Get Back to Life Without Pelvic Pain
Contrary to what you may have been told, severe pelvic pain is not normal, and can be a symptom of a complex GYN condition. Pelvic pain is pain in the lowest part of the abdomen and pelvis. It can be dull or sharp, constant or intermittent, mild, moderate, or severe, and can sometimes radiate to the lower back, buttocks, or thighs.
Because many conditions or diseases could be causing this, it is important to get a careful diagnosis. The wrong treatment can make some conditions worse. The Center for Innovative GYN Care® (CIGC®) specialists are experts in diagnostics and treatment for complex GYN conditions.
Pelvic pain in women can be caused by:
- The intestines (gastrointestinal)
- The bladder (urological)
- The reproductive organs (gynecological)
- Pelvic muscles and joints (musculoskeletal)
- Mental health issues (psychological)
Chronic pelvic pain refers to pain of at least six months’ duration that occurs below the umbilicus and is severe enough to affect quality of life or require treatment. In the United States, approximately 15 percent of women report chronic pelvic pain, and four percent report the pain to be severe enough to miss work. Chronic pelvic pain is the principal indication for 20 percent of hysterectomies and 40 percent of laparoscopies.
Pelvic Pain Causes1
Gynecological Causes of Pelvic Pain
Gynecological causes of pelvic pain account for more than 50 percent of pelvic pain issues and include:
- Endometriosis: This is the most common cause and is present in about 70 percent of women with chronic pelvic pain
- Fibroids: Large fibroids can cause pressure symptoms
- Acute pain can occur with degeneration (dying), twisting, or expulsion of the fibroid through the cervix
- Adenomyosis: This condition causes heavy bleeding and pain with menstruation
- Pain is due to bleeding and swelling of endometrial glands in the uterine muscle
- Ovarian tumor or pelvic mass: An abnormal growth on the ovary or in the pelvis can cause pain
- The pain can be caused by twisting of the ovary or pressure of the mass on surrounding organs
- Pelvic adhesions (scar tissue): Dense adhesions from infection, endometriosis, or prior surgery can cause chronic pelvic pain
- Mild adhesions can be found during the laparoscopy but may not be the cause of the pain. Adhesions involving the bowel can cause abdominal bloating, constipation, and pain. Adhesions involving the uterus and the bladder are found in patients with multiple cesarean deliveries.
- Pelvic inflammatory disease (PID): An infection of the tubes, ovaries, and uterus that is caused by an untreated sexually transmitted infection
- Thirty percent of women with PID will subsequently develop chronic pelvic pain due to the scar tissue caused by the infection
- Pelvic congestion syndrome (PCS): This condition refers to dilated uterine and ovarian veins found on a pelvic ultrasound
- This is a controversial entity and has not been proven to be a real cause of chronic pelvic pain
Urological Causes of Pelvic Pain
The most common urological cause of chronic pelvic pain is interstitial cystitis/painful bladder syndrome. Interstitial cystitis (IC) is a more common cause of pain than most physicians or patients realize and can be found in more than 60 percent of patients with endometriosis. IC should always be evaluated in patients with endometriosis, or for those complaining of pelvic pain. Other urological causes include recurrent urinary tract infections, urethral diverticulum, and bladder cancer.
Gastrointestinal Causes of Pelvic Pain
- Irritable bowel syndrome (IBS): This syndrome is characterized by chronic or intermittent abdominal pain that is associated with bowel function or dysfunction
- About 10 percent of the general population has symptoms compatible with IBS; women are diagnosed more than twice as often as men
- Inflammatory bowel disease (IBD): Fatigue, diarrhea, crampy abdominal pain, weight loss, fever, and rectal bleeding are symptoms of Crohn’s disease and ulcerative colitis
- Both of these are serious chronic and often debilitating diseases that require medical attention and sometimes multiple surgical treatments
- Other potential causes of chronic pelvic pain include diverticulitis, colon cancer, chronic constipation, and celiac disease
Musculoskeletal Causes of Pelvic Pain
- Fibromyalgia: This is a disorder in which the patient reports pain in all four quadrants of the body and has at least 11 areas throughout the body that are tender to touch (knees, shoulders, elbows, neck, etc.). Other musculoskeletal causes of chronic pelvic pain include pelvic floor muscle spasms, chronic abdominal wall pain, inflammation of the pubic bone, hip joint, and muscle tendon abnormalities.
Psychological Causes of Pelvic Pain
Psychological or mental health causes include drug seeking and opiate dependency, physical and sexual abuse experience, depression, and somatization disorder.
Pelvic Pain Symptoms
Pelvic pain can be acute (sudden), chronic, intermittent, or cyclic in nature. Cyclic pain is usually associated with the menstrual flow. Pain can also be associated with urination, defecation, physical activity, or intercourse.
Additional symptoms include:
- Excessive vaginal bleeding
- Nausea or vomiting
- Signs of shock
- Lower back pain
Pelvic Pain Diagnosis
Due to the many causes of pelvic pain, diagnosis can be difficult. Many women with chronic pain are often disappointed with the quality of their medical consultations. Medical history, physical examination, psychological assessment, and counseling may require several visits to be complete.
Pelvic ultrasound is a great tool for identifying pelvic masses, ovarian cysts, and fibroids. It is less reliable for distinguishing between benign and malignant masses and diagnosing adenomyosis. An MRI is necessary in some cases to better identify an abnormality found on the ultrasound and for diagnosis of adenomyosis. A CT scan can identify diverticular disease, and pelvic, colon, and bladder masses.
A blood test, urine test, and testing for chlamydia and gonorrhea infection are necessary when bladder or genital infection is suspected. A pregnancy test should be obtained if tubal pregnancy is suspected.
Laparoscopic Surgery for Pelvic Pain
Conditions such as endometriosis and pelvic adhesions (scar tissue) can only be diagnosed with a laparoscopic procedure. If any abnormality is identified, it can be treated at the same time. One third of laparoscopic surgeries are performed because of abdominal/pelvic pain. One large study showed the following findings during laparoscopy in women with chronic pelvic pain: 35 percent had no visible abnormalities; 33 percent had endometriosis; 24 percent had adhesions; five percent had PID; and three percent had ovarian cysts.
A laparoscope is inserted through a small incision in the umbilicus and the pelvic organs are examined. Endometriosis, scar tissue, fibroids, ovarian cysts, and pelvic masses can all be removed during laparoscopy with an additional one or two small incisions. The duration of the surgery and recovery generally depend on the findings.
Endometriosis, pelvic adhesions, ovarian cysts, and fibroids can return and cause recurrent pelvic pain, requiring a repeat laparoscopy for treatment.
If laparoscopy does not identify the cause of pelvic pain, it is necessary to perform cystoscopy and laparoscopy to rule out urological and gastrointestinal causes of pain.
Cystoscopy uses a thin camera to identify a bladder tumor and interstitial cystitis. A colonoscopy identifies colon tumors as well as inflammatory bowel disease.
Pelvic Pain Treatment
Treatment Before Diagnosis
If pelvic pain is caused by endometriosis, laparoscopic surgery is indicated, especially if fertility is desired. Medical therapy should usually not be used, since it does not diagnose the extent of disease, and cannot assess the best option for medical therapy.
In general, the following infectious causes of pelvic pain are treated with antibiotics rather than a surgical procedure:
- Pelvic inflammatory disease (PID): This condition is treated with a combination of broad-spectrum antibiotics, because the specific bacteria causing the infection is often unknown
- In some instances, the patient has to be admitted to the hospital for IV antibiotics
- Urinary tract infection (UTI): Oral antibiotics are prescribed for specific bacteria found on urine analysis
- A simple bladder infection can be treated with three to five days of oral antibiotics. Recurrent bladder infections sometimes require daily antibiotic therapy for suppression. Hospitalization and IV antibiotic therapy are required in cases of complicated kidney infections.
- Irritable bowel syndrome (IBS): Modifications in diet, behavioral changes, medications, and psychotherapy are used alone or in combination, depending on the severity of the symptoms
- Interstitial cystitis/painful bladder syndrome: None of the currently available therapies for this disorder are curative
- Ongoing physical and pharmacologic therapies are prescribed to control the symptoms
The following conditions are treated with surgery:
- Endometriosis: Laparoscopic resection of endometriotic implants is accomplished using two to three small incisions
- For women who have completed childbearing and in cases of severe endometriosis, removal of the uterus and ovaries is an effective option
- Pelvic/ovarian mass: This includes the removal of a mass with or without the removal of the ovary
- The preservation of the ovary depends on several factors, including the age of the patient, the size of the mass, whether there is any viable ovary remaining, and the possibility of malignancy
- Fibroids: The removal of fibroids (myomectomy) or removal of the uterus (hysterectomy) are surgical treatment options
- Adenomyosis: Laparoscopic hysterectomy (removal of the uterus) is the treatment of choice for women with significant symptoms from adenomyosis
- Adhesions: Laparoscopic cut down of scar tissue (lysis of adhesions) is most effective in patients with dense adhesions and adhesions involving the bowel
- In cases of mild adhesions, cutting down of adhesions may not treat the pain and other causes of pain need to be considered. If scar tissue is caused by multiple cesarean deliveries, the removal of the uterus may be necessary to avoid adhesion reformation and repeat surgery.
- Pelvic congestion syndrome (PCS): Surgical treatment options include the removal of the uterus and ovaries, embolization of the ovarian veins, sclerotherapy, and surgical ligation of the ovarian veins
- There are only a few observational studies and case reports that studied the effectiveness of these treatment options
Laparoscopic Uterosacral Nerve Ablation (LUNA)
This procedure involves the destruction of the uterine nerve fibers located in the uterosacral ligament. A 2-cm segment of the uterosacral ligament is removed. This procedure is used in patients with unexplained pelvic pain, and the removal of the uterine nerves is thought to help relieve the pain. Some studies have shown that patients with unexplained painful menses remained pain free for 12 months following the procedure. Other studies showed that in patients with endometriosis, the addition of LUNA to the surgical treatment of endometriosis did not improve the pain2. Success rates for this procedure decline rapidly over several years, possibly due to the regrowth of nerves.
Laparoscopic Presacral Neurectomy
This procedure involves resection of the group of nerves (sacral nerve plexus) located in the pelvis that are thought to cause pelvic pain. This procedure is technically more difficult than LUNA because of the presence of large vessels and ureters near the area of dissection. This procedure is considered most effective for relieving pelvic pain located in the middle of the pelvis versus the right or left side. LPSN is more effective than LUNA for unexplained menstrual pain. As with LUNA, success rates decline over several years due to the regrowth of nerves3.
Alternative Treatment Options for Chronic Pelvic Pain
Treatments for trigger-point pain and for unexplained pelvic pain include physical therapy, trigger-point injections, local anesthetic patches, acupuncture, psychotherapy, behavioral and relaxation feedback therapies, and nerve stimulation.
The CIGC Difference
The CIGC laparoscopic pelvic pain specialists have made a commitment to diagnosing conditions that can cause pelvic pain, and performing the most minimally invasive procedures with advanced, modern techniques. Even the most complex GYN surgeries at CIGC are performed with exceptional outcomes.
DualPortGYN® and LAAM-BUAO® (laparoscopic-assisted abdominal myomectomy) were developed to improve patient outcomes of GYN surgery. DualPortGYN and LAAM® take advantage of advanced surgical techniques that enhance the safety of each procedure.
Specialists Not OBGYNs
The majority of the care provided by an OBGYN is obstetrics, with a small percentage of the practice devoted to surgery. We partner with OBGYNs to ensure patients get the best possible care. Treating pelvic pain requires extensive experience and high surgical volume to ensure patients have the best possible outcomes.
The CIGC surgical specialists are board-certified and fellowship-trained, and have undergone extensive training in the advanced techniques and procedures involved in laparoscopy. CIGC laparoscopic procedures for pelvic pain are far superior to the open or robotic procedures. Our procedures have a short recovery period, minimal scarring, and minimal discomfort, meaning you are back on your feet quickly.
Patients looking to make the best decision for themselves need to conduct extensive research and be their own advocate. Our patients share their success stories. Please refer to the testimonials section for more information.
Ready for a Consultation
If you’re suffering with pelvic pain, our specialists are ready to provide an evaluation of your symptoms and conditions and recommend an appropriate solution.
1 Steege JF, Siedhoff MT. Chronic pelvic pain. Obstet Gynec. 2014 Sept;124(3):616-29
2 Daniels J, Gray R, Hills RK, et al. Laparoscopic uterosacral nerve ablation for alleviating chronic pelvic pain: a randomized controlled trial. JAMA. 2009 Sep 2;302(9):955-61
3 Kwok A, Lam A, Ford R. Laparoscopic presacral neurectomy: a review. Obstet Gynecol Surv. 2001 Feb;56(2):99-104