Charles E. Miller, M.D. & AssociatesCharles E. Miller, M.D. & Associates
Specialists in Minimally Invasive Gynecologic Surgery

Chronic Pelvic Pain

What is Chronic Pelvic Pain?

Chronic pelvic pain is defined as severe pain that lies below the umbilicus for at least six months. This pain can cause disruption in daily lifestyle functioning and may require treatment. 
What causes Chronic Pelvic Pain?
There are several entities that can be a cause of chronic pelvic pain. Several major body systems comprise of causes of chronic pelvic pain. These are most commonly the Gynecologic, Urologic, Musculoskeletal, Gastrointestinal, Psychological and Neurologic systems. In each system there are several causes as well. Below, is a list of probable causes by body systems, in no particular order for cause of pain.
  • Endometriosis – Implants of cells of the lining of the uterine cavity (endometrium) outside of the uterus in the pelvis, potentially causing inflammation, scarring, and/or pain.
  • Adenomyosis – Implants of cells of the lining of the uterine cavity (endometrium) growing into the muscle of the uterus causing painful periods and abnormal uterine bleeding
  • Pelvic Adhesions – Scar tissue formed from an inflammatory process, such as endometriosis, chronic infection, bowel disease, or previous surgery, that distorts the normal pelvic anatomy limiting its natural mobility
  • Pelvic Congestion – Pooling of blood in the veins (varicosities) of the uterus and ovaries causing pain after long periods of standing, deep penetration with intercourse and pain after intercourse. With this condition, pain seems to improve with laying down and rest.
  • Pelvic Inflammatory Disease – Infection causing inflammation and possibly scar tissue.
  • Uterine Fibroids – Non-cancerous growths of the uterine muscle causing space-occupying symptoms, such as pressure and pain.
  • Cancer of the pelvic organs – Abnormal cell growth of the pelvic organs can cause increasing inflammation and scarring as it continues to grow
  • Ovarian Remnant Syndrome or Residual Ovarian Syndrome – Part of the ovary is left behind from a previous surgery causing ovarian function to continue, which may have been the source of pain initially. 
  • Interstitial Cystitis or Painful Bladder Syndrome – Chronic inflammation of the bladder causing pain, urgency and frequency
  • Urinary Tract Infections – If recurrent, can cause chronic pain
  • Pelvic Myofascial Pain – Pain occurring from the pelvic floor muscles that involuntary spasm, usually during intercourse or from prolonged periods of sitting
  • Inflammatory Bowel Disease– Abdominal pain and altered bowel habits with potentially rectal bleeding; 2 disease processes- Ulcerative Colitis and Crohn’s Disease
  • Irritable Bowel Syndrome – Changed bowel habits with or without diarrhea and/or constipation with chronic abdominal pain in the absence of any other cause
  • Depression – No exact correlation with chronic pelvic pain, but may stressful events in the presence of depression may worsen pelvic pain
  • Prior Physical or Sexual AbuseMay alter brain signals of pain and cause pelvic pain especially during stress
  • Neuropathic Pain – Dysfunction of the nervous system in the absence of any other cause
How is Chronic Pelvic Pain diagnosed?
Diagnosing the cause of chronic pelvic pain is difficult because the pain may be due to one or a combination of causes of chronic pain. Therefore, diagnosing the cause of chronic pelvic pain can take a few months.   
The most important steps in diagnosing the cause of chronic pelvic pain is obtaining a medical history and performing a physical exam. If you are seeking a physician consultation for your chronic pelvic pain, please refer to the Patient Forms website link and complete The International Pelvic Pain Society’s Pelvic Pain Assessment Form and bring it to your first appointment. This is a questionnaire covering all the organ systems listed above. It is reviewed by your physician and is used as a tool, along with a consultation and physical exam, to help you and your physician evaluate your cause of chronic pelvic pain. To aid in the diagnosis of your chronic pelvic pain, other tools, such as lab tests and radiologic imaging, may be added to your evaluation. Below, are examples of the work-up we may discuss or perform for each of the potential causes or to rule out causes of chronic pelvic pain.
  • Endometriosis – On the pelvic exam, we try to palpate for nodules of endometriosis and may use a transvaginal ultrasound to detect endometriosis in the ovaries. Definitive diagnosis is made with a laparoscopy.
  • Adenomyosis – Imaging with transvaginal ultrasound or MRI may aid in this diagnosis. Unfortunately, the only definitive way to diagnose adenomyosis is actually sending the uterus from a hysterectomy to pathology.
  • Pelvic Adhesions – A pelvic exam will help to determine your pelvic organs’ mobility because adhesions or scar tissue limit the natural mobility of the organs. Occasionally, a transvaginal ultrasound may see displacement of the pelvic organs due to adhesions.
  • Pelvic Congestion – A radiologic procedure called a Tilt Table Venogram is used to help diagnose pelvic vein varicosities. The Tilt Table Venogram is a procedure where the radiologist introduces a catheter through the femoral vein (major vein of the leg) and guides it to the pelvic veins under visual guidance by radiologic imaging to identify dilated pelvic veins.
  • Pelvic Inflammatory Disease – A swab from the cervix is sent for a culture. Pelvic exam may reveal uterine and/or cervical tenderness. 
  • Uterine Fibroids – Pelvic exam may reveal an enlarged, irregular uterus. Imaging with a transvaginal ultrasound will help map out the location of the fibroids.
  • Cancer of the pelvic organs – If cancer is suspected, a referral to a gynecologic oncologist is strongly recommended for further work-up.
  • Ovarian Remnant Syndrome or Residual Ovarian Syndrome – Pelvic exam and transvaginal ultrasound help to detect if any remaining ovarian tissue is present and a cause of pain.
  • Interstitial Cystitis or Painful Bladder Syndrome – An office procedure called a potassium sensitivity test may be performed. If surgery is scheduled for suspicion or to rule out other causes of pelvic pain, a concomitant procedure is performed where a camera is placed into the bladder to evaluate for signs of Interstitial Cystitis. 
  • Urinary Tract Infections – Urine cultures are obtained in the office and treated if positive.
  • Pelvic Myofascial Pain – A pelvic exam is performed palpating the muscles of the pelvic floor to feel if the muscles are contracted and/or tender.
  • Inflammatory Bowel Disease – If this condition is suspected, a referral to a gastrointestinal physician is strongly recommended.
  • Irritable Bowel Syndrome – This is a diagnosis of exclusion and a referral to the gastrointestinal physician is recommended.
  • Depression – History is very important when diagnosing depression. If this is suspected, a referral to a psychiatrist may be recommended to treat the depression and see if pelvic pain symptoms improve.
  • Prior Physical or Sexual Abuse – History is very important when this situation has occurred. Appropriate referral and therapy is strongly recommended.
  • Neuropathic Pain – A physical exam is performed to test pain and sensation of the potentially involved nerves
How is Chronic Pelvic Pain treated?
Chronic pelvic pain is difficult to diagnose and treat since there can be a single cause or multiple causes. Some of these causes are diagnoses of exclusion, so treatment can be empiric with or without resolution of symptoms. A step by step treatment plan will be made when you see your physician for a consultation, however, time is necessary to help treat chronic pelvic pain.
Below, are examples of treatment plans that may be recommended for each of the potential causes of chronic pelvic pain. Treatment plans may vary based on age and childbearing plans.
  • Endometriosis – Medical therapy with NSAIDs and birth control pills are usually the first line treatment for pain thought to be caused by endometriosis. If this medical therapy fails, there are other medications that can be tried, such as Progestins, Danazol, and Depo Lupron. Surgical therapy with laparoscopic resection of endometriosis with or without a presacral neurectomy may be recommended if medical therapy fails or is thought to be a cause of infertility.
  • Adenomyosis– NSAIDs and birth control pills can be tried empirically, unfortunately, however, the only definitive treatment is a hysterectomy.
  • Pelvic AdhesionsLaparoscopic surgery to remove the adhesions may be recommended, however, surgery itself can cause reformation of scar tissue. Therefore a discussion with your physician is recommended to evaluate the benefit of surgery.
  • Pelvic Congestion – A radiologic procedure is recommended to block the veins of the pelvis if they are dilated on the Tilt Table Venogram. If surgery is scheduled, these veins can be identified and transected.
  • Pelvic Inflammatory Disease– Depending on the patient’s symptoms and condition, antibiotics may be prescribed to be taken at home by pill form or in the hospital by IV form. Surgery may be recommended if an abscess has formed in the fallopian tube and/or ovary and symptoms are not improving on antibiotics.
  • Uterine Fibroids – Please click on the link for Fibroids
  • Cancer of the pelvic organs– A referral to a gynecologic oncologist is strongly recommended for a discussion of treatment for any cancer of the pelvic organs.
  • Ovarian Remnant Syndrome or Residual Ovarian Syndrome– Birth control pills may be initiated to suppress ovarian function, however, if this fails laparoscopic surgery may be recommended to remove the ovarian remnant.
  • Interstitial Cystitis or Painful Bladder Syndrome – The surgical procedure of over distending the bladder with fluid to diagnose interstitial cystitis can be therapeutic as well. Usually, medication treatment with Elmiron is initiated to help treat the symptoms after the diagnosis. If symptoms do not improve, instillation of the medication Dimethyl Sulfoxide (DMSO) into the bladder may be helpful.
  • Urinary Tract Infections– Active infections are treated with antibiotics after a urine culture is obtained. Prophylactic antibiotics and/or behavioral changes may be recommended to prevent or minimize the occurrence of recurrent urinary tract infections.
  • Pelvic Myofascial Pain – Pelvic floor physical therapy may be recommended to help identify the muscles involved and provide feedback for pelvic relaxation. Trigger point injections may also be recommended. A small amount of local anesthetic is injected into the muscle at the site of tenderness. A few treatments may be necessary to see a significant improvement.
  • Inflammatory Bowel Disease– A referral to a gastrointestinal specialist is strongly recommended for a discussion of treatment of inflammatory bowel disease.
  • Irritable Bowel Syndrome– Diet modification, stress reduction and a referral to a gastrointestinal physician may be recommended.
  • Depression – This can be treated with psychotherapy, behavioral changes and/or medication. A referral to a psychiatrist may be recommended.
  • Prior Physical or Sexual AbuseThis can be treated with psychotherapy, behavioral changes and/or medication. A referral to a psychiatrist may be recommended.
  • Neuropathic Pain – Medications can help with the treatment of neuropathic pain. A laparoscopic presacral neurectomy may be recommended if the pain is located centrally in the pelvis. A referral to a pain specialist may be necessary.
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