Chronic Pelvic Pain

Chronic pelvic pain is a longstanding symptom in the lower abdomen and pelvis, not limited to periods or intercourse. Many people see several doctors for months of pelvic or lower abdominal pain without finding a clear explanation. This information is general and does not replace individual diagnosis or treatment decisions.

What is chronic pelvic pain?

Chronic pelvic pain is not the name of a single disease; it is an umbrella term describing the persistent nature of the pain. This is defined as pelvic pain that is not limited to periods or sex and that continues for a long time. How long is considered "chronic" varies between sources; what matters is that the pain continues over weeks and months in a way that affects the person's life.

How does chronic pelvic pain differ from period pain or painful intercourse?

Pain that occurs only during a menstrual period is cyclical pain and is a separate topic. Pain that occurs only during or after sex is also assessed separately. In chronic pelvic pain, the pain continues independently of these two situations; it may increase with periods or sex but does not depend on them. Pelvic pain during pregnancy is a different picture and is assessed separately.

What can cause chronic pelvic pain?

It often cannot be reduced to one cause. Several organ systems and the nervous system may contribute together, so one intervention should not be expected to resolve pain completely. Possible contributors include:

• Gynaecological causes: conditions such as endometriosis and adenomyosis, or adhesions after infection or surgery. No clear finding on examination or ultrasound is also common.
• Bladder, bowel and musculoskeletal contributors: bladder pain syndrome (interstitial cystitis) and irritable bowel syndrome may coexist. Pelvic floor tension and tenderness, or abdominal wall, back and hip musculoskeletal problems, may increase pain. Many patients have several of these together.
• Nervous system sensitisation and psychological factors: persistent pain may make the nervous system more sensitive to pain signals. Depression, anxiety and difficult life experiences can affect pain, while pain may worsen them; the relationship works both ways.

When and how is chronic pelvic pain assessed?

When the pain starts to affect daily activities, sleep, work or relationships, it is appropriate to see a doctor for assessment; there is no need to wait for a set duration to pass.

Assessment begins with a detailed history. The doctor asks about the location and nature of the pain, and its relationship with the menstrual cycle, sex, urination and bowel movements. A pain diary kept over a period of time can make it easier to see what triggers or eases the pain.

The examination also assesses musculoskeletal sources, including the abdominal wall, lower back, hip and pelvic floor muscles. Laboratory and imaging tests are useful when the history and examination call for them; the same list of tests is not applied to every patient. Besides ultrasound, further investigations relating to the urinary tract or bowel may be requested depending on the history.

Surgical procedures such as laparoscopy are not a first step. Whether such a procedure is needed is determined by the doctor for the individual after a detailed assessment.

How is chronic pelvic pain managed?

Because more than one system can contribute to the pain, management often requires an approach in which, alongside the gynaecologist, physiotherapy, urology, gastroenterology, pain medicine and mental health fields all play a role together. The goal is often to improve function and quality of life rather than to eliminate the pain completely.

If tension in the pelvic floor muscles is contributing to the pain, pelvic floor physiotherapy is one of the options. Some musculoskeletal approaches, such as trigger point injections, can also be used. The evidence for acupuncture and yoga is limited.

Medication is planned according to the nature of the pain and any accompanying condition. Some medicines used for nerve pain may be considered; however, the evidence specific to pelvic pain is limited and recommendations are being updated. Opioid medicines are not recommended for this pain, because they do not address the cause of the pain and carry a risk of side effects, tolerance and dependence. Medicine use should be carried out under the doctor's supervision.

Why do psychological support and sexual health matter in treatment?

Treating accompanying depression and anxiety is an important part of pain care. Cognitive behavioural therapy is reported to provide a small to moderate benefit, and sex therapy can also be helpful for genito-pelvic pain.

What should I expect from treatment, and when is reassessment needed?

The course of chronic pelvic pain varies from person to person. The pain should not be expected to resolve completely with a single intervention at the outset; the response should be reviewed together over time. There is no guarantee that major surgery, such as removal of the uterus or ovaries, will resolve the pain; such decisions are made jointly by the doctor and patient in selected situations after detailed assessment. Reassessment is needed when the nature of the pain changes, new symptoms are added, or there is no response to treatment.