Chronic Pelvic Pain

What is chronic pelvic pain?

Chronic pelvic pain (CPP) is pain that that lasts for more than six months.

How common is CPP?

CPP affects nearly 15% (one in seven) of all women in the reproductive age.

What does CPP do?

There are a number of initial insults (the primary pain factor) that may result in the development of CPP, including endometriosis, adenomyosis or infections. While pain usually indicates specific injury to some part of the body, CPP is very different. Often, the initial problem is addressed or lessened, but the pain persists because of changes in the nervous system, muscles or other tissues. For instance, you often feel muscles tense when you have been injured around the area of trauma. Similarly, local disturbances occur in the pelvis, affecting the bowel, bladder, muscles, connective tissue and nerves of the pelvis (the secondary pain factors). Often these secondary factors become the predominant problem, overshadowing the original disease process which may no longer be detectable.

As this longterm unrelenting pain continues, even the strongest person’s defences may break down, which results in emotional and behavioural changes. By the time the pain becomes chronic, multiple systems, rather than a single problem, are involved in the pain process. The exact contribution of each pain factor to the total amount of your pain will need to be assessed.

What are the symptoms?

The symptoms of CPP are variable and do not always correspond to the severity of disease. However, symptoms may include pain with periods, ovulation, intercourse, pain when passing urine or opening bowels or lower back pain.

How is CPP diagnosed?

At the present time there is no simple diagnostic test (such as a blood test) for CPP. Obviously, if the original source of injury remains, pain will continue: therefore, much of the initial assessment will be focussed on determining wether this is the case and to determine the manifestations of any secondary factors. This will involve an extensive personal history and examination. Information may be sought form your previous health care providers and further investigations ordered.  You may be required to complete a Pain Diary. Such extensive assessment may need to be performed over a number of consultations and will often require the input of a number of other specialists and practitioners.

Part of the assessment may involve a laparoscopy (a small telescope is passed through a small incision at the umbilicus to visualise the internal organs) and obtaining a tissue sample (a biopsy). This is usually a day surgery procedure under a general anaesthetic and some primary disease factors, such as endometriosis, may be treated at the same time (see the separate information sheet).

What are the treatment options?

It is important to realize that your CPP has evolved over a long period of time and treatment may therefore also be a long term process. Multiple interactive problems are likely, and therefore the question is not what treatment, but which treatments will required. Therefore, a multidisciplinary approach to CPP will usually involve gynaecologists, pain physicians, occupational and physiotherapists, psychologists and other specialties as required. The primary factor that caused your problem, although important to identify and treat, may evolve into a minor issue, with secondary factors becoming more important. Therefore, all factors must be treated, rather than just the ones you or your prior physicians thought to be most important. Treatment options include:

  1. Surgery – A number of primary and secondary factors are amenable to surgical therapy, with a varying degree of success, such as endometriosis. However, in established CPP, no single surgical intervention is likely to effect a cure.
  2. Drug therapy – Drug treatment may focus on pain control and dealing with the secondary factors.  Medications that may be used come from a variety of backgrounds, including medications used to treat pain (analgesics), depression (anti-depressants) or seizures (anti-epileptics). Some forms of therapy may require injections or topical applications.

Some of these medications may be administered by other health care professionals in the pain team, but will always be coordinated through this clinic.

As some of these medications have a potential for abuse, lost or stolen scripts will not be replaced and refills will not be issued. If it is discovered that you are obtaining additional medications, such as opiates, through another physician without discussion and permission, you may be discharged from the clinic.

  1. Physical therapy – Occupational and physiotherapy will reduce the effects of inactivity on your body, help your body to function more normally, simplify your activities of daily living and teach relaxation and stress management techniques.
  2. Psychology – CPP extracts both a physical and emotional toll and can result in dramatic changes to your lifestyle. Psychologists assist individuals to gain emotional confidence, increase control over their thoughts and feelings, reach a level of control and adjustment and gain a better understanding of the emotional contributors to pain.
  3. Complementary therapy – Many women find natural and complementary therapies helpful in the treatment of CPP. They can relieve the symptoms and may also assist the body to recover from drug or surgical treatments. Some women also find that natural and alternative therapies provide them with a sense of control. There are a vast number of therapies available but those used most commonly in the treatment of CPP involve dietary changes, exercise, herbal medicine, Traditional Chinese Medicine (TCM), aromatherapy, homeopathy, massage and yoga. Women interested in using complementary therapies should consult a qualified practitioner who can properly advise them on a course of treatment. It is also important that women disclose their use of any complementary therapies to their doctor, particularly if they are also undergoing medical treatment for CPP.

How effective is treatment?

Despite effective therapy there is no cure for CPP. Regardless of the type of treatment, it is estimated that 1 in 5 women will have recurrence of symptoms within five years.

Further Information

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