Chronic pelvic pain is defined as the feeling of pain or discomfort felt in the area from the underside of the belly button to the upper part of the thigh called the pelvic region. Pelvic pain, which is as common as back pain and asthma, can also be seen with pain during intercourse, which people are afraid to talk about and which affects their quality of life.

There are more than one cause of chronic pelvic pain. Although pain is a problem in itself in some cases, it can also be a symptom of a different problem in some cases. Therefore, in chronic pelvic pain due to a different disease or problem, treating this problem may be sufficient for the treatment of pain. However, it is usually not possible to attribute chronic pelvic pain to a single cause. In such cases, it is aimed at improving the patient's quality of life by reducing both the pain and other symptoms experienced by the patient.

Chronic Pelvic Pain Symptoms

Chronic pelvic pain is in the form of blunt, sharp, or constant pain in the form of a cramp. Pressure or weight may be felt in the pelvic area at the same time. This feeling may be temporary or permanent. The severity of pelvic pain may vary; it may be mild, not disruptive to daily life, or it may be severe enough to restrict daily activities. Patients usually describe chronic pain as follows.

• Constant and severe pain
• Periodic incoming and outgoing pain
• Dull pain
• Sharp pains in the form of cramps
• The feeling of weight and pressure in the pelvis

However, some patients may complain of pain during intercourse, while urinating, or sitting for a long time.

Factors Leading to Chronic Pelvic Pain

Pelvic pain is considered chronic if it persists for 6 months or longer. The factors causing chronic pelvic pain are listed as follows:

• Endometriosis

  It is a condition in which tissue similar to the endometrial tissue that normally covers the inside of the uterus begins to grow in places other than the uterus, such as the ovary, Fallopian tubes, and abdominal lining. Endometriosis can affect women of all ages. This tissue responds by accumulating and breaking down just like the endometrium in response to hormonal changes in each menstrual cycle, causing minor bleeding inside the pelvis.

  It causes inflammation, swelling, and scarring of the normal tissue surrounding endometriosis tissues. As a result, fibrous tissue bands may form that may cause the tissues and organs in the pelvis to stick together. Endometriosis can cause pain, especially during menstruation.

• Tension in Pelvic Floor Muscles
  Adhesions in the Pelvis

  Adhesions can be caused by an old infection, endometriosis, previous surgery, or other problems in the area. Pelvic adhesions may cause chronic pelvic pain in some women and may also lead to other symptoms, depending on where they are seen.

• Ovarian Cysts

  Ovarian cysts occur when the ovaries are unable to release eggs. When this happens, a growth called a cyst occurs in the area, which may produce swelling, pressure, or pelvic pain on the side of the body where the cyst is located.

• Pelvic Congestion Syndrome (PCS) (Congestion in Vessels on the Pelvic Floor)

  PCS, which is quite common and potentially causes serious restrictions in daily activities in women, is one of the causes of chronic pelvic pain. Approximately one-third of all women experience chronic pelvic pain at some point in their lives. PCS is associated with what is known as ovarian and pelvic vein enlargement.

  This can cause varicose veins in the pelvis, thighs, hip areas, or vaginal area. By definition, chronic pain lasts longer than six months and is not related to a woman's menstrual cycle. PCS should be considered if the pain worsens while sitting or standing and is relieved by lying down. Some patients may also experience pain while urinating (dysuria) or during/after sexual activity (dyspareunia). PCS, a complex medical condition, requires a multidisciplinary team approach for treatment and evaluation.

• Irritable Bowel Syndrome

  Irritable bowel syndrome (IBS) is a disease that affects your gastrointestinal tract. This includes the small intestine and the large intestine (colon). It is diagnosed when a person has abdominal pain or spasm associated with a change in the appearance or frequency of bowel movements. It causes changes such as belly cramps, gas, bloating, diarrhea, or constipation. IBS is a long-term, chronic condition and can be painful.

• Bladder Pain Syndrome (Interstitial Cystitis)

  Bladder pain syndrome is a condition that is not sufficiently understood that you have pelvic pain and voiding problems. It is sometimes called interstitial cystitis (IC) or painful bladder syndrome (bps). The main symptoms of bps (interstitial cystitis) include intense pelvic pain (felt on your lower abdomen), a sudden strong urge to urinate, more frequent urination than usual, pain in the lower abdomen that relieves after urinating and increases when your bladder is full, waking up several times during the night to need a toilet, difficulty urinating urinary incontinence, and blood in the urine (hematuria). Although BPS (interstitial cystitis) can affect people of all ages, it is much more common in women than men, usually above 30 years of age.

• Psychological Factors

  (History of Depression, Chronic Stress, Sexual or Physical Abuse)

Diagnosis of Chronic Pelvic Pain

Examination and imaging methods are used for the correct diagnosis in people who apply with pain complaints.

• Gynecological/Pelvic Examination

  The gynecological/pelvic examination performed with the patient's history helps to detect areas of infection, abnormal growth of the pelvic floor muscles, tension, or sensitivity.

• Laboratory Tests

  Blood tests, culture tests, urine tests, and different laboratory tests may be requested for symptoms. For example, vaginal culture tests may be required to screen for infections such as chlamydia or gonorrhea in the gynecological examination or urinalysis may be required to determine urinary tract infection.

• Ultrasound 

  Ultrasound is performed to evaluate the ovaries, uterus, and tubes structurally.

• Other Imaging Tests

  If any abnormality is detected during gynecological examination and ultrasound evaluation, advanced examination, and imaging methods such as computed tomography (CT) or magnetic resonance imaging (MRI) can be used.

Chronic Pelvic Pain Treatment

The purpose of chronic pelvic pain treatment is to reduce symptoms and improve quality of life. Although a personalized treatment approach is adopted, the optimal approach to pain usually includes a combination of treatments. In this direction, the treatments listed below are planned and applied individually or together according to the needs of the patient.

• Painkillers

  Analgesics such as acetaminophen and nonsteroidal anti-inflammatory drugs are generally well tolerated, but studies have concluded that nonsteroidal anti-inflammatory drugs are not effective in treating chronic pelvic pain associated with endometriosis.

• Hormonal Treatment

  Oral contraceptives are effective in treating dysmenorrhea associated with endometriosis, although there is only limited evidence that they are beneficial for non-menstrual pelvic pain. The intrauterine system (Mirena) releasing levonorgestrel has been shown to reduce the recurrence of dysmenorrhea if placed after laparoscopic treatment of endometriosis.

• Antidepressants

  Oral contraceptives are effective in treating dysmenorrhea associated with endometriosis, although there is only limited evidence that they are beneficial for non-menstrual pelvic pain. The intrauterine system (Mirena) releasing levonorgestrel has been shown to reduce the recurrence of dysmenorrhea if placed after laparoscopic treatment of endometriosis.

• Surgical Treatments 

• Physical Treatment (Stretching Exercises, Massage, and Relaxation Techniques) 

• Diet and Nutrition Treatment

• Neuromodulation

  Neuromodulation devices stimulate the nerves with electrical signals or other forms of energy. For selected patients, through a multidisciplinary assessment, in addition to other care, or when symptoms do not adequately respond to more conservative measures, e.g., when existing drugs are ineffective or become problematic for long-term use), tolerance, dependence, adverse side effects or development of toxicity) neuromodulation treatment may be considered.

• Trigger Point Injections

  It aims to reduce the tension of the connective tissue and restore the mobility of the muscle fascia. Patients who were treated for at least one month had a 25% or greater improvement.

• Psychotherapy 

• Acupuncture

  Patients who cannot benefit from other treatments, especially medication, for chronic pelvic pain are trying alternative methods to solve their problems. Acupuncture is also one of these methods. Acupuncture, which has been used in the treatment of many diseases in the far east for thousands of years and the west for the last 60 years, is also used in the treatment of chronic pelvic pain.

• Cognitive Behavior Therapy

  Regardless of the underlying cause, it is a critical component of care for women with chronic pelvic pain. One promising treatment modality is a mixture of cognitive psychotherapy and physiotherapy, called somatocognitive therapy. Its purpose is to promote awareness of one's own body, develop coping strategies, and release muscle pain manually.