|Year : 2013 | Volume
| Issue : 2 | Page : 53-58
Chronic female pelvic pain
Gaurab Maitra1, Subhabrata Pal2, Subrata Ray3, Amitava Rudra4
1 Consultant, Apollo Gleneagles Hospitals, Kolkata, West Bengal, India
2 Associate Consultant, Apollo Gleneagles Hospitals, Kolkata, West Bengal, India
3 Consultant, Pain Clinic, Kolkata, West Bengal, India
4 Department of Anesthesia and Pain Management, KPC Medical College, Kolkata, West Bengal, India
|Date of Web Publication||4-Oct-2013|
Apollo Gleneagles Hospitals, Kolkata, West Bengal
Source of Support: None, Conflict of Interest: None
Chronic pelvic pain (CPP) is defined as nonmalignant pain perceived in the structures related to the pelvis that has been present for more than 6 months or a non acute pain mechanism of shorter duration. Pain in the pelvic region can arise from musculoskeletal, gynaecological, urologic, gastrointestinal and or neurologic conditions. Key gynaecological conditions that contribute to CPP include pelvic inflammatory disease (PID), endometriosis, adnexa pathologies (ovarian cysts, ovarian remnant syndrome), uterine pathologies (leiomyoma, adenomyosis) and pelvic girdle pain associated with pregnancy. Several major and minor sexually transmitted diseases (STD) can cause pelvic and vulvar pain. A common painful condition of the urinary system is Interstitial cystitis(IC. A second urologic condition that can lead to development of CPP is urethral syndrome. Irritable bowel syndrome (IBS) is associated with dysmenorrhoea in 60% of cases. Other bowel conditions contributing to pelvic pain include diverticular disease,Crohn's disease ulcerative colitis and chronic appendicitis. Musculoskeletal pathologies that can cause pelvic pain include sacroiliac joint (SIJ) dysfunction, symphysis pubis and sacro-coccygeal joint dysfunction, coccyx injury or malposition and neuropathic structures in the lower thoracic, lumbar and sacral plexus. Prolonged pelvic girdle pain, lasting more than 6 months postpartum is estimated in 3% to 30% of women. Nerve irritation or entrapment as a cause of pelvic pain can be related to injury of the upper lumbar segments giving rise to irritation of the sensory nerves to the ventral trunk or from direct trauma from abdominal incisions or retractors used during abdominal surgical procedures. Afflictions of the iliohypogastric, ilioinguinal, genitofemoral, pudendal and obturator nerves are of greatest concern in patients with pelvic pain. Patient education about the disease and treatment involved is paramount. A knowledge of the differential diagnosis of the pain generators leads to a diagnosis specific management of the pain condition. Using a multidisciplinary approach can improve outcomes for patients suffering from the condition and minimize the associated disability.
Keywords: Chronic pelvic pain, nonmalignant, multifactorial, gynaecological, urological, gastrointestinal, musculoskeletal, nervous systems, patient education, physical strategies, stress management
|How to cite this article:|
Maitra G, Pal S, Ray S, Rudra A. Chronic female pelvic pain. Indian J Pain 2013;27:53-8
| Introduction|| |
Chronic pelvic pain (CPP) is defined as nonmalignant pain perceived in the structures related to the pelvis that has been present for more than 6 months or a nonacute pain mechanism of shorter duration.  Pain in the pelvic region can arise from musculoskeletal, gynecological, urological, gastrointestinal, and/or neurological conditions. Such pain can involve both the somatic (T12-S5) and visceral (T10-S5) systems, making the differential diagnosis challenging. ,, Of the various diagnoses, the most frequently noted are endometriosis (33%) and other gynecological conditions (33%). Conversely, a lack of pathology is found in 33%-35% of women with pelvic pain who have received diagnostic laparoscopy. 
CPP can disrupt work, physical activity, sexual relationship, sleep, and family life. Women report problems in communicating the impact of their long-standing symptoms to their doctors of different specialty and may feel at their inability to rapidly identify a causal pathological process and institute curative therapy.  The challenge in identifying the pain generators and effectively treat this condition explains the tendency for pelvic pain to become chronic and frustration associated with its management for both the patient and the health care provider.  Pelvic pain is a common condition with a prevalence of 16%-25%. 
| General Neuroanatomic Considerations|| |
One must consider the contribution of various thoracic, lumbar, sacral, pelvic floor, and visceral structures to pain generation in the pelvic region.
Musculoskeletal afflictions found in nearby structures can refer pain to the pelvic region. For example, hip pathologies are known to refer pain deep in the groin. The anterior sacroiliac joint (SIJ) is innervated by nerves from L3 to S2 and posterior SIJ by S1 and S2. The pain from SIJ can be experienced in the buttock, upper thigh, and groin. Similarly, pubic symphysis is innervated by ilioinguinal nerve, irritation of which can produce pain locally, and in the lower abdomen and groin.
Chronic cases of pelvic pain may be due to viscerosomatic convergence, which is a possible explanation for patient complaints of pelvic pain, which originates in urogynecological or gastrointestinal systems. 
Nerve entrapment syndromes are not uncommon in pelvic regions as a result of trauma, such as stretching, compression, or entrapment within a surgical suture.
The innervations of the pelvic area are iliohypogastric, ilioinguinal, lateral femoral cutaneous, and genitofemoral nerves originating from T12 to L3 as well as nerve to levator ani and pudendal nerves originating from S2 to S5. These nerves share the same spinal cord levels as the pelvic organs innervated by superior and inferior hypogastric plexi. Thus nerve entrapment can refer pain to pelvic area as exemplified by obturator or genitofemoral nerve entrapment referring pain to the upper thigh and labia majora, respectively.
| Differential Diagnosis and Management Guidelines|| |
Possible explanations for CPP include disorders of the gynaecological, urological, gastrointestinal, musculoskeletal, and the nervous systems. Pelvic congestion syndrome (PCS) with dilated pelvic veins resulting in reduced blood flow may be an explanation for some causes of CPP. Janicki proposes that CPP may be a form of complex regional pain syndrome (CRPS) or it may be a form of central sensitization of the nervous system. ,
Pelvic Pain Originating from the Gynecological System
Key gynecological conditions that contribute to CPP include pelvic inflammatory disease (PID), endometriosis, adnexa pathologies (ovarian cysts, ovarian remnant syndrome), uterine pathologies (leiomyoma, adenomyosis), and pelvic girdle pain associated with pregnancy. Several major and minor sexually transmitted diseases (STD) can cause pelvic and vulvar pain and include syphilis, chlamydia gonorrhea and HIV/AIDS, trichomoniasis, vaginitis, and genital herpes. An unfortunate consequence of contracting STD is the possibility of developing PID with highest incidence in women 15-25 years of age and is the leading cause of infertility in women.  Treatment of young women for PID presenting with adnexa, uterine, and cervical motion tenderness in the absence of other pathologies can help prevent progression of pelvic pain.
Endometriosis is defined as the presence of endometrial glands and stroma outside the endometrial cavity.  Typical patients are women in their thirties, nulliparous, involuntarily infertile with secondary dysmenorrheal and pelvic pain.  Treatment options for endometriosis include medical, surgical, and interventional pain management techniques. Conservative measures are first started as nonsteroidal anti-inflammatory drugs, progestins, androgenic hormones, estrogen - progesterone combinations and gonadotropin releasing hormone agonists.  The goal of hormone therapy is to lead to atrophy of endometrial implants. Surgical treatment options include laparoscopic excision of endometrial implants, total abdominal hysterectomy with or without bilateral salpingo-ophorectomy, presacral neurectomy (PSN), and laparoscopic uterine nerve ablation.  Patients also benefit from interventional pain management techniques, such as superior hypogastric plexus block and neuromodulation. ,
The mechanisms for persistent pelvic girdle pain are attributed to hormonal and biochemical factors but are not well understood.
Treatment for pelvic girdle pain is limited and often self-resolving when the patient's physiological condition returns back to their normal prepregnancy state. However, a few subsets of patients will continue to have pain after resolution of pregnancy. According to the European guidelines for the diagnosis and treatment of pelvic girdle pain, treatment should be multifactorial and begin with the use of individual exercise program focusing on specific stabilizing exercises, individual physical therapy, use of pelvic belt applied for short periods of trial and intra-articular injection of SIJ pain.  Self-medications during pregnancy included in categories A and B [US Food and Drug Administration (FDA)] are acetaminophen, opioids, local anesthetics, and epidural steroids given in a limited trial basis. , Interventional treatments include local anesthetics and steroid injections at the SIJ with fluoroscopy and trigger point injections at hypersensitive trigger points.
PCS is a disease of childbearing years, usually in late twenties and early thirties.  Deep dyspareunia and postcoital pain lasting for few to several days are hallmark of this condition. Treatment with medications that lead to hormonal suppression may relieve symptoms. Physical therapy may be of benefit where the use of manual lymph drainage techniques, postural measures may assist in decongesting circulation.
Vulvodynia is defined as a chronic vulvar discomfort with duration of at least 3 months.  Many clinicians suspect a neuropathic etiology for vulvodynia and may be related to stretch injury of nerve to levator ani or pudendal nerve in response to prolonged second stage of labor. Other causes include hormonal changes, tumors and cysts, surgical side effect, or result of use of steroids or antiviral medications. Treatment strategies include oral tricyclic antidepressants (TCAs) antiseizure agents such as gabapentin, pregabalin, topical creams with estrogen or lidocaine, behavioral therapy, biofeedback, surgery (vestibuloplasty, vestibulectomy), botulinum therapy, interventional pain techniques. ,,,,,,,
Vulvar vestibulitis syndrome (VVS) is a subset of vulvodynia, its pathogenesis is unclear and the serial use of antibiotics or highly progestational agents appears to trigger the onset of VVS, and it is very difficult to treat. Psychotherapy, biofeedback, and counseling are the mainstays of treatment. Topical estrogen can be helpful in managing pain.
Dyspareunia is another subset of vulvodynia, specifically describing pain with sexual intercourse in absence of vaginismus.  Conservative management may include massage, mechanical dilators, relaxation training with the goal of decreasing physical symptoms. 
Clitoral pain is another subset of vulvodynia caused by neuralgia of pudendal nerve. Etiology may be metabolic (diabetes), traumatic (tight clothing, violent stimulation), and idiopathic. Treatment consists of membrane-stabilizing medications, such as pregabalin, amitriptyline. Pudendal nerve block can be performed. 
Pelvic Pain Originating from the Urological System
A common painful condition of the urinary system is interstitial cystitis (IC). This condition affects bladder wall function, presenting with bladder pain along with increased urinary frequency, urgency, and nocturia without infection.  The pelvic pain from IC is commonly referred to the lower back, buttock, and perineal areas. In chronic cases there can be tension myalgia of the pelvic floor muscles. Diagnosis of IC is made based on visual observation of Hunter's ulcers in the bladder mucosa and a positive potassium chloride sensitivity test.  Treatment is multimodal, firstline beginning with oral agents - nonsteroidal anti-inflammatory drugs, opioids, penton polysulfate sodium (PPS), amitriptyline, hydroxyzine, and gabapentin. , A PPS agent is the only FDA-approved oral agent for IC. Intravesicular therapy with dimethyl sulfoxide alone or combined with heparin has demonstrated efficacy of 50%-90%.  In a study by Zabihi et al found several neuromodulation for IC patients with significant improvement in pelvic pain.
A second urological condition that can lead to the development of CPP is urethral syndrome, which is a noninfectious condition presenting as midline suprapubic or urethral pain with functional disturbance of dysuria caused by stenotic or fibrous changes of urethra.
Pelvic Pain Originating from the Gastrointestinal System
Irritable bowel syndrome (IBS) is associated with dysmenorrhea in 60% of cases.  Other bowel conditions contributing to pelvic pain include diverticular disease, Crohn's disease ulcerative colitis, and chronic appendicitis, which are typically managed by primary care provider.
Functional gastrointestinal disorder is a pain syndrome with poorly defined pathology of which IBS is one type.  Functional gastrointestinal disorder presents as abdominal pain that is exacerbated by ingesting food and/or engaging in a bowel function. IBS presents with symptoms of abdominal pain, intestinal gas, bloating constipation, and diarrhea. Once identified, referral to a gastrointestinal specialist is merited.
Pelvic Pain Originating from the Musculoskeletal System
Musculoskeletal pathologies that can cause pelvic pain include SIJ dysfunction, symphysis pubis, and sacro-coccygeal joint dysfunction, coccyx injury or malposition, and neuropathic structures in the lower thoracic, lumbar, and sacral plexus. Prolonged pelvic girdle pain, lasting more than 6 months postpartum is estimated in 3%-30% of women.  As a component of pelvic ring pain, SIJ dysfunction is commonly seen in peripartum pain conditions. Pain management techniques for SIJ pathology include local steroid injections, radiofrequency thermocoagulation (RFTC), cooled radiofrequency, and cryoneurolysis of the nerves innervating the SIJ under fluoroscopic guidance.
Coccygeal joint dysfunction is an uncommon condition that causes pain in and around coccyx because of local trauma or overload and is exacerbated by sitting and bending. It is most commonly seen in women as a result of the morphology of the female coccyx and the propensity to hypermotility. A history of trauma, obesity, and transient exacerbation of pain when standing up from sitting are common features of coccydynia. The ganglion impar is located anterior to the coccygeal joint and transmits sympathetic stimuli. Hyperactivity of sympathetic system as a result of visceral pathology may refer pain to this region. Conservative management includes physical therapy, high velocity thrust manipulation of coccygeal joint, psychological treatment, and intra-articular injections. Interventional pain management of coccydynia consists of various methods of blocking the sympathetic or visceral component of pain via ganglion of Walter. Treatment includes injections with steroids, RFTC, cryoneurolysis, and sacral neuromodulation. ,
Proctalgia fugax is described as a sudden cramping rectal pain that is usually present at night. It disappears within several minutes with no objective findings and its etiology is unclear. 
The etiology may be related to internal anal sphincter spasm or thickening. Physical therapy may be helpful in applying Thick's massage or stretching of sphincter and levator ani.  Usually treatment begins with hip baths and topical nitroglycerine ointment. Interventional pain techniques are very effective with complete pain resolution in 25% of patients after receiving nerve blocks of pudendal nerve with local anesthetic and steroids.  When pharmacological biofeedback mechanism fails sacral neuromodulation can be an option for proctalgia fugax.
Pelvic Pain Originating from the Neurological System
Nerve irritation or entrapment as a cause of pelvic pain can be related to injury of the upper lumbar segments giving rise to irritation of the sensory nerves to the ventral trunk or from direct trauma from abdominal incisions or retractors used during abdominal surgical procedures.  Afflictions of the iliohypogastric, ilioinguinal, genitofemoral, pudendal, and obturator nerves are of greatest concern in patients with pelvic pain. Involvement of iliohypogastric nerve causes pain in the lateral pelvic or suprapubic area, whereas pain along the inguinal area radiating to the labia suggests involvement of ilioinguinal and genitofemoral nerve. Obturator nerve involvement cause chronic pain condition of pelvis and lower extremity accompanied by weakness of the adductors and sensory changes of the medial thigh and knee joint. Pudendal nerve can contribute to perineal pain as it supplies sensory and motor innervation via nerve to levator ani, the perineal branch and dorsal nerve to clitoris. Interventional pain management strategies for pain involving the above-mentioned nerves are injections of local anesthetics and steroids, RFTC, cryoneurolysis, and neuromodulation. ,
| Supportive Strategies for Managing Pain|| |
Patient education about the disease and treatment involved is paramount. Preparing the patient for intervention and understanding the best strategies to comply with is crucial. Components of CPP education also include the mechanisms involved and the interaction of the visceral and musculoskeletal system.
Physical strategies to enhance self-efficacy and enhance coping with chronic pain can be selected based on patient needs. Specific mechanical strategies include physical management and manual therapy for joint and soft tissue structures.
Strategies for stress management, sleep, and relaxation techniques are also vital.
Transcutaneous electrical neuromuscular stimulation has also been used for pain management.
Rehabilitation of pelvic floor dysfunction can include stretching techniques to relax hypertonicity of pelvic floor muscles.
| Conclusion|| |
CPP is a multifactorial pain condition that is prevalent among women. A knowledge of the differential diagnosis of the pain generators leads to a diagnosis-specific management of the pain condition. Using a multidisciplinary approach can improve outcomes for patients suffering from the condition and minimize the associated disability.
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