Pelvic Pain

Pelvic pain is a common health problem experienced by many women. It is pain or discomfort felt in the lower part of the torso, beneath the abdomen, and between the hipbones. Pelvic pain doesn’t include pain that occurs in the external genital region.

Depending on the nature and intensity of the pain, Pelvic pain can be divided into Acute pain- in which the pain starts suddenly with intense severity, and Chronic pain- where the pain can either be intermittent or constant but lasts for several months. Acute pelvic pain is usually sharp, excruciating, and the patient can feel cramps similar to menstrual cramps. On the other hand, chronic pelvic pain is dull pain, and less intense. The intensity of both acute and chronic pelvic pain is related to the menstrual cycle. The intensity may increase right before or during the menstrual periods. Pelvic pain is termed as chronic when constant pelvic pain, with no improvement, lasts for more than 6 months despite of treatment.

Causes of Pelvic Pain:

The cause of pelvic pain is usually some disorder or disease of the female reproductive organs- uterus, cervix, vagina, fallopian tubes and ovaries. At times, it can also be due to diseases of the organs near the pelvis, such as appendix, rectum, bladder, intestines, kidneys, ureters. In rare cases, the cause of pelvic pain can be unknown.

The common gynecologic causes of acute pelvic pain include:

1. Ectopic pregnancy- this is a type of pregnancy which occurs outside the uterus.
2. Miscarriage
3. Ruptured ovarian cyst
4. Ruptured fallopian tube
5. Infection of the female reproductive organs, known as Pelvic inflammatory disease (PID)

The common non-gynecologic causes of acute pelvic pain include:

1. Urinary tract infection (UTI)
2. Appendicitis

The common gynecologic causes of chronic pelvic pain include:

1. Menstrual cramps- This is the most common cause of chronic pelvic pain. The intensity of pain shifts at various stages of the menstrual cycle.
2. Endometriosis
3. Endometrial polyps- small protrusions in the uterine cavity.
4. Uterine fibroids- these are abnormal growths on the uterine wall.
5. Cancers of the reproductive organs.

The common non-gynecologic causes of chronic pelvic pain include:

1. Presence of Adhesions in the lower abdomen or pelvic cavity. Adhesions are scar tissues which are formed between internal organs after surgeries. Presence of adhesions can cause constant pain which can take months to resolve.
2. Digestive system diseases- Irritable bowel syndrome (IBS), inflammatory bowel diseases (IBD), Cancers of the digestive tract.
3. Urinary tract disorders- Kidney stones
4. Musculoskeletal disorders- Strained abdominal muscles, Fibromyalgia.

Psychological factors such as stress and depression can rarely cause pelvic pain.

Symptoms accompanying Pelvic pain:

Depending on the cause of the Pelvic pain, it can be accompanied by other symptoms such as:

1. Vaginal bleeding or discharge
2. Nausea
3. Vomiting
4. Fever or chills
5. Dizziness

Diagnosis of Pelvic Pain:

In case of sudden intensely severe pain in the lower abdomen or pelvis, doctors will perform emergency surgery if the following are suspected: Appendicitis, Ruptured pelvic abscess, and Ruptured ectopic pregnancy.

If the above are not suspected, then the first step in the diagnosis of the cause of Pelvic pain includes- Patient history taking. For this the doctors ask the following questions about the nature and severity of the Pelvic pain:

1. Whether the pain is sudden or constant.
2. The duration of the pain.
3. The location of the pain.
4. Does the pain increase in severity during the menstrual cycle?
5. Other symptoms that occur along with the pain.

In the next step, the doctor will perform a complete physical and pelvic examination.

Further, for definitive diagnosis of the cause of Pelvic pain, diagnostic tests and investigations are ordered by the doctor. These include the following:

1. Urinalysis-Urine test to check the amounts of the chemical components of urine.
2. Urine pregnancy test- in women of child-bearing age.
3. Ultrasound

The above three are the most important tests for the diagnosis of the cause of Pelvic pain. If these tests are inconclusive or the doctor thinks more tests are necessary then the following tests might also be needed:

1. Blood tests
2. CT or MRI scans
3. Urine culture to check for infections that can cause in pelvic pain

If none of the above tests are conclusive of the cause of the Pelvic pain, Laparoscopic surgery may be performed. In this surgical procedure, a laparoscope, which is a thin tube with a camera and light, is inserted into an incision in the abdominal wall. This minor surgical procedure can help the doctor to identify the cause of pelvic pain.

Different symptoms suggest different types of disorders:

1. Vaginal bleeding- ectopic pregnancy, menstruation or miscarriage.
2. Vaginal discharge- infection of the female reproductive organs.
3. Fever and chills- can be present when there is infection in the body. This infection can be in any organ system of the body.

Treatment for Pelvic pain:

Treatment plan depends on the cause of the pelvic pain, the extent of the disease, overall health of the patient and the tolerance of the patient to certain medications and therapies. The first step in treatment of pelvic pain is to identify the underlying cause and cure it. Besides that, initially for pain relief the following medications and methods can be used:

1. Pain medications: Initially for the treatment of pain, oral pain medications such as non steroidal anti-inflammatory (NSAIDs) drugs are used. Most common NSAID used for pelvic pain relief is Ibuprofen. Besides Ibuprofen, other pain medications can also be used, such as Acetaminophen and Opiod analgesics. These medications are very effective in moderate intensity pain. In case the patient experiences muscle pain in the pelvic region, appropriate rest, heat or physical therapy can prove to be effective.
2. Pain during Menstrual cycle: In case of dysmenorrhea, that is painful menstrual cramps, a combination of oral contraceptives can be used to relieve pain. Other hormonal treatments such as Progestins or GnRH agonists can also be considered.
3. Antibiotic medications: These are for infectious causes of pelvic pain.
4. Nerve stimulation therapy: Nerve stimulation therapies or Neuromodulation have proved to be effective in treating chronic pelvic pain. In this method, the sacral nerve, found in the lower back, is stimulated. This can provide some benefit for pain relief.
5. Surgery: Surgical methods are used when oral medications and other therapies fail to relieve the pain. For pain relief the following surgical procedures can be used -
6. Uterosacral nerve ablation or Presacral neurectomy: In this surgery the nerves to the uterus are cut off.
7. Hysterectomy: If pain still persists after the nerves to the uterus are cut, the Uterus can be surgically removed.
8. Total abdominal hysterectomy- Surgical removal of all the organs of the female reproductive system.
9. Psychological cause of Pelvic pain- In case no physical cause is found, pelvic pain can be a result of stress, depression or some type of trauma. In mild cases, psychotherapy is recommended for such patients. In other cases, multidisciplinary treatment- physical therapy, nutritional changes, environment changes, pain medications can all be combined together.