Chronic Pelvic Pain

What is the Definition of Chronic Pelvic Pain?

Chronic pelvic pain is chronic pain in the pelvis which is not caused by clearly defined diseases such as endometriosis or adenomyosis. “Chronic pelvic pain” is the indication for hysterectomy in 10% of hysterectomies performed in the U.S.

How is Chronic Pelvic Pain Diagnosed?

Frequently the diagnosis is made in error because of failure to diagnose the actual condition responsible for the pain. In these cases, the patient is denied an effective rational treatment aimed at the underlying disease. Commonly, undiagnosed adenomyosis or fibroids are the cause of pelvic pain. A woman with chronic pelvic pain must undergo a systematic and thorough investigation in order to rule out a variety of conditions. These include gynecological, gastrointestinal, urological, neurological, and musculoskeletal diseases. Gynecological conditions which can cause pelvic pain include fibroids, adenomyosis, endometriosis, pelvic inflammatory disease, pelvic adhesions, ovarian diseases (such as a cyst), pelvic congestion syndrome, and fallopian tube diseases. If gynecologic causes have been excluded, gastrointestinal evaluation may be required to rule out such conditions as inflammatory bowel disease, diverticulitis, and irritable bowel syndrome. Urological conditions which may cause pelvic pain include bladder infection, urolithiasis (stones in the urinary tract), and urethral inflammation.

Disorders of the pelvic floor musculoskeletal system are a common cause of chronic pelvic pain. Pelvic floor tension myalgia has been linked to painful intercourse (dyspareunia), urinary urgency and frequency, perineal pain (vulvodynia) as well as generalized pelvic pain. Typically, the pelvic floor musculature is hypertonic with trigger points. Irritation of these trigger points may refer pain to in the lower abdomen, suprapubic region, hips, perineum, tailbone, or lower back. This phenomenon may lead to confusion regarding the source of the pain. Expert evaluation of the pelvic floor will positively identify the musculoskeletal source of the pain and identify the specific trigger points. Laparoscopy in these patients yields negative findings. Physical therapy of the condition is directed to the specific findings and to release the trigger points.

Pelvic congestion syndrome is a dull or achy pain, mostly in parous women, caused by pelvic varicose veins.  The pain is aggravated by situations that increase intra-abdominal pressure, such as constipation requiring straining to pass stool, prolonged standing/walking, heavy lifting.  The pain is often relieved by lying down.  Pain during intercourse is typical and may last for hours and days.  Patients may avoid intercourse for that reason.  Adnexal tenderness during examination is typical.  Ultrasound has limited value for diagnosing the condition.  Laparoscopy is also limited because the varicose veins are under the peritoneal surface and also the intraperitoneal air compresses the veins.   Diagnosis can be done by transfemoral venography.  A catheter is inserted into the left femoral vein and into the left ovarian vein.  The ovarian vein is enlarged (>4mm)and or incompetent along with enlarged uterine veins.  CT and MRI venography allows the non-invasive detection of enlarged veins and also immediate treatment with particle embolization of the ovarian veins.  Such treatment may reduce fertility.  Other treatment options are hysterectomy with or without oophorectomy.  Ovarian suppression with Lupron may also provide temporary relief.  Pelvic varicosities may be present in completely asymptomatic women.  It is therefore critical to establish the diagnosis of Pelvic congestion syndrome as a diagnosis of exclusion, in maltiparous women, with dilated pelvic veins with reflux, when all other potential causes of pelvic pain have been ruled out.  In my experience, many women with undiagnosed adenomyosis were misdiagnosed and mistreated for pelvic congestion syndrome.

Sometimes chronic pelvic pain is psychosomatic. In 50% of women with chronic pelvic pain, a history of childhood sexual abuse can be identified. Therefore, when all organic causes of pelvic pain have been ruled out, a psychological evaluation is essential. Occasionally chronic pelvic pain is found to be associated with congestion of the pelvic veins (pelvic varicose veins). The diagnosis of pelvic varicosities requires special imaging studies, such as pelvic venography or ultrasound.

What is the Treatment for Chronic Pelvic Pain?

True chronic pelvic pain with no apparent organic cause is best treated by an interdisciplinary approach which includes a gynecologist, nutritionist, psychologist, and other specialists as needed. Medical therapy may include birth control pills and non-steroidal anti-inflammatory agents (such as ibuprofen). Medical treatment for chronic pelvic pain due to pelvic varicosities may include progestins, non-steroidal anti-inflammatory drugs, birth control pills, Danazol (a mild androgenic steroid), or GnRH agonists. Pelvic congestion syndrome is treated with transcatheter embolotherapy (obstruction of the vessels by inserting into them, through a catheter, non-absorbable, inactive particles) of the insufficient veins responsible for the venous varicosities. This approach is effective in 85% of cases when carefully diagnosed. These measures are effective in 70% of cases. In some cases, psychotherapy proves to be an effective measure.

What is the Role of Hysterectomy in Treating Chronic Pelvic Pain?

Hysterectomy is rarely justified. Limited studies suggest that on rare occasions pelvic venous congestion does not respond to conservative measures. In these cases, limited surgery such as ligation or embolization of the pelvic veins has been effective to relieve this pain. Hysterectomy, with or without resection of the ovaries, is reserved for the relatively rare cases that do not respond to conservative or limited surgical approaches. Hysterectomy is effective for pain relief of pelvic congestion syndrome in only 77% of cases and 20% experience recurrent pain. Clearly, the better approach to this syndrome is venous embolotherapy. Hysterectomy is by no means foolproof and fails to relieve chronic pelvic pain in about 25% of cases.