Pelvic pain can be extremely debilitating, and can occur in both men and women. The cause of a person’s pelvic pain can be difficult to diagnose because it can be caused by multiple health issues. If the cause of your pelvic pain is identifiable, treatment typically focuses on curing the source. If no specific underlying cause can be found, treatment consists of pain management.
Acute pelvic pain has a sudden onset and lasts for fewer than 3 months. Some causes of acute pelvic pain can be emergencies — such as ectopic pregnancies, infection, and appendicitis. Acute pelvic pain is more common than long-term pelvic pain, and is often experienced by patients after surgery or soft tissue traumas.
Pelvic pain that persists for more than 3 months is considered chronic. In contrast to acute pelvic pain, chronic pelvic pain is rarer and its causes can be more challenging to determine.
In women with pelvic pain, the healthcare provider generally begins with a careful history and examination, as well as a pregnancy test. Some women may also need blood work, imaging studies, and surgical evaluation to help diagnose their condition.
In men, the work-up of pelvic pain is similar; imaging, blood work, and surgical evaluation should be performed. Unique to men is prostatitis — inflammation of the prostate. Prostatitis may be bacterial or nonbacterial in nature. Prostatitis is estimated to affect 10-14% of men, regardless of age or ethnicity (Naber, 2008).
Acute prostatitis is pelvic pain of less than 3 months’ duration. It is associated with severe, mainly Gram-negative bacterial infection; treatment consists of broad-spectrum antibiotic therapy for 2-4 weeks, which can be tailored according to pathogen identification and susceptibility tests (Naber, 2008).
Persistent male pelvic pain is referred to as Chronic Pelvic Pain Syndrome. The chief goal of preliminary testing is to rule out bacterial infection in the prostate. Only 10% of patients with chronic prostatitis symptoms actually have bacterial infection, which usually arises from common uropathogens (Naber, 2008).
Chronic Prostatitis/Chronic Pelvic Pain Syndrome
Prostatitis can be bacterial or nonbacterial in origin. Chronic bacterial prostatitis is a persistent bacterial infection of the prostate that causes pelvic pain and urinary symptoms. It is treatable with antibiotics. In contrast, chronic nonbacterial prostatitis is pelvic pain and urinary symptoms without bacterial infection. Antibiotics are not an effective therapy against this type of prostatitis. Since there are no standard diagnostic tests for chronic prostatitis, diagnosis is generally made by ruling out other diseases.
Bacterial prostatitis may begin with congestion of the prostate gland, which can create a breeding ground for bacteria. Generally the condition is short-term and can be eradicated with antibiotics. Sometimes, however, the infection may persist over a period of months, resulting in chronic pain. Chronic bacterial prostatitis may occur with or follow pelvic pain. Certain medications may help reduce pain in patients with the condition; these include alpha-adrenergic blockers, which help relax the muscles of the prostate gland; and nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, celecoxib and others. For example, a Chinese study of 64 patients with chronic prostatitis who were treated with either celecoxib (200 mg daily) or placebo for six weeks found celecoxib provided significant symptomatic improvement limited to the duration of the therapy compared to placebo (Zhao et al, 2009).
Another method of treatment for chronic nonbacterial prostatitis is transcutaneous electrical nerve stimulation (TENS), which uses externally applied leads to stimulate the nerves for therapeutic purposes. For example, a clinical study demonstrated a significantly beneficial effect of TENS on pain in 24 chronic prostatitis patients who received TENS, painkillers or neither (Sikiru L et al, 2008).
Testicular Pain
Another variety of pelvic pain in men is testicular pain.
Testicular pain affects one or both testicles and possibly the scrotum. It can be short-term (acute), or long-term (chronic). Sudden pain in a testicle may be a symptom of testicular torsion, or impedance of blood flow to the testicle usually caused by a kink in the spermatic cord. Patients with testicular torsion may experience symptoms of a urinary tract infection such as fever, urinary frequency and pain upon voiding. The scrotum may be red and warm to the touch. Lack of blood flow, or ischemia, within the testicle is an emergent condition requiring immediate surgical correction. Without oxygen and nutrients, the tissues comprising the testicle will die, necessitating removal of the testicle.
Another cause of pain in the testicular region is epididymitis. This condition involves inflammation of the epididymis, a tube of the spermatic duct system located at the rear (posterior) of each testicle. Epididymitis may be caused by the sexually transmitted diseases gonorrhea and chlamydia, or by bacterial infection, and is generally treated with antibiotics.
A condition that often occurs in conjunction with epididymitis is orchiditis. This inflammation of the testes produces symptoms including ejaculation of blood, hematuria (blood in the urine), pain, and visible swelling of the affected testicle and the lymph nodes in the groin, or inguinal region. Orchiditis can be caused by epididymal infection (chlamydia and gonorrhea) that has spread to the testicles. It also occurs in adolescent boys who have active mumps infection. The antidepressant medication trimipramine (Surmontil) has also been reported as a cause of orchiditis.
Acute appendicitis can cause pain in the testicles and groin due to the spread of purulent discharge to these areas. A person with acute appendicitis may also experience abdominal pain. Appendicitis is another medical emergency and may require surgery to remove the inflamed appendix.
Rectal Pain
The rectum is the lowermost part of the large intestine immediately preceding the anus, the opening at the end of the digestive tract. Unfortunately, the typical American diet is low in fiber, which can negatively impact the rectum and anus. When fiber and water intake are inadequate, stools are difficult to pass and may even tear, stretch and inflame tissues of the lower digestive tract.
Fiber, an indigestible substance found in plants, helps improve digestion and prevent constipation. Good sources of dietary fiber are fruits, vegetables, and whole grains. The typical American consumes approximately 15 grams of fiber each day. However, The American Dietetic Association recommends significantly more fiber intake than the average American consumes, or 25 grams of fiber per day for women and 38 grams of fiber per day for men. Optimal digestion is also promoted by adequate water intake, or at least 8 8-oz glasses per day.
Anal fissures, or tears in the anal canal most often caused by straining, are a common complication of inadequate dietary fiber and water intake. Many cases of rectal pain are caused by anal fissures. Healing of anal fissures is promoted by increasing dietary fiber and water intake to combat constipation, as well as taking sitz baths and stool softeners. In fact, conservative measures have healing rates of up to 85% and have largely replaced surgery as first-line management (Wray et al, 2008). However, should these measures fail, your physician may perform surgery to correct damaged anal tissues. Surgery is reserved as a last resort since invasive procedures carry a higher risk of complications.
The development of hemorrhoids, or inflamed and swollen veins in the lower rectum and anus, is another cause of rectal pain. As with anal fissures, hemorrhoids are generally caused by straining. There are two types of hemorrhoids: internal and external. Internal hemorrhoids develop within the lower rectum. External hemorrhoids are located outside of the body, around the anus. Internal hemorrhoids may protrude, or prolapse, through the anus, causing pain, bleeding, and itching. Most prolapsed hemorrhoids shrink back inside the rectum on their own. Severely prolapsed hemorrhoids may protrude permanently and require treatment. As with anal fissures, treatment focuses on increasing intake of dietary fiber and water to help reduce the pressure on hemorrhoids caused by straining. Doctors may also suggest taking a bulk stool softener or a fiber supplement such as psyllium (Metamucil) or methylcellulose (Citrucel). Surgery is indicated only when more conservative measures fail to help hemorrhoids to shrink and disappear.
Rectal pain can also be caused by an abscess in the perianal region. An anorectal abscess is caused by an obstruction of an anal gland, which promotes inflammation and formation of a pocket of pus within the tissues around the anus. Most cases of anorectal abscess are sporadic, although the condition is associated with diseases such as diabetes mellitus and Crohn’s. The infections that cause anorectal abscess may be bacterial or viral, and may be the result of a sexually transmitted disease. Anorectal abscesses must be treated surgically by incision and drainage.
Chronic anorectal abscess may lead to a painful anal fistula, an abnormal canal between the anus and the rectum. Treatment of anal fistula often requires a fistulotomy, in which a surgeon repairs the fistula with as little damage to the anal sphincter muscles as possible. In some cases, the surgeon may use fibrin glue, made from plasma protein, or a plug of collagen protein, to fill and close a fistula rather than dissecting it.
Inguinal Pain
Inguinal pain is pain in the groin. It is often caused by damage or irritation of the ilioinguinal nerve. The ilioinguinal nerve begins at the spine in the middle of the back, passes through the hip area into the groin, and continues down the legs. Like other sizeable nerves, the ilioinguinal nerve has significant potential to cause pain due to its extensive length and association with multiple organs.
Damage to the ilioinguinal nerve can occur from a variety of events, but most often presents after surgery in the abdominopelvic area. For example, inguinal pain may occur as a complication of surgical repair of a hernia. In women, it may occur after Cesarean deliveries and hysterectomies. After these procedures, scarred sections of the inguinal nerve may develop into neuromas. Neuroma resection is often used to correct inguinal nerve pain caused by these procedures.
There are a wide variety of treatment options are available to patients who suffer from inguinal nerve pain. One of these is taking neuropathic pain medication. If medication fails to help alleviate pain, injections to block the nerve may be tried. Spinal Cord Stimulation (SCS) can also reduce inguinal nerve pain. Removal of the inguinal nerve is a reserved as a last resort in correcting inguinal nerve pain. Following this procedure, patients may experience semi-permanent numbness in place of pain.
An inguinal hernia is a protrusion of abdominal-cavity contents through the inguinal canal. Inguinal hernias are a common cause of inguinal pain, occurring in possibly 27% of men and 3% of women (Jenkins et al, 2008). The larger size of the male inguinal canal might be one reason why men are more likely to have an inguinal hernia than women. Repair of inguinal hernias, termed herniorrhaphy or hernioplasty, is a frequently performed surgical procedure and is now often performed as outpatient surgery.
Indirect inguinal hernia is a protrusion of tissues through the inguinal ring. It is caused in the embryonic period by failure of the internal inguinal ring to close after the testicle passes through it. Direct inguinal hernia is a protrusion through a weak point in the fascia of the abdominal wall.
Inguinal hernias can produce serious complications. For example, vital organs such as the intestines may prolapse into the hernia and become pinched. When strangulated in this manner, the flow of contents through these organs may be impeded, leading to harmful obstruction. In addition, strangulated tissues may become deprived of blood flow, leading to potentially fatal consequences.
Osteitis Pubis
The pubic symphysis is the joint at the front of the pelvis where two ends of the pubic bone meet. When the pubic symphysis becomes inflamed, it leads to sclerosis and bony changes that cause both acute and chronic groin pain. Osteitis pubis, or inflammation of the pubic symphysis, causes varying degrees of lower abdominal and pelvic pain. It often occurs as a complication of invasive procedures involving the pelvis, and as an inflammatory process in athletes.
The symptoms of osteitis pubis may include loss of flexibility in the groin region, groin pain, and difficulty exercising. The pain of osteitis pubis may even make it difficult to perform routine activities such as standing up or getting out of a car.
Osteitis pubis is common in athletes who play physically demanding sports. In such sports, intense physical activity and rapid changes of direction mays place extreme tension upon the pubic bone, resulting in pain and inflammation.
Treatment of osteitis pubis focuses on lowering inflammation in the affected area and managing the pain. Your doctor may recommend medication, altering physical activity until the affected area heals, and performing stretching and strengthening exercises.
Vulvodynia
Vulvodynia is pain associated with the vulva that lasts more than three months. The vulva refers to tissues and structures surrounding the opening of the vagina. Vulvodynia is not caused by infection or skin disease and usually has no apparent cause. The pain may be constant, intermittent, or occur only when the vulva is touched, and is characterized as burning, stinging or dull soreness. Vulvodynia may be so painful that activities such as sitting for long periods and intercourse are difficult or impossible. Due to the limitations it places upon those who suffer from the condition, Vulvodynia is associated with depression.
The cause of vulvodynia is unknown, but the condition is associated with injury to the nerves within the vulva, past vaginal infections and skin hypersensitivity. Many women with vulvodynia have a history of recurrent vaginitis or vaginal yeast infections. As with many other conditions that cause pelvic pain, treatment of vulvodynia focuses on managing the pain.
Interstitial Cystitis
Interstitial cystitis is a chronic condition of the urinary bladder characterized by pelvic pain. Other symptoms of interstitial cystitis include nocturia, or the need to get up in the night to urinate, and urinary frequency.
Although the cause of interstitial cystitis is unknown, factors contributing to development of the disorder may be autoimmune, neurological, allergic, or genetic in nature. Irrespective of the etiology, patients with interstitial cystitis commonly present with damage to the lining of the bladder, or urothelium. Such damage can result from reasons including urinary tract infection (UTI), excessive consumption of coffee or sodas, and traumatic injury. Disruption of the urothelium may encourage leakage of urinary products into surrounding tissues, causing pain and inflammation. Certain medications, administered orally or introduced directly into the bladder via catheter, may work to repair and rebuild the damaged urothelium, thereby reducing symptoms.
The symptoms of interstitial cystitis may resemble a routine bladder infection (cystitis) or UTI. However, interstitial cystitis is not caused by bacterial infection, and administration of antibiotics is ineffective as treatment. Also, in men, the symptoms of interstitial cystitis may mimic prostatitis and epididymitis and, in women, endometriosis and uterine fibroids leading to misdiagnosis in some cases.
Treatment of interstitial cystitis may include medication, pelvic floor treatments, and adjustments to diet. Biofeedback, a relaxation technique aimed at helping control functions of the autonomous nervous system, has shown some benefit in controlling pain associated with interstitial cystitis. In addition, electronic pain-killing options are available, such as transcutaneous electrical nerve stimulation (TENS), the use of electric current produced by externally applied leads to stimulate the nerves for therapeutic purposes. TENS is thought to work by increasing blood flow to the affected area. Another mode of treatment for interstitial cystitis that uses electricity to control pain is percutaneous nerve stimulation. Percutaneous nerve stimulation is accomplished with a fine needle electrode. Frequently, in bladder conditions, percutaneous nerve stimulation is applied to nerves in the tibia and the sacrum. Percutaneous nerve stimulation of the posterior tibia has been shown to reduce pain and frequency in bladder conditions, and modulation of the sacral nerves, which produce feeling in the bladder, may lower pain and urgency. If a trial period shows percutaneous nerve stimulation is of benefit to a person with interstitial cystitis, a permanent neuromodulatory device and leads may be implanted.
Orchialgia
Orchialgia refers to pain in the testes. It may be short-term (acute), or chronic, which is defined as more than three months of constant or intermittent pain. The pain of orchialgia may involve not only the testicle, but also surrounding structures such as the spermatic cord and scrotum.
Orchialgia may be caused by such reasons as injury, infection, surgery, cancer, and testicular torsion, and may present as a possible complication after vasectomy. Other causes include spermatocele and varicocele. A spermatocele, a cyst containing milky fluid and spermatozoa, occurs in the rete testis, or the network of tubules carrying sperm from the seminiferous tubules to the vasa efferentia, the efferent ducts that carry semen to the first section of the epididymis. A varicocele is an abnormal enlargement of a scrotal vein. It occurs when defective valves, or compression by a nearby structure, cause dilatation of the veins near the testes.
Treatment of orchialgia depends upon its underlying cause. Treatment may involve administration of nonsteroidal anti-inflammatory drugs (NSAIDS) to lower pain and inflammation, and antibiotics if infection is present. Pain-generating cysts normally resolve without intervention over a period of weeks. Another way of treating the pain of orchialgia is through injections. For example, spermatic cord nerve blockade containing a combination of local anesthetic and steroids has been shown to be effective in the treatment of orchialgia, as has transrectal injection. In extreme cases, a painful testicle may be removed (orchiectomy) to bring pain relief.
Pelvic Neuropathy
Neuropathy is a term pertaining to nerve damage. Neuropathies in the pelvic area may cause pelvic pain. For example, the pudendal nerve, which provides sensation in the genitalia, perineum and rectum, can develop neuropathy that results in pain during intercourse, elimination and sitting. And pelvic pain may be caused by neuropathy of the ilio-inguinal and ilio-hypogastric nerves, which often arises as a complication of surgery in the lower abdominal wall. In addition, genitofemoral neuropathies may cause pelvic pain as well as low abdominal and low back pain.
Nerve blocks are a particularly effective therapy for individuals with pelvic neuropathy. Nerve blocks may be delivered as repeated injections over time. If they fail to help alleviate pain, spinal cord stimulation may be tried.
Infection
Infection can be the culprit behind pelvic pain in females as well as males. One infection-related cause of chronic pelvic pain in women is Pelvic Inflammatory Disease (PID). Multiple studies have shown that 20 to 50 percent of women presenting with pelvic pain have PID Kruszka P et al. (2010). Each year in the United States, it is estimated that more than 750,000 women experience an episode of acute PID, more than 75,000 women may become infertile each year as a result of PID, and a large proportion of the ectopic pregnancies occurring every year are due to the consequences of PID (CDC, 2010).
PID occurs when bacteria migrate deeply into a woman’s reproductive organs and pelvic cavity. Many different organisms can cause PID, including the bacteria that cause gonorrhea and chlamydia, two common bacterial sexually transmitted diseases. PID can lead to scarring of the fallopian tubes and tissues in and near the uterus and ovaries. Women with repeated episodes of PID are more likely to suffer infertility, ectopic pregnancy, and chronic pelvic pain.
There are no definitive tests to diagnose PID. If symptoms such as lower abdominal pain are present, a health care provider may perform a physical examination to assess the pain and check for fever, abnormal discharge, and evidence of gonorrheal or chlamydial infection. Sometimes, a pelvic ultrasound or laparoscopy may be ordered. If your physician diagnoses you with PID, he or she will discuss an appropriate course of treatment with you.
Ectopic Pregnancy
An ectopic pregnancy is an abnormal pregnancy that occurs outside the womb (uterus). As an ectopic pregnancy grows, it produces severe pelvic pain in the mother. Ectopic pregnancies are not viable and can be life-threatening.
A common site for an ectopic pregnancy is in one of the two fallopian tubes. When these tubes are scarred, movement of the fertilized egg toward the uterus may be impeded. Since the fertilized egg cannot reach the uterus, it implants and develops in the fallopian tube. As the pregnancy grows larger, the fallopian tube may rupture, causing severe pain, internal bleeding and shock. Immediate medical attention is needed to treat an ectopic pregnancy.
Scarring of the fallopian tubes is most often caused by a past ectopic pregnancy, infection, or surgery in the area. In addition, up to 50% of women who have ectopic pregnancies have experienced inflammation of the fallopian tubes (salpingitis) or PID (Kruszka P et al, 2010). Although scarred fallopian tubes and PID are responsible for most ectopic pregnancies, some cases are caused by complications of a ruptured appendix, endometriosis, and scarring from previous pelvic surgery.
Ovarian Cysts
An ovarian cyst is a fluid-filled sac that forms on or inside of an ovary.
The most common variety of ovarian cyst is a functional cyst. This type of cyst forms routinely during the menstrual cycle, and is not the same as cysts produced by cancer.
During each menstrual cycle, an egg develops in a fluid-filled sac called a follicle. If this follicle fails to break open and expel the mature egg, the unruptured follicle forms a follicular cyst. Another type of routine cyst associated with the menstrual cycle is a corpus luteum cyst. This type of cyst forms from the ruptured follicle, or corpus luteum, and is associated with minor bleeding that can irritate tissues within the pelvic cavity.
Functional ovarian cysts usually resolve within two to three months without treatment. Oral contraceptives may be prescribed to help inhibit the development of new ovarian cysts. In rare cases, surgery is needed to remove or biopsy persistent, atypical or very large ovarian cysts.
A common condition that is associated with ovarian cysts that does not typically produce pelvic pain is polycystic ovary syndrome (PCOS). In PCOS, a condition caused by hormonal imbalance, eggs do not mature and are not released from follicles, but form ovarian cysts. In addition, this condition may cause menstrual irregularity, acne, changes in hair growth, and infertility. Talk to your doctor if you experience any of these signs.
Sudden and severe pelvic pain, often with nausea and vomiting, may be a sign of ovarian torsion or twisting of the ovary, which cuts off its blood supply, or rupture of a cyst with internal bleeding. Such pain can also be a sign of an ectopic pregnancy. Since these situations can be serious, never postpone medical attention for severe pelvic pain.
Endometriosis
In endometriosis, abnormal tissue that behaves like the uterine lining (endometrium) grows in the pelvic cavity, causing severe pelvic pain, irregular bleeding, and possible infertility. Typically, the abnormal tissue forms on the ovaries, bowel, rectum, bladder, and the delicate lining of the pelvis. These tissue deposits respond to the menstrual cycle, just as the uterine lining does, thickening, sloughing and bleeding each month in response to cycling hormone levels. Unlike the tissue that comprises the uterine lining, however, blood and tissue are unable to exit the body through the vagina as menses. Instead, these products stagnate inside the body, leading to complications such as pain, and development of cysts and scar tissue (adhesions).
Although the cause of endometriosis is unknown, one theory is that cells from the uterine lining that are loosened during menstruation may migrate through the fallopian tubes into the pelvis. Once there, they implant and grow in the pelvic or abdominal cavities. This is called retrograde menstruation. Sometimes, endometriosis is hereditary.
Although there is no cure for endometriosis, your doctor may prescribe:
- Hormone therapy
- Medications to control pain
- Medications to thwart the progression of endometriosis
- Surgery to remove areas of endometriosis
- Hysterectomy with removal of both ovaries
Diagnosis and Treatment
If you have pelvic pain, your doctor may refer you to an OB/GYN, urologist, or other specialist. In order to determine the source of your pelvic pain, you may be given a pelvic examination, lab testing, and ultrasounds or CT scans of the abdomen and pelvis.
Treatment of your pelvic pain is based on the underlying cause, and can include:
- Anti-inflammatory medications (e.g, ibuprofen, naproxen),
- Anti-depressants
- Neuropathic medications (e.g., gabapentin, Lyrica).
- Physical therapy, which can pelvic floor muscle training, hot and cold applications, ultrasound therapy, and stretching
- Biofeedback ( a technique in which a person learns to control pain through thoughts)
- Relaxation techniques
- Nerve blocks (e.g., ilioinguinal nerve block)
- Spinal Cord Stimulation (SCS), which works by introducing an electrical current into the epidural space near the source of chronic pain impulses.
The highly trained practitioners at Louisiana Pain Specialists care about your quality of life and understand the stress and inconvenience of living with a painful condition. With our numerous combined years of experience, we aim to bring you back to health as quickly, efficiently and non-invasively as possible. Call our pain relief clinic today, and our friendly staff will schedule an appointment for you.
Sources
Centers for Disease Control and Prevention (CDC). (2010). Pelvic Inflammatory Disease (PID) – CDC Fact Sheet. Retrieved March 12, 2011 from www.cdc.gov/std/pid/stdfact-pid.htm
Jenkins J et al. (2008). Inguinal hernias. BMJ 336 (7638): 269–272.
Kruszka P et al. (2010). Evaluation of acute pelvic pain in women. Am Fam Physician. 82(2):141-7.
Lopatkin N et al. (2007). [Results of a multicenter trial of serenoa repens extract (permixon) in patients with chronic abacterial prostatitis]. Urologiia. (5):3-7.
Naber K. (2008). Management of bacterial prostatitis: what’s new? BJU Int. 101 Suppl 3:7-10.
Sikiru L et al. (2008). Transcutaneous electrical nerve stimulation (TENS) in the symptomatic management of chronic prostatitis/chronic pelvic pain syndrome: a placebo-control randomized trial. Int Braz J Urol. 34(6):708-13; discussion 714.
Wray D et al. (2008) Anal fissure: a review. Br J Hosp Med (Lond). 2008 Aug;69(8):455-8.
Zhao W et al. Celecoxib reduces symptoms in men with difficult chronic pelvic pain syndrome (Category IIIA). Braz J Med Biol Res. 42(10):963-7.
