Chronic pelvic pain is one of the most common medical problems among women. It is defined as pain in the pelvis that lasts more than six months and affects quality of life.
Our Approach to Pelvic Pain
Many conditions can cause chronic pelvic pain, and different systems in the body may be involved. When all possible sources of the pain are explored and treated, many women find their pain lessens significantly or goes away.
At UCSF Health, we perform comprehensive evaluations that include physical exams focused on the health problems commonly associated with pelvic pain in women. After the evaluation, we work with each patient to develop a personalized treatment plan that addresses all aspects of her well-being affected by pelvic pain.
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Chronic pelvic pain has many possible causes and may involve different systems in the body, including the urinary, reproductive gastrointestinal, musculosketal and neurological systems. Symptoms may vary depending on the cause. When we explore all the potential sources and address the issues we uncover, many women find relief.
Endometriosis is a condition in which the lining of the uterus (endometrium) grows outside the uterus. The lining can attach to the ovaries, fallopian tubes, intestines or other structures in the pelvis. Adenomyosis occurs when tissue from the lining of the uterus grows in the muscle of the uterus.
Endometriosis may cause pelvic pain, especially during menstruation. Hormones of the menstrual cycle cause the endometriosis to bleed each month. This can be painful and result in the formation of pelvic adhesions, also known as scar tissue. Blood trapped in the ovary can build up into a cyst. This is called an endometrioma.
Adhesions are bands of scar tissue that bind organs together. They are created by previous infections, such as appendicitis or pelvic inflammatory disease, by pelvic or abdominal surgery, or by endometriosis. Adhesions can be difficult to diagnose, but in some cases the uterus and ovaries feel bound together on pelvic examination. A definitive diagnosis of adhesions is usually made during surgical exploration, frequently via laparoscopy.
Symptoms from adhesions include generalized pelvic discomfort or localized pain. Surgery to cut bands of scar tissue can relieve pain. However, sometimes the adhesions re-form.
Vulvodynia is pain at the opening to the vagina or the surrounding lips (vulva). The cause is unknown. It's thought that the nerves, muscles and tissues in the area are inflamed, so treatment is focused on addressing these factors.
Women with this condition may find it painful to insert a tampon, have sexual intercourse or even wear tight pants. Symptoms include burning, stinging, stabbing, irritation and rawness. The pain may be constant or intermittent, localized or diffuse.
Non-gynecologic problems can also cause pelvic pain. The most common are:
Irritable Bowel Syndrome
Irritable bowel syndrome (IBS) can cause diarrhea, constipation, or a combination of both. Symptoms of bloating and discomfort may be relieved by a bowel movement. Stress and diet can aggravate the condition. The gynecology provider may make a referral to a gastrointestinal specialist for diagnosis and treatment.
Interstitial cystitis (IC) is a painful bladder syndrome. This and other bladder symptoms, such as the need to urinate frequently or urgently, may need to be evaluated by a urologist.
Musculoskeletal causes of pelvic pain are very common but are often overlooked. The muscles, joints and nerves in the pelvis can be injured just like any other part of your body. For instance, tissues can be overstretched, torn or cut in childbirth or surgery; muscles can weaken or tighten from disuse and injury; and habitual postures and movements can slowly stretch or compress structures in the pelvis, leading to pain and dysfunction. The pelvic muscles, joints and nerves may be the sole cause of pain or just a piece of the problem.
Chronic pain can be created by spasms of the muscles that line the pelvis, also known as the pelvic floor muscles. This "sling" of muscles, along with connective tissue called fascia, lift and support the pelvic organs including the bladder, uterus and rectum. Spasms in these muscles — known as pelvic floor tension myalgia or levator ani syndrome — may cause pain locally. Tight bands of muscle, known as trigger points, may be tender to the touch, and they may refer pain to other areas of the pelvis, abdomen and low back.
A thorough examination of the abdomen and pelvis can uncover these sources of pain, which can be treated with physical therapy and biofeedback.
Depression and Anxiety
Many women with chronic pain suffer from anxiety, depression, or both, which worsens pain. Recurring or chronic pain can cause some women to feel depressed. These feelings are normal. In other cases, pelvic pain can be a symptom of depression or anxiety. It's essential to address depression or anxiety with therapy and medications as needed.
The diagnosis of chronic pelvic pain requires a good patient history and physical exam. At your appointment, please come prepared to discuss many aspects of your health, including your past medical history, pain history, sexual history and mental health.
The physical exam will thoroughly assess the many possible sources of pelvic pain discussed under "Symptoms," with particular attention to the musculoskeletal system including the back, abdomen and pelvis. A Q-tip test may be performed to test the nerves outside and near the vagina.
If needed, we may order other diagnostic tests such as blood work, urine tests, a pelvic ultrasound or laproscopy. You may be referred to a urogynecologist if you have bladder symptoms, or a gastroenterologist if you have gastrointestinal symptoms. If you have a musculoskeletal component to your chronic pelvic pain, we may refer you to a physical therapist for further evaluation and treatment.
Treatment for chronic pelvic pain is tailored to each patient, depending on the underlying causes of the pain. Some treatment options include:
- Hormones for conditions such as endometriosis or heavy menstrual bleeding.
- Pain medications such as narcotics, nonsteroidal anti-inflammatories or medicines for nerve pain.
- Surgery for some women with adhesions, adenomyosis or endometriosis.
- Physical therapy and biofeedback for women with myofascial (connective tissue) or muscle pain.
- Psychological therapy, medication, or both to help you cope with chronic pain. A therapist can offer support and tools to handle living with chronic pain, and can also help you and your partner cope with the relationship and sexual issues that can arise as a result of chronic pain.
- Mind/body techniques such as meditation, breathwork, guided imagery and yoga.
- Nutrition and supplements — for instance, a diet rich in fruits, vegetables and grains is important. Avoiding foods that can increase inflammation and increasing foods that decrease inflammation can be useful.
- Alternative healing systems such as traditional Chinese medicine, which have been found to help relieve pain. We can refer you to an appropriate provider.
Chronic pain is very difficult to deal with. It's important to set reasonable goals and develop a treatment plan that addresses your unique health needs. It's also important to attend to your emotional health, and to focus on what brings joy and meaning to your life.
Some studies show physical therapy helps 60 percent of women with chronic pelvic pain and levator ani syndrome. It helps to align bone or muscular imbalances, decrease abnormal muscle tension and soft tissue, and strengthen your core muscles to prevent further injury. A physical therapist can also help identify other factors that may contribute to your pain, such as poor posture, positioning and habits.
During a visit, your physical therapist will conduct a thorough musculoskeletal examination, identifying sources of pain and dysfunction. Sometimes alignment of the feet, hips, and back will affect the posture of the pelvis and perpetuate the pain cycle. A woman who has had chronic pelvic pain long-term may notice she has symptoms in other areas of her body. Patients may notice changes in the muscles, skin and tissue of the pelvis, back and abdomen.
Your physical therapist will examine the muscles of the pelvic floor as well as the abdomen, thighs and back. The therapist will work with you to develop a treatment plan to address your specific issues and goals.
Physical therapy techniques for disorders of the joints and soft tissues of the pelvis may include education, internal and external myofascial release, manual therapy, therapeutic exercise, and treatments such as electrical stimulation or biofeedback. You may also use tools for self treatment at home, such as dilators and a product called Crystal Wand. A home program is also a vital component of physical therapy, maintaining and improving the musculoskeletal changes we make in the clinic.
UCSF Health medical specialists have reviewed this information. It is for educational purposes only and is not intended to replace the advice of your doctor or other health care provider. We encourage you to discuss any questions or concerns you may have with your provider.