Chronic pelvic pain

Chronic pelvic pain is one of the most common reasons people are referred to a gynecologist, and one of the most common reasons they end up disappointed. The pelvis contains the uterus and ovaries, but it also contains the bladder, the bowel, the pelvic floor muscles, several major nerves, the hip joints, and a dense network of veins. Any of them can hurt, and more than one usually is. The work of the first visit is to figure out which structures are involved rather than to assume the answer is gynecologic.

What we mean by chronic pelvic pain

Chronic pelvic pain is pain below the navel, present for six months or longer, severe enough to affect how you live: what you can do at work, whether you can exercise, whether sex is possible, how you sleep. It may be constant or it may come in episodes, and it may or may not vary with the menstrual cycle. That last detail is one of the more useful things you can tell us, because cyclical pain and non-cyclical pain point in different directions even when they feel identical.

Many people arrive having been worked up already, sometimes extensively, and having been told that everything looks normal. A normal ultrasound and a normal examination are worth having, but they narrow the field rather than close it, because the most common causes of chronic pelvic pain do not produce abnormal images. Pain with no visible lesion is not pain with no cause. It usually means the cause is muscular, neurologic, visceral, or vascular rather than structural in the way a scan can show.

The gynecologic causes, which are real but not the whole list

Endometriosis is the first thing most people think of, and it deserves that position; it is common, it is often missed, and its pain is classically cyclical at the start and then spreads across the month. Adenomyosis, where endometrial-type tissue sits within the uterine muscle, produces heavy painful periods and a tender, enlarged uterus. Fibroids cause pain when they are large, when they press on the bladder or bowel, or when one degenerates. Ovarian cysts hurt acutely when they rupture or twist, but a small simple cyst on a scan is rarely the explanation for pain that has lasted a year.

Older pelvic infection can leave adhesions behind, as can previous abdominal or pelvic surgery, and adhesions are a legitimate but overdiagnosed cause. Pain localized to the vulvar vestibule, or pain that begins at the moment of entry during sex rather than with deep penetration, points away from the pelvic organs entirely and toward vulvodynia and the pelvic floor. These distinctions are not academic. They determine whether the right next step is a hormone, a physical therapist, a bladder-directed treatment, or a vascular study.

The causes that are not gynecologic, and deserve equal weight

In a general gynecology practice, the non-gynecologic causes of chronic pelvic pain are collectively at least as common as the gynecologic ones, and they are the ones most often left unexamined after a normal pelvic ultrasound. Several of them can be identified on a careful history and physical examination, without imaging at all.

• Pelvic floor muscle dysfunction: muscles held in a shortened, guarded state, causing aching, pain with sex, difficulty emptying the bladder or bowel, and tenderness that is reproducible on examination
• Interstitial cystitis and bladder pain syndrome: urinary urgency and frequency with pain that builds as the bladder fills and eases after voiding, with repeatedly negative urine cultures
• Irritable bowel syndrome: pain tied to bowel habit and relieved in part by defecation, often with bloating that worsens through the day
• Musculoskeletal and hip causes: hip labral and impingement problems, sacroiliac joint dysfunction, and abdominal wall trigger points, particularly after pregnancy, injury, or a long period of altered gait
• Nerve entrapment: pudendal, ilioinguinal, or iliohypogastric nerve pain, often after surgery, with burning or electric pain in a defined skin distribution and pain that worsens with sitting
• Pelvic congestion from dilated pelvic veins: a heavy, dragging ache that builds through the day, is worse with prolonged standing, and improves when lying down

Pelvic congestion syndrome is worth a separate word, because it sits in the gap between specialties and consequently gets overlooked. Incompetent valves in the ovarian or internal iliac veins allow blood to pool in the pelvis, and the resulting ache is postural in a way that most gynecologic pain is not. Diagnosis involves imaging the veins, usually starting with ultrasound and moving to CT or MR venography. When treatment is indicated, the procedure is pelvic vein embolization, and that is done inside our own group by the interventional radiology team at 1Vascular, so the evaluation, the procedure, and the follow-up stay under one roof. It is not the explanation for most chronic pelvic pain, but in the subset where it is, the fix is definite and it is unfortunate to miss.

When the nervous system becomes part of the problem

Pain that persists for months changes the system that carries it. Nerve pathways in the spinal cord and brain become more efficient at transmitting pain signals, the threshold at which a sensation is registered as painful falls, and areas that were never injured start to hurt. This is central sensitization. It is a measurable physiological change, not a figure of speech, and it explains why someone may still be in pain after the original cause has been treated successfully, and why light touch or a full bladder can become unbearable.

Sensitization means your nervous system has learned the pain too well. It does not mean the pain is invented, and it never means the search for a cause is over.

Two things follow from this. The first is that treating only the original driver often fails in long-standing pain, because there is now a second problem layered on the first; this is where pelvic floor physical therapy, graded activity, sleep treatment, and sometimes medications that act on nerve signaling such as certain antidepressants or gabapentinoids earn their place. The second is that a sensitized nervous system does not exclude ongoing structural disease. People with endometriosis or bladder pain syndrome frequently have both, and each needs its own treatment.

How we actually work it out

The history does most of the work. We want to know where the pain is, what it feels like, what makes it better and worse, its relationship to the cycle, to sex, to urination, to bowel movements, to sitting, to standing, and to exercise. A pain diary kept over two or three cycles is more useful than any single test, because it exposes patterns that are invisible in a fifteen-minute conversation: the ache that always builds by late afternoon, the flare that follows a specific food, the three days each month that are worse than the rest.

The examination is deliberate and slow, and we explain each part before doing it. Rather than a quick bimanual, we palpate one structure at a time and ask what reproduces your pain: the abdominal wall with the muscles tensed, which distinguishes wall from viscera; the levator muscles individually; the bladder base; the cervix and the uterosacral ligaments; the ovaries; and the hips and sacroiliac joints. Reproducing your familiar pain on a specific structure is worth more than an image. Investigations follow the examination rather than preceding it, and typically include a pelvic ultrasound, urine testing, and then targeted studies such as venography, MRI, cystoscopy, or a gastroenterology or physical therapy referral depending on what the examination found.

You should expect the plan to be layered rather than single-threaded, because the pain usually is. It is common to start hormonal suppression for suspected endometriosis, begin pelvic floor physical therapy, and address bladder or bowel symptoms in parallel, then reassess at six to twelve weeks and keep what helped. Progress in chronic pelvic pain is usually incremental, and it is measured in function restored rather than in a number reaching zero.