Causes and Diagnosis of Pelvic Pain

The International Association for the Study of Pain define pain as "An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage." Pain is subjective but always unpleasant and emotional. There is not always an identifiable stimuli and can instead be the result of pathophysiological causes.

Chronic pelvic pain is often a result of a change in the complex interactions that occur within your pelvis. Amongst the urinary, gastrointestinal, musculoskeletal, endocrine, neurologic and gynaecologic systems. The experience of the pain can be influenced by psychological and sociocultural factors, such as personal outlook and available support.

You'll experience a change in the normal sensations and processes in your body. Consciously you may change your posture and movement. Involuntarily, the way that your organs function may change.

Chronic pelvic pain is often linked to depression and social isolation. The figures are staggering - 15% of all sick days taken by women are a result of suffering from pelvic pain. 50% of female sufferers report depression and 26% have considered suicide.


Common Causes of Pelvic Pain

The most common causes of pelvic pain are issues with the urinary system, gastrointestinal and gynaecologic system. Less common causes include musculoskeletal, social, environmental and psychiatric/neurologic issues. In most chronic pelvic pain cases, the original cause is no longer present.

You can be predisposed to experiencing pelvic pain more so than others if you already suffer with a gastrointestinal disease. You can also be genetically more susceptible to the sensation of pain or not have the correct psychological state to cope with it.

  • Issues with the female gynaecologic system:
  • Other issues in the pelvis include musculoskeletal, social, environmental and psychiatric/neurologic issues:
    • Degenerative Disk Disease
    • Over-Exercising - Leading to issues with the pudendal nerves (in the perineum).
    • Pelvic Abscesses
    • Pelvic Adhesion's - Often as a result of a previous pelvic surgery or infection.
    • Pelvic Organ Prolapse (Vaginal Prolapse / POP)
    • Poor Posture - The pelvic pain often fluctuates.
    • Stress Fractures
    • Tight (Overactive) Pelvic Muscles
    • Neurological Disorders - Neurological conditions can disrupt nerve signals, and these blockages cause damage which can be painful. Neurological dysfunctions often contribute towards gastrointestinal causes of pelvic pain in women.

Diagnosing Pelvic Pain

It is rare for the original cause of chronic pelvic pain to be diagnosed. 61% of women do not find out what caused their pain to begin with, often as it has gone away before they have visited their doctor. The chronic pain now persists due to the changes that happened to the muscles, nerves and others tissues, as a result of the original cause. In these situations your GP will look to rule out serious diseases and conditions, and begin treatment for your symptoms.

Many women who do receive a diagnosis for the original cause of their pelvic pain, find that there are more than one condition that are contributing to the pain. These causes are evaluated for their malignancy and significance, to determine the speed and intensity treatment is required.

As part of the process of diagnosing your pelvic pain and symptoms, your doctor will hold a discussion with you, complete a gentle physical examination, and take some samples for laboratory testing.

  • Discussion:
    • of your medical history - bring any previous lab tests, prescriptions and x-rays with you.
    • of any history of physical or sexual abuse - also used to asses current safety.
    • including questions - asking 1) how and when the pain began; 2) what makes the pain better or worse; 3) does the pain change throughout the day, week or month; (4) is the pain effected by your menstrual cycle; (5) does the pain affect your sleep; (6) has the pain spread since it first occurred; (7) are there any problems with your skin, muscles, joints or back; (8) is there pain when you urinate or defecate; (9) are you anxious or depressed as a result of the pain; (10) what have you tried to make the pain better and what has/hasn't worked; (11) what medical treatments have you had, did they work; (12) what do you believe is the cause; and (13) what concerns you most.
  • A gentle physical examination to determine:
    • quality of the pain
    • areas and single points of tenderness
    • presence of any masses
    • your posture
    • condition of your pelvic skin
    • pelvic mobility
    • strength of your pelvic floor - often with an electronic biofeedback machine which scores the 'squeeze' of your pelvic floor on a vaginal probe.
    • Carnett's sign abdominal test - lying on your back, you will be asked to raise both legs whilst the doctor places a finger on your abdomen. This will help determine whether the pain is within the abdomen rather than the visceral nervous system.
    • condition of pelvic organs - which may be functioning differently as a result of muscle tightness caused by the pain. Usually a hysteroscopy or ultrasound will be used to look inside your uterus to determine if endometriosis, or other obvious issues, are present.
  • Laboratory tests include:
    • cancer screening
    • pregnancy test
    • complete blood count
    • erythrcyte sedimentation rate - which can reveal the presence of inflamed activity in the body.
    • vaginal swabs for STD's - most notably chlamydia and gonorrhoea which often lead to pelvic inflammatory disease.
    • urinalysis and urine culture - to reveal any infection.


There are several warning signs that the cause of your pelvic pain is a result of other conditions, such as:

  • unexplained weight loss
  • blood in your stool (hematochezia)
  • irregular bleeding in perimenopausal and postmenopausal women

If you experience any of these symptoms, it is even more important to speak to your GP as soon as possible.


Sources

International Association for the Study of Pain. (2017). IASP Terminology. [online]. The International Association for the Study of Pain, 2017.[viewed 03/05/18]. Available from: http://www.iasp-pain.org/Education/Content.aspx?ItemNumber=1698

International Pelvic Pain Society. (2013). The International Pelvic Pain Society, INC. IPPS. Patient Education Brochure. [online] The International Pelvic Pain Society, 2013. [viewed 03/05/18]. Available from: https://pelvicpain.org/docs/patients/FINAL_IPPS-patient-ed-broch-12-14.pdf

International Pelvic Pain Society. (2014). Chronic Pelvic Pain. [online] The International Pelvic Pain Society, 2014. [viewed 02/05/18]. Available from: https://pelvicpain.org/docs/patients/Basic-Chronic-Pelvic-Pain.pdf

Kaercher, C. W. Genro, V. K. Souza, C. A. Alfonsin, M. Berton, G. Filho, J. S. C. (2011). BMC Women's Health. Baropodometry on women suffering from chronic pelvic pain - a cross-sectional study. [online] 11, p 51. [viewed 01/05/18]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3228674/#!po=68.7500

Latthe, P. Mignini, L. Gray, R. Hills, R. Khan, K. (2006). BMJ. Factors predisposing women to chronic pelvic pain: systematic review. [online] 332(7544), p749-755. [viewed 09/05/18]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1420707

Montenegro, M. L. L. S. Mateus-Vasconcelos, E. C. L. Rosa e Silva, J. C. Candido dos Reis, F. J. Nogueira, A. A. Poli-Neto, O. B. (2009). BMC Musculoskeletal Disorders. Postural changes in women with chronic pelvic pain: a case control study. [online] 10, p82. [viewed 01/05/18]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2713205/#!po=70.0000

Ortiz, D. D. (2008). American Family Physician. Chronic Pelvic Pain in Women. [online] 77(11), p 1535-1542. [viewed 01/05/18]. Available from: https://www.aafp.org/afp/2008/0601/p1535.pdf

Paplanus, S. (2016). Male Pelvic Pain. [online] IPPS Annual Meeting, 2016. [viewed 01/05/18]. Available from: https://pelvicpain.org/docs/patients/Male-Pelvic-Pain.pdf

Siemens, D. R. (2016). Canadian Urological Association Journal. Thinking outside of the pelvis: Managing chronic urological pain. [online] 10(11-12), p 369-370. [viewed 11/05/18]. Available from: https://www.cuaj.ca/index.php/journal/article/download/4277/2905

The Practice Committee of the American Society for Reproductive Medicine. (2008). Fertility and Sterility. Treatment of pelvic pain associated with endometriosis. [90(5), p S260-S269. [viewed 04/05/18]. Available from: https://www.fertstert.org/article/S0015-0282(08)03474-2/fulltext