What Is Pelvic Pain?

The female gynecologic patient in pain presents a difficult problem for members of the health care team. One of the problems is that gynecological pain is approached by the gynecologist as organ disease of largely the uterus, tubes, or ovaries. The second problem is that the same pain is approached by the pain medicine specialist who has a restricted ability to perform pelvic examinations and who less familiarity with the pelvis. Another problem is that consultation for pain in the perineal or pelvic area is often delayed by the patient until it becomes intolerable and agonizing. The reason for this is that patients are loath to seek medical advice regarding their sexual organs, and they attempt to manage pain with over-the-counter analgesic drugs as long as possible.

Perineal pain problems may be due to surgical diseases such as hemorrhoids, rectal fissures or abscesses. These are not difficult to distinguish from the gynecologic problems of Bartholin's gland infection and an abscess, and skene's glands urthritis. Pain, tenderness, and dyspareunia are the common symptoms. Diagnosis must be made by a careful digital physical examination and culture of the affected area.

Low abdominal or pelvic pain may be due to vascular, bowel or urinary tract disorders. Mesenteric thrombosis must also be considered and is sudden in onset; it causes severe and knifelike pain. The abdomen is tender and may be rigid due to intra peritoneal bleeding or necrotic bowel . Nausea and vomiting can occur early, and hyperactive bowel sounds give way to absent bowel sounds and abdominal distension. A helpful feature is that the pain and tenderness usually are in the upper and middle abdomen. Other surgical problems can occur in the disguise of bowel problems and these include appendicitis, diverticulitis, colitis, Crohne's disease, and bowel perforation. Common problems include anorexia, nausea, vomiting, abdominal pain, tenderness, and rigidity. Fever and elevated white count are usual. Ileus, bowel distension, absence of borborigmi are also frequently present. The differential diagnosis includes atopic pregnancy, ovarian or cystic torsion, and acute salpingitis (PID). Careful pelvic examination, X-ray of the abdomen, ultrasound, and laparoscopy are all helpful in establishing the etiology behind such problems.

Pain relating to the female sexual organs can be discussed from the standpoints of anatomy, as well as from the standpoint of i.e., whether it is acute or chronic. A unisex diagram is used for the patient to locate her specific area of pain or pains. This is then compared to subsequent patterns of pain on future follow-up visits. Complaints of pain may focus on the abdomen, the perineum, or the area between the two which may be referred to as the pelvic floor. An initial history and physical examination lay appropriate focus on the pelvic area. In reference to the perineum, the areas of concern include the skin, the introitus, the vestibular glands, and the lowest portion of the vagina. The pelvic floor is composed of principally the levator muscles, coccygeal and obturator muscles. The pelvis itself is the area above the pelvic floor that actually constitutes the lowest portion of the abdomen. Pain in the perineum can be due to abnormalities of the pudendal nerve, the genital branch of the genitofemoral nerve and the posterior femoral cutaneous nerve.

The skin of the perineum may display variable signs of infection due to viral, bacterial, or fungal causes. Two common viral infections are caused by the herpes virus and by the human papaloma virus. The herpes virus is often present in the cervix of asymptomatic women and in the urethras and prostates of asymptomatic men. The infection cycle is predictable and almost self-diagnostic. The incubation period after the infection is short, from two to seven days. Then tingling and itching occurs just before typical vesicular eruptions develop, which are notably painful. Dysurea, then dyspareunia, and even pain in the groin due to lymphadinopathy may develop. Treatment consists of generous applications of zostrics cream, which dry up the vesicular eruptions relatively quickly and are followed up with the current, potent oral antivirals such as acylovir or famcylovir. The problem is that the virus infection often enters a latent phase during which it is present and hidden in the sacral sensory nerve ganglia. Activation may occur months or years later. During repeat acute phases of the infection, there may be viremia and the virus can again be identified by blood culture.

Moving on upward from the introitus, pain problems can be manifested as vaginitis or even vaginismus. Vaginal problems are frequently associated with itching, burning, discharge, and pain. The most common symptom then often becomes dyspareunia in the sexually active female. There are many bacterial and viral causes, and candidiasis also looms as a causative agent. The most common protozoan culprit is trichomonas. The correct diagnosis is made by visual inspection of the mucous membrane with a careful speculum examination and sampling of the discharge for culture, inspection, and staining if deemed necessary.

Vagismus was first described by Simms as an involuntary disorder of the supporting musculature of the vagina, including the levator ani, pubococcygeus and sometimes the deep transverse perineal muscles. Extreme muscle spasm prevents vaginal entry and causes significant sexual dysfunction and psychological disturbance. The patient is always anxious and distressed about a pelvic examination. The doctor must reassure the patient that he/she can indeed examine her without undue pain, and that the examination can be modified as needed. A slow, careful, single digit exploration should be carried out prior to any attempt at speculum insertion. These patients often have had attempted examinations with speculum insertion first, which has only proved to be disastrous both for the patient and the examiner. The psychologic impact of such a scenario reinforces to the patient that she has something seriously wrong with her anatomy.

A final differential diagnosis is the hymenal syndrome. This entity can often be diagnosed as vestibulitis or a psychogenic disorder due to the intense pain displayed by the patient. This is compounded by attempts at speculum examination that causes the patient to scream in agony-this is extremely disturbing to the examining physician who may declare the patient a histronic complainer. The exam is actually made by a careful exam of the hymenal area with a cotton applicator. Even the lightest touch will elicit severe pain from the patient. This disorder can be diagnosed and sometimes treated with a series of several local anesthetic nerve block injections with multiple daily applications of lidocaine cream. The combined desensitization of the local area and the nerve block itself usually can result in healing and diminished pain over time with series of treatments.

Pain in the Higher Pelvis

Organ problems related to the uterus include acute dysmenorrhea, cervicitis, endometriosis, endometritis, uterine fibroids, and uterine inversion. Acute dysmenorrhea is the most common of all causes of pain for women, and is said to be responsible for the majority of days absent from school or workplace. Most women rely on over-the-counter analgesic drugs for pain relief, so that the ones who seek out medical management are really ones who are refractory. The pain of dysmenorrhea is usually intermittent cramping and sharp. It may begin prior to the onset of menstruation and become gradually progressive until it reaches incapacitating levels. Patients treat themselves with non-steroidal anti-inflammatory drugs which can be purchased over-the-counter without prescription. It is thought that the cause of cramping and pain are excessive prostaglandin levels at this time and progestational drugs are frequently prescribed because of their effectiveness in suppressing prostaglandin production. This treatment often results in significant relief of pain.

Cervicitis: The cervix is remarkably devoid of pain sensation except during dilation. Superficial infections may occur and generous lymphatic drainage causes referred pain in the low back of the female patient. Excoriations and crypt formations may be found on examination without any real complaints of pain from the patient. One of the classic signs of cervicitis is mucous discharge which may become melodorous. Diagnosis is made by visual inspection of the cervix with colposcopy added for definition and mapping. Treatment usually consists of destruction of the superficial involved tissues by caudary cryotherapy weaving surgical incision by performing a conization of the cervix.

Endometriosis is second only to dysmenhorrhea and pudendal neuropathy as a leading cause of pain in women. The diagnosis is suggested by the presence of dysmenhorrhea, dysprunea, dysfunctional uterine bleeding, and infertility. Confirmation is by laparotomy or laparoscopy. The lesions may be seen on the surface of the pelvic viscera adjacent to the uterus. Non-pigmented lesions progress in time to become pigmented. Removal of these lesions usually causes great improvement of the symptoms.t

Endometritis may develop shortly after a miscarriage or a term delivery. Usually there is lower abdominal tenderness and an abrupt rise in temperature to 101 to 103. Pelvic examination reveals exquisite tenderness with minimal movement of the cervix which in turn moves the uterus and the perimeteral structures. Local cultures and blood cultures should be obtained to identify the causative agent and institute treatment with the appropriate antibiotics. A probe should be inserted through the cervical canal to make sure that drainage is satisfactory.

Fibroids are the most common tumors of the uterus. They may be asymtpomatic, but they often become painful with age and deteroriation. Fibroids are not fibrous tissue, but smooth muscle tumors often with rich blood supplies. They range in size from microscopic to several inches in diameter. Although they usually occur in the fundus of the uterus, fibroids may also grow in the cervix and even in the round and broad ligaments. Pain may be caused by torsion and compromise of the local blood supply. Unusual pain has also been the result of sub serous fibroids attaching to nearby organs with subsequent pain referred to the other nearby organ. Attachment to the liver produces pain which simulates cholecystitis during involution of the fibroid stalk.

Uterine inversion is a rare but serious problem which can occur during abortion or during delivery of a placenta. The uterine cavity becomes partially or completely inverted because of strenuous pushing or pulling there is usually immediate severe pain and serious bleeding. The diagnosis is made by speculum examination or is readily apparent if the uterus is completely inverted and extruding from the introitus. The patient may have to be anesthetized while the uterine corpus is carefully replaced while trying to avoid rupture. The patient may go into shock because of the severity of the pain and/or bleeding. Immediate detection and therapy must follow one another in management of this problem.

The fallopian tube may become inflamed and infected producing acute onset of pain in one or both lower abdominal quadrants with rebound tenderness and the temperature up to 104. Abdominal pain when the cervix is moved is usually an indication of an acute infectious process in the fallopian tubes with bimanual examination there is usually point tenderness along the path of the fallopian tubes. There may be small masses palpable indicative of pyosalpinx or hydrosalpinx.

The fallopian tube is the site of most ectopic pregnancies. There is usually little or no pain until rupture becomes imminent. At that time, hemorrhage is the chief concern because it is responsible for a large number of fatalities. The differential diagnosis is that of a corpus ludeum cyst, urinary tract disease, appendicitis, and salpingitis. Diagnosis and treatment of this problem must occur rapidly so that hemorrhage is contained. Mild abdominal complaints and missed periods may bring the patient to a physician. Diagnosis before rupture occurs can be made particularly with the help of ultrasound. The treatment is surgical with conservation of the fallopian tube if possible.

The two ovaries are widely separated in the lateral portion of the lower abdominal space. Symptoms of difficulty or of problems are usually unilateral. Pain has a gradual onset and progresses to tenderness. A mass may be identified by physical examination when the ovary is enlarged. A corpus luteum may enlarge to the size of a cyst. If the cyst breaks and blood enters the perineal cavity there may be exquisite pain and tenderness. Menstrual period is often delayed so that the condition is often confused with ectopic pregnancy. Brisk bleeding caused by rupture of a vessel along the margin of the cyst may require a laparoscopy or laparotomy be done to prevent significant hemorrhage.

Ovarian cysts of several types may grow to sizes that cause local vascular impairment. This causes pain and necessitates immediate attention. In the early stages, ovarian cysts may be asymptomatic except for a sense of ache or heaviness in the pelvis. If the cyst becomes twisted the vascular supply is impaired and frequently a sharp stabbing pain with radiation into the iliac fossa and low back become obvious. Torsion of an ovarian cyst requires immediate surgical treatment. Urinary tract infections frequently cause burning pain at the time of micturation; there may be a dull ache in the lower abdomen over the central portion of the pubic bone. Frequency and urgency of a severe degreee is common and the urine may be cloudy and foul-smelling. The patient often complains of lassitude, heaviness, and perineal pressure. The cause may be inflammation or infection in the ureter, the bladder, or the urethra. So in this light it can be located both in the upper and lower pelvic areas. Differential diagnosis requires physical examination, culture of the urine, and sometimes urethroscopy or cystoscopy.

Sudden agonizing episodic pain located in the costovertebral angle and flank area with radiation to the lower quadrant of the abdomen are the symptoms of renal colic caused by infection or stone in the urinary tract. There may also be hematuria, nausea, and vomiting. Blood in the urine, the episodic nature, and the severity of the pain are usually diagnostic.

Pelvic Neuropathy

My original training was in gynecology and because of that chronic pelvic pain was always presumed due to organ abnormalities. However, in the past 15 years I have learned that most of the causes of pelvic pain are due to neuropathic causes not organ based causes. Once trained in both gynecology and anesthesiology, my examinations began to be more focused upon identification of actual nerve involvement that elicited the pain state of which the patient was complaining . This broad background allows me an unprecedented understanding and appreciation of chronic pelvic pain, and it allows me to bridge the abyss between the gynecologist who is more organopathic in his/her approach to this difficult management area and the pain specialist who is primarily neuropathic in his/her approach to the same problem. Over the past 15 years of my clinical experience in this area, it has been fascinating to note the large number of patients who suffer from neuropathy of one type of another and who may also have organ based pain components in lieu of many past surgical operations directed at that cause. The following neuropathies are some, but certainly not all, common examples of patients that I see on consultation.

Lower Abdomen

Ilio-Inguinal and Ilio-Hypogastric Nerve Disturbances: The patients in this category have past histories that often include surgical trauma in the area of the lower abdominal wall. Figure 6 shows the area involved in pain usually associated with these nerves. The genesis of the pain is not known for sure but suspect is the retraction placed upon nerves located around the incision line that may result in over-stretch and avulsive type neural injuries. The onset of pain after the initial trauma will be variable due to the intensity of the injury and perhaps the fiber size. Many of the gynecological patients have exposure to the Pfannensteil type incision that cross cut both the ilioinguinal and iliohypogastric nerves. In addition, the injury may be from retraction in the lower corners of the incision which anatomically are perfectly located in this strategic area. This can be seen in F6. Interesting enough, many of the patients in this group of patients have histories of repeated abdominal exploration of one type or another because their original physician was convinced the initial problem of intra-abdominal pathology had not been solved or perhaps that recurrent pain might be due to abdominal adhesions or other yet defined pathology. This is becoming less so nowadays due to the widespread use of laparoscopy, but the latter procedure in itself may cause abdominal neuropathy due to placement of the scope, obturator, or one or more ancillary sites percutaneously. A classic example of such a patient type can be seen in postsurgical laparotomies where the obvious incisions can be seen and the maximal tender points are noted along the skin area marked by the incisional scar line.

These cases are managed by repeated spaced local anesthetic nerve blocks spaced over time to take advantage of the maximal signal depression but not so frequently as to set up a denovo peripheral pain generated signal from mechanical stimulation alone. Most patients will fall into the responding category by four to six weeks. Those who do not can benefit from abdominal catheter placement and continuous local anesthetic irrigation of the nerves between the transversalis and oblique muscle groups. (ref here of Ghia paper) Those who do not respond to that tact can be treated with cryotherapy for destruction of those few refractory nerves still causing problems. For ultimate failures in instances where multiple nests of neuromas may still be active and have been refractory to all the above modalities, one can consider surgical intervention and extirpation of the local nests to try to correct the problem.

Genito-Femoral Nerve Disorders:

For the purposes of discussion, this group is often labeled "Genitofemoral Neuropathies". These patients come in with variable stories of low abdominal pain, or even back pain that has migrated to the front of their body and now descends into the scrotal area. The pain is often incapitating when it occurs in sharp repeated attacks. There is a distinct message to be understood in regard to successes on an immediate basis. On the one hand, it is tremendously reassuring to note the significant reductions in pain after the individual nerve blocks and maximum tender point injections. Almost all patients will have pain reduction within minutes of office therapy. It is hoped that patients will exhibit gradual reductions in pain scores over time and that they will have an increase in their function at the same time. There are some failures to be expected in every type of pain management problem and this disorder is no different. Sometimes the reasons for failure must be viewed as an open invitation to explore further the possibility of an overlooked pathological condition that may have been missed on the first pass. For example one patient we managed recently had been refractory to repeated therapy over time, and upon surgical exploration it was discovered that a suture was found around the genital branch of the genito-femoral nerve just at the site of a former hernia repair. Since the distal portion of the nerve was notably atrophic, it was resected above the area of involvement and the patient follow-up has been gratifying in that the patient is now pain free.

Introitus Hymenal Syndrome:

As mentioned above, this is a most interesting group of patients. What is unusual is the very small area of involvement in regard to this syndrome. It is important to recall that the perineum is richly innervate from nerves derived from different spinal cord segments so that there is some overlap protection in regard to innervation. These patients are many times so distraught and histrionic that the initial practitioner may entirely miss the diagnosis due to pre-occupation with the reaction the patient displays during physical and gynecological examination. Often the patient complains so violently that a pelvic exam is not even possible ie the examiner cannot get past the introitus. In other instances the examiner does get past the introitus only to find there is no evidence of pain on examination of the vagina, cervix, and uterus and fallopian tubes and ovaries. The past history of these patients often reveal an infectious problem with candida albicans. It would appear that repeated infections to this agent can cause irritation of the superficial nerves in and around the area of the hymenal ring. Patients usually have a history of normal, healthy sexual patterns before the onset of their vaginal pain but develop significant dysfunction sexually secondary to their disease process. This is usually manifest by symptoms of severe dyspareunia totally focused in the area of the vaginal outlet. In a recent group of patients treated by us 4 of 5 patients experienced complete relief of pain and a return to normal sexual function within eight weeks of definitive therapy - surgical extirpation of the hymenal ring. In the one patient who did not have complete relief of pain there was also a problem of significant psychological degree. This patient because of a previous hysterectomy and oophorectomy had problems adjusting to exogenous estrogen and thus had a thin vaginal mucosa with other associated problems.

The patient workup must include at least three successful hymenal blocks which can be performed prior to consideration for surgery. In our series of patients all had repeated hymenal local anesthetic blocks with demonstrated complete relief of symptoms. The association of the aforementioned infectious process and specifically the offending agent is too consistent to be coincidence. As noted before, one might speculate that the fungus may gain deep mucous membrane penetrance and result in a damaging effect upon the nerve endings, perhaps even causing neuroma-like formation to occur.

Vagina, Cervix Area

Pudendal Neuropathies. A large percentage of patients with pelvic pain have findings that are consistent with pudendal neuropathy. These patients have compaints of vaginal pain with intercourse, bladder pain during micturation, rectal pain during defecation, and sitting pain. R18 One treatment method suggested for relief of pain from pudendal neuropathy included use of pudendal blocks to see if there was a favorable response from repeated neural blockade. F8

The theory of the beneficial effect of repeated peripheral nerve blockade is based upon the "healing" that occurs in instances of peripheral neuropathy. Basically, it would appear the dorsal root ganglion stands as the first "smart"sentinel for pain message transmission from the peripheral nervous system to the central nervous system. And, as such, it can undergo unique chemical "unfavorable plastic" changes when exposed to continuous noxious pain input; more importantly, it can reverse those "unfavorable plastic" changes in a favorable fashion when once again exposed to non-noxious input for certain time periods.

In a recent paper I describe a variation on the usual theme of options for treatment of the patient who is diagnosed with pudendal neuropathy. I believed it is possible that, in the past, some patients with pudendal neuropathy had a correct diagnosis only to do poorly from therapy because of ineffective delivery of therapeutic medication near enough to the pudendal nerve to elicit a beneficial therapeutic effect. I also believed this may have occurred due to the possibility that these pudendal blocks, performed trans-vaginally via a blind approach may have missed the primary target; identified as the ischial spinous process. The approach used utilized the technology of the CT scanner to precisely locate the ischial spinous process and thus allow more direct anatomic needle guidance. In turn, this approach theoretically guaranteed delivery of the medication more immediately adjacent at or onto the pudendal nerve. Twenty-six female patients with a diagnosis of pudendal neuropathy were treated over a several month period. During time they received five CT guided pudendal block treatments. The outcomes in regard to how well the patient's did after this therapy are summarized, Three different questions were used to evaluate the outcome from the patient's perspective. These were:

1. On a pain scale of 1-10, where 10 is the worst pain you have ever experienced and 0 is perfect comfort: How bad was your pain before treatments? How bad is it now, after treatments?
2. In regard to activities, where 10 is so restrictive your are kept in bed full-time and 0 is you can do anything you want in comfort: How much was your activity before treatment? How much is your activity now, after treatment?
3. Your pain, how is it now compared to before your treatments? My pain is worse My pain is the same My pain is some better My pain is much better My pain is gone I am cured

In the first question I wanted to find out how well the patients did in regard to their primary complaint, namely, pelvic pain. All twenty-six patients were asked to score their pain before and after therapy based upon the classic ten scale of pain with ten being the worst possible pain imaginable. Sixteen of twenty-six patients (62%) had significant pain reduction from before therapy to after therapy. However, ten patients of twenty-six patients (38%) did not have significant pain reduction. My final conclusion was that the 62% was a very good percentage considering the many missed diagnoses and many variable therapeutic trials used over and over without success in this group of patients.