What is chronic pelvic pain?

Pelvic pain is pain that you feel in your lower abdomen or pelvis. Pain is described as ‘chronic’ if it occurs all or some of the time for more than 6 months. Chronic pelvic pain is a description of the symptoms you are experiencing. It is common and affects around 1 in 6 women. It can be distressing and affect quality of life and a woman’s ability to carry out everyday activities.

What causes chronic pelvic pain?                       

Chronic pelvic pain is usually caused by a combination of physical, psychological and/or social factors rather than a single underlying condition, although for many women a cause cannot be found.

Possible causes include:

  • Endometriosis, a condition where the cells of the lining of the womb (endometrium) are found elsewhere in the body, usually in the pelvis – endometriosis and adenomyosis (a condition where the endometrium is found in the muscle of the womb) can cause pain around the time of a period and during sex
  • Pelvic inflammatory disease, which is an infection in the fallopian tubes and/or pelvis
  • Interstitial cystitis (bladder inflammation)
  • Adhesions (areas of scarred tissue that may be a result of a previous infection, endometriosis or surgery)
  • Trapped or damaged nerves in the pelvic area
  • Pelvic organ prolapsed
  • Musculoskeletal pain (pain in the joints, muscles, ligaments and bones of the pelvis)
  • Irritable bowel syndrome (IBS)
  • Depression, including postnatal depression
  • Traumatic experiences, such as sexual and/or physical abuse.

Mr Chattopadhyay will be able to rule out any serious problems that you may be worried about.

What will happen when I see Mr Chattopadhyay?

At your appointment, you should have the opportunity to describe the pain you are having and to discuss your concerns. The way you describe your symptoms is important in making a diagnosis. You should let Mr Chattopadhyay know about:

  • the pattern of your pain
  • what makes your pain better or worse (certain kinds of movement or position, for example)
  • what medication you have tried
  • whether you have noticed other problems that might be linked to the pain, for example with your periods, sex, bladder or bowel, or psychological symptoms.

You may be asked to keep a pain diary where you note down when your pain occurs, how severe it is, how long it lasts and what seems to affect it, for example your periods. You may be asked about aspects of your everyday life including your sleep patterns, appetite and general wellbeing. You may be asked whether you currently or in the past have experienced physical or sexual abuse. You may also be asked whether you are feeling depressed or tearful. This is because long-term pain is known to cause depression, which in turn may make your pain worse. Knowing how your pain affects you means this can be taken into account in deciding on the most appropriate treatment for you. If you have bladder, bowel or psychological symptoms, you may be referred to other specialists as part of your investigations and the treatment offered.

After you have described your symptoms you may be offered:

  • an examination of your abdomen
  • a vaginal examination.

Mr Chattopadhyay will listen to you and take your concerns seriously. By working in partnership with you, he will aim to identify the possible cause of your pain and offer the most appropriate treatment.

What tests might I be offered?

  • Screening tests for pelvic infections (including sexually transmitted infections)

Suitable samples to screen for infection, particularly Chlamydia trachomatis and gonorrhoea, should be taken if there is any suspicion of pelvic inflammatory disease (PID). All sexually active women with chronic pelvic pain should be offered screening for sexually transmitted infections (STIs). A positive endocervical sample supports but does not prove the diagnosis of PID.The absence of a result positive for Chlamydia trachomatis or gonococcus does not rule out the diagnosis of PID. If PID is suspected clinically, this condition is best managed in conjunction with a genitourinary medicine physician in order that up-to-date microbiological advice and contact tracing can be arranged. Sexually active women with chronic pelvic pain should be offered screening for STIs.

  • An ultrasound scan – this may be a transvaginal scan of your pelvis, which involves gently inserting an ultrasound probe into your vagina.
  • An MRI (magnetic resonance imaging) scan of your pelvis.

Transvaginal scanning (TVS) is an appropriate investigation to identify and assess adnexal masses.

TVS and MRI are useful tests to diagnose adenomyosis. The role of MRI in diagnosing small deposits of endometriosis is uncertain. A systematic review of the value of TVS in the diagnosis of endometriosis found that endometriomas may be accurately distinguished from other adnexal masses. It is also useful in identifying structural abnormalities such as hydrosalpinges or fibroids, which may be relevant even if not the cause of the pain.

TVS is of little value for the positive identification of other causes of chronic pelvic pain, including peritoneal endometriosis. However, in a study of 120 consecutive women with chronic pelvic pain undergoing TVS prior to laparoscopy, the presence of soft markers such as tenderness or poor ovarian mobility improved the prelaparoscopy probability of identifying relevant pathology at laparoscopy from 58% to 73% (likelihood ratio [LR] 1.9, 95% CI 1.2–3.1). In the absence of soft markers, the prelaparoscopy likelihood of pathology fell to 20% (LR 0.18, 95% CI 0.09–0.34).TVS may therefore have a role in identifying those women who are less likely to obtain a positive diagnosis from a diagnostic laparoscopy.62

The sensitivities of MRI and TVS for the diagnosis of adenomyosis are comparable in the best hands. Sensitivities of 70–78% and specificities of 86–93% for MRI, with figures of 65–68% and 65–98% for TVS, were achieved in two prospective blinded studies of consecutive womans undergoing hysterectomy and in a systematic review, using histopathology as the gold standard.63–66A systematic review of 14 trials examining the diagnostic accuracy of TVS for diagnosing adenomyosis found a sensitivity of 82.5% and specificity of 84.6%.64

While MRI lacks sensitivity in the detection of endometriotic deposits, it may be useful in the assessment of palpable nodules in the pelvis or when symptoms suggest the presence of rectovaginal disease.67 It may also reveal rare pathology.

You may also be offered a laparoscopy, particularly if Mr Chattopadhyay thinks you may have endometriosis, adhesions or pelvic infection.

Diagnostic laparoscopy has been regarded in the past as the ‘gold standard’ in the diagnosis of chronic pelvic pain. It may be better seen as a second-line investigation if other therapeutic interventions fail. Diagnostic laparoscopy may have a role in developing your beliefs about your pain. Diagnostic laparoscopy is the only test capable of reliably diagnosing peritoneal endometriosis and adhesions, it is therefore seen as an essential tool in the assessment of women with chronic pelvic pain. However, it carries significant risks: an estimated risk of death of approximately 1 in 10 000, and a risk of injury to bowel, bladder or blood vessel of approx- imately 2.4 in 1000, of whom two-thirds will require laparotomy.

Clearly, conditions such as IBS and adenomyosis are not visible at laparoscopy, but there is also a risk that some forms of endometriosis will be missed. Endometriosis is a disease with a large variety of appearances and many authorities consider that it is significantly underdiagnosed at laparoscopy. Some recommend that all suspicious areas should be biopsied. It is well known that the existing scoring systems do not correlate with severity of pain and that deeply infiltrating endometriosis, which is strongly correlated with pain, may be misinterpreted as minimal disease. One-third to one-half of diagnostic laparoscopies will be negative and much of the pathology identified is not necessarily the cause of pain.

The risks and benefits of diagnostic laparoscopy and the possibility of negative findings should be discussed before the decision is made to perform a laparoscopy. Perhaps it should be performed only when the index of suspicion of adhesive disease or endometriosis requiring surgical intervention is high, or when you have specific concerns which could be addressed by diagnostic laparoscopy such as the existence of endometriosis or adhesions potentially affecting your fertility.

What treatment may help?

If Mr Chattopadhyay thinks that your pain is due to a particular cause then you should be offered treatment for that condition:

  • irritable bowel syndrome (IBS) – medication and changes to your diet may help
  • infections should be treated (usually with antibiotics)
  • if your pain is related to your periods, you may be offered hormone treatment, for example the pill, injections or the Mirena IUS (hormone coil) to stop your periods for 3–6 months, instead of having a laparoscopy – these treatments may also be worth trying even if there is no pattern to your pain
  • surgery for mild adhesions does not appear to help pelvic pain – however, it may be considered in cases of severe adhesions caused by endometriosis or previous surgery.

Many women find that they can cope better with the pain if they have been listened to, taken seriously, have a full explanation of their test results and agree a plan of action. You may be reassured by finding that nothing is seriously wrong and the pain may get better with time. Some women find acupuncture or complementary therapies, or changing diet, helpful. Whatever your situation, you should be offered pain relief. If this does not help, you may be referred to a pain management team or a specialist pain clinic.

Chronic pelvic pain can be very difficult to live with and can cause emotional, social and economic difficulties. You may experience depression, difficulty sleeping and disruption to your daily routine. Talk to your GP if this is the case. The support of other women who also experience pelvic pain may also help: see below for information about support groups.

Further information and support groups:

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