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PELVIC PAIN

abdominal pain

A Diagnosis of Exclusion

Pelvic pain is a complex disorder that affects both men and women.  If you are experiencing a piercing pain in the pelvis or genitals, or pain accompanying your everyday movements and activities that involve those areas, you may be suffering from pelvic pain. If this pain has continued unabated for six months or more, it could be an identifiable disorder called chronic pelvic pain (CPP). Pelvic Pain is a nebulous condition that is typically diagnosed only after excluding other things. It’s cause is unknown and it is notoriously difficult to treat.

Pelvic pain is considered a “diagnosis of exclusion” – only entertained after more obvious and testable pathologies are ruled out. Since there are a myriad of possible causes and contributing factors to this mysterious condition, it is crucial to understand them in order to initiate a correct treatment program that will yield results. Fortunately, at the Ainsworth Institute of Pain Management, our physicians are experts in treating pelvic pain, and can offer a variety of treatments, many of which are not available anywhere else in New York City.

People with pelvic pain say they begin to feel pain when engaging in ordinary, everyday non-painful activities. Activities like going to the bathroom, sexual contact, or ovulation. If you feel you fit this profile, schedule an appointment with the Ainsworth Institute of Pain Management today.

What is Chronic Pelvic Pain?

Pelvic pain is neuropathic in nature. That means it is pain caused as the result of nerve damage, in this case nerves associated with the pelvic area. As will be discussed in the causes section below, there are many different and divulgent factors that can lead to nerve injury or insult. Pelvic pain is a catch-all diagnosis that may contain other intersecting and overlapping pathologies.

While Pelvic Pain can affect both men and women, the greatest incidence is in women between the ages of 26 and 30.[1] It is estimated that 33-39% of woman will experience pelvic pain at least one point in their lives with as many as 20% of these cases progressing to Chronic Pelvic Pain (CPP). It is also estimated that up to 5% of the general population of women will experience CPP – that estimate rises to 20% in those with a previous diagnosis of pelvic inflammatory disease (PID). [2] A current estimate of those suffering from CPP in the United States is reported to be as high as 14.7%.[3],[4]

Pelvic Pain - A Closer Look

CPP is a complex, debilitating disorder defined as “a non-malignant pain perceived in the pelvis in either men or women.” In the case of documented nocioceptive pain that becomes chronic, the pain must have been continuous for at least 6 months, although this timeline has been debated.[5] If “non-acute” mechanisms of pain and/or central sensitization are noted, then the pain may be regarded as “chronic,” irrespective of the time period. More often than not, one will note the presence of behavioral, sexual and emotional sequelae.[6]

 

Pelvic Pain is a broad diagnosis of exclusion that likely encompasses other pathologic states, and even more likely encompasses an evolution of those states to a neuropathic state. Like all neuropathic pain, Pelvic Pain is a result of an insult or injury to the somatosensory nervous system (peripheral or central), whereby an insult to the nervous tissue leads a pain syndrome often characterized by disproportionate pain.[5]  Depending on the nerve involved or the nerve injury, the distribution of the pain will be different.

Pelvic pain may start in one area, but as time goes on, the sympathetic nervous system will get involved and cause more and more nerves to become involved which will cause the pain to spread and become more intense.

What are the Symptoms?

Symptoms of a body area affected by Pelvic Pain include:

 Burning and/or lancinating pain in the pelvis, anus, and/or genitals
 Pain with sitting
 Pain with urinating and/or defecating
 Pain with intercourse or painful ejaculation
 Paresthesias (pins & needles sensation) and numbness

Is Pelvic Pain a Form of CRPS?

The short answer is…maybe.  This was first proposed by a doctor in 2003.  Dr. Hunter subscribes to this notion as he has published as well as lecturing extensively on this notion. [8]  In the case of CRPS, the changes are visible (i.e. skin color changes, loss of hair, brittle toe nails, changes in blood flow, etc). In the case of CPP, the changes are internal and cannot be seen – instead of a bright red leg, people with pelvic pain might be told they have bulging blood vessels on an MRI but also told it is not pelvic congestion syndrome.  In CRPS, simple things like light touch or clothes cause extreme pain.  In CPP, things like urinating or sexual intercourse cause pain.  The similarities are there, it is just not as accepted.

What are the Causes?

As mentioned above, the exact cause of Pelvic Pain is unknown. A number of inciting pathologies that render one susceptible to the signs and symptoms characteristic of Pelvic Pain, though, have been implicated. Among them are disease states, and causes specific to gender and organs.

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Other Names

There are several diseases and conditions that are thought may contribute to the development of Pelvic Pain. It has been postulated that particular disease states damage organs leading to somatic or visceral pain, which over time develops into neuropathic pain. Some such disease states include:
Interstitial Cystitis

Prostatitis
Pelvic Inflammatory Disease or PID
Vestibulitis
Ectopic Pregnancy
Varicocele

CPP is also inclusive of a variety of presentations many of which can be attributed to a local neuralgia:
Pudendal Neuralgia
Coccydynia
Penile Pain Syndrome
Meralgia Parenthetic

Gender Specific Causes

CPP is typically more prevalent in the female population (affecting over 9 million women in the US), and has often initially been labeled as interstitial cystitis/painful bladder syndrome (IC/PBS). In as many as 61% of women, the cause of their CPP was unknown.[7] In men, CPP is typically referred to as chronic prostatitis (CP). Predisposing and/or associated factors in the female population include a history of multiple laparoscopies,[8] endometriosis, sexual or physical abuse,[9] vulvar vesitibulitis, fibromyalgia, and irritable bowel syndrome.[10],[11],[12] In men, CPP is thought to be either an inflammatory or non-inflammatory insult to the prostate, with the syndrome accounting for up to 90-95% of all cases of prostatitis.[3]

WOMEN
Infection – something as simple as a UTI or an STD can cause excess inflammation which may lead to scarring and ultimately increasing pain

Interstitial Cystitis – a common diagnosis in both men and women with CPP.  This is a chronic irritation of the inner lining of the bladder.  It is very hard to prove that it is indeed the actual cause of the pain
Endometriosis – an all too common condition that causes adhesions in the internal pelvic region that leads to different organs and other structures sticking to each other which leads to intense pain
Dysmenrrhea – this can sometimes be a sign or symptoms of something else underlying like fibroids or adhesions
Dyspareunia – pain or discomfort with intercourse is never normal.  Irregular blood flow or a local nerve injury can sometimes be the cause
Myofascial Pain Syndrome and Pelvic Floor Dysfunction – abnormally tense or contracted muscles can pinch nearby nerves or just cause pain unto itself from having painful muscles
Vulvitis or Vulvodynia – pain on the external aspect or opening of the vagina can be the sign of a nerve injury like pudendal neuralgia
Cystitis – Urinary Tract Infections (UTI) are a common cause of acute pelvic pain, but rarely a cause in the chronic setting.  Pain lasting beyond a few weeks is almost never due to an infection
Ovarian Remnant Syndrome – a very rare condition whereby small pieces of ovarian tissue are inadvertently left in the pelvic cavity after an oophorectomy of one or both ovaries
Sympathetically Mediated Pain – when a nerve is injured, the sympathetic nervous system can become involved which will lead to changes in blood flow and the spreading of pain to other areas beyod where the pain started
Pelvic Congestion Syndrome – increased blood flow in the pelvic region can lead to swollen vessels which in turn can cause pain
Pelvic Fibrosisexcess connective tissue growth in the pelvic region can lead to scarring
Fibroids –
an all too common cause of CPP.  Fortunately fibroids are easy to diagnose with imaging like Ultrasound or MRI
Pelvis Neurodystonica
– a very technical term for describing a combination of neural dysfunction and abnormal tone in the pelvic region

Irritable Bowel Syndrome (IBS) – also a diagnosis of exclusion, IBS typically causes abdominal pain however it can lead to pain centered in the pelvic region
Sexual/Physical Abuse – patients who have experienced sexual trauma or been assaulted often have manifestations of pelvic pain as a result of the attack
Cancer Pain – tumors themselves do not cause pain, but rather from the mass effect of the tumor pushing on something nearby that results in pain.  This is a extremely rare cause of CPP
Psychiatric Disorders – severe anxiety can often lead to chronic pain in any number of areas, the pelvic region being one of them
Surgical Procedures (adhesions) – even the most perfectly performed surgery can inadvertently lead to CPP.  If traction is placed on a particular nerve in a certain way during the case, that nerve may become inflamed and cause a neuralgia

MEN
Chronic Orchalgia – testicular pain typically makes most men fear the worst.  The easiest way to rule out more serious conditions is an ultrasound and a trip to the Urologist

Prostatodynia – a very common cause of pain in men.  This can typically be the result of a previous infection that left some scar tissue behind
Prostatitis – infections of the prostate can sometimes be associated with an STD, but not always.  When treated swiftly with antibiotics, the symptoms should go away pretty quickly.  Symptoms lasting more than a few weeks are rarely from an infection at this point.
Interstitial Cystitis – a common diagnosis in both men and women with CPP.  This is a chronic irritation of the inner lining of the bladder.  It is very hard to prove that it is indeed the actual cause of the pain
Ureteral Obstruction – a rare cause of pain that typically causes pain in the acute phase than chronic
Irritable Bowel Syndrome (IBS) – also a diagnosis of exclusion, IBS typically causes abdominal pain however it can lead to pain centered in the pelvic region
Sexual/Physical Abuse – patients who have experienced sexual trauma or been assaulted often have manifestations of pelvic pain as a result of the attack
Cancer Pain – tumors themselves do not cause pain, but rather from the mass effect of the tumor pushing on something nearby that results in pain.  This is a extremely rare cause of CPP
Psychiatric Disorders – severe anxiety can often lead to chronic pain in any number of areas, the pelvic region being one of themSexual/Physical

Surgical Procedures (adhesions) – even the most perfectly performed surgery can inadvertently lead to CPP.  If traction is placed on a particular nerve in a certain way during the case, that nerve may become inflamed and cause a neuralgia

Organ Specific Causes

Reproductive
Visceral: uterus, ovaries, bladder, urethra
Somatic: skin, vulva, clitoris, vaginal canal
Adhesions, endometriosis, salpingo-oophoritis

Vascular
Dilated pelvic vein/pelvic congestions theory

Musculocutaneous
Ligamentous structures, muscular (iliopsoas, piriformis, quadrates lumborum, sacroiliac joint, obturator internus, pubococcygeus)
Skeletal (referred pain)
Pelvic floor muscle tension/spasm

Spinal
Degenerative joint disease, disc herniation, spondylosis, neoplasm of spinal cord/sacral nerve, coccydynia, degenerative disease

Neurologic
Neuralgia/cutaneous nerve entrapment (surgical scar in the lower part of the abdomen), iliohypogastric, ilioingiunal, genitofemoral, lateral femoral cutaneous nerve, shinges (herpes zoster infection), spine-related nerve compressions

Gastrointestinal
Irritable bowel syndrome, abdominal epilepsy, abdominal migraine, recurrent small bowel obstruction, hernia

Urologic
Bladder dysfunction, chronic (nonbacterial) prostatitis, chronic orchalgia, and prostatodynia

Psychological (Psychosocial/Sexual)
Anxiety, depression, somatization, physical or sexual abuse, drug addiction, dependence, family problems, sexual dysfunction

What are my Treatment Options?

Treatments for Pelvic PainIn most cases, those suffering from Pelvic Pain or Chronic Pelvic Pain are already under the care of either a OB/GYN or Urologist and only consult a Pain Management Physician afterward. Once they do it is imperative for the physician to obtain a thorough history and conduct a comprehensive physical (with a focuses abdominal examination) as many of the causes of Pelvic Pain can be reversible. Pelvic examination, lab testing, and ultrasounds or CT scans of the abdomen and pelvis are often utilized to rule out other more conventional causes.

Both diagnosis and management of patients with Pelvic Pain require good integration and knowledge of all pelvic organ systems and other systems including musculoskeletal, neurologic, and psychiatric. A significant number of patients with Pelvic Pain may have a variety of associated problems including bladder or bowel dysfunction, sexual dysfunction, and other systemic or constitutional symptoms. Other associated problems, such as depression, anxiety, and drug addiction, may also coexist.

Find a REAL Pelvic Pain Expert

pelvic specialist

Pelvic pain treatment requires a specialist with experience and precision.  At the Ainsworth Institute of Pain Management, we offer some of the most modern and cutting edge treatments for chronic pelvic pain.  Our very own Dr. Hunter is widely considered one of the WORLD’S experts in pelvic pain with a number of publications on the topic to his credit. 

When looking for a specialist to treat pelvic pain, the doctor should be boarded in either pain management, gynecology or urology – make sure to ask what they are boarded in and what formal training they have in the field.  Don’t accept any substitutes.  There are a number of unscrupulous physicians out there who market themselves a “pelvic pain specialists” who have no training in pain, no training in women’s health, no training in pelvic pain…basically someone who has no business treating patients with pelvic pain.  If the person says they worked with someone or worked in a women’s health department and that’s the only experience they have, WALK AWAY

When looking for a physical therapist that specializes in pelvic floor therapy, find out how many active patients the therapists has, what exercises he/she offers and what doctor’s he/she works with in the community.  There are very few out there with the qualifications and experience so make sure to find the right one.

Bogus Treatments for Pelvic Pain

Pelvic pain is one of THE most difficult pain syndromes to treat – anyone who says any different is trying to sell something…and therein lies the problem.  There are a number of physicians marketing themselves as “Pelvic Pain Specialists” who have no business treating anyone with pelvic pain but unfortunately patients don’t know the difference until it is too late.  They know that patients with pelvic pain are so desperate that they will try anything new or different for the small hope of finding any shred of pain relief.  As a result they will use smoke and mirrors to pass off therapies as “new” or “different,” knowing full well that a patient with pelvic pain will come across these treatments, see they are things they haven’t tried yet and will sign up to be a guinea pig.  Worse yet, they will charge cash.

Evidence-Based Treatment Options

Superior Hypogastric Block – This procedure is used as both a diagnostic and therapeutic tool. Under radiographic guidance, a thin needle is inserted through the skin and advanced toward the L5 vertebra – the location of the superior hypogastric plaexus. A blockade of the superior hypogastric plexus has been reported to decrease pelvic pain by 70%.[14]Pelvic Pain New York City

Ganglion of Impar Block – Like the Superior Hypogastric Block, this procedure can also be used for both diagnostic and therapeutic purposes. This procedure is performed under radiographic guidance with the target being a small area directly in front of the coccyx (tailbone). This injection is extremely effective in treating pain originating from the cervix, colon, bladder, rectum and endometrium. Studies have reported 70-100% pain relief from this procedure.[13]

Inferior Hypogastric Block – Similar to the Superior Hypogastric Plexus Block and the Impar blocks, this can be diagnostic and therapeutic. This procedure is typically considered when more lower and external pelvic pain and if the treating the impar is ineffective

Hypogastric Nerve Block – This is an unconventional block that not many are trained to perform due to the skill involved to reach this nerve selectively, while leaving other structures unharmed.  The hypogastric nerve connects the superior and inferior hypogastric plexuses which make it an excellent target for treating neuropathic pain.

Peripheral Nerve Block – A peripheral nerve block can be extremely effective way of treating many types pain, including CPP. There are an abundance of nerves providing innervation to the pelvic region and its organs – any of which can be targeted and blocked with a small amount of local anesthetic to provide dramatic pain relief. Many of these injections can be performed under ultrasound guidance.pudendal nerve

  • Pudendal Nerve Block
  • Genitofemoral Nerve Block
  • Ilioinguinal Nerve Block
  • Iliohypogastric Nerve Block
  • Lateral Femoral Cutaneous Nerve Block
  • Obterator Nerve Block
  • Subcostal Nerve Block

Neurolysis & Ablation – In many cases an injection will provide relief, but this is only a temporary solution. In cases such as these, neurolysis or neuroablation can be utilized to provide longer relief. There are several different techniques available:

  • Radiofrequency Ablation (RFA) – Radio waves are applied to a nerve, subsequently stunning it and preventing from transmitting pain.
  • Chemodenervation – Small amounts of either alcohol or phenol are injected, thus blocking the nerve’s ability to transmit a signal.

S2 Dorsal Root Ganglion Block – The hard part of treating pelvic pain is finding which nerve or nerves is/are either the cause of the pain or is/are responsible for transmitting the pain signals.  The S2 level is unique in that it captures all but 1 of the pelvic nerves thus making it an excellent target for hard to treat pelvic pain.Pelvic Pain New York City Pudendal Neuralgia

Epidural Steroid Injection – These injections are more commonly used for neck and low back pain, however they can also be used to provide local pain relief to a specific dermatome – in the case of pelvic pain, a dermatome overlying pain in the pelvic region.

IV Infusion Therapy – A simple procedure commonly performed in the office. Your doctor will administer a small IV catheter, and then infuse special medications intravenously in an attempt to halt the pain process. 

Spinal Cord Stimulation – This is a regularly performed procedure utilizing technology similar to that of cardiac pacemakers. This method involves placing small electrodes into the epidural space near the spinal cord. These electrodes produce a small electrical current over the spinal cord that your brain will interpret as a gentle massage or feeling of “champagne bubbles.” In the case of pelvic pain, the leads are placed over the sacral nerve roots, or in the thoracic region.[15-16]

DRG Stimulation for Chronic Pelvic Pain Pudendal NeuralgiaDRG StimulationA variant of Spinal Cord Stimulation but way more effective.  This procedure involves placing leads a fraction of the size of traditional stimulator leads directly over the nerve levels that are transmitting the pain.  Our very own doctor discovered the use of DRG Stimulation for the use of pelvic pain by using unique lead combinations that isolate discomfort in the pelvic region.[17]

Intrathecal Pumps – This is a method whereby a small catheter is placed in the subarachnoid space and minuscule amounts of medication are delivered directly to the spinal cord and the rest of the CNS. This enables your physician to provide the same medications but at a fraction of the dose due to the proximity to the spinal cord.  More importantly, our doctors have been putting a revolutionary drug inside the pumps called ziconotide and are reported amazing successes!

Other Treatment Options

Medication Management & Pharmacologic Therapy – There are a wide-variety of medications found to be effective in treating CPP – these include non-steroidal anti-inflammatories (i.e. ibuprofen or naproxen), membrane stabilizers (Lyrica or gabapentin), antidepressants (Cymbalta or amitriptyline), anticonvulsants (Keppra) and opioids (oxycodone or hydrocodone).  Opioids should be the last option.

Physical Therapy & Biofeedback – Exercises focusing on pelvic floor muscle relaxation, as well as ultrasounds and stretching have been shown to help relieve pelvic pain.

The Ainsworth Institute is Here to Help
Our doctors at the Ainsworth Institute of Pain Management are experiences in managing and treating pelvic pain. Dramatic improvements are possible with the right treatment. The sooner treatment is started, the better the chances of success. Call and schedule an appointment now with one of our board-certified pain management experts.

References


[1] Reiter RC: Chronic pelvic pain. Clin Obstet Gynecol. 1990; 33:130-136.
[2] Ryder RM: Chronic pelvic pain. Am Fam Physician. 196; 54:2225-2232.
[3] Zondervan KT, Yudkin PL, Vessey MP, et al. The community prevalence of chronic pelvic pain in women and associated illness behavior. Br J Gen Pract. 2001;51: 541-547.
[4] Fall M, Baranowski AP, Elneil S, et al. Guidelines on chronic pelvic pain. In: EAU Guidelines. Edition presented at the 23rd EAU Annual Congress, Milan, 2008.
[5] Kothari S. Neuromodulation approaches to chronic pelvic pain and coccydynia. Acta Neurochir Suppl. 2007;97: 365-371.
[6] Fall M, Baranowski AP, Fowler CJ, et al. EAU guidelines on chronic pelvic pain. Eur Urol 2004:46(6):681-689.
[7] Mathias SC, Kupperman M, Liberman RF, et al. Prevalence, health-related quality of life, and economic correlates. J Obstet Gynaecol. 1999;106:1149-55.
[8] Janicki, TI. Chronic pelvic pain as a form of complex regional pain syndrome. Clin Obstet Gynecol. 2003;46: 797-803.
[9] Heim C, Ehlert U, Hanker JP, et al. Abuserelated posttraumatic stress disorder and alterations of the hypothalamic-pituitaryadrenal axis in women with chronic pelvic pain. Psychosom Med. 1998;60:309–318.
[10] Aaron LA, Herrell R, Ashton S, et al. Co- morbid clinical conditions in chronic fatigue: a co-twin control study. J Gen Intern Med. 2001;16:24–31.
[11] Martinez-Lavin M. Is fibromyalgia a generalized reflex sympathetic dystrophy? Clin Exp Rheumatol. 2001;19:1–3.
[12] Longstreth GF. Irritable bowel syndrome and chronic pelvic pain. Obstet Gynecol Surv. 1994;49:505–507.
[13] Benzon, Honorio. Essentials of Pain Medicine. Philadelphia: Saunders Elsevier, 2011. Print
[14] De Leon Casasola OA, Kent E, Lema MJ: Neurolytic superior hypogastric plexus block for chronic pelvic pain associated with cancer. Pain. 1993; 54:145-151.
[15] Hunter C, Davé N, Diwan S, Deer T. Neuromodulation of Pelvic Visceral Pain: A Review of the Literature and Case Series of Potential Novel Targets for Treatment. Pain Practice 2013;13(1):3-17.
[16] Hunter C, Stovall B, Chen G, Carlson J, Levy R. Anatomy, Pathophysiology and Interventional Therapies for Chronic Pelvic Pain: A Review. Pain Physician. 2018; 21:147-167
[17] Hunter C, Yang A. Dorsal Root Ganglion Stimulation for Chronic Pelvic Pain: A Case Series and Technical Report on a Novel Lead Configuration. Neuromodulation. 2018 Aug 1. doi: 10.1111/ner.12801.

Corey Hunter, M.D.

Founder at Ainsworth Institute
Dr. Corey Hunter is a nationally recognized interventional pain physician and the founder of Ainsworth Insitute. His publications have appeared in textbooks on treating pain and he is a regular contributor in leading pain management journals.