Chronic Pelvic Pain

Brief Overview: Chronic pelvic pain (CPP) is pain perceived in the pelvis (lower abdomen, hips, or pelvic floor) lasting 6 months or more. It may be constant or intermittent, and often has multiple contributing factors — gynecologic, urologic, gastrointestinal, musculoskeletal, or psychological. CPP frequently leads to reduced quality of life and functional impairment.

Prevalence: Affects ~15–20% of women at some point; less common but present in men (often linked to prostatitis or pelvic floor dysfunction)

Etiology:

  • Gynecologic: endometriosis, pelvic adhesions, uterine fibroids.
  • Urologic: interstitial cystitis/painful bladder syndrome, chronic prostatitis.
  • GI: irritable bowel syndrome, inflammatory bowel disease, diverticulitis.
  • Musculoskeletal: pelvic floor myofascial pain, hip or lumbar spine disorders.
  • Neuropathic: pudendal neuralgia, nerve entrapments.
  • Psychological: trauma history, depression, anxiety.
  • Often multifactorial — more than one system involved.

Risk Factors:

  • Female
  • Prior pelvic surgery or trauma
  • History of endometriosis or gynecologic disorders
  • Recurrent urinary tract infections or bladder dysfunction
  • GI conditions (IBS, diverticulitis)
  • Musculoskeletal abnormalities (poor posture, pelvic instability)
  • Depression, anxiety, PTSD, history of abuse

Commonly Associated Conditions:

  • Interstitial cystitis/painful bladder syndrome.
  • Irritable bowel syndrome.
  • Pelvic floor dysfunction.
  • Fibromyalgia, chronic fatigue syndrome.
  • Anxiety, depression, sleep disorders.

Common Medications:

  • Analgesics: acetaminophen, NSAIDs
  • Neuropathic pain agents: gabapentin, pregabalin, duloxetine, amitriptyline
  • Hormonal therapy (women): combined OCPs, progestins, GnRH agonists (if endometriosis-related)
  • Bladder-focused: pentosan polysulfate (interstitial cystitis)
  • Muscle relaxants: baclofen, diazepam (pelvic floor dysfunction)
  • Topical vaginal estrogens (in postmenopausal atrophy)
  • Opioids: generally avoided long-term, reserved for refractory cases with palliative oversight

Common Labs, Imaging, and Tests:

  • Ultrasound, CT, MRI
  • Colonoscopy, sigmoidoscopy
  • Laparoscopy, cystoscopy
  • Blood and urine tests
  • Physical exam: abdominal, pelvic, rectal, etc.

Common Symptoms:

  • Persistent pain in pelvic region (dull, pressure-like, or sharp).
  • Pain may worsen with sitting, standing, urination, bowel movements, or sex.
  • Associated urinary frequency/urgency, constipation/diarrhea, bloating.
  • Low back, hip, or thigh pain.
  • Fatigue, mood changes, sleep disturbance.

Common Treatments:

  • Non-Pharmacologic:
    • Physical therapy: pelvic floor therapy, posture correction, stretching.
    • Behavioral therapy: CBT, mindfulness, stress management.
    • Lifestyle changes: diet modification (avoid bladder/GI irritants).
    • Complementary therapies: acupuncture, yoga, relaxation exercises.
    • Support groups for coping strategies.
  • Pharmacologic:
    • Analgesics, neuropathic agents, hormonal therapy, bladder-directed meds (as above).
    • Antidepressants (TCAs, SNRIs) when mood and pain are interconnected.
  • Interventional:
    • Nerve blocks (pudendal, hypogastric plexus).
    • Trigger point injections.
    • Surgical management (endometriosis excision, adhesiolysis) in selected patients.

Physical Findings:

  • Pelvic or abdominal tenderness on exam
  • Myofascial trigger points in pelvic floor muscles
  • Tender bladder or uterus on palpation
  • Limited hip or lumbar spine range of motion if musculoskeletal cause
  • Exam may be normal despite severe symptoms (functional pain)

Potential Complications and Contraindications:

  • Complications:
    • Reduced quality of life, disability.
    • Depression, anxiety, relationship/sexual difficulties.
    • Sleep disruption, fatigue.
    • Unnecessary surgeries if diagnosis unclear.
  • Contraindications:
    • Caution with long-term opioids (dependence, poor efficacy for chronic pelvic pain).
    • Caution with muscle relaxants or benzodiazepines in seniors (fall/sedation risk).

General Health and Lifestyle Guidance:

  • Encourage regular gentle activity (walking, stretching, yoga). Ask your healthcare provider what exercises are recommended for you.
  • Pelvic floor physical therapy is often very effective. Discuss with your healthcare provider if this might be appropriate for you.
  • Maintain a healthy bowel routine (hydration, adequate dietary fiber (as advised by your healthcare provider), avoid constipation).
  • Identify and avoid bladder/GI irritants (caffeine, alcohol, spicy foods).
  • Use heat therapy (warm baths, heating pads) for relief.
  • Manage stress with relaxation techniques, support groups, or counseling.
  • Ensure adequate sleep hygiene.

Suggested Questions to Ask Patients:

  • Where do you feel the pain, and how long have you had it?
  • Does it get worse with urination, bowel movements, or sexual activity?
  • What makes the pain better or worse?
  • Have you had prior pelvic surgery, infections, or trauma?
  • How does the pain affect your daily activities, mood, or sleep?
  • Do you have urinary or bowel changes?
  • Have you tried pelvic floor therapy or relaxation strategies?
  • What medications are you taking now for pain or other conditions?

Suggested Talking Points:

  • Chronic pelvic pain can have many causes, often involving more than one body system.
  • It’s important to look at the whole picture — bladder, bowel, muscles, and stress can all contribute.
  • Pelvic floor therapy and lifestyle changes often help more than medications alone.
  • Generally, you want to avoid long-term opioid use when possible, since safer options are available.
  • Managing stress, sleep, and bowel/bladder health is part of managing pain.

Sources:

This content was created with the assistance of AI. Any AI-generated content was reviewed by a Nurse Practitioner.