Chronic Pelvic Pain
Introduction
 We believe it is important to consider all aspects of a woman’s health; mind, body and spirit when caring for women with CPP. There are many potential sources of pelvic pain that should be investigated. Pelvic pain may involve the urinary, reproductive, gastrointestinal, neurological, psychological, and musculoskeletal systems. When all the different sources of CPP are explored and treated, many women find relief from their pelvic pain. For some women that means complete remission of their pain, for other women it means a significant improvement in their quality of life.
We begin by asking you to complete a comprehensive history form and bring it with you on your first visit. This form was created by experts in the field of chronic pelvic pain. It addresses many aspects of your health such as past medical history, medications, an in depth description of your pain, emotional health, sexual health, what treatments you have tried, etc. Take your time filling this out. We will review this history form with you when you come to your first visit. After reviewing your history and records, we will conduct a special physical exam that pays particular attention to the health problems common among women with pelvic pain. At the end of the visit we will develop a treatment plan together that includes caring for all aspects of your health that are affected by living with chronic pelvic pain.
Signs and Symptoms
Chronic pelvic pain is one of the most common medical problems among women. It is defined as pain in the pelvis lasting more than 6 months that affects a woman’s quality of life. There are many sources of pelvic pain that should be investigated.
Gynecologic sources of chronic pelvic pain:
Endometriosis:
This is a condition in which the lining of the uterus (endometrium) grows outside the uterus. The lining can attach to the ovaries, fallopian tubes, intestines or other structures in the pelvis. It may cause pelvic pain, especially during menstruation. Hormones of the menstrual cycle cause the endometriosis to bleed each month. This can be painful and result in the formation of pelvic adhesions, also known as scar tissue. Blood trapped in the ovary can build up into a cyst. This is called an endometrioma. Adenomyosis occurs when tissue from the lining of the uterus grows in the muscle of the uterus.
Pelvic Adhesions:
Adhesions are bands of scar tissue that bind organs together. They are created by previous infections such as appendicitis or pelvic inflammatory disease, by pelvic or abdominal surgery or by endometriosis. Symptoms from adhesions include generalized pelvic discomfort or localized pain. Adhesions can be difficult to diagnose, however in some cases, the uterus and ovaries feel bound together on pelvic examination. A definitive diagnosis of adhesions is usually made during surgical exploration, frequently via laparoscopy. Surgery to cut bands of scar tissue can relieve pain. However, sometimes the adhesions re-form.
Vulvodynia:
Vulvodynia is pain at the opening to the vagina or the surrounding lips (vulva). Women with this condition may find it painful to insert a tampon, have sexual intercourse or even wear tight pants. Symptoms include burning, stinging, stabbing, irritation and/or rawness. The pain may be constant or intermittent, localized or diffuse. The cause is not known. It is thought that the nerves, muscles and tissues in the area are inflamed so the treatment is focused on treating these factors.
Non-gynecologic problems that can cause pelvic pain:
The most common are:
Irritable bowel syndrome (IBS):
IBS can be associated with diarrhea, constipation or a combination of both. Symptoms of bloating and discomfort may be relieved by a bowel movement. Stress and diet can aggravate the condition. The gynecology provider may make a referral to a gastrointestinal specialist for diagnosis and treatment.
Interstitial cystitis (IC):
IC is a painful bladder syndrome. This and other bladder symptoms such as the need to urinate frequently or urgently may need to be evaluated by a urologist.
Musculoskeletal:
These causes of pelvic pain are very common and often over looked. The muscles, joints and nerves in the pelvis can be injured just like any other part of your body. For instance tissues can be overstretched, torn or cut as in childbirth, or surgery. Muscles can weaken or tighten from disuse and injury. Habitual postures and movements can slowly stretch or compress structures in the pelvis leading to pain and dysfunction. The pelvic muscles, joints and nerves may be the sole cause of pain or just a piece of the problem.
Chronic pain can be created by spasm of the muscles that line the pelvis, also known as your pelvic floor muscles. This “sling” of muscles, along with connective tissue called fascia, lift and support the pelvic organs including the bladder, uterus, and rectum. Spasms in these muscles, also known as pelvic floor tension myalgia or levator ani syndrome, may cause pain locally. Tight bands of muscle, known as trigger points, may be tender to the touch, and they may refer pain to other areas of the pelvis, abdomen and low back. A thorough examination of the abdomen and pelvis can uncover these myofascial sources of pain that can be treated with physical therapy and biofeedback.
Psychological
Many women with chronic pain suffer from anxiety and/or depression which worsen pain. Recurring or chronic pain can cause some women to feel depressed. These feelings are normal. In some cases, pelvic pain can be a symptom of depression or anxiety. It is essential that these psychological issues be addressed with therapy and/or medications as needed.
Diagnosis
The diagnosis of chronic pelvic pain requires a good patient history (see the IPPS history form to be completed and brought to your first visit) and physical exam. Please come prepared to discuss many aspects of your health: past medical history, pain history, sexual history and mental health. The physical exam should thoroughly assess the many sources of pelvic pain discussed under signs and symptoms. Particular attention is paid to the musculoskeletal system including the back, abdomen and pelvis. A q-tip test may be performed to test the nerves outside and near the vagina. Other diagnostic tests may be ordered such as blood work, urine tests, pelvic sonogram or laproscopy if needed. You may be referred to a urogynecologist if you have bladder symptoms or a gastroenterologist if you have gastrointestinal symptoms. If you have a musculoskeletal component to your chronic pelvic pain, you may be referred to a physical therapist for further evaluation and treatment.
Treatment
Treatment for chronic pelvic pain is individualized depending on the underlying causes identified.
Here are some examples of treatment recommendations:
Sometimes hormones are prescribed to help with conditions such as endometriosis or heavy menstrual bleeding.Pain medications such as narcotics, nonsteroidal anti-inflammatories, or medicines for nerve pain could also be prescribed.Women with adhesions, adenomyosis or endometriosis may benefit from surgery.
Women with myofascial or muscle pain are referred for physical therapy and biofeedback. (See more info below)
Many women find that psychological therapy and/or medicines help them cope with chronic pain. A therapist can offer support and tools to cope with the burden of living with chronic pain. They can also help you and your partner cope with the relationship and sexual issues that can arise as a result of having chronic pain.
Mind/body techniques such as meditation, breathwork, guided imagery, and yoga can be very helpful.
Nutrition and supplements can be very useful. For instance, a diet rich in fruits, vegetables and grains is important. Avoiding foods that can increase inflammation and increasing foods that decrease inflammation can be useful.
Alternative healing systems such as traditional Chinese medicine have been found to help relieve pain. We can refer you to an appropriate provider.
Chronic pain can really get you down so it is important to care for your spirit. Focus on what brings you joy and meaning to your life. It is important to set reasonable goals and develop a treatment plan that addresses your unique health needs.
As you can see, we believe it is important to care for you as a whole person; mind, body and spirit.
What happens during physical therapy? How and why does it help?
During your physical therapy visit, your clinician will conduct a thorough musculoskeletal examination, identifying sources of pain and dysfunction. Sometimes alignment of the feet, hips, and back will affect the posture of the pelvis and perpetuate the pain cycle. A woman who has had chronic pelvic pain long-term may notice she has symptoms in other areas of her body. Patients suffering from CPP may notice changes in the muscles, skin and tissue of the pelvis, back and abdomen. Your physical therapist will examine the muscles of the pelvic floor as well as the abdomen, thighs and back. Together with each patient, the therapist will develop a treatment plan to address your specific issues and goals.
Physical therapy techniques for disorders of the joints and soft tissues of the pelvis may include education, internal and external myofascial release, manual therapy, therapeutic exercise, and modalities such as electrical stimulation or biofeedback. You may also use tools for self treatment such as dilators and Crystal Wand™. A home program is also a vital component of physical therapy. Your home program maintains and improves the musculoskeletal changes we make in the clinic.
Some studies show physical therapy works on 60% of women with levator ani syndrome and chronic pelvic pain. Physical therapy helps to align bony or muscular imbalances, decrease abnormal muscle tension and soft tissue, and strengthen your core muscles to prevent further injury. A physical therapist may help you identify other factors that may contribute to your pain such as poor posture, positioning, and habits. It is important to be consistent with attending physical therapy appointments for the full duration of rehabilitation and performing your home program even if you are feeling better.
For more information on the causes and treatments for CPP go to: www.pelvicpain.org/pdf/Patients/CPP_Pt_Ed_Booklet.pdf
See also: Lee A. Learman, MD, PhD
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