Chronic Pelvic Pain

What is Chronic Pelvic Pain (CPP)?

Your pelvis is between is the lower part of your tummy and your legs. Please see the diagram below.

Any pain that lasts longer than 6 months in this region is called Chronic Pelvic Pain. It can affect 1 in 6 women. CPP can be very distressing and it can have a significant impact on the quality of life of women who suffer from this.

What causes CPP?

There are many possible causes of pelvic pain. CPP is a combination of physical, psychological and social problems.

It is poorly understood and a combination of factors may influence pain sensation in any given individual.¹

Organs in your pelvis include your bowel (back passage), bladder, womb (uterus), ovaries and your fallopian tubes. Pelvic pain usually that starts from one of these organs.

In some cases, the pain comes from your pelvic bones that lie next to these organs, or from nearby muscles, nerves, blood vessels or joints.

Physical problems causing CPP may include:

• Endometriosis is a condition where the cells of the lining of the womb (endometrium) are found elsewhere in the body, usually in the pelvis.
  – Adenomyosis (a condition where the endometrium is found in the muscle of the womb) can cause pain around the time of a period and during sex.

• Pelvic inflammatory disease, which is an infection in the fallopian tubes and/or pelvis.

• Interstitial cystitis (bladder inflammation).

• Adhesions (areas of scarred tissue that may be a result of a previous infection, endometriosis or surgery).

• Trapped or damaged nerves in the pelvic area.
• Pelvic organs prolapse.

• Musculoskeletal pain (pain in the joints, muscles, ligaments, and bones of the pelvis).

• Irritable bowel syndrome (IBS).

Neuropathic pain (Originating from nerve endings)

Sometimes, a reason for the pain may never be found in the form of physical disease.

In these cases, the problem could be in the perception of pain by nerve endings in the pelvis. The pain may persist long after the physical disease has healed. Long lasting pain may lead to changes in perception of pain by the brain.

Damage to nerves following infection, surgery, trauma nor fibrosis may also make you more sensitive to pain¹.

For these patients, the brain is sensitised to pain and even the slightest of triggers can be perceived excessively, causing severe distress.

Psychosocial causes

Extreme stress, abusive relationships (including childhood sexual abuse), depression and anxiety can over sensitise the brain to pain and lead to CPP.

There is a chance that CPP could lead to further depression and anxiety. This could result in a vicious cycle where each condition makes the other conditions worse, reducing patient’s quality of life significantly.

What will my Doctor do?

Your Doctor will take a detailed history from you about your pain pattern. This will help to work out if it is related to your periods or sex, or if pain is constant.

Any information about previous surgeries, sexually transmitted infections, bowel or bladder issues which contribute to the pain will be discussed.

Your Doctor will also ask you about any musculoskeletal problems such as backache or joint problems that you may be aware of.

Any psychological factors such as depression, anxiety and abusive relationships will also be discussed.

If you are suffering from depression or anxiety, these factors still may not be the cause of your CPP. Your Doctor will discuss this further with you.

It is well known that stress, anxiety and depression release chemicals that exaggerate pain sensitivity.⁴ If this is the case, treatment should be directed to treat any psychological issues. This can lead to endorphins (hormones that make you feel happy) being released, which will lead to physical pain being eased.

What will happen during my exampination?

Your Doctor will ask you to have a physical examination. This includes internal examination of your vagina. Your examination is essential to work out what is causing your pain, and to locate the precise pain-sensitive area.

If you are unable to tolerate the examination, you can ask your Doctor to stop at any time. Any internal examination will only take place if you are comfortable for this to happen.

What tests will be requested?

• Screening tests for sexually transmitted infections.

• Urine test.

• Ultrasound or an MRI.

• Laparoscopy.

Laparoscopy is commonly known as keyhole surgery. It involves general anaesthesia, 3 to 4 small cuts in your tummy and your Doctor looking at your pelvis using a small telescope.

This may help find a physical disease, which can usually be treated at the same time. If the disease is extensive, you may be offered a repeat surgery.

There is a 1 in 4 chance that your laparoscopy is not able to determine the cause of your pain. While this can be reassuring for some women, it may also lead to frustration for others.

Your Doctor will discuss ways to deal with the pain after further examination of your symptoms and history.

How will I be treated?

At first, you will be offered pain relief. Any other treatments will depend on your symptoms and diagnosis.

1. If a diagnosis of endometriosis/adenomyosis is made, you may be offered hormones. This will either be in the form of pills, injections or a coil.

2. If you have suffered from an infection, your Doctor will prescribe you with antibiotics.

3. Your Doctor may recommend keyhole surgery if other treatments have not worked.

If your symptoms suggest bowel, bladder or musculoskeletal problems, you will be referred to the appropriate department.

If no physical disorder is found, either your Doctor or the pain team that you are referred to may prescribe you some medication. This may include drugs that are traditionally used to treat epilepsy or depression. This medicine will change the way your nerves and brain process pain. These are called pain modifiers.³

Current research suggests that complementary therapies, such as psychological counselling, acupuncture, mindfulness exercises and diet changes may help improve your symptoms. Your Doctor may recommend one of these therapies or refer you to a specialist who offer one of these therapies.²

Many women find that they can cope better with the pain if they have been listened to, taken seriously, have a full explanation of their test results and agree a plan of action. You may be reassured by finding that nothing is seriously wrong and the pain may get better with time.

Chronic pelvic pain can be very difficult to live with and can cause emotional, social and economic difficulties. You may experience depression, difficulty sleeping and disruption to your daily routine.

Talk to your GP if this is the case.

The support of other women who also experience pelvic pain may also help. See below for information about support groups.

Further information and support groups

IBS Network: www.theibsnetwork.org

Pelvic Pain Support Network: www.pelvicpain.org.uk

Bladder & Bowel Foundation: www.bladderandbowelfoundation.org

References

1. Newson, D., 2021. Pelvic Pain | Doctor.  Patient info available at: https://patient.info/doctor/pelvic-pain#nav-1 [Accessed 6 November 2021].

2.      The University of Edinburgh 2021. Pain where no cause is found during investigations available at: https://www.ed.ac.uk/centre-reproductive-health/exppect-pelvic-pain/information-for-patients/conditions/pain-no-cause-found  

3.      Rcog.org.uk. 2021. Chronic (long-term) pelvic pain available at: https://www.rcog.org.uk/globalassets/documents/patients/patient-information-leaflets/gynaecology/pi-chronic-long-term-pelvic-pain-2.pdf  [Accessed 6 November 2021].

4       The University of Edinburgh. 2021. Persistent pelvic pain. available at: https://www.ed.ac.uk/centre-reproductive-health/exppect-pelvic- pain/information-for-patients/persistent-pelvic-pain  [Accessed 6 November 2021].

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Leaflet Reference: PIL1366
Date for Review: 09/02/2025