What Is Chronic Pelvic Pain? What To Do?

What Is Chronic Pelvic Pain /Chronic Pelvic Pain (CPP) is defined as cyclical or non-cyclical pain of at least 6 months’ duration. Aspects of pain may include dysmenorrhea, dyspareunia, dysuria and dyschezia. Dysmenorrhea in isolation does not constitute CPP. CPP affects up to 24% of women worldwide ^[rx]. It accounts for 20% of gynecological clinic referrals ^[rx,rx]. It has a considerable impact on patients’ quality of life and their income, and annual costs to the NHS have been estimated at approximately £326 million ^[rx] in addition to the costs to the public due to sick leave. One of the challenging issues is the long delay in women getting a diagnosis and accessing adequate care ^[rx].

Chronic pelvic pain can be a disabling, chronic, persistent pain, within the pelvis in women. Relatively common, chronic pelvic pain is associated with comorbidities such as irritable bowel syndrome, major depressive disorder, or pelvic inflammatory syndrome. One in seven women in the United States is affected. The prevalence is similar to migraine headaches, asthma, and chronic back pain. Chronic pelvic pain is considered a form of chronic regional pain syndrome. The diagnosis of chronic pelvic pain is made after three to six months of pelvic pain and is often based on history or physical; there are numerous associated symptoms or precipitating factors that help establish the diagnosis.  While imaging and laboratory findings are often inconclusive in making the diagnosis of chronic pelvic pain, often, they are useful in the diagnosis of a comorbid condition responsible for the development of chronic pelvic pain. An estimated fifty percent of cases remain undiagnosed.

Chronic pelvic pain (CPP) is a debilitating problem that afflicts 15–20% of women in the United States.¹ CPP is defined as noncyclic pain in the pelvis or abdomen which has been present for at least 6 months and is severe enough to cause functional disability or lead to medical care.^[rx] However, CPP should not be viewed as a single disease entity, but rather a constellation of symptoms that can be caused separate but frequently overlapping conditions, including endometriosis, pelvic myofascial pain, vulvodynia, interstitial cystitis/bladder pain syndrome (IC/BPS), and irritable bowel syndrome (IBS).

Chronic pelvic pain is a form of centralized pain, where the body develops a low threshold for pain, often a result of chronic pain. For example, if a woman developed endometriosis, the acute pain associated with this condition could become centralized during a three to six months duration, as the pain becomes chronic. In centralized pain, the previous mild to moderate pain is experienced as severe pain (hyperalgesia), or tactile sensations can be interpreted as painful (allodynia). Furthermore, chronic pelvic pain has a strong association with previous physical or emotional trauma. Thus the etiology of chronic pelvic pain may also be related to functional somatic pain syndrome. Treatment of chronic pelvic pain is often complicated, with limited evidence-based treatment options. Treatment is usually focused on the suspected etiology of the chronic pelvic pain, such as treating a comorbid mood disorder, neuropathy, or uterine dysfunction. Chronic pelvic pain is seen in an estimated four to sixteen percent of women.[rx][rx][rx] Given its prevalence, there must be a high suspicion in patients experiencing chronic pelvic pain. Management of chronic pelvic pain requires a team approach; a collaboration between multiple specialties is needed to provide adequate pain relief. Some patients with chronic pelvic pain may benefit from cognitive behavioral therapy and hormone replacement. In contrast, others may require more invasive treatment interventions such as spinal cord stimulation or total hysterectomy.     

Causes of Chronic Pelvic Pain

Chronic pelvic pain is associated with dysfunctions such as irritable bowel syndrome, interstitial cystitis, as well as other nonspecific chronic fatigue syndromes. Chronic pelvic pain is also associated with mental health disorders, including posttraumatic stress disorder and major depressive disorder. The relationship between chronic pelvic pain and comorbid conditions is often the primary focus of its diagnosis and management. In over half of cases of chronic pelvic pain, there is comorbid endometriosis, pelvic adhesions, irritable bowel, or interstitial cystitis.[rx][rx] Furthermore, multiple comorbidities can be present simultaneously alongside chronic pelvic pain.[rx][rx] Chronic pelvic pain is a form of reflex dystrophy, where there is both a neurological component to symptoms, as well as a psychological.[rx]][rx] The pathophysiology of chronic pelvic pain is likely that of centralized pain. Patients with chronic pelvic pain develop hyperesthesia and allodynia as a result of pelvic floor dysfunction.[rx][rx] Many comorbidities can lead to chronic pain; chronic cystitis, endometriosis, adhesions, or musculoskeletal injury are but a few associated with chronic pelvic pain. [rx] Many women have pain symptoms for over two years before seeking medical care.[rx] The persistent nature of the pain is what puts the patient at risk for centralization and the development of chronic pelvic pain. As chronic pain develops, the central nervous system undergoes a systemic change and becomes persistently in a state of high activity. When this occurs, the central nervous system responds to various stimuli as if they were painful. Chronic pelvic pain’s etiology is likely secondary to comorbidities that caused chronic pain.[rx] There is a synergistic effect of pain that can develop. As one organ system becomes dysfunctional, as in the case of interstitial cystitis, another organ can also develop pathology, such as in irritable bowel syndrome. As comorbidities develop, the chronic nature of symptoms leads to centralized pain, only enhancing the pain more. Collectively, persistent and increased sensitivity to pain becomes chronic pelvic pain.[rx][rx]

Pain can either be widespread as in chronic pain syndrome or more focal, as seen in chronic pelvic pain. Location often aids in diagnosis and management. Patients with widespread symptoms of pain, including pelvic pain, pain of multiple limbs, axial skeleton, and pain above the diaphragm, have much more significant psychological comorbidities (generalized anxiety disorder, major depressive disorder, and posttraumatic stress disorder) compared to focal symptoms. Emotional state and stress levels influence visceral pain, such as chronic pelvic pain.[rx][rx] Patients with widespread symptoms require a longer duration of treatments compared to patients with more focal pelvic pain.[rx][rx] There is a sizeable psychiatric component the chronic pelvic pain. It is theorized chronic pelvic pain has both environmental and genetic elements. Women with chronic pelvic pain have a higher incidence of depression, anxiety, and sleep disorders. However, repetitive trauma, such as childhood sexual abuse, could explain both the somatic symptoms of chronic pelvic pain, as well as the associated posttraumatic stress.[rx][rx][rx][rx] Anatomical changes from various pathology may also be the primary source in the development of chronic pelvic pain. Leiomyomas, nerve root entrapment, sacral cysts, and cauda equina syndrome have all been associated with chronic pelvic pain.[rx][rx] Patients with the pelvic inflammatory disease are more likely to develop chronic pelvic pain. Furthermore, the risk of developing chronic pelvic pain is increased if the patient is also a smoker, is in poor mental health, and had two or more episodes of pelvic inflammatory disease.[rx] In many cases of chronic pelvic pain, comorbid irritable bowel syndrome was neither previously diagnosed nor treated before the diagnosis.[rx] Endometriosis is a comorbidity associated with both chronic pelvic pain and irritable bowel syndrome.[rx][rx][rx]

CPP is a complex condition that can have many causes. It may be connected to other conditions. Some of these conditions include:

• Irritable bowel syndrome – A condition that affects your large intestine that can cause bloating, cramping, constipation, or diarrhea.
• Endometriosis (pronounced en-doh-mee-tree-OH-sis) – The tissue from the lining of your uterus grows on the outside of that organ.
• Tense pelvic floor muscles – The muscles at the bottom of your pelvic area tense up or cramp.
• Painful bladder syndrome – Your bladder becomes sensitive and easily irritated.
• Scar tissue in the pelvic area – You may have scar tissue from an infection, an operation, or other treatment that now causes pain.

Symptoms

When asked to locate your pain, you might sweep your hand over your entire pelvic area rather than point to a single spot. You might describe your chronic pelvic pain in one or more of the following ways:

• Pelvic pain or cramps before or during your period
• Pain during or after sex
• Pain when you ovulate
• Painful bowel movements
• Rectal bleeding during your period
• Pain when you urinate
• Lower back pain
• Infertility
• Spotting between periods
• Bloating in your abdomen
• Severe and steady pain
• Pain that comes and goes (intermittent)
• Dull aching
• Sharp pains or cramping
• Pressure or heaviness deep within your pelvis

In addition, you may experience:

• Pain during intercourse
• Pain while having a bowel movement or urinating
• Pain when you sit for long periods of time

Diagnosis of Chronic Pelvic Pain

History and Physical

When obtaining a history from a patient with suspected chronic pelvic, there is often comorbid chronic pain — furthermore, possible signs and symptoms of allodynia or hyperalgesia, suggestive of central sensitization. The etiology of chronic pelvic pain can usually be determined by a full past medical and surgical history, as well as the patient’s gynecological and labor history.

Chronic pelvic pain in women is often defined as persistent, noncyclic pain, but can also be cyclical. The patient’s pain is located within the pelvis and has lasted greater than six months duration. The pain must also be unrelated to pregnancy.[rx] The consistency can be constant or episodic. Some definitions do not consider cyclical pain to be apart of chronic pelvic pain, given this could be defined as dysmenorrhea.[rx][rx]

The patient’s history should include questions about precipitating and alleviating factors, including the association between menses and pain, urination, sexual activity, and bowel movements, and response to prior treatments. Pain may identify other areas where the patient experiences pain or may reveal a dermatomal distribution, suggesting a non-visceral source. Furthermore, the evaluation of mental health disorders should be complete, as well. Associated symptoms for patients with chronic pelvic pain include but are not limited to, gastrointestinal, urinary, sexual, and psychological, and menstrual symptoms. Also, impaired quality of life should be assessed. Patients with chronic pelvic pain can often experience motor or autonomic dysfunction.[rx] On history, cramping pain, hot, burning, or electrical type pain should be differentiated from sharp or dull pain. Pain fluctuation with menstrual cycle compared to the constant pain. Pain with urination or defecation, postcoital bleeding, postmenopausal bleeding, the postmenopausal onset of pain, history of prior abdominal surgery or previous abdominal infection, or unexplained weight loss should also be summarized as part of the history.

Red flag findings that may indicate systemic disease include postcoital bleeding, postmenopausal bleeding or onset of pain, unexplained weight loss, pelvic mass, and hematuria. Physical examination, including a gynecological speculum and bimanual examination and full abdominal exam, should be completed. The external genitalia should be examined — examination of the pelvic floor musculature for tenderness or hypertonicity. On physical exam, evaluation for an adnexal mass, enlarged or tender uterus, lack of uterine mobility on bimanual exam should be completed. Pain upon palpation of the lumbar spine, sacroiliac joint, and the pelvis should be noted.[rx] The Carnett test should also be done to determine if there is abdominal wall pain for patients experiencing pelvic pain.

For the Carnett test, the patient is asked to raise both of their legs off the exam table while in a supine position. The provider places their finger on the patient’s painful abdominal to determine whether the patient’s pain increases with the legs are flexed, and the abdominal muscles have contracted. In myofascial pain, the patient is likely to experience more considerable pain with leg flexion, while visceral pain improves with leg flexion. Women with chronic pelvic pain have also been having to up to five times more asymmetry of their iliac crest height and symphyseal levels.[rx]

Evaluation

Diagnosis is based on findings from the history and physical examination. If the findings on history and physical are suggestive of a specific diagnosis that is causing chronic pelvic pain, the diagnosis should be confirmed.

A cotton swab can be applied to the abdomen to help determine if there is a cutaneous source of pain. Completing the cotton tip applicator test helps determine if there is cutaneous allodynia. This test is 100% specific for patients with chronic pelvic pain.[rx]

The effects on quality of life and function should also be part of the assessment and can be completed by filling out a standardized questionnaire.[rx]

The first step in the evaluation of a patient with suspected chronic pelvic pain is to determine if they have any alarm symptoms, concern for acute abdomen, or potential malignancy.  If there are no alarm symptoms and no accurate diagnosis, then labs and imaging are warranted. The initial workup would include a CBC, ESR, UA, gonorrhea, chlamydia, and pelvic ultrasound. If a specific etiology is suggested after the initial workup, it should be evaluated and treated. Pelvic ultrasonography is indicated to rule out anatomic abnormalities. Ordering transvaginal ultrasonography is an essential part of the initial workup for suspected chronic pelvic pain. It can help identify cysts, masses, and adenomyosis. Furthermore, ultrasound detects hydrosalpinx, an indicator of pelvic inflammatory disease; comorbidity is often seen in chronic pelvic pain. Separately, a pelvic ultrasound is useful to identify masses less than four centimeters that may be missed on the physical exam.[rx][rx] An MRI may be needed following an ultrasound if abnormalities are seen.[rx]

Separately, if the patient is experiencing severe, uncontrolled pain, or there is a concern for acute abdomen, the patient should be referred for laparoscopic surgery or sent to the emergency department.[rx][rx] If laparoscopic surgery is inconclusive, the patient’s chronic pelvic pain is likely secondary to chronic regional pain syndrome.

A complete blood count with differential, urine pregnancy test erythrocyte sedimentation rate, urinalysis, chlamydia, and gonorrhea are often ordered to rule out pregnancy, chronic inflammation or infection as the source of the chronic pelvic pain

Diagnostic nerve blocks can be useful to determine if the patient with chronic pelvic pain complains of symptoms of neuropathic pain. If a sacral nerve root is numbed from a nerve block, and the patient’s pain is eliminated, this helps confirm the diagnosis of chronic pelvic pain secondary to peripheral nerve dysfunction.[rx]

Pain mapping can also be done during laparoscopic surgery, and the patient is under local sedation. The patient’s tissue is probed with surgical tools. The patient is asked about the severity of their pain. It can be a helpful test to focus treatment on the specific area of pain.[rx]

Ultrasound – This test uses high-frequency sound waves to produce precise images of structures within your body. This procedure is especially useful for detecting masses or cysts in the ovaries, uterus or fallopian tubes.

Other imaging tests – Your doctor may recommend abdominal X-rays, computerized tomography (CT) scans or magnetic resonance imaging (MRI) to help detect abnormal structures or growths.

Laparoscopy – During this surgical procedure, your doctor makes a small incision in your abdomen and inserts a thin tube attached to a small camera (laparoscope). The laparoscope allows your doctor to view your pelvic organs and check for abnormal tissues or signs of infection. This procedure is especially useful in detecting endometriosis and chronic pelvic inflammatory disease.

Treatment of Chronic Pelvic Pain

Non-surgical Interventions

Serotonin-norepinephrine reuptake inhibitors (SNRI) – such as duloxetine and venlafaxine, increase the available amount of norepinephrine and serotonin by inhibiting reuptake in the descending pain modulatory pathways, which appears to decrease pain sensitivity.^[rx,rx] Duloxetine is FDA-approved for the treatment of several chronic pain conditions, including fibromyalgia and chronic low back pain. Milnacipram is approved for fibromyalgia and venlafaxine for neuropathic pain. In patients with fibromyalgia, duloxetine resulted in significant improvements in pain and quality of life.^[rx,rx] SNRIs are generally well tolerated with few bothersome side effects. Additionally, SNRIs are also quite effective for the treatment of depression and anxiety, so maybe a good choice in patients with these comorbid conditions. There is no data regarding SNRIs for the treatment of CPP.

Tricyclic antidepressants (TCA) – such as amitriptyline and nortriptyline, also increases available amount of norepinephrine and serotonin by inhibiting reuptake in the descending pain modulatory pathways, decreasing pain sensitivity.^[rx]TCAs were initially developed for the treatment of mood disorders, but have largely been replaced by more effective and well-tolerated medications such as SSRIs. TCAs have been widely used off-label for many chronic pain conditions, despite only modest symptom improvement in most studies.^[rx] Additionally, their use is often limited by bothersome anticholinergic side effects, specifically sedation, drowsiness, dry mouth, and constipation. Slow titration does seem to minimize risk of side effects, and many side effects diminish with continued use. Data is limited in CPP, but amitriptyline did show modest efficacy in one study.^[rx]

Cyclobenzaprine – is a centrally active muscle relaxer that has a tricyclic structure and is suspected to function in a manner similar to TCAs, likely by increasing the available amount of norepinephrine and serotonin. However, it does not appear to have any antidepressant effect. Cyclobenzaprine is frequently used off-label in fibromyalgia and is associated with improved pain, sleep, and fatigue in several studies.^[rx,rx] Drowsiness is a frequently reported side effect, so nighttime administration may improve tolerability and maximize sleep benefits. Cyclobenzaprine has not been studied in CPP.

Gabapentinoids – such as gabapentin and pregabalin, are centrally acting calcium channel blockers. The mechanism of action is not entirely clear, but it does appear to decrease the availability of glutamate and substance P, thereby decreasing the activity of the ascending pain pathways. Additionally, it acts as a membrane stabilizer and has some anti-inflammatory effects.^[rx] Gabapentinoids have been widely used off-label for a variety of chronic pain conditions, including fibromyalgia and peripheral neuropathy. Gabapentinoids are typically well tolerated with drowsiness and dizziness the most commonly listed side effects, which often improve over time. Side effects can be minimized by slow titration and by giving most or all of the daily dose at night with smaller doses during the day.^[rx] In patients with fibromyalgia, gabapentinoids were associated with improved pain, sleep, quality of life, fatigue, and anxiety.^[rx] Data is CPP is limited, but several small studies indicated improved pain and mood.^[rx,rx] In an RCT comparing gabapentin and amitriptyline in patients with CPP, gabapentin resulted in greater pain improvement and better tolerability.^[rx]

The first step in the treatment of a patient with chronic pelvic pain with an unknown source of their pain is over counter analgesic (acetaminophen, NSAIDs). These pain relievers are typically well-tolerated. If there is adequate pain relief, no further pain management is needed at this time. If there is inadequate pain relief and a cyclical component to the patient’s pelvic pain, hormonal replacement therapy is recommended (either oral contraceptive pills, depot medroxyprogesterone, or an intrauterine device). If hormonal treatment is ineffective, or the patient’s pain was not cyclical, or their pelvic pain is suspected to be neuropathic, it is essential to evaluate the patient for an underlying mood disorder. If a mood disorder is presumed, antidepressant therapy (SSRI) is recommended. If a patient with suspected chronic pelvic pain secondary to neuropathic pain does not have an underlying mood disorder, various treatment options exist. Depending on the patient’s preference and their various comorbidities, the patient may benefit from tricyclic antidepressants (TCAs), pregabalin, gabapentin, or SNRIs such as venlafaxine, or duloxetine. If pain is uncontrolled with these various treatment options, it is recommended to refer to a Pain Medicine specialist, and possibly start a trial of opioid analgesics.[rx][rx][rx] For cases of suspected chronic pelvic pain secondary to suspected neuropathy gabapentin used as a single agent or in combination with amitriptyline, has been shown to be more effective than amitriptyline used alone.[rx][rx][rx]

If a local steroid injection is successful, either radiofrequency ablation, peripheral nerve blocks, or neuromodulation with a spinal cord stimulator may be a viable treatment option.[rx][rx] Botulinum toxin injections for patients with chronic pelvic pain have been shown to decrease pain with sexual activity, decrease pelvic pressure, as well as persistent, non-cyclical pelvic pain.[rx] Cutaneous treatment option such as trigger point injections with a local anesthetic such as lidocaine is another consideration for short term pain relief. Interestingly, patient pain relief lasts longer than the duration of the injection’s effectiveness. These injections are often done to relieve hypertonicity and pain secondary to the pelvic floor or abdominal wall muscles. If trigger points are beneficial, they are not only therapeutic but potentially diagnostic for myofascial pain syndrome. Myofascial pain has been associated with centralized pain.[rx][rx][rx] Alongside cognitive behavioral therapy, patient education regarding their chronic pelvic pain, including the psychological aspect of their pain, is beneficial.[rx][rx]

Cognitive-behavioral therapy (CBT) – has been extensively studied in many chronic pain conditions.^[rx] CBT was initially developed as a treatment for depression but has since been adapted to treat many other psychological conditions and chronic pain disorders. CBT is a goal-directed psychological therapy in which patients learn to recognize how their thoughts and behaviors impact their pain and functioning and learn how to alter those thoughts and behaviors. CBT techniques for chronic pain include education about the contribution of thoughts, emotions, and behaviors to the physical symptoms or emotional experience of chronic pain, cognitive restructuring and reframing, relaxation techniques to minimize autonomic arousal, graded activity, and pacing, sleep hygiene, problem-solving strategies, coping skills, and interpersonal skills.^[rx,rx]

While most patients with chronic pain would likely benefit from education regarding pacing, sleep, and coping mechanisms, this intervention is likely to be highly impactful for patients with comorbid chronic pain and psychological disorders. In particular, CBT has been associated with significant improvements in catastrophizing in patients with chronic pain conditions.^[rx,rx] Increasing adaptive coping skills and pain-related self-efficacy helps to mitigate the additive insult of these comorbid disorders.

The data supporting CBT – for treatment of other chronic pain conditions is much more robust than that for treatment of CPP, but there is increasing evidence of its efficacy in this population. Among patients with vulvodynia, CBT interventions resulted in improved pain, dyspareunia, sexual function, and anxiety.^[rxrx] Similarly, patients with endometriosis reported improved pain, dyschezia, and quality of life.^[rx] These patients also demonstrated parallel changes on functional MRI.^[rx]

Exercise – has been widely studied and has proven to be an effective treatment for many chronic pain conditions. Exercise interventions are associated with improvements in pain, quality of life, mood, sleep, physical function, and social and emotional function in patients with chronic pain.^[rx–rx]Exercise interventions may include strength training, flexibility, aerobic activity, or a combination. Each of the activity types seems to have specific benefits. Although it does not appear than a single modality is more significantly effective than the others, aerobic activity and strength training have the most robust evidence for improved pain symptoms.^[rx]

Differential Diagnosis

There are multiple etiologies of chronic pelvic pain that part of the differential diagnosis. As the patient’s pain becomes chronic, it centralizes, leading to chronic pelvic pain. A list of the various possible etiologies for chronic pelvic pain are listed below:

• Gynecological – Endometriosis, pelvic inflammatory disease, pelvic adhesion disease, recurrent ovarian cysts, leiomyoma, adenomyosis, hydrosalpinx, and post-tubal ligation pain syndrome
• Gastroenterological – Irritable bowel syndrome, celiac disease, inflammatory bowel disease, colorectal carcinoma, and hernias
• Urological –  Interstitial cystitis (painful bladder syndrome), recurrent cystitis
• Radiation cystitis, chronic urolithiasis, bladder cancer, and urethral syndrome
•  Musculoskeletal – Abdominal wall myofascial pain, fibromyalgia, coccygodynia, pelvic floor tension myalgia, piriformis syndrome
• Neurological/vascular – ilioinguinal nerve entrapment, iliohypogastric nerve entrapment, pudendal neuralgia, spinal cord injury, pelvic congestion syndrome, peripheral neuropathy, and vulvar varicosities

The five most common etiologies of chronic pelvic pain include irritable bowel syndrome, musculoskeletal pelvic floor pain, painful bladder syndrome, peripheral neuropathy, and chronic uterine pain disorders.

Prognosis

Following any gynecological surgical procedure related to chronic pelvic pain, there is a forty-six percent improvement of the patients’ pain, and a thirty-one percent improvement of symptoms of comorbid depression.[rx] Prognosis is often poor in patients with chronic pelvic pain, similar to other chronic pain syndromes. Treating the underlying origin of the patient’s pain leads to the best improvements in quality of life, as well as treating comorbid mood disorders.

Physical therapy can be a useful treatment modality in chronic pelvic pain — specifically, pelvic floor therapy. After completing therapy, patients with chronic pelvic pain used 22% less pharmacological pain relievers compared to patients who did not participate in treatment. [rx] Furthermore, patients have been shown to have decreased pain as well as decreased urinary frequency and urgency in patients with chronic pelvic pain secondary to painful bladder syndrome.[rx]

Hysterectomy led to fifty percent pain relief, in forty percent of patients with chronic pelvic pain, secondary to a gynecological origin.[rx] Yet, in up to forty percent of patients, chronic pelvic pain will continue, and five percent of patients will complain of worsening pain following surgery.[rx]

The prognosis of patients with chronic pelvic pain was better in patients with fewer comorbidities.[rx]

It is unclear when the optimal time for patients with chronic pelvic pain to opt for surgery.

Also, complicating matters is the lack of long-term research studies in the treatment of chronic pelvic pain.

Many of the endpoints of studies are measured in months rather than years.[rx][rx]

Pain mapping is useful to reduce pain in about fifty percent of patients.[rx]

Complications

It is essential when discussing chronic pelvic pain to be mindful of the history of trauma. Many women with a history of chronic pelvic pain have a history of abuse and suffer from the comorbid posttraumatic stress disorder.[rx]

Patients with gynecological etiologies of their chronic pelvic pain, who elect to undergo an elective hysterectomy may continue to experience pelvic pain postoperatively.

Tolerance to opioid analgesics can develop over time requiring increased dosages for adequate pain relief of their chronic pelvic pain.

Insomnia is prevalent in patients with centralized pain disorders and should be treated appropriately.[rx]

Specifically, in chronic pelvic pain, laparoscopic surgery is inconclusive in forty percent of cases in helping identify a source of the patient’s pain.[rx] Infection and bleeding are but a few complications associated with laparoscopic surgery and or hysterectomy.

Deterrence and Patient Education

• Chronic pelvic pain can be defined as chronic internal pain in the area below the belly button, within the pelvis that lasts six months or longer.
• The pain is often non-cyclical but can be associated with menstrual periods.
• The pain is described as persistent and often severe. It can be dull and achy, but also sharp or cramping in nature. Other patients describe their pain as a pressure like within their pelvis.
• Patients may complain of pain while having a bowel movement, during sexual intercourse, or after prolonged sitting.
• Chronic pelvic pain often occurs due to a process called central sensitization, where a patient may experience from either a non-painful stimulus or increased pain from a usually mildly painful trigger.
• Chronic pelvic pain can be caused by several possible comorbidities including endometriosis, pelvic inflammatory disease, irritable bowel syndrome (IBS), bladder pain syndrome/interstitial cystitis, pelvic floor pain, and fibromyalgia
• Diagnosis can often be aided by diagnostic tests such as a pelvic ultrasound but may even require laparoscopy surgery.
• Patients may require a referral to a chronic pain specialist or a gynecologist for further management of chronic pelvic pain.
• Treatment is based on the origin of chronic pelvic pain. Treatments include pain relievers, oral contraceptive pills, pelvic floor therapy, cognitive behavioral therapy, nutrition counseling, neuromodulatory procedures, and surgery.