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 urinary system:
- Bladder Malignancy
- Urolithiasis
- Urinary Tract Infection (UTI)
- Issues with the gastrointestinal system, including Bowel Problems:
- Coeliac Disease
- Colon Cancer
- Diverticular Disease (Diverticulitis)
- Inflammatory Bowel Disease
- Irritable Bowel Syndrome (IBS) - The pelvic pain often fluctuates.
- Pelvic Floor Dyssynergia
- Ulcerative Colitis - The pelvic pain often fluctuates.
- Issues with the female gynaecologic system:
- Adenomyosis - Usually diagnosed during an ultrasound.
- Endometriosis - Usually diagnosed through a hysteroscopy. It is found in 70% of women suffering from chronic pelvic pain, although is not always the only cause.
- Endometrial Cancer - Associated with irregular bleeding in perimenopausal or postmenopausal women.
- Fibroids
- Ovarian Cyst
- Pelvic Congestion Syndrome
- Pelvic Inflammatory Disease - Often as a result of an untreated STD such as gonorrhoea or chlamydia.
- Vaginismus
- Vulvodynia - Specific tenderness of the vulva and immediate area.
- Issues with the male gynaecologic system:
- Genital Dysaesthesia
- Prostate Conditions
- 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. Further details of each can be found below.
Adenomyosis
Adenomyosis is a condition where endometrial tissue (the tissue that normally lines the uterus) grows into the wall of the uterus. This is different from endometrosis, because the tissue does not grow outside the uterus, rather inside.
Adenomyosis normally affects women after childbearing age, but it can affect all women, and the pain felt can be very intense. Some women who suffer adenomyosis say that the pain is not only confined to the pelvic area but spreads into the legs. It can lead to very heavy periods (menorrhagia) and can cause fertility problems such as difficulty conceiving and greater risk of miscarriage.
Treatment for adenomyosis normally includes hormone therapy and painkillers. The standard surgical adenomyosis treatment is hysterectomy.
Endometriosis
Endometriosis is a relatively common condition where cells like the ones found in the lining of the womb grow outside of the womb on other organs such as your ovaries, fallopian tubes and bladder. Like the cells inside of your womb, these will break down every month during your period, but can cause a great deal of pain because the blood has nowhere to go.
Endometriosis can cause chronic pelvic pain, and lots of women describe it as being like constant period pain. Endometriosis can cause very heavy periods and can lead to fertility problems such as increased risk of miscarriage and difficulty getting pregnant. Doctors aren't 100% sure what causes endometrosis, but it's more common if your mum or sister has it too, which suggests it could be inherited, and women who started their period early and those who had frequent heavy periods can be more at risk.
Treatment for endometriosis includes hormone treatments, painkillers and surgery, including laporoscopy and hysterectomy.
Fibroids
Fibroids are non-cancerous growths, or tumours, that grow in and around the womb (uterus). Fibroids are very common, and most women don't even know that they have them, however they can cause heavy periods (menorrhagia) and pelvic pain.
If fibroids become particularly large, they can cause a great deal of pain in the pelvic area, and may make sexual intercourse uncomfortable. Unless fibroids are causing problems, no treatment is usually necessary, however if fibroids are causing pain and discomfort, doctors may provide medication such as hormone treatments to reduce heavy periods, painkillers and fibroid surgery which involves removing either just the fibroids themselves, or removing the whole uterus as part of a hysterectomy.
IBS (Irritable Bowel Syndrome)
IBS, or Irritable Bowel Syndrome is very common, and affects up to 1 in 5 people at some point in their lives. IBS causes painful cramps, diarrhoea, constipation and bloating, and can cause chronic pelvic pain if it goes on for a long time. IBS is often linked to certain foods and stress, but it can be managed.
The key to managing IBS often lies in diet – GPs often recommend that you keep a food diary to see if there are particular foods that trigger IBS symptoms. It's also recommended to eat little and often and to not rush food. Stress is often one of the biggest IBS triggers, so learning relaxation techniques such as breathing exercises, yoga and regular gentle exercise can help keep IBS symptoms under control.
There are medications that can be given to help deal with the symptoms of IBS, these include laxatives for people who suffer IBS with constipation, antimotility medication to help with diarrhoea and antispasmodic medication to help treat stomach cramps.
IBS can be really damaging to your pelvic floor, so it's important not to strain to go to the toilet – if you suffer from constipation, try using a Squatty Potty (available from our friends at StressNoMore.co.uk).
Ovarian Cysts
Ovarian cysts are very common, and many women have them and never know anything about it. However, if the cysts get bigger, or depending on the type of ovarian cyst, it may cause stomach pain, pelvic pain and bloating.
There are different types of ovarian cyst – and don't panic, an ovarian cyst is only very rarely ovarian cancer. Follicular cysts and corpus luteal cysts form during your menstrual cycle when the egg doesn't leave the ovary properly – if you have one of these cysts, it will usually go away by itself within a few months and you probably won't even know you have it. You can also get growths of cells on the ovary and these are called ovarian tumours. Most of the time they are benign and harmless, but very rarely can be cancerous, so if you think you have an ovarian cyst, it's worth seeing your doctor just to be checked out.
Pelvic Abscess
Pelvic abscesses are rare and can sometimes occur if you've had an infection in your pelvic area, for example if you've had appendicitis or an operation. If you've got a pelvic abscess, you will feel poorly with it, you'll have a fever and a lot of pelvic pain. If you have a pelvic abscess, you will need an operation to clear it up.
If you've had an operation or an infection in your pelvic area and start to feel ill afterwards, it's important to see your doctor if you think you have a pelvic abscess. If a pelvic abscess isn't treated, it can cause widespread damage and make you very ill. Pelvic abscess treatment involves an operation to drain the abscess, then doctors will put a tube into your stomach so that the abscess can keep on draining.
Pelvic Congestion
Pelvic congestion is the name given to varicose veins in the stomach. This can cause chronic pelvic pain, and just like the pain from varicose veins in the legs, it gets worse after lots of standing, and the pain goes away when the sufferer lies down.
Pelvic Congestion treatment involves painkillers and hormone therapy to make the ovaries work less quickly. The only full treatment for pelvic congestion involves surgery to take away the varicose veins. Pelvic pain caused by pelvic congestion is usually a dull and aching pain.
Pelvic Inflammatory Disease
Pelvic Inflammatory Disease or PID is an infection that affects the womb, ovaries and fallopian tubes. It's very common but can cause a great deal of pelvic pain and discomfort, and painful intercourse, as well as discharge and fever.
PID mainly affects women between the ages of 16-24 and is most common in sexually active women. If you think you might have PID, it's important to see your GP, because left untreated, it can eventually cause infertility. If you have had chlamydia, gonorrhoea or another sexually transmitted disease, it's important to keep an eye out for the signs of PID afterwards. You can prevent PID by using condoms. PID causes inflammation and infection of the womb, fallopian tubes and abscesses, so it's important to get checked if you think you might have pelvic inflammatory disease.
Prolapse
Prolapse is the name given to when one or more of your organs slips out of place. It can cause a heavy, dragging feeling and be really uncomfortable, especially if you have been walking around or have been on your feet all day. A Kegel8 Ultra Pelvic Toner can help with prolapse.
Prolapse can be uncomfortable and distressing, but it's a lot more common than you may think. It's estimated that 50% of women over 50 will suffer some form of pelvic organ prolapse in their life. If you have one prolapse, for example a rectocele or rectal prolapse, it's more likely that you will suffer another prolapse, for example a cystocele or bladder prolapse, so it's really important to strengthen your pelvic floor if you have prolapse or think you may be at risk of prolapse. By strengthening the pelvic floor, the muscles can better support your pelvic organs and can reduce the pelvic pain and everyday symptoms of prolapse to make your life much easier.
Urinary Tract Infection
A urinary tract infection or UTI is a very common cause of pelvic pain and discomfort in the lower abdomen. As well as this, you may feel burning or pain when you urinate, you may need to go for a wee more often, or you may feel generally unwell.
Urinary tract infections are common and easily treatable. They can affect men and women of all ages but are more common in women. They usually pass within a few days, and you can take cystitis powder to make your wee less acidic so it will burn less. They can also be treated with a short course of antibiotics.
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Sources
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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 21/11/2024]. 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 21/11/2024]. 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 21/11/2024]. Available from: https://www.aafp.org/pubs/afp/issues/2008/0601/p1535.pdf
Paplanus, S. (2016). Male Pelvic Pain. [online] IPPS Annual Meeting, 2016. [viewed 21/11/2024].
