PELVIC PAIN

Pelvic pain is far more common than expected. Chronic pelvic pain can affect up to 15% of women and affects males too.

Pelvic pain is usually mild but can be severe and debilitating. It can start suddenly or slowly, and can be felt it in a small area of the pelvis or over a much wider area that may include the abdomen or the lower back. It can last days or years and can sometimes be hard to treat.

Pelvic pain is often short term or acute, and lasts a few days to a few weeks and is usually mild. In females the causes of acute pelvic pain can usually be described by when they occur, e.g., whether the pain is related to the menstrual cycle or not.

Pelvic pain is subacute if it lasts between 4 and 12 weeks.

Chronic pelvic pain, on the other hand, lasts for 3 months or longer, even after the initial injury or underlying cause of pain has been treated. Chronic pelvic pain occurs in about 1 in 6 women and this usually occurs in those that have experienced some form of acute pelvic pain. This means that the pain can continue for much longer than expected, i.e., persistent pelvic pain. In some of those cases the pain can be difficult to treat.


PELVIC PAIN SYMPTOMS

Pelvic pain can occur suddenly or slowly, depending on the cause. It usually occurs immediately after an injury, but sometimes the onset of symptoms can be delayed.

Symptoms may include pain related to the menstrual cycle, being a sharp or dull pain; the pain can be localized to a specific area, to only one side or even be in a much larger area that may include the abdomen or the lower back. Pain can radiate into other areas of the pelvis or go beyond the pelvis altogether and radiate to the abdomen or back. There might also be tingling, numbness, pins and needles and weakness.

Severity can be rated on a scale from 1 to 10, or be described as mild, moderate or severe.

People can be very unwell if there is a more serious cause like an infection causing the pain. If there is an infection, the area could also be red swollen and warm.


PELVIC PAIN CAUSES

The pelvis forms the lowest part of the abdomen. It is formed by the pelvic bones on the front and sides and the bottom of the spine (sacrum) at the back. The pelvis contains organs that include the bowel, bladder and either female reproductive organs (womb (uterus) and ovaries) or male reproductive organs (prostate and associated structures). The pelvis also contains many nerves and blood vessels.

The precise location of the pelvic pain and associated symptoms can provide valuable clues about the underlying cause. It is also important to know if a female with pelvic pain is pregnant or not.

Problems deep within the pelvis itself tend to result from problems with one or more of the organs in the pelvis. Whereas pain in the lower abdomen wall or lower back can be caused by problems with muscles, ligaments and other soft tissues in that area. If there is also associated lower back pain, the spine itself may also be a cause of the pain in that area.

A few pelvic pain causes are:

  • Gynacological organ causes might include:
  • Ovulation
  • Period pain or menstrual cramps (dysmenorrhoea)
  • Pelvic inflammatory disease is an infection of the womb, fallopian tubes or ovaries
  • Fibroids are non-cancerous tumours that grow in or around the uterus. If fibroids get twisted or breakdown in any way, this can cause uterus pain
  • Endometriosis is a long-term condition where the lining of the uterus is found outside the uterus. The endometriosis pain can be found close to the uterus, e.g., on the ovaries or fallopian tubes, or further away from the uterus in the abdomen or even lungs
  • Adenomyosis is when endometriosis affects the muscle of the uterus
  • Ovarian cysts are fluid-filled sacs that develops on an ovary and cause ovary pain when they swell, burst or become twisted.
  • Chronic pelvic pain of which here can be multiple causes and this might include vulvodynia, women that have had some form of pelvic mesh surgery
  • Bowel (intestine) causes might include:
  • Constipation
  • Irritable bowel syndrome (IBS) is a long-term condition of the bowel (intestine) that can cause stomach cramps, bloating, diarrhoea and constipation
  • Diverticulitis
  • Adhesions (scar) can occur after any type of abdominal surgery. Scarring is part of the healing process after any surgery, which causes tissues to become sticky, which can cause bowel tissues to stick together
  • Hernia: is when an internal part of the body pushes through a weakness in the surrounding muscle or tissue wall
  • Inflammatory bowel disease like Crohn’s disease or ulcerative colitis.
  • Bladder causes
  • Interstitial cystitis is a long-term inflammatory problem of the bladder
  • Urinary tract infection probably also have pain or a burning sensation when you urinate, and you may need to urinate more often
  • Kidney stones
  • Males can have certain problems with regards to pelvic pain. When the testicle is painful it is called testicular pain or sometimes referred to as orchialgia. There are many causes of testicular pain and these include epididymitis (inflammation of the small tubes at the back of the testicle), varicoceles (swollen veins around the testicle), hydroceles (swelling around the testicle), trauma, or even twisting of the testicle (torsion), which is a medical emergency. Chronic testicular pain is usually nerve pain in nature. Another pelvic pain males can experience is inflammation of the prostate (prostatitis).
  • Strains and sprains of the lower pelvis or pelvic floor muscles or the abdominal wall muscles can occur. Sometimes pelvic floor muscle pain can be related to a myofascial pain syndrome which causes significant muscle spasms and tenderness. Problems with the pelvic floor muscles e.g. muscle spasms, can be a significant cause of pelvic pain.
  • Myofascial pain: this is pain that occurs because of problems with the surrounding muscles and ligaments of the pelvis and pelvic floor as mentioned above. The muscles may develop discrete little tight knots (taut bands) that are called myo-fascial trigger points. Trigger points are hyperirritable spots in the covering (fascia) surrounding muscle and can be very painful and quite debilitating. When a trigger point is touched or examined, it can cause exquisite pain in and around the area.
  • Lumbar spondylosis (osteoarthritis) is spinal arthritis, which is an age-related condition that affects the joints, discs and ligaments of the spine. Sometimes nearby joints in the spine or the sacroiliac joint can contribute to pelvic pain.
  • Another joint that can sometimes cause pelvic pain is the hip joint
  • Osteitis pubis is inflammation of the pubic symphysis joint, which is where each pelvic bone joins in the middle just above the bladder region in the lower abdomen.
  • Referred pain: referred pain is where pain in one part of the body can be felt in another part of the body that is nearby. This occurs when different parts of the body share the same nerves to send signals to the spine and brain. Pelvic bone or muscle problems can cause pelvic pain. Problems with some spinal nerves being compressed (pinched nerves) can sometimes cause pelvic pain. This compression condition is called lumbar foraminal stenosis and can cause radiating pain anywhere down into the buttock, pelvis, or leg.
  • Nerve pain: sometimes neurological problems can cause pelvic pain. Neurological causes might include pudendal neuralgia.
  • When pain persists following acute pain, this can sometimes cause changes within the nerves and set up some forms of nerve pain, also called neuropathic pain. Nerve pain can sometimes be hard to diagnose and usually needs to be assessed and treated by pain specialists.
  • Sometimes trapped or damaged nerves in the pelvis can cause chronic pelvic pain
  • Sensitisation: sometimes a problem in the nervous system called sensitisation can occur. This is when the pain, usually a nerve pain seems to be spreading up into the abdomen or down around the buttock, legs and thigh. Fibromyalgia sufferers could sometimes have pelvic pain.
  • Post-surgical pain: after an operation or surgery, pain can sometimes persist after the tissue has had sufficient time to heal. This can occur in up to 25% of all surgeries and sometimes the persistent pelvic pain can be intolerable and debilitating. Post-surgical pelvic pain can be caused by almost any type of abdominal or pelvic operation, even a simple laparoscopy. Persistent postoperative pain can be caused by many things, including nerve injury or scarring, ongoing inflammation or infection and muscle weakness. This is a complex pain condition and should be assessed and managed by pain specialist physicians in conjunction with the operating surgeons.

Contact us to find out what's causing your pain.


WHO GETS PELVIC PAIN?

Although anyone can get pelvic pain some people are more likely to develop it. The main group of people who experience pelvic pain are adult females, but it can also occur in adult males.

Those that have had multiple surgical operations on the abdomen or pelvis can also be at higher risk of developing chronic pelvic pain.

Preexisting anxiety and depression is also considered a risk factor for the development of pelvic pain.


HOW DO I GET A PELVIC PAIN DIAGNOSIS?

Pelvic pain is usually mild and settles by itself, but in some circumstances the pain can be complex and should be assessed by a medical professional or pain specialist, who will take the time to understand the pain story and perform a physical examination before setting forward a diagnosis and treatment plan.

In some circumstances imaging tests may be required. Types of imaging tests might be X-rays, CT scan, MRI scan, bone scan or ultrasound.

Once a pelvic pain diagnosis is made, the medical professional or pain specialist will determine the best treatment options. 

Book an appointment to have a Pain Specialist make a pelvic pain diagnosis.


WHAT PELVIC PAIN TREATMENT IS AVAILABLE? 

Treatment of the pelvic pain depends on whether the problem is acute (meaning it only occurred recently i.e. days and weeks) or chronic (meaning it has been present for more than 2-3 months).

 

ACUTE PELVIC PAIN TREATMENT

Most acute pelvic pain is mild, e.g., associated with menstruation and settles with simple treatments. The treatment of acute pelvic pain usually depends on the cause.

  • Simple treatments like hot or cold packs, physical activity for muscle cramps.
  • Pain medications like anti-inflammatories and anti-spasm medications to provide pain relief.
  • Antibiotics can be used when infection is the cause of the pelvic pain.

If the cause of the pain has been treated but the pain continues and is long lasting (chronic pain), debilitating, and has not been responding to treatments, an assessment should be made by a pain management specialist, who can assess and treat most types of chronic pain.

CHRONIC PELVIC PAIN TREATMENT

Through years of experience, we’ve figured out that good and long-lasting chronic pelvic pain relief doesn’t work unless all bases are covered.

The best pelvic pain management combines pain-reducing treatments with other selected therapies like physical and psychological rehabilitation treatment.

TYPES OF TREATMENT

  • Medications to reduce the pain. These may be simple over the counter medications or can be medications prescribed by a pain specialist. Medications might include muscle relaxants or anti-neuropathic (nerve pain) medications. Sometimes analgesic compound creams are used to ease pain, e.g., by application to painful areas like the vulval region.
  • Pain interventions: injection therapies can be used to target, diagnose and manage chronic pain caused by muscle, joint and nerve pain. This includes interventional therapies like nerve blocks (abdominal nerves like the ilioinguinal nerves, genitofemoral nerves, pudendal nerves, sacral nerves, medial branch nerve, cluneal nerves, gluteal nerves) radiofrequency ablation (RFA), and pulsed radiofrequency (PRF) to the nerves previously blocked, or epidural and nerve root steroid injections. Sympathetic nerve blocks at the hypogastric plexus can also be performed.
  • Some of these therapies can be focused on various structures that might be causing or making the pain worse like the pelvic floor. Botox injections can be considered for certain types of pelvic muscular abnormalities like over-active pelvic muscles.
  • Nerve stimulation, also called neuromodulation or spinal cord stimulation is an advanced pain reduction technique that can work really well for severe pelvic pain. Some forms of spinal cord stimulation are high frequency stimulation (HF10), tonic stimulation, multi-waveform stimulation, Burst DR stimulation and dorsal root ganglion (DRG) stimulation. Sacral nerve stimulation is a commonly used treatment for pelvic nerve pain that does not respond to other forms of treatment (refractory pain).
  • Surgery is generally recommended when tests show structural changes that need corrective surgery. These are typically performed by a gynaecological surgeon or a general/abdominal surgeon; the type of surgeon depends on the cause of the pain. Types of surgery might include, laparoscopy, removing adhesions (adhesiolysis), removing hernia and repairing defects (heriorraphy), removal of fibroids (fibroidectomy), removal of cysts (cystectomy) or the ovary (oophorectomy), removal of the uterus (hysterectomy), removal of the appendix (appendicectomy), removal of bowel (recection). Surgery is not a common treatment for chronic pelvic pain.
  • Rehabilitation: most types of chronic pain treatment should be managed alongside some form of specialist rehabilitation. This is when the best results occur.

HOW DO I GET PELVIC PAIN RELIEF? 

Significant pelvic pain is best assessed by a medical doctor like a general practitioner (GP). They will make an assessment and make sure there are no warning signs for something serious. The type of specialist that the GP refers onto depends on the cause and what treatment is required.

If they suspect something more serious is causing the pelvic pain, they may do some scans or blood tests and make a referral to the appropriate specialist for treatment, like a gynaecologist. But if no serious cause is diagnosed, a referral may be made to a pain specialist for an assessment and therapy with the use of advanced pain-reduction techniques.

If the pain is mild or improving, GPs may:

  • Reassure that there is no serious cause for concern and advise that the pain should improve with physical activity and simple pain medications.

If the pain persists or returns GPs may:

  • Use stronger pain medications
  • Suggest management by an expert pain pelvic physiotherapist if the pelvic muscles are suspected to be a cause or contributor to the pain or if there is significant weakness associated with lack of movement caused by the pain.
  • Refer to a pain specialist physician to provide more comprehensive pelvic pain management using options like joint and nerve blocks, sympathetic blocks and radiofrequency ablation (RFA), pulsed radiofrequency or nerve  stimulation and neuromodulation using sacral nerve stimulation or spinal cord stimulation as mentioned above.
  • Refer to a neurosurgeon or spine surgeon for an opinion.

Contact us to book an appointment with a pain specialist.


WARNING SIGNS OF MORE SERIOUS PELVIC PROBLEMS

In some instances, pain can indicate more serious pelvic problems or diseases elsewhere. These might include pregnancy-related problems and emergencies, burst organs like the appendix, infections, obstructed bowel, bone fractures, cancer, or severe nerve compression (trapped or pinched nerve). 

  • Pregnancy related pelvic pain should be assessed immediately by either a GP or an obstetrician. Possible causes of pelvic pain in pregnancy include miscarriage, ectopic pregnancy, rupture of ovarian cysts, premature labour, or even more serious issues like placental abruption.
  • Appendicitis (a painful swelling of the appendix (a finger-like pouch connected to the large intestine)), usually causes pain in the lower right-hand side of the abdomen
  • Infections of the pelvis tend to occur if patients have a weakened immune system from any cause or medical condition. Sometimes infections of the spine can occur if there is an infection elsewhere in the body. People with spinal infections usually feel unwell and can have sweats and a fever. Other issues include pelvic abcess, a severe infection of the pelvis, and peritonitis (inflammation of a thin layer of tissue that lines the inside of the abdomen (peritoneum))
  • Intestinal obstruction causes sudden abdominal pain that gradually becomes more severe
  • A hernia strangulates when too much bowel has come through the gap in the muscle or ligament and then it becomes squeezed. This can cut off the blood supply to the portion of intestine in the hernia and cause this part to stop working and die.
  • Rupture or twisting (torsion) of an ovarian cyst
  • Kidney stones can produce pelvic pain
  • Fractures of the spine or pelvic organs can be caused by a direct hit, fall, accident.
  • Ovarian cancer, bowel cancer, or secondary cancer, which has spread to the bones of the lower spine or pelvis and surrounding bones.
  • Nerve compression, called myelopathy, where there is a dangerous compression of the spinal cord in the neck. Myelopathy could cause symptoms that might include weakness or problems with coordination in the legs or feet.

Seek urgent and specialist medical advice if you experience:

  • Sudden, unrelenting, disabling and severe pelvic pain with or without lower abdominal and/or back pain
  • Signs of infection like fever or feeling unwell, or if the area is red, hot or swollen
  • Abdominal pain that starts in the middle but moves down to either the left or right lower abdomen or pelvis
  • Nausea and vomiting
  • Any unusual bleeding from the uterus
  • Severe testicular pain
  • Blood in the urine or bowel motions
  • Recent injury or fall
  • Numbness or tingling of the legs
  • Weakness in the legs
  • Problems with bladder or bowel function
  • Worsening stiffness
  • Recent weight loss
  • Pain that does not settle by itself after a few days or weeks
  • Possible pregnancy