Pelvic Pain

Pelvic Pain_FFHA2019

In general, doctors think about pelvic pain in two categories: acute (or sudden pain) and chronic (pain that has been going on for a longer time). Here, we will briefly review some causes of sudden pelvic pain. We’ll also talk about some signs that you may need immediate medical care. The rest of the article will focus on some of the less-talked-about causes of long-term pelvic pain. This article is not meant to replace the advice of a medical professional, so if you think you are experiencing an emergency, please call 911.

Acute Pelvic Pain

The reasons behind sudden pelvic pain can differ based on your age and if there is a possibility that you could be pregnant. In women who are not pregnant, some of the most common causes of sudden pelvic pain can include:

• Infections anywhere in the pelvis
• A bursting or twisting of an ovarian cyst
• A uterine fibroid
• Menstrual cramps

Pain that is not related to your uterus, tubes, ovaries, or vagina could be coming from your intestines (for example, appendicitis or diverticulitis, especially if you have a fever, nausea, and vomiting). It could also be a bladder infection, or a kidney stone, or other less common causes.

If you do have a positive pregnancy test, possibilities include a pregnancy that is outside of the uterus (called an ectopic pregnancy), a miscarriage, or labor.

Seek medical attention immediately for pain that does not go away if you:

• Are pregnant
• Have heavy vaginal bleeding
• Have a fever
• Cannot keep down food
• Feel dizzy or lightheaded
• Have chest pain or trouble breathing
• Feel weak or sick in other ways

Chronic Pelvic Pain

Pelvic pain that has lasted over time is a common problem among women of all ages. There are many causes of pelvic pain and most women have more than one cause of their pain. Thus, it is difficult to diagnose and sometimes challenging to treat. Many women may start to feel as though their “pain is in their head” when in fact it is not. It is important to work closely with a doctor who understands the complex nature of female pelvic pain and the impact that is has on your life.

If pelvic pain is affecting your quality of life, it may be time to see a physician who specializes in sorting through these types of pain. Some important questions that your doctor may ask include:

• Your past medical, surgical, and psychological history
• What you are most worried about, what questions you have, and what your goals for your treatment are
• How long the pain has been going on for and why you think it started
• Where the pain is
• Is it sharp, dull, or crampy?
• Is it deep or on the surface?
• Does it move?
• Is there anything that makes it better or worse?
• What have you tried so far for the pain?

Your doctor is also very likely to ask you about a history of physical and sexual abuse and should ask your partner to step out of the room when asking such sensitive questions.  Your doctor is likely to ask if it is okay to do a physical and pelvic exam during your visit. Remember that it is up to you if you are comfortable doing a physical exam on your first visit to see your physician.

The Major Organs of the Female Pelvis

The Gynecologic System:

• Uterus and cervix (the opening of the uterus)
• Fallopian tubes
• Ovaries
• Vagina

The Urologic System:        

• The bladder
• Ureters (tubes that carry urine from the kidneys to the bladder)
• Urethra (the exit point for urine)

The Gastrointestinal System:

• The small intestine
• Large intestine
• Rectum

A bowl of muscle often referred to as “the pelvic floor” holds all of these organs in your body. The contents of the pelvis are all neighbors and share many of the same nerves. So, it can be hard for our brains to figure out where exactly the pain is coming from. This is especially true if the pain has been going on for a long time. Continue reading to learn more about some major causes of long-term pelvic pain in women. Remember that many women may have more than one of these diseases at a time.

Gynecologic Causes of Pelvic Pain

Endometriosis:

A common and under-diagnosed cause of long-term pelvic pain is a disorder called endometriosis, which has been getting more attention in the media. Endometriosis is a complex disease. It happens when a woman’s body experiences “backwards menstruation.” This means that the portion of a woman’s uterine lining that bleeds each month (called the endometrium) has made its way through the fallopian tubes and outside of the uterus into a woman’s abdomen and deep into her pelvis. It can cause large and painful ovarian cysts and painful scar tissue internally. During your period, this uterine tissue that is not in the right place reacts to your cycling hormones and can bleed and cause pain.  For this reason, one of the common signs of endometriosis is pain that gets worse each month with your period.

This disorder can only be diagnosed with a surgery where a small camera is placed in the abdomen to look for the endometriosis and biopsy it. It is treated often with a combination of hormone therapy (like birth control pills). Sometimes surgery is recommended to remove the scarring, cysts, and the endometriosis tissue.  If a woman does not want to become pregnant in the future, the final step in treatment of this disease is a hysterectomy. Women with pain from this disease are strongly encouraged to seek pelvic floor physical therapy to help with their pain. They may benefit from special types of pain medications for nerve pain. Endometriosis is also a major cause of infertility. Goals of treatment are important to discuss with your doctor.

Adenomyosis:

Adenomyosis is often found in women who have painful, heavy periods. This is a disease similar to endometriosis (discussed above). In this situation, the lining of the uterus that bleeds during a period is too deep in the muscular layer of the uterus. The process of bleeding into the muscle is very painful.  Adenomyosis can sometimes be seen on special types of x-rays, but cannot be truly diagnosed until after a woman has a hysterectomy. A pathologist would then carefully evaluate her uterus under a microscope. However, based on her symptoms, a gynecologist can be very suspicious this is what is going on. It can be treated with birth control pills, a hormonal IUD, or ultimately, a hysterectomy.

Uterine Fibroids:

Uterine fibroids are tumors of the uterine wall that are made out of the same muscle that contracts during labor. Uterine fibroids are almost always not cancer. They can sometimes be very painful if they grow too large for the blood vessels that bring them oxygen to grow (this is called “degeneration”).  They can also put a lot of pressure on a woman’s bladder or rectum. There are many treatments for uterine fibroids. The treatment depends on a woman’s goals for her fertility and her feelings about keeping her uterus.

Treatments

• Hormonal therapies to shrink the fibroids
• A procedure called uterine artery embolization (which cuts off the blood supply to the fibroid)
• A myomectomy (removal of the fibroids with repair of the uterus afterwards)
• A hysterectomy

There are also several new therapies that are being tested the treatment of fibroids.

Prior Pelvic Inflammatory Disease (PID)

Up to 30% of women who have had PID will develop long-term pelvic pain afterwards. PID is usually caused by an untreated sexually transmitted infection such as gonorrhea or chlamydia. However, many women can get PID without ever having a sexually transmitted infection. Having a history of PID can also cause scar tissue to form in the pelvis, which is a large cause of pelvic pain. Sometimes, women may benefit from surgery. In general, treatment with medications and physical therapy should be tried first.

Scar Tissue and Prior Pelvic Surgery

Pelvic pain can also be caused by having had multiple pelvic surgeries. These surgeries can result in scar tissue or nerve pain. Scar tissue can form between pelvic organs or on the wall of your abdomen or pelvis. This can be treated by nerve injections, physical therapy or even surgery.

Urinary Causes of Pelvic Pain

Interstitial Cystitis/Painful Bladder Syndrome

Interstitial Cystitis or Painful Bladder Syndrome is a disorder of the bladder that causes women to have pain when their bladder fills with urine. This causes frequent urges to urinate. It can be very painful for some women, and not very painful for others. Treatments range from simple dietary changes to surgical procedures.  The cause of this disorder is mostly unknown. If you are having bladder pain, the first steps are to see a doctor who can make sure that you don’t have a bladder infection, a kidney or bladder stone, blood in your urine, or overactive bladder. The doctor will also be able to tell if you have another abnormality of your bladder or urinary tract, such as an out-pouching of the urethra called a urethral diverticulum.

Gastrointestinal (Bowel) Causes of Pelvic Pain

Irritable Bowel Syndrome

Irritable bowel syndrome is a chronic pelvic disorder. It often overlaps with other pelvic pain disorders such as endometriosis or painful bladder syndrome. Women with this disorder often have significant intestinal symptoms, such as diarrhea, constipation, fecal urgency, or painful bowel movements. If you have rectal bleeding, it is important to see a gastroenterology specialist.

Other Gastrointestinal Disorders

Other disorders can include inflammatory bowel disease (which includes Crohn’s disease and Ulcerative Colitis), diverticular disease, celiac disease, or other rare conditions, including cancer.

Pelvic Floor Causes of Pelvic Pain

The muscular bowl that supports women’s pelvic organs is a complex structure comprised of muscles, nerves, and blood vessels. It manages the huge task of maintaining bladder and bowel control. It also handles the changes during childbirth.  As a result, there are many opportunities in a woman’s life for her pelvic floor to contribute to pain.

Myofascial Pain Syndrome

Women who have pain in their pelvic floor muscles often experience pain in the pelvis, vagina, vulva (or external vagina), rectum, bladder, or even in their thighs, buttocks, or hips.  Sex may be very painful. Your doctor may do a careful exam to try and isolate your pain to a specific muscle in your pelvis. Often, women have very tight deep pelvic floor muscles or trigger points. Pelvic floor physical therapy by a trained women’s health physical therapist is often very helpful for this condition. Other treatment options are pelvic floor injections or implants to stimulate the pelvic nerves.

Psychosocial Factors

Finally, depression, anxiety, substance abuse, and physical, sexual, and emotional abuse play a very real role in making pelvic pain worse. Also, pain itself can worsen these mental health conditions. For pelvic pain to be treated successfully, specialists must view women as a whole person. They must consider how she interacts daily with her environment. Ask your pelvic pain doctor to refer you to a mental health specialist if they do not offer this service. This can help you to deal with emotional burden of living with pain.