Chronic Pelvic Pain

Any pelvic pain that typically lasts six months or longer is referred to as Chronic Pelvic Pain. It can be caused by gynecological diseases, gastrointestinal disorders, and urological diseases. Pelvic pain can become more likely to occur if there are psychological factors present, such as depression, stress, or a history of physical or sexual abuse.
The American College of Obstetricians and Gynecologists defines pelvic pain in women as “pain that is cyclical or noncyclical, lasting six or more months, located in the pelvic anatomic region, anterior abdominal wall or lower umbilicus, in the lumbosacral region or in the buttocks, and is severe enough to cause functional incapacity or lead to seeking medical attention”.[1]

 

  1. American College of Obstetricians and Gynecologists Committee on Practice Bulletins – Gynecology (ACOGCPB-G) Chronic pelvic pain. Clinical management guidelines for obstetrician-gynaecologists. ACOG Practice Bulletin Number 51. Obstetrics and Gynaecology 2004; 103(3): 589-605.
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  • Endometriosis
  • Muscle spasms or tension in the pelvis
  • Chronic pelvic inflammatory disease
  • Irritable bowel syndrome
  • Bladder pain syndrome
  • Interstitial cystitis

Causes of chronic pelvic pain

Endometriosis

Endometriosis is a common gynecological disorder that results in the appearance of normal uterine tissue (endometrial tissue) in numerous places outside the uterus, causing a chronic inflammatory reaction. The uterosacral ligaments, fallopian tubes, and ovaries are where the condition most frequently manifests itself. Rarely, endometrial tissues can form anywhere in the pelvis, colon, or bladder, as well as in distant organs like the lungs and other body parts.
Statistically, endometriosis occurs in 7%-10% of women of reproductive age (25-40 years), up to 50% of infertile women, and affects 71%-87% of women with chronic pelvic pain.
It is important to note that the degree of discomfort does not always correspond to the severity, extent, or intensity of endometriosis. Many women with mild endometriosis may experience severe pain or vice versa. In addition, we frequently observe endometriosis in women who have no symptoms at all.

 

Endometriosis symptoms

  • Pain during periods (dysmenorrhoea). Pelvic pain and cramps that start before menstruation and last for several days after menstruation. Many times, pain is located in the lumbar region and abdomen.
  • Pain during intercourse (dyspareunia)
  • Pain and swelling in the abdomen and defecation disorders
  • Pain when urinating (dysuria)
  • Menorrhagia (excessive blood loss during periods)
  • Chronic fatigue
  • Infertility/Subfertility

Treatments

Drug Therapies

The aim of drug therapies for endometriosis is to reduce estrogens in the body, so that menstruation, internal bleeding, and irritation are reduced.

  • Hormone therapy
  • Pain medications
  • Muscle relaxants (baclofen, tizanidine, oxybutynin, diazepam). They reduce cramps and muscle pain in the pelvis and bladder.
  • Non-steroidal anti-inflammatory drugs
  • Antidepressants (desipramine, amitriptyline). Prescribed doses are pain-specific and much lower than those given for the treatment of depression.
  • Anticonvulsants (gabapentin, pregabalin, topiramate). Here again, the administered doses given are pain-specific and much lower than those indicated for the treatment of epileptic seizures.

 

 

Invasive Treatments

  • Nerve block It can be used for diagnostic and therapeutic purposes. Although only a temporary solution, it is a significant tool in the hands of a specialist.
  • Muscle infiltrates. Patients with endometriosis tend to have muscle spasms in the pelvic floor, abdominal region, and lumbar region. These points (trigger points) can be blocked/infiltrated with local anesthetic, with or without the use of corticosteroids. It can be used for diagnostic and therapeutic purposes.
  • Pulse radiofrequency ablation
  • Transcutaneous Electrical Nerve Stimulation (TENS)
  • Physiotherapy. A cornerstone (or around 50%) in pelvic pain treatment. Specific pelvic exercises help patients better control and relax their muscles, thus alleviating their pain.
  • Acupuncture Doctors frequently recommend acupuncture practitioners to their patients, and these referrals have excellent outcomes.

Diagnosis

For women suffering from endometriosis, both the diagnostic and therapeutic journey is always long and painful. The majority of women hesitate to seek medical attention, as they mistakenly consider painful symptoms during periods normal. Additionally, health professionals (doctors, nurses) sometimes underestimate the degree and intensity of the pain that endometriosis patients experience and mistakenly attribute it to menstruation or the patient’s imagination. These events frequently cause a delay in referring women to specialists (gynecologists, pain specialists). Consequently, patients endure excruciating chronic pain during this time, which has an impact on their ability to work, their relationship with their partner, and their sense of self-esteem. These women also exhibit depressive and emotional distress symptoms.
Diagnostic laparoscopic biopsy remains the ideal diagnostic method (gold standard) after ruling out other possible causes of pelvic pain.

Pain management

A multidisciplinary team of medical experts is necessary for the management of chronic pelvic pain, especially in endometriosis. The medical team consists of a gynecologist (Specialist in endometriosis), who acts as the leader and guide of the others, a doctor with a special interest in chronic pain (pain specialist), a specialist nurse, a physiotherapist, and a psychologist. Pain management and treatment must be individualized and it should strongly consider both the disease itself and the treatment effects on the woman’s Quality of Life.
Pain management may involve one or more of the following approaches: medication, nerve block, injections into trigger points, and, of course, physiotherapy. Such treatments can be combined with laparoscopic surgery, which will be used to make the diagnosis, as well as with additional endometriosis treatment.

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