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What is chronic pelvic pain?
Consistent pelvic pain for more than 6 months duration.
Pain can be cyclic, daily or intermittent. It must be a problem that has been bothersome for a long time.
What causes chronic pelvic pain?
Pelvic pain can be caused by one or more body systems. Reasons are not always gynecologic. Some are gastrointestinal, bladder or ureter, musculoskeletal, neurologic or psychosomatic. It is important that a complete and thorough exam is performed to determine the cause.
If the problem is gynecologic some of the causes may be, but are not limited to:
Women who experience pelvic pain that is aggravated by exercise or motion may have damage to pelvic muscles or the joints that hold the pelvic bones together. In cases that may be musculoskeletal we obtain physical therapy consults. Chiropractic is sometimes helpful.
When pain moves around and is not consistent the bowel may be then reason. Irritable bowel syndrome is a common problem that affects women. Some women are able to control pain with diet. Irritable bowel is reported more frequently in women with endometriosis.
Nerve damage in the pelvis could be caused by surgery. More surgery to remove adhesions or retreat endometriosis then worsens the nerve damage. Infection can also cause this problem. When we are trying to sort out cause of pain estrogen suppression can be helpful.
Research studies on causes of pelvic pain commonly report a higher incidence in women who have been victims of sexual assault.
What are the symptoms of chronic pelvic pain?
The nature, intensity and distribution of pain can vary. Some women report cyclic pain in the same location. Others have pain that moves around. Some pain can change in intensity from dull to sharp for seconds or minutes to hours and days. Some women identify aggravating events.
Chronic pelvic pain diagnosis
A combination of history, physical examination, laboratory, and additional diagnostic studies as indicated must be done to determine the cause of pelvic pain. Pain mapping is a procedure used to identify the location of the pain with various diagnostic modalities.
Ultrasound - Ultrasound is a way to diagnose some gynecologic conditions. Ultrasound is a noninvasive pelvic imaging technology. It is generally perceived as being no different than a pelvic exam as far as patient discomfort goes. It can help in finding uterine fibroids, ovarian tumors, pelvic abnormalities, adenomyosis and certain cases of endometriosis and occasionally cancer. It is much more accurate than a simple pelvic examination. Limited pain mapping is possible with ultrasound guidance.
Transvaginal Hydrolaparoscopy (THL) - THL as previously described is useful for diagnosing infertility and endometriosis. We have used it for pain mapping in some cases. Under oral sedation the patient is conscious and helps the physician identify where and how extensive the pain is. This permits the physician to adequately address the possible treatment modes for pelvic pain. If the pelvic pain is not identified in the posterior pelvis, laparoscopy may be necessary to evaluate the anterior pelvis and the upper abdomen.
Diagnostic Laparoscopy - This requires 2-4 small incisions in the abdomen so a scope can be inserted through the belly button to diagnose and possibly treat pelvic pain. A 3-mm fiberoptic scope is inserted through the abdomen while the patient has IV sedation to perform pelvic pain mapping. If pathology is found, then operative laparoscopy can be performed at the same time with a general anesthetic. Return to work should be anticipated in approximately 2 weeks.
Treatment options for chronic pelvic pain
Medicine - Analgesic treatment such as NSAIDS and narcotics are used for cyclic symptoms. Oral contraceptives can be useful for painful menstrual cramps. GnRHa is used to suppress estrogen production to relieve pain. Antidepressants can help in pain management because it elevated serotonin in the brain to help offset pain.
An accurate diagnosis will lead to the most effective therapy.
Nerve blocks – Sometimes nerves are irritated in the pelvic region. When there is a pinpoint location of pain a trigger point nerve block injection can turn off the pain. Relief can sometimes be permanent or for months.
Surgical - Depending upon the findings at the time of pain mapping or with preoperative ultrasound evaluation, there are several surgical options. These include removal of fibroids, endometriosis and hysterectomy.
These operative procedures are often very successful.
Psychotherapy - This has helped some women in dealing with pain. We do not believe women with chronic pelvic pain have mental illness. However chronic pain affects the whole person.
Acupuncture - This has been used to help relieve pain in some women.
When no cause for pain is found or therapy is ineffective a woman may need ongoing pain management. This is supervised by specialist in chronic pain management. The treatment usually involves daily narcotics and other medications known to reduce the input of pain into the brain. We work with chronic pain clinics in the Denver area.