Persistent pelvic pain

Overview

A lot of the women we see at Aceso have trouble with pelvic pain. If it has been present for more than 6 months, and especially if it is present more days than not, then it is called persistent (or chronic) pelvic pain. From the outset, it should be recognised that this is often due to several causes, which may be inter-related.

Possible causes

Common issues we will look out for include:

  1. Endometriosis
  2. Painful bladder syndrome/Interstitial cystitis
  3. Vulvodynia/vestibulitis
  4. Irritable bowel syndrome
  5. Pelvic muscle pain and dysfunction
  6. Pudendal nerve pain (neuralgia)
  7. Chronic vaginal infection or irritation – for example, due to thrush, chlamydia, or after menopause

Sometimes, something such as an ovarian cyst might be found, but in general cysts cause reasonably rapid onset of pain, and often resolve by themselves. In some cases, some of the above issues might have already been diagnosed, and the tendency is to try and fit all the symptoms into one category (“it’s my endo”). In our experience, this is usually a mistake, and might explain why some women have had several surgeries for endometriosis, but never really got a lot better.

What to do

The first step is to take a careful and thorough history.

In some cases, particularly when the problem has been there for a long time, if there have already been several operations done and/or several different practitioners involved, the history and examination might have to be spread across two visits. Please bring any copies of operation notes or letters you have from previous doctors.

How we can help

If you are experiencing persistent pelvic pain and would like to talk to us about how we can help, please feel free to contact us. You can also request an appointment online.

Frequently when we break the issues down and start thinking about the sources of pain more holistically we can make some real progress.

Be prepared for it to take some time – a complex problem is unlikely to be solved with one simple solution, be that a drug or an operation.

However we will take your symptoms seriously and try our best to help make some progress.

Further reading

Further information

Conditions

Adenomyosis

Adenomyosis is similar to endometriosis. It occurs when the inside lining of the uterus (endometrium) is found within the muscular wall of the uterus. This may cause the uterus to become enlarged. Adenomyosis may be patchy, or severe, causing a severely enlarged uterus. Find out more

Endometriosis

Endometriosis is a common disorder that affects many women in New Zealand. It occurs when endometrial tissue, which should only be found in the uterus, also grows outside the uterus, such as on ovaries or the bowel. This can be very painful and is why women with endometriosis usually have pain around the same time as their period. Find out more

Irritable bowel syndrome (IBS)

People with IBS may have cramping abdominal pain, diarrhoea and constipation. Symptoms can alternate in the same patient, with periods of both loose bowel motions and constipation. Many will get painful bloating, and in some women this will get worse before their period. Find out more

Ovarian cysts

Ovarian cysts are very common. There are a number of different types, with different symptoms and a range of treatments. In many cases, they will cause no problems at all, and resolve on their own without intervention. Find out more

Painful bladder syndrome / interstitial cystitis

This refers to a group of conditions characterised by pain with bladder filling and emptying, along with increased frequency of urination and passing urine at night. All of these symptoms closely mimic those of a urinary infection, but the urine culture will be clear. Find out more

Painful pelvic floor (pelvic muscle dysfunction)

This is a condition that is frequently overlooked as a cause for pelvic pain. Typically pain is sporadic and not linked to the menstrual cycle, although all pain may get a bit worse around the time of the period. Pain may last a few minutes to a few hours, is often felt low in the pelvis where a woman may have been told her ovaries or endometriosis are, and can be brought on by sex, prolonged sitting, exercise, or randomly. Find out more

Vulvodynia

Vulvodynia is the ongoing pain and discomfort of the vulva. The cause is unknown, but it is likely that factors relating to the body's nerves, hormones or immune system are involved. The pain may be limited to only specific areas, or it may involve the entire vulvar area. Find out more

Procedures

Hysterectomy

A hysterectomy is when a woman's uterus is removed. This may be because methods to stop heavy bleeding are not successful, side effects of medications are intolerable, fibroids are problematic or endometriosis is severe enough that a more permanent solution is required. Find out more

Mirena

A mirena is a small plastic device placed inside the uterus with small strings extending out through the cervix. In addition to being used for contraception, mirena can be used to treat endometriosis. Find out more

Endometriosis resection

This entails keyhole surgery, where a camera is placed through the bellybutton to view the pelvis. The abdomen and pelvis are carefully explored, and abnormal tissue removed. Cysts may also be removed from the ovaries. Find out more

Treatment for IBS

IBS treatment will depend on the triggers that have been identified and may include: dietary help with FODMAPs; probiotics and occasionally specialized antibiotics; help to deal with stress; or medications that alter the way nerves transmit pain.

Ovarian cyst removal

This entails keyhole surgery, where a camera is placed through the bellybutton to view the pelvis. The abdomen and pelvis are explored, and the cyst carefully removed from the ovary. The ovary may be stitched to allow it to heal better. Find out more

Treatment for interstitial cystitis

Figuring out and avoiding triggers with close dietary management, reducing inflammation with specific anti-histamines, treating abnormal pain sensation with pain medications such as amitriptyline and relaxing the pelvic floor are all key strategies. In some women a cystoscopy will be needed and in more extreme cases the bladder wall may need repairing.

Treatment for painful pelvic floor

This is usually with a specialist pelvic floor physiotherapist to identify the muscles, and then massage out trigger points and relax them. If this is unsuccessful there are other therapies we can discuss including targeted Botox, although this is not necessarily a long-term fix.

Treatment for vulvodynia

Treatments can include topical medications to reduce nerve impulses, Botox to associated muscles in spasm, physiotherapy and desensitisation to develop confidence and control, and advice about avoiding any irritants (such as perfumed soaps or body washes, waxing/shaving, synthetic underwear).