Indian Journal of Pain

: 2017  |  Volume : 31  |  Issue : 2  |  Page : 141--142

Pelvic pain: Understanding the psychological conundrum

Madhur R. P. Chadha1, Apurv Mahalle2, Sorabh Garg1,  
1 Department of Pain Medicine, Primus Hospital, New Delhi, India
2 Department of Pain Medicine, Data Meghe Institute of Medical Sciences, Wardha, Maharashtra, India

Correspondence Address:
Madhur R. P. Chadha
Department of Pain Medicine, Primus Hospital, New Delhi

How to cite this article:
Chadha MR, Mahalle A, Garg S. Pelvic pain: Understanding the psychological conundrum.Indian J Pain 2017;31:141-142

How to cite this URL:
Chadha MR, Mahalle A, Garg S. Pelvic pain: Understanding the psychological conundrum. Indian J Pain [serial online] 2017 [cited 2019 Nov 16 ];31:141-142
Available from:

Full Text


Since ages, pelvic pain is poorly understood condition, given the underlying complex-compact anatomy, pathophysiology of origin, and associated psychology aspects. Chronic pelvic pain (CPP) is defined as a nonmalignant, continuous, or recurrent pain in structures related to the pelvis and lasting at least for 6 months. It is a multipronged condition leading to dysfunction in one or more of the following body systems: gynecological, urological, musculoskeletal, and neurological.

The community prevalence of CPP in United States, United Kingdom, and New Zealand is estimated to be between 14% and 25%.[1] Women with pelvic pain report depression, low mood, anxiety, limitation in daily activity along with poor sexual relations affecting the complete family thread.[2]

As initial understanding of pelvic pain has changed, even categorization has shown a new paradigm shift with classification now, based on both organic and nonorganic causes also including the musculoskeletal causes of pain. Recent research for solution in pelvic pain has focused widely on the emotional context, behavioral aspect, and fear-avoidance model to comprehend to make sense of this baffling condition [Table 1].{Table 1}

A CPP patient cannot be treated only for the organic cause. For an effective management, a complete understanding of the pain process needs to be undertaken. Identification of psychological aspect to CPP (yellow flags) is of utmost importance as pure interventions: Drug perspective or needles to radiofrequency alone lacks evidence.

The reason behind fear-avoidance model (FAM) is these population of sufferer's catastrophize pain, they are fearful, overfocused, and are more vigilant of these episodes of pain. This leads to avoidance of daily activities, a self-destructive thought process, and inactive lifestyle which lands them into low mood, depression with upregulated pain sensitivity and perceptions.

Lethem et al.[3] while introducing the FAM considered the three variables: pain-related fear, pain-related anxiety, and pain catastrophizing. These form the current center piece of FAM pie and are believed to lead patient into disability, reinjury fears, and negative behavior, avoidance, escapism, and negative cognitions. The psychological model gives a fair bit of understanding on how pain can persist in certain individuals after injury and why others recover completely.

Understanding the psychology (yellow flags) is extremely important when dealing with CPP conditions.

The foremost part of pelvic pain psychology under FAM model is fear – fear of movement, injury, and physical activity that increases pain leading to further restriction of activities, amplifying their negative cognitions, and deconditioning of muscles.

Other is anxiety – pain-related anxiety leading to preventive behaviors and pain-related fears leading to defensive behaviors. This anxiety brings out two characteristics patterns: avoidance and hypervigilance for impending pain.[4] This leads to attention bias, i.e., amplification of pain occurs at innocuous levels as they are selectively focused and attending to their pains leading to lowering of pain threshold and upregulation of pain perceptions to even a trivial pressure sensation [5] blurring the lines between an actual pain stimulus and an expected stimulus. One of the major causes of pelvic floor muscle tension, trigger points, and dyspareunia can be attributed to this component of FAM.

Moreover, final component – catastrophizing involves the tendency to focus on pain sensation (rumination), to exaggerate the threat of pain (magnification), and to negatively self-evaluate the ability to deal with pain (helplessness).[6] There is a strong evidence showing association between catastrophizing and pain intensity in acute/chronic pain conditions and also between catastrophizing and physical and psychological disabilities.[7] These psychological variables increase the distress associated with pelvic pain, and level of depression was significantly higher in women with CPP as suggested by George SZ et al.[8]

Sexual dysfunction in CPP has a direct relation to the psychological distresses as examined by Payne [9] suggested that women with vulvodynia reported more hypervigilance for pain during intercourse suggesting the increased attention paid to a threat of potentially painful stimuli during intercourse may have interfered with the sexual arousal and diminished the experience of intercourse. Other studies too have concluded that catastrophizing thoughts about pain were associated with dyspareunia in women suffering from vulvodynia.[10]{Figure 1}

The way CPP should be treated and viewed needs to undergo a paradigm shift with more comprehensive approach using the FAM model. This includes integrating the CBT, physical therapies alongside interventions, and medical management. This will help build a better, effective, and viable model for effective treatment as mentioned by Bergeron and Lord.[11]

The drawback to the whole aspect is the lack of knowledge and skills with the medical fraternity to treat this conundrum in a defined way. A planned integrated pain management program is the need of the hour to cater these debilitating conditions. Understanding the yellow flags and identifying the organic and psychology profile of patient are the initial leads to treating CPP. With introduction of physical therapy protocols, cognitive and distraction techniques in the curriculum pain program would be the welcome change. Need for multicenter RCTs targeting both the old and new concepts including targeted pain interventions for specific variables, along with studies focused on changes in cognition and behavioral process related to psychological aspects is the way forward for solution.

Unless brought into practice and developed systematically, CPP will keep the medical science on its toes and the sufferers in a melancholy daze, as this is a condition which makes you miss the past, barely makes you float in the present, and makes you dread in the future.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


1Mathias SD, Kuppermann M, Liberman RF, Lipschutz RC, Steege JF. Chronic pelvic pain: Prevalence, health-related quality of life, and economic correlates. Obstet Gynecol 1996;87:321-7.
2Grace V, Zondervan K. Chronic pelvic pain in women in New Zealand: Comparative well-being, comorbidity, and impact on work and other activities. Health Care Women Int 2006;27:585-99.
3Lethem J, Slade PD, Troup JD, Bentley G. Outline of a fear-avoidance model of exaggerated pain perception – I. Behav Res Ther 1983;21:401-8.
4Leeuw M, Goossens ME, Linton SJ, Crombez G, Boersma K, Vlaeyen JW, et al. The fear-avoidance model of musculoskeletal pain: Current state of scientific evidence. J Behav Med 2007;30:77-94.
5Hollins M, Harper D, Gallagher S, Owings EW, Lim PF, Miller V, et al. Perceived intensity and unpleasantness of cutaneous and auditory stimuli: An evaluation of the generalized hypervigilance hypothesis. Pain 2009;141:215-21.
6Sullivan MJ, Thorn B, Haythornthwaite JA, Keefe F, Martin M, Bradley LA, et al. Theoretical perspectives on the relation between catastrophizing and pain. Clin J Pain 2001;17:52-64.
7Somers TJ, Keefe FJ, Pells JJ, Dixon KE, Waters SJ, Riordan PA, et al. Pain catastrophizing and pain-related fear in osteoarthritis patients: Relationships to pain and disability. J Pain Symptom Manage 2009;37:863-72.
8George SZ, Wittmer VT, Fillingim RB, Robinson ME. Sex and pain-related psychological variables are associated with thermal pain sensitivity for patients with chronic low back pain. J Pain 2007;8:2-10.
9Payne S. Sex, gender, and irritable bowel syndrome: Making the connections. Gend Med 2004;1:18-28.
10Granot M, Lavee Y. Psychological factors associated with perception of experimental pain in vulvar vestibulitis syndrome. J Sex Marital Ther 2005;31:285-302.
11Bergeron S, Lord MJ. The integration of pelvi-perineal re-education and cognitive behavioural therapy in the multidisciplinary treatment of the sexual pain disorders. Sex Relation Ther 2003;18:7.