In the U.S., about 15 percent of women have chronic pelvic pain. Many conditions or diseases could be causing this. It is important to get a careful diagnosis. The wrong treatment can make some conditions worse. CIGC specialists are experts in diagnostics & treatment for complex GYN conditions.
This is a very complex topic due to numerous conditions and diseases that can cause pelvic pain. Pelvic pain in women can be caused by the intestines (gastrointestinal), the bladder (urologic), the reproductive organs (gynecologic), pelvic muscles and joints (musculoskeletal), and mental health issues (psychological). Pelvic pain can be acute (sudden), chronic, or cyclic in nature. Cyclic pain is usually associated with the menstrual flow. Pain can be also associated with urination, defecation, and physical activity or intercourse.
WHAT DEFINES CHRONIC PELVIC PAIN?
Chronic pelvic pain refers to pain of at least six months’ duration that occurs below the umbilicus and severe enough to affect quality of life or require treatment.
HOW COMMON IS CHRONIC PELVIC PAIN?
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.
WHAT ARE THE GYNECOLOGIC CAUSES OF CHRONIC PELVIC PAIN?
Gynecologic causes account for approximately 20 percent and include:
- Endometriosis: This is the most common cause and is present in about 70 percent of women with chronic pelvic pain.
- Pelvic Inflammatory Disease (PID): PID is infection of the tubes, ovaries, and uterus and 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 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 Congestion Syndrome: 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. Dilated veins can be found in asymptomatic women.
- 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.
- Fibroids: Large fibroids can cause pressure symptoms. Acute pain can occur with degeneration (dying), twisting, or expulsion of the fibroid through the cervix.
WHAT ARE THE UROLOGIC CAUSES OF CHRONIC PELVIC PAIN?
The most common urologic cause of chronic pelvic pain is interstitial cystitis/painful bladder syndrome. Other causes include recurrent urinary tract infection, urethral diverticulum, and bladder cancer.
WHAT ARE THE GASTROINTESTINAL CAUSES OF CHRONIC 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: Fatigue, diarrhea, crampy abdominal pain, weight loss, fever, and rectal bleeding are the 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 pain include diverticulitis, colon cancer, chronic constipation, and Celiac disease.
WHAT ARE THE 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.
WHAT ARE THE MENTAL HEALTH ISSUES THAT CAN CAUSE CHRONIC PELVIC PAIN?
These causes include drug seeking and opiate dependency, physical and sexual abuse experience, depression, and somatization disorder.
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.
Due to many causes of pelvic pain, the 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.
WHAT RADIOLOGIC STUDIES ARE USED FOR DIAGNOSIS OF PELVIC PAIN?
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, pelvic masses, colon and bladder masses.
WHAT LABORATORY STUDIES ARE USED FOR DIAGNOSIS OF PELVIC PAIN?
A blood test, urine test, and testing for Chlamydia and gonorrhea infection are necessary when bladder or genital infection is suspected. Pregnancy test should be obtained if tubal pregnancy is suspected.
WHY IS LAPAROSCOPIC SURGERY USED FOR PELVIC PAIN?
Conditions such as endometriosis and pelvic adhesions (scar tissue) cannot be diagnosed by radiologic studies or laboratory studies. Laparoscopic evaluation of the pelvis is necessary to make the correct diagnosis. 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, 5 percent had PID, and 3 percent had ovarian cysts.
WHAT IS DONE DURING LAPAROSCOPY?
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.
WHEN WOULD ADDITIONAL SURGERY BE NECESSARY?
Endometriosis, pelvic adhesions, ovarian cysts, and fibroids can return and cause recurrent pelvic pain, requiring a repeat laparoscopy for treatment.
WHAT IF LAPAROSCOPY DOES NOT SHOW ANY ABNORMALITIES?
If laparoscopy does not identify the cause of pelvic pain, it is necessary to perform cystoscopy and laparoscopy to rule out urologic and gastrointestinal causes of pain. Cystoscopy: A thin camera is inserted into the bladder. This procedure can identify a bladder tumor and interstitial cystitis. Colonoscopy: This procedure will identify colon tumors as well as inflammatory bowel disease.
IS TREATMENT BEFORE DIAGNOSIS (EMPIRIC TREATMENT) APPROPRIATE?
In cases of suspected endometriosis, empiric treatment with medications can be used, especially if the patient does not want to undergo a surgical procedure. The disadvantage of this approach is that a satisfactory response does not confirm the diagnosis and prolonged medical treatment may be necessary to see an improvement in symptoms. In cases of moderate and severe endometriosis, medical management may not be effective.
WHAT CONDITIONS ARE TREATED WITH MEDICATIONS?
In general, infectious causes of pain are treated with antibiotics rather than a surgical procedure.
- 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.
- UTI (bladder or kidney infection): Oral antibiotics are prescribed for specific bacteria found on urine analysis. A simple bladder infection can be treated with three to five days’ worth 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: 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. To learn more about treatment of this disorder click here.
- Pelvic Congestion Syndrome: Although this diagnosis is controversial, there are some studies that have shown effective treatment with progesterone injections. It is important to understand that endometriosis can also be treated with progesterone injections, therefore the diagnosis of pelvic congestion syndrome (without laparoscopy to rule out endometriosis) may be incorrect.
WHAT CONDITIONS ARE TREATED WITH SURGERY?
- 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. To learn more about the resection of pelvic adhesions click here.
- Adenomyosis: Laparoscopic hysterectomy (removal of the uterus) is the treatment of choice for women with significant symptoms from adenomyosis.
- Endometriosis: Laparoscopic resection of endometriosis 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. For more information on treatment of endometriosis click here.
- 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. To learn more about treatment of pelvic masses click here.
- Pelvic congestion syndrome: Surgical treatment options include the removal of the uterus and ovaries, embolization of the ovarian veins, sclerotherapy, and surgical ligation of the ovarian veins. However, there are only a few observational studies and case reports that studied the effectiveness of these treatment options.
- Fibroids: The removal of fibroids (myomectomy) or removal of the uterus (hysterectomy) are surgical treatment options. To learn more about fibroid treatment click here.
WHAT IS 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 pain. Success rates of this procedure decline rapidly over several years, possibly due to the regrowth of nerves.
WHAT IS LAPAROSCOPIC PRESACRALNEURECTOMY (LPSN)?
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 nerves.
WHAT ARE 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.
WHY CIGC FOR MY PELVIC PAIN TREATMENT?
Because so many conditions and diseases could be causing your pelvic pain, it is important to assess the situation and diagnose carefully. In such a situation, it is important to seek a GYN specialist so that your condition is identified correctly, and treated thoroughly on the first try. There are many reasons CIGC has the experts you need.
Why Not My OB/GYN?
The majority of the care provided by an OB/GYN is obstetrics, with a small percentage of the practice devoted to surgery. We partner with OB/GYNs 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 outcome.
CIGC surgical specialists have undergone extensive training, are board-certified, and are fellowship-trained 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.
Many OB/GYN surgeons perform open procedures or robotic procedures to cure pelvic pain. Open procedures are painful, require a hospital stay, and leave much more visible scarring. Robotic procedures involve long surgeries, more incisions, higher expenses and have higher risks. CIGC does not use either of these methods for those reasons.
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, so you can hear it from them about their experiences.
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