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.
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. 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).  A current estimate of those suffering from CPP in the United States is reported to be as high as 14.7%.,
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. 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.
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.
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
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.
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:
CPP is also inclusive of a variety of presentations many of which can be attributed to a local neuralgia:
Penile Pain Syndrome
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. 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, endometriosis, sexual or physical abuse, vulvar vesitibulitis, fibromyalgia, and irritable bowel syndrome.,, 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.
Myofascial Pain Syndrome
Ovarian Remnant Congestion
Sympathetically Mediated Pain
Irritable Bowel Syndrome
Surgical Procedures (adhesions)
Irritable Bowel Syndrome
Surgical Procedures (adhesions)
Visceral: uterus, ovaries, bladder, urethra
Somatic: skin, vulva, clitoris, vaginal canal
Adhesions, endometriosis, salpingo-oophoritis
Dilated pelvic vein/pelvic congestions theory
Ligamentous structures, muscular (iliopsoas, piriformis, quadrates lumborum, sacroiliac joint, obturator internus, pubococcygeus)
Skeletal (referred pain)
Pelvic floor muscle tension/spasm
Degenerative joint disease, disc herniation, spondylosis, neoplasm of spinal cord/sacral nerve, coccydynia, degenerative disease
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
Irritable bowel syndrome, abdominal epilepsy, abdominal migraine, recurrent small bowel obstruction, hernia
Bladder dysfunction, chronic (nonbacterial) prostatitis, chronic orchalgia, and prostatodynia
Anxiety, depression, somatization, physical or sexual abuse, drug addiction, dependence, family problems, sexual dysfunction
In 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 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%.
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.
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 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.
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 – A 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.
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!
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.
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 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.
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