Chronic pelvic pain is a chronic condition located in the pelvis, in both men and women, lasting more than 6 months. Chronic pelvic pain is a diagnostic challenge for clinicians as it is a condition with an uncertain natural history and multifactorial aetiology.
Chronic pelvic pain syndrome includes any pain based in the lower abdomen (subumbilical) that persists for at least 6 consecutive months and is severe enough to cause functional disability and require medical or surgical treatment. It may be a symptom in many different organic pathologies (gynaecological, gastroenterological, urological, rheumatological, neuropsychiatric etc.) or it may be a distinct pathological condition. In many cases, neuropathic pain may occur as a consequence of abnormal functioning of the peripheral nervous system. In these situations where the aetiology cannot be identified and treated, therapy addresses not the pathogenesis but the symptomatology, with the aim of reducing pain and improving the patient’s quality of life.
Clinical picture of chronic pelvic pain
Patients manifesting specific symptoms are anxious and usually undiagnosed. Chronic pelvic pain occurs against an inflammatory background and has cognitive, emotional, behavioural, sexual, bowel and gynaecological consequences.
For the clinician, chronic pelvic pain is not easy to fit into a diagnosis. Often, patients with chronic pelvic pain have had previous unsuccessful surgery, or have developed resistance to painkillers, and are at the time of consultation with a vulnerable psyche and in the absence of a solution with immediate results are even more hopeless.
Statistically, chronic pelvic pain occurs in young women and in men aged 35-40.
Diagnosis of chronic pelvic pain
Diagnosing this condition is a challenge for the doctor and a real test for the patient, with a considerable amount of time dominated by pain and anxiety. About 50% of women with chronic pelvic pain remain undiagnosed and only a third seek specialist medical help.
Although women are most commonly diagnosed with chronic pelvic pain, there are studies that say it also occurs frequently in men. The challenge in diagnosis remains just as great, with male patients having to consult doctors from different specialties, from gastroenterologist to urologist, to identify a definite cause.
Pelvic pain can occur through irritation of the nerves in that area by some cause or by damage to the nerves in that area.
The clinical consultation is complex and different from a normal consultation and takes longer than a normal consultation.
In the clinical examination, the medical history is guided primarily by the surgical and physiological history. The diagnostician should have as much information as possible about the history of the disease and the course of lower abdominal surgery, where appropriate.
The clinical consultation aims to map the pain in the abdomen, testing the intensity, the kind of pain and its location in various positions: lying down, on one side, standing, gynaecological position.
Visceral pain is caused by irritation of small nerve threads in the pelvic organs or their supporting tissues. Visceral pain is vague, difficult to localize, sometimes localized in the entire lower abdomen and radiating to the lumbar region. It is frequently accompanied by 1 or 2 of the following vegetative symptoms – nausea, fatigue, irritability or even syncope through irritation of the solar plexus. Symptoms of SNS (sympathetic nervous system) activation may occur – pupil dilation, tachycardia, pallor, sweating, anxiety.
Somatic pain is caused by irritation of larger nerve fibres – femoral nerve, sciatic nerve. Somatic pain can be located very precisely by the patient, who perceives it as a burn, electric shock, stinging. It is not accompanied by vegetative phenomena, and very importantly, which also distinguishes it from visceral pain, it radiates caudally to the dermatomas characteristic of the affected area. The causes that lead to somatic pain also lead to pelvic motor dysfunction both in the pelvic organs (sexual dysfunction, ejaculatory dysfunction) and locomotor dysfunction.
An important aid in the history taking are questionnaires: quality of life questionnaires, questionnaires for investigating pathological history, visual analogue scale, etc. These questionnaires assess pain intensity using the visual analogue scale, factors that aggravate or relieve pain. Also in the questionnaires that the patient has to fill in before the assessment, personal pathological history, medication taken in the past, obstetric history – these are some of the information that we can get from the questionnaires. The questionnaires have the advantage that they are filled in by the patient before the examination, in tranquility, so details about the pain syndrome that she may have forgotten during the contact with the doctor in the office, are highlighted and noted in the questionnaire.
One of the questions in the medical history should focus on the location of the pain. The primary location of the pain helps the clinician to identify the spinal cord area and therefore the affected nerve. For example, in gluteal pain the pain originates from S1-S2 and in perineal pain the origin is S2-S4.
Causes of chronic pelvic pain
Chronic pelvic pain is often caused by certain surgical procedures or due to certain problems affecting the nerve pathways in the area of the nerves concerned. The threads may be affected either because of an irritation caused by a local fibrosis process or because of a compressive injury, a vascular compression, or a section made during surgery or a suture compressing the nerve.
Depending on the type of pain, visceral or somatic, the causes of pelvic pain are:
Causes of visceral pain:
- Uterine pathology
- Adnexal pathology
Causes of somatic pain:
- Sciatic nerve disease
- Retroperitoneal tumors (nerve pain that comes from a tumor originating in the sacral area)
In women, the most common cause of chronic pelvic pain is endometriosis, with approximately 80% of women with pelvic pain having laparoscopic endometriosis implants.
Other causes of chronic pelvic pain: adhesions, fibroids, pelvic inflammatory disease, cervical stenosis, ovarian cysts, ectopic ovary.
Treatment of chronic pelvic pain
The treatment of chronic pelvic pain must be approached holistically, which involves a careful investigation of the cause and source of the pain.
More often than not, even when the cause of the pain is identified, the results of treatment to eradicate it may be delayed. The reason is that the memory of the pain may persist. During this pathology, cortical mechanisms may intervene that can be felt even in the absence of the painful stimulus. Such patients may experience pain for 6-8 months being treated with neuroleptics and antidepressants to make them forget the pain.
Chronic pelvic pain caused by endometriosis
Chronic pelvic pain in endometriosis varies depending on the location of the implants, and usually occurs with menstruation, being later occasioned by ovulation then becoming quasi permanent, without being punctuated by menstruation, being accompanied by bowel symptoms, constipation, diarrhoea, mimicking urinary infections. There is no standard clinical picture.
There are also a number of other causes of pelvic pain caused by conditions of the pelvic organs unrelated to the reproductive system, such as the bowel, urinary tract, appendix, or pelvic muscles.
More than in other pathologies, pelvic frame pain requires a holistic view of the whole universe of factors causing or aggravating it. Pain is not a pathology, it is just information transmitted through the nerve pathway to the brain. It is information that needs to be addressed dynamically.
Before making a diagnosis, you need to understand what has caused it, the doctor must take a full and accurate history of the patient, the history of the symptoms – when they appeared, where they appeared, where the pain radiates, in what context it worsens – so you can decipher the origin, causes and triggers. The clinical examination must be carried out with great care, as it can reveal things that lead to the condition that caused the disability.
A correct diagnosis, carried out through a detailed history and clinical examination, plus complementary examinations and diagnostic tests – such as xilin (lidocaine) infiltration or laparoscopy – provide all the prerequisites for an optimal therapeutic course.