Pelvic Pain

Pelvic pain is pain that occurs in the lowest part of the abdomen and pelvis (the area below the navel and between the hips). When asked to indicate where the pain is, patients typically brush a hand over that whole area rather than point to a precise spot. Pelvic pain can occur suddenly, sharply and briefly (acute) or be constant or intermittent over a long period of time (chronic). Chronic pelvic pain (CPP) is generally accepted to be pain in the pelvic area that has been present for more than three months.

CPP can be a symptom of an underlying disease or be a disorder in itself. A number of conditions can cause CPP, so patients with this problem may need to see more than one specialist. If the source of the pain can be found, treatment focuses on that cause. If no cause can be found, treatment focuses on management of the pain.

CPP is found mostly in women, but can also occur in men.For some women, the cause of their CPP lies in the reproductive system. However, for other patients, male or female, CPP is related to a problem in the bowel, bladder, or the nerves supplying the pelvis.

There are four main causes of CPP:

• Neuropathic pain – typically burning tingling, shooting or stabbing pain that occurs when nerve fibres are damaged or become trapped. Nerve entrapment syndromes can also occur, as they do in other parts of the body.
• Endometriosis – this is a reasonably common condition in women, in which the tissue that normally lines the uterus also grows in other pelvic structures, including the ovaries, bowel, bladder or tissue lining the pelvis. The connection between endometriosis and CPP is well known. However, this only applies to moderate to severe endometriosis; mild endometriosis almost certainly does not cause the degree of pain seen in women with CPP.
• Levator ani syndrome – this pain comes from multiple trigger points and pressure areas in the musculoskeletal tissues of the pelvic floor, and is felt as an aching or pressure sensation high in the rectum, often worsened by sitting and relieved by walking. Any type of pressure on the pelvic floor can cause the pain to get worse. This pressure could come from intercourse, faeces within the rectum, or passage of faeces during a bowel movement.
• Proctalgia fugax - a rare condition where patients experience recurrent episodes of sudden, sharp shooting pain that starts around the anus and runs up into the pelvis and perhaps into the abdomen. These episodes last for seconds to minutes and may occur up to around 100 times a day. Attacks may come in rapid succession and then go away for long periods at a time.

Diagnosis

The symptoms described by patients with CPP are very helpful for pinpointing the cause of their pain. Therefore, if you have been referred to me for CPP, it would be helpful to write down a detailed list of your symptoms, including the following:

• How long has the pain been there?
• Is the pain continuous or does it come and go?
• Is the pain worse lying down or standing up?
• Is the pain related to your menstrual cycle and/or intercourse?
• Is the pain worse before or after going to the toilet?
• Does it hurt to touch the skin over the affected area?
• Is the pain shooting or dull in nature?
• Is there any shooting pain going up into the abdomen?
• Have you tried anything in the past that has helped to ease the pain?
• Are you being treated for a mental health problem?
• Have you had any injury, physical illness, or surgery in the recent past?

You will also need an examination of the pelvic floor so see how well the pelvic floor muscles are coordinated and if there are any trigger points for the pain, to exclude endometriosis as a cause, and if there are any sensory changes suggesting neuropathic pain. There are no laboratory investigations that would pinpoint the cause of CPP, apart from a laparoscopy for endometriosis. However, I do sometimes take patients to the operating theatre for a pelvic examination under anaesthesia via the rectum or vagina to exclude a range of underlying causes of CPP.

Treatment

My colorectal practice is unusual in that I see patients with CPP referred by my colorectal, gastroenterology and gynaecology colleagues whom most colorectal surgeons would not see. I believe that the most important part of my work as a colorectal surgeon is to know when and when not to operate. People with CPP often have a coexisting condition, like irritable bowel syndrome, fibromyalgia, chronic fatigue syndrome, a connective tissue disorder, or a mental health problem, and some may have more than one coexisting condition. My clinical experience over a number of years has taught me that the symptoms of these conditions also have considerable overlap, and need teasing out before I can recommend the best possible treatment plan, which does not necessarily involve surgery.

If neuropathic pain is the cause of CPP, we can start specific medication for this, and here I work very closely with chronic pain physicians. Pudendal nerve entrapment syndrome is a known cause of CPP. If nerve entrapment is the problem, this can sometimes be helped by a nerve release procedure.

If moderate to severe endometriosis is the cause of your CPP, you will need to see a gynaecologist. However, if you have seen a gynaecologist first and your endometriosis has been found to be mild, it is wise to ask for a referral to a colorectal specialist to check for other causes of your CPP before proceeding with a gynaecological procedure. In the same vein, if your CPP has been attributed to adhesions (bands of scar tissue that form between abdominal tissues and organs, causing them to stick together), it is worth a visit to a colorectal specialist to look for alternative causes for your pain. Adhesions do not contain nerves that transmit pain signals and there is no evidence that they cause CPP.

There are several treatments that can help patients with levator ani syndrome. These include pelvic floor physiotherapy, medications (commonly amitriptyline, pregabalin, or gabapentin), and/or Botulinum toxin injection into the pelvic floor muscles. These treatments are often trialled in consultation with a chronic pain physician.

Proctalgia fugax is difficult to treat. As the pain in intermittent and short-lived, painkillers are not particularly useful. For more debilitating cases, a few drugs can be trialled. Most people are happy to find out they have no underlying serious condition and manage the symptoms by themselves. Treatment is best given jointly by a colorectal surgeon and a chronic pain specialist.

CPP is notorious for being hard to treat and is often difficult to manage at the non-specialist level. It is rarely cured completely, but the pain can often be brought down to a manageable level where people can regain a good degree of control over their lives. I have a long-standing special interest in this condition and am receiving increasing numbers of CPP referrals from my fellow specialists. If you are suffering from CPP, it would be worthwhile discussing with your GP the possibility of a referral to me.

For more information on Pelvic Pain, please visit www.pelvicphysiotherapy.com