Pelvic Pain

September 21, 2011

Pelvic pain is one of the most commonly reported symptoms in gynecology practice. Pelvic pain can be acute (of short and limited duration) or chronic (of longer duration).

ACUTE PELVIC PAIN

Acute pelvic pain is pelvic pain lasting no more than one month. Acute pain of the pelvis can originate from the gastrointestinal organs (bowel or stomach), genitourinary system (gynecologic organs—uterus, fallopian tubes, or ovaries or urinary system—bladder, kidneys, ureters, or urethra), or can be musculoskeletal (muscles and bones of the pelvis) in nature.

Pregnancy

The causes of acute pelvic pain with pregnancy include ruptured ectopic pregnancy, threatened or incomplete abortion (miscarriage), and degeneration of fibroids. An ectopic pregnancy occurs when the fetus implants outside the uterine cavity—in a fallopian tube, for example. The pain associated with ectopic pregnancy is due to dilation of the tube or blood in the peritoneal cavity, which causes irritation.

Pelvic Inflammatory Disease (PID)

This is an acute infection involving the uterus, fallopian tubes, and ovaries. Often, PID is caused by a sexually transmitted infection such as chlamydia or gonorrhea. The diagnosis is usually made when lower abdominal pain and tenderness develop in association with fever, vaginal discharge, and an abnormal increase in the white blood cell count. Treatment consists of antibiotic therapy.

Leaking or Ruptured Ovarian Cyst

With either condition, a small amount of blood can leak into the pelvic cavity and cause local irritation and pain. There are many different types of ovarian cysts, most of which are benign (not cancer). Some of these resolve on their own and some require surgical intervention.

Twisted Ovary or Fallopian Tube

The twisting of an ovary or fallopian tube is called “torsion.” This can cause blood supply to be compromised to the tube or ovary and intense pain can result. The diagnosis is usually made using ultrasound and physical examination. Treatment consists of surgical intervention.

Fibroid Uterus

Fibroids occasionally cause pelvic pain, especially when they encroach on adjacent structures like the rectum or bladder. Pain can also develop if the fibroid begins to degenerate as it outgrows its blood supply; this is occasionally seen in the pregnant uterus. In rare instances, acute pain is caused by fibroid torsion. If fibroids remain painful it is usually recommended that these be removed. If this is not possible, pain medication will be prescribed.

Appendicitis

This is the most common intestinal source of acute pelvic pain. Symptoms include pain with loss of appetite and nausea, fever, chills, and vomiting. Usually pain begins in the area of the belly button and moves to the lower right area of the pelvis. Diagnostic laparoscopy (surgery where small “stab-wound” incisions are made to look through a laparoscope and then operate if necessary in the pelvis or abdomen) may be useful in ruling out other sources of pelvic pain. Appendicitis often is mistaken for PID.

Diverticulum

A diverticulum is an outpouching of the colonic mucosa through the colon wall. Inflammation and infection of the diverticulum cause diverticulitis. This diverticulum usually affects older women; it rarely occurs in women who are younger than 30-40 years. The diagnosis is usually made using computed tomography (CT) scan and treatment consists of antibiotics.

Intestinal Obstruction

Obstruction is a common cause of pain in women with adhesions (scar tissue) from previous abdominal surgery. Symptoms include colicky abdominal pain and distension, vomiting, and constipation. Abdominal x-ray films determine whether obstruction is partial or complete. Nasogastric suction, intravenous fluid, and surgical intervention may be needed.

Urinary Tract Infection and Stones

The pain can be severe and crampy and may radiate to the groin. The sensation of having to go to the bathroom frequently and urgently, and blood in the urine are common findings. Kidney ultrasound, urine culture, and blood tests are used to make a diagnosis. Antibiotic and surgical management may be necessary.

CHRONIC PELVIC PAIN

One of the most common reasons for a woman to visit her provider is for chronic pelvic pain. A diagnosis is made when the duration of pain is more than one month. Approximately 15% of hysterectomies in the United States are performed due to chronic pelvic pain. Below are some common causes of chronic pelvic pain.

Endometriosis and Pelvic Adhesions

This is the most common gynecologic reason for chronic pelvic pain. Endometriosis is a disease where endometrial tissue, which usually is only present as the uterine lining, implants itself on other areas in the pelvis. This diagnosis must be made surgically, although on occasion a large area of endometriosis on the ovary (an endometrioma) can be identified on ultrasound.

Irritable Bowel Syndrome

The exact cause of this condition is unknown but it is a common cause of lower abdominal pain. Symptoms include excessive flatulence, alternating diarrhea and constipation, and abdominal distension. The diagnosis is usually based on physical examination and history. A multidisciplinary program consisting of medical and psychological approaches is needed. The patient must be evaluated for more serious forms of intestinal disease, such as Crohn’s disease, ulcerative colitis, intestinal neoplasms, and hernia.

Interstitial Cystitis

This is an autoimmune disease of the lining of the bladder that leads to pain with urination and lower abdominal pain and discomfort. The pain can be partially relieved by emptying the bladder. The diagnosis is usually made by performing cystoscopy (when a tiny scope is placed into the bladder) looking for pinpoint hemorrhages on the bladder wall. This is considered the hallmark finding. Treatment may consist of anticholinergic, antispasmodic, and anti-inflammatory medications. Distending the bladder with fluid may provide temporary relief.

Myofascial Syndrome

This condition is responsible for chronic pelvic pain in up to 15% of all cases. Trigger points can be observed upon examination and local injection of anesthetic into the painful points can be helpful.

The uterus and ovaries share the same visceral innervation with the ileum, colon, and rectum. Therefore, it is often difficult to differentiate the source of the pain. A multidisciplinary team consisting of psychologists, anesthesiologists, physiotherapists, gastroenterologists, and gynecologists can best help a patient manage chronic pelvic pain.

Patients typically require pain medication, although tricyclic antidepressant and behavioral therapy usually reduce the need for such medication. The approach should be supportive, therapeutic, and sympathetic. Specific skills are taught using cognitive-behavioral approaches. Relaxation techniques, stress management, sexual and marital counseling, and psychotherapy are also useful.

Acupuncture and nerve blocks to pelvic structures (uterosacral—associated with the uterus, hypogastric— associated with the stomach, or epidural—spinal area nerve blocks) can also be used to control the pain. A presacral neurectomy (cutting of specific nerves leading to pelvic structures) or sympathectomy (cutting of specific nerves that are associated with pelvic pain) can help patients whose pain does not respond to standard treatment.

SEE ALSO: Abdominal pain, Endometriosis, Irritable bowel syndrome, Laparoscopy, Ovarian cyst, Ultrasound, Urinary tract infections, Uterine fibroids

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