Pelvic pain
Encyclopedia
Pelvic pain is a symptom that can affect both women and men. The pelvic pain
that persists for a period of 3 months or more to be considered chronic while less than this duration is considered acute. The pain may indicate the existence of poorly-understood conditions that likely represent abnormal psychoneuromuscular function. Differentiating between acute and chronic pain is important in understanding chronic pelvic pain syndromes. Acute pain is most common, often experienced by patients after surgery or other soft tissue traumas. It tends to be immediate, severe and short lived however, pain that extends beyond a normal recovery period and lasts longer than 3–6 months constitutes chronic pain.
Chronic pelvic pain (CPP) accounts for 10% of all visits to gynecologists. In addition, CPP is the reason for 20—30% of all laparoscopies in adults.
Gynecologic
Abdominal
Internal hernia
s 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 sign
s 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.
. 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.
A hysterectomy
is sometimes performed.
, and protocols aimed at quieting the pelvic nerves through myofascial trigger point release with psychological re-training for anxiety control. Antibiotics are not recommended.
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.
between 8—21.8%, and noncyclical pain between 2.1—24%.
Pain
Pain is an unpleasant sensation often caused by intense or damaging stimuli such as stubbing a toe, burning a finger, putting iodine on a cut, and bumping the "funny bone."...
that persists for a period of 3 months or more to be considered chronic while less than this duration is considered acute. The pain may indicate the existence of poorly-understood conditions that likely represent abnormal psychoneuromuscular function. Differentiating between acute and chronic pain is important in understanding chronic pelvic pain syndromes. Acute pain is most common, often experienced by patients after surgery or other soft tissue traumas. It tends to be immediate, severe and short lived however, pain that extends beyond a normal recovery period and lasts longer than 3–6 months constitutes chronic pain.
Female
Most women, at some time in their lives, experience pelvic pain. As girls enter puberty, pelvic or abdominal pain becomes a frequent complaint.Chronic pelvic pain (CPP) accounts for 10% of all visits to gynecologists. 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 painPelvic girdle painPregnancy related Pelvic Girdle Pain causes pain, instability and limitation of mobility and functioning in any of the three pelvic joints...
(SPD or DSP)
Gynecologic
- DysmenorrheaDysmenorrheaDysmenorrhea is a gynecological medical condition of pain during menstruation that interferes with daily activities, as defined by ACOG and others. Still, dysmenorrhea is often defined simply as menstrual pain, or at least menstrual pain that is excessive...
—pain during the menstrual period - EndometriosisEndometriosisEndometriosis is a gynecological medical condition in which cells from the lining of the uterus appear and flourish outside the uterine cavity, most commonly on the ovaries. The uterine cavity is lined by endometrial cells, which are under the influence of female hormones...
—pain caused by uterine tissue that is outside the uterus - Müllerian abnormalities
- Pelvic inflammatory diseasePelvic inflammatory diseasePelvic inflammatory disease is a generic term for inflammation of the uterus, fallopian tubes, and/or ovaries as it progresses to scar formation with adhesions to nearby tissues and organs. This may lead to infections. PID is a vague term and can refer to viral, fungal, parasitic, though most...
—pain caused by damage from infections - Ovarian cystOvarian cystAn ovarian cyst is any collection of fluid, surrounded by a very thin wall, within an ovary. Any ovarian follicle that is larger than about two centimeters is termed an ovarian cyst. An ovarian cyst can be as small as a pea, or larger than an orange....
s—the ovaryOvaryThe ovary is an ovum-producing reproductive organ, often found in pairs as part of the vertebrate female reproductive system. Ovaries in anatomically female individuals are analogous to testes in anatomically male individuals, in that they are both gonads and endocrine glands.-Human anatomy:Ovaries...
produces a large, painful cyst, which may rupture - Ovarian torsionOvarian torsionOvarian torsion refers to the rotation of the ovary to such a degree as to occlude the ovarian artery and/or vein.-Epidemiology:Ovarian torsion accounts for about 3% of gynecologic emergencies. In 70 percent, it is diagnosed in women between 20 and 39 years. The risk is greater during pregnancy...
—the ovary is twisted in a way that interferes with its blood supply - Ectopic pregnancyEctopic pregnancyAn ectopic pregnancy, or eccysis , is a complication of pregnancy in which the embryo implants outside the uterine cavity. With rare exceptions, ectopic pregnancies are not viable. Furthermore, they are dangerous for the parent, since internal haemorrhage is a life threatening complication...
—a pregnancy implanted outside the uterus
Abdominal
- Loin pain hematuria syndromeLoin pain hematuria syndromeLoin pain hematuria syndrome, also LPHS, is the combination of unilateral or bilateral flank pain and microscopic or macroscopic amounts of blood in the urine that is otherwise unexplained.-Diagnosis:LPHS is considered a diagnosis of exclusion...
- ProctitisProctitisProctitis is an inflammation of the anus and the lining of the rectum, affecting only the last 6 inches of the rectum.-Overview:Symptoms are ineffectual straining to empty the bowels, diarrhea, rectal bleeding and possible discharge, a feeling of not having adequately emptied the bowels,...
—infection or inflammation of the anus or rectum - ColitisColitisIn medicine, colitis refers to an inflammation of the colon and is often used to describe an inflammation of the large intestine .Colitides may be acute and self-limited or chronic, i.e...
—infection or inflammation of the colon - AppendicitisAppendicitisAppendicitis is a condition characterized by inflammation of the appendix. It is classified as a medical emergency and many cases require removal of the inflamed appendix, either by laparotomy or laparoscopy. Untreated, mortality is high, mainly because of the risk of rupture leading to...
—infection or inflammation of the bowel
Internal hernia
Internal hernia
Internal hernias occur when there is protrusion of a viscus into a retroperitoneal fossa or a foramen in the abdominal cavity. If a loop of bowel passes through the mesenteric defect, that loop is at risk for incarceration, strangulation, or for becoming the lead point of a small bowel...
s are difficult to identify in women, and misdiagnosis with endometriosis
Endometriosis
Endometriosis is a gynecological medical condition in which cells from the lining of the uterus appear and flourish outside the uterine cavity, most commonly on the ovaries. The uterine cavity is lined by endometrial cells, which are under the influence of female hormones...
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 sign
Medical sign
A medical sign is an objective indication of some medical fact or characteristic that may be detected by a physician during a physical examination of a patient....
s 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 testPregnancy test
A pregnancy test attempts to determine whether or not a woman is pregnant.These markers are found in urine and blood, and pregnancy tests require sampling one of these substances. The first of these markers to be discovered, human chorionic gonadotropin , was discovered in 1930 to be produced by...
. 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
Hysterectomy
A hysterectomy is the surgical removal of the uterus, usually performed by a gynecologist. Hysterectomy may be total or partial...
is sometimes performed.
Male
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, phytotherapyPhytotherapy
Phytotherapy is the study of the use of extracts from natural origin as medicines or health-promoting agents.Traditional phytotherapy is often used as synonym for herbalism and regarded as "alternative medicine" by much of Western medicine, although effects of many substances found in plants have...
, 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 prostatitisChronic bacterial prostatitis
Chronic bacterial prostatitis is a bacterial infection of the prostate gland. It should be distinguished from other forms of prostatitis such as acute bacterial prostatitis and chronic pelvic pain syndrome .-Signs and symptoms:...
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%, dyspareuniaDyspareunia
Dyspareunia is painful sexual intercourse, due to medical or psychological causes. The symptom is reported almost exclusively by women, although the problem can also occur in men. The causes are often reversible, even when long-standing, but self-perpetuating pain is a factor after the original...
between 8—21.8%, and noncyclical pain between 2.1—24%.
External links
- Pelvic Pain Support Network
- 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