Chronic Pelvic Pain

Chronic pelvic pain is a symptom rather than a diagnosis and is usually caused by a combination of physical, psychological and/or social factors rather than a single underlying condition. In men the contents of the pelvis include the large bowel, the bladder and the prostate gland. In women the contents of the pelvis include the large bowel, the bladder, the uterus (womb), the ovaries and the fallopian tubes. There are therefore many potential causes for chronic pelvic pain, these include:

Men:

• Irritable Bowel Syndrome (IBS)
• Prostatitis/ Chronic Pelvic Pain Syndrome (CPPS)
• Infection
• Musculoskeletal pain (e.g., lower back pain)
• Hernia
• Psychological causes (depression/anxiety)

Women:

• Irritable bowel syndrome (IBS)
• Endometriosis
• Adenomyosis
• Pelvic Inflammatory Disease (PID)
• Interstitial cystitis
• Musculoskeletal pain (e.g., lower back pain)
• Pelvic Adhesions
• Vulvodynia
• Pelvic organ prolapse
• Hernia
• Psychological causes (depression/anxiety/sexual abuse PTSD)

The most common cause of pelvic pain in men is prostatitis (irritation of the prostate gland). The prostate is a small gland that sits underneath a man’s bladder and is responsible for producing the fluid element of semen.

It is thought that 35-50% of men will experience prostatitis at some point during their lifetime.

Whilst prostatitis can result from acute (sudden) bacterial infection, the most common type of prostatitis is chronic (long-term) prostatitis, affecting 95% of prostatitis sufferers. Chronic pelvic pain in men and chronic prostatitis are terms often used to describe the same thing and a more accurate term accepted as covering both conditions is Chronic Pelvic Pain Syndrome (CPPS).

CPPS causes recurrent feelings of genital pain over a period of months or years in the absence of any proven signs of infection. The pain can affect different parts of the genitals including your:

• Penis, often at the tip
• Testicles (balls)
• Perineum (area between the testicles and your bottom)
• Lower abdomen (tummy)

Sometimes the pain can be made worse when passing urine (peeing) and on ejaculation. Passing urine can also sometimes feel slower than normal. CPPS can also be caused by, or can cause itself, problems with anxiety and depression. This can lead to problems with your sexual function such as struggling to get an erection (erectile dysfunction) or premature ejaculation.

The precise cause for CPPS in men is poorly understood and therefore management can be difficult. Whilst the initial management involves investigating for any treatable cause (such as infection), this often fails to find an obvious explanation for symptoms.

The key to managing CPPS is to look for triggers for your pain. This can be particular types of exercise, sitting for long periods, or some types of sex. If you see a clear pattern that is triggering your symptoms, try to change your behaviour to reduce the triggers. CPPS has also been associated with smoking, coffee, fizzy drinks, and spicy foods so you should cut back on these too if you can.

Painful episodes often respond to simple painkillers such as paracetamol or ibuprofen. A hot bath can also help to relax the pelvic muscles and relieve your symptoms.

You can also read about helpful pelvic floor exercises here.

Some treatments are available from your GP. This can include medical treatments:

• Alpha blockers – medications that help to relax the pelvic floor muscles and prostate
• Nerve painkillers – especially with symptoms that started recently these medications can be helpful

More complex management is usually led by a specialist (urologist). This can include combinations of treatments including medication, psychological therapy and physiotherapy.

It is important to understand that CPPS is not associated with infertility or cancer.

Whilst there are many possible causes for chronic pelvic pain in women (see above), in many cases a physical cause cannot be found. Between a third and a half of laparoscopies performed to investigate chronic pelvic pain find no obvious cause. Once serious medical pathology has been ruled out, it can be a difficult symptom to treat, and women may need significant support in managing and coping with their pain. However, even when no reasons can be found for the cause of the pain, many women find that the quality of their lives improve when they get a better understanding of their symptoms and can be reassured that there is no serious underlying medical problem.

The most common physical causes of chronic pelvic pain in women are:

• Endometriosis – a condition where cells of the lining of the womb (the endometrium) are found elsewhere in the body, usually in the pelvis.
• Chronic pelvic inflammatory disease – a bacterial infection of the womb, fallopian tubes or ovaries, which often follows a chlamydia or gonorrhoea infection and needs immediate treatment with antibiotics.
• Irritable bowel syndrome – a common long-term condition of the digestive system that can cause stomach cramps, bloating, diarrhoea and constipation.

Less common causes of chronic pelvic pain include:

• Constantly returning ovarian cysts – these are fluid or blood-filled sacs that develop on the ovaries
• A urinary tract infection that keeps coming back
• Lower back pain
• Prolapse of the womb – where the womb slips down from its normal position and usually causes a “dragging” pain.
• Adenomyosis – endometriosis that affects the muscle of the womb, causing painful, heavy periods.
• Fibroids – non-cancerous tumours that grow in or around the womb; fibroids can be painful if they twist or deteriorate, but uncomplicated fibroids aren’t usually painful.
• Chronic interstitial cystitis – long-term inflammation of the bladder.
• Inflammatory bowel disease (IBD) – a term used to describe two chronic conditions, ulcerative colitis and Crohn’s disease, which affect the gut.
• Hernia – where an internal part of the body pushes through a weakness in the surrounding muscle or tissue wall.
• Trapped or damaged nerves in the pelvic area – these may cause sharp, stabbing or aching pain in a specific area, which often gets worse with certain movements (Vulvodynia).

Psychological causes:

In any form of pain, the importance of psychosocial context cannot be underestimated. A patient’s beliefs about pain or disability are better predictors of ultimate level of disability than are a doctor’s ratings of disease severity. The perception of pain includes psychological sensations, emotions, behaviours and thoughts.

Chronic pelvic pain is a symptom rather than a diagnosis and is usually caused by a combination of physical, psychological and/or social factors rather than a single underlying condition.

Whilst chronic pain can lead to depression and anxiety, depression, anxiety and the associated negative thinking can lead to a heightened perception of pain and exacerbate its impact on daily living and its chronicity.

It is against this background that the role of depression, anxiety and PTSD (particularly when resulting from a history of sexual abuse) need to be viewed when managing chronic pelvic pain.

Where there are clear psychological factors underpinning chronic pelvic pain and where significant underlying organic pathology has been excluded, there may be a role for Cognitive Behavioural Therapy (CBT). There is strong evidence that, in selected cases, CBT can have a significant impact upon the severity of chronic pain and its effects on daily living.

Pelvic pain requires investigation. Sudden and severe pelvic pain could represent a medical emergency (e.g., ruptured ectopic pregnancy). You should consult your GP if you develop new pelvic pain which is sufficient to disrupt your daily life, or it gets worse over time.

What tests might I be offered?

• Screening tests for pelvic infections (including urinary & sexually transmitted infections)
• An ultrasound scan – this may be a transvaginal scan of your pelvis, which involves gently inserting an ultrasound probe into the vagina
• An MRI (magnetic resonance imaging) scan of your pelvis.

You may also be offered a laparoscopy, particularly if your doctor thinks you may have endometriosis, adhesions or pelvic infection. This is an operation carried out under general anaesthetic. It usually involves two or three small cuts in the abdomen. A narrow telescope (called a laparoscope) is inserted through the abdominal wall to examine your pelvis. As with any surgical procedure, there are risks and benefits and these will be explained to you.

In a third to a half of laparoscopies done to investigate chronic pelvic pain, no obvious cause is found. This may be reassuring but can also be frustrating. However, having more information can help you and your doctor decide what is the best treatment for you.

Attempts to control or accept chronic pain are not ends within themselves, rather they may be a means of preventing pain from interfering with living the life one desires. Learning to “coexist” with pain rather than focusing on “getting rid of it” when combined with more traditional modes of pain relief can be an important step in the management of chronic pelvic pain.

It is important to undergo initial investigation of your pelvic pain to identify any treatable “organic” cause and, in the first instance you should consult a GP to find out whether further investigations are warranted. However, there are several lifestyle adaptations and behaviours that may help you manage your symptoms.

These include:

• Use of over the counter painkillers
• Regular exercise (including flexibility exercises, sitting exercises, swimming and dance, as well as yoga and Pilates)
• Maintaining a daily routine (including work if possible)
• Meditation

There are also a series of free online resources aimed at helping to manage chronic pain. These include The Pain Management Workbook produced by NHS Ayrshire & Arran’s musculoskeletal Service, and the Chronic Pain Self-Help Guide produced by NHS inform, Scotland.

If you have been referred for a specialist opinion your details will be reviewed and it may be recommended that you are seen by a hospital clinician. Information to support you in choosing your preferred hospital, including waiting times can be found using the links below.

How long will I wait?

If a hospital assessment and/or treatment is clinically recommended your information will be sent to a specialist. Click below to find out more about waiting times for routine hospital assessment and/or treatment.

• Waiting times
• Find services near you