelvic infections.