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 for six months or more, it could be an identifiable disorder called chronic pelvic pain (CPP).
Chronic Pelvic Pain is considered a diagnosis of exclusion – only considered after more obvious and testable conditions are ruled out. Since there are many possible causes and contributing factors, it is crucial to understand them in order to initiate a correct treatment program that will yield the best results.
Patients with pelvic pain experience pain when engaging in ordinary, everyday non-painful activities. Activities like urination, sexual intercourse, or ovulation can be extremely uncomfortable. If you feel you fit this profile, schedule an appointment with one of our board-certified pain medicine physicians today.
What is Chronic Pelvic Pain (CPP)?
Pelvic pain is the result of damage to nerves associated with the pelvic area. There are many different factors that can lead to nerve injury. An injury to the nervous system leading to disproportionate pain lasting for longer than typically expected is a hallmark of Chronic Pelvic Pain (CPP). Depending on the nerves involved or the type of nerve injury, the distribution of the pain will be different.
Pelvic pain may start in one area, but as time goes on, the location and intensity may change. The sympathetic nervous system becomes activated, and this causes pain to spread and become more intense.
What are the symptoms of Pelvic Pain?
Symptoms of Pelvic Pain include:
- Burning and/or sharp pain in the pelvis, anus, and/or genitals
- Pain when sitting
- Pain when urinating and/or defecating
- Pain with intercourse or painful ejaculation
- Paresthesia (pins & needles sensation) and numbness
What are the causes pelvic pain?
The exact cause of pelvic pain is unclear, but a number of conditions can make patients susceptible.
There are several conditions that may contribute to the development of pelvic pain. Such disease states/conditions include:
- Irritable Bowel Syndrome (IBS)– IBS typically causes abdominal pain however it can lead to pain centered in the pelvic region.
- Infection– something as simple as a urinary tact infection (UTI) or an STD can cause inflammation which may lead to scarring and result in chronic pelvic 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.
- Myofascial Pain Syndrome – Pelvic Floor Dysfunction– abnormally tense or contracted muscles in the pelvis can cause inflammation around pelvic nerves.
- Psychiatric Disorders– severe anxiety or depression can often lead to chronic pain in any number of areas, the pelvic region being very common.
- Sexual/Physical Abuse– patients who have experienced sexual trauma or been assaulted often have manifestations of pelvic pain as a result of the attack.
- Complication from Surgical Procedures – even the most perfectly performed surgery can inadvertently lead to CPP secondary to adhesions or nerve injury. If traction is placed on a particular nerve in a certain way during the surgery, that nerve may become chronically inflamed.
- 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 beyond where the pain started. This is also known as Chronic Regional Pain Syndrome (CRPS).
Pudendal Neuralgia – Chronic pain, burning or numbness in the pelvic region.
Pudendal Neuralgia is a chronic pain condition that affects the genital and anal regions. Patients may experience burning or stabbing pain in those areas, pain during sexual intercourse, frequent urination, a subjective feeling that the area is swollen, difficulty with sexual arousal, and pain during ejaculation in men. Many sexually transmitted diseases (STDs) mimic the symptoms of pudendal neuralgia, so the first step is STD testing, which is frequently negative.
Treatment options for Pudendal Neuralgia include:
- Pudendal Nerve Block – an injection of local anesthetic and steroid around the pudendal nerve
- Superior Hypogastic Plexus Block – an injection of local anesthetic and steroid around a nerve plexus. This will interrupt the pain pathway.
- Medication management
- Pelvic Physical Therapy
- Spinal Cord Stimulation
Gender Specific Causes
CPP is typically more prevalent in the female population (affecting over 9 million women in the US). Predisposing and/or associated factors include a history of multiple laparoscopies, endometriosis, sexual or physical abuse, vulvar vestibulitis, fibromyalgia, and irritable bowel syndrome. In men, CPP is thought to be either a result inflammatory or non-inflammatory insult to the prostate, with the syndrome accounting for up to 90-95% of all cases of prostatitis.
- Cystitis – Urinary Tract Infections (UTIs) are a common cause of acute pelvic pain, but rarely a cause chronic pelvic pain.
- Dysmenorrhea– severe pain or discomfort during the menstrual cycle. This can sometimes be a sign or symptom of another condition such as uterine fibroids or adhesions.
- Dyspareunia – pain or discomfort with intercourse. Irregular blood flow or a local nerve injury can sometimes be the cause.
- Endometriosis – a common condition that causes adhesions in the internal pelvic region that leads to different organs and other structures being stuck to each other – leading to intense pain.
- Pelvic Congestion Syndrome– increased blood flow in the pelvic region can lead to swollen vessels which in turn can cause pain.
- Pelvis Neurodystonia– a combination of nerve dysfunction and abnormal muscle tone in the pelvic region.
- Uterine Fibroids –a common cause of CPP. Fortunately fibroids are easy to diagnose with imaging like Ultrasound or MRI.
- Vulvitis or Vulvodynia– pain around the external aspect or opening of the vagina can be the sign of a nerve injury.
- Chronic Orchalgia – chronic testicular pain that can lead to CPP.
- Prostatitis – infection of the prostate. When treated swiftly with antibiotics, the symptoms should resolve. Symptoms lasting more than a few weeks can be due to an infection.
- Prostatodynia – a very common cause of pain in men. This can typically be the result of a previous infection that left scar tissue in the prostate after resolving.
- Ureteral Obstruction –Blockage in one or both of the tubes (ureters) that carry urine from your kidneys to the bladder.
Treatment option for Pelvic Pain Conditions
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 area – in the case of pelvic pain, the injection targets pain in a particular nerve’s distribution in the pelvic region.
Ganglion Impar Block– 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 coccyx, cervix, colon, bladder, rectum and endometrium. Studies have reported 70-100% pain relief from this procedure.
Superior Hypogastric Block–this procedure is used as both a diagnostic and therapeutic tool. Under radio-graphic guidance, a thin needle is inserted through the skin and advanced toward the L5 vertebra – towards the superior hypogastric plexus. A blockade of the superior hypogastric plexus has been reported to decrease pelvic pain by 70%.
Peripheral Nerve Block –A peripheral nerve block can be extremely effective way of treating 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.
Radiofrequency Ablation (RFA) –Radio waves are applied to a nerve, subsequently preventing it from transmitting pain.
Spinal Cord Stimulation–this procedure utilizes 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. In the case of pelvic pain, the leads are often placed over the sacral nerve roots.
Medication Management & Pharmacologic Therapy–There are a wide-variety of medications found to be effective in treating CPP – these include non-steroidal anti-inflammatory (i.e. ibuprofen or naproxen), nerve stabilizers (Lyrica or gabapentin), antidepressants, and anticonvulsants.
Physical Therapy –Exercises focusing on pelvic floor muscle relaxation, as well as ultrasounds and stretching have been shown to help relieve pelvic pain.
Are Nerve Blocks and injections painful?
Our patients do not find any of these treatments painful. All nerve blocks and injections can be done with with local anesthesia, or IV sedation for your comfort. Your doctor will discuss all options with you. We make sure that you are not in any discomfort during any of the procedures that we perform.
Unique Pain Medicine is Here to Help
Our doctors at Unique Pain Medicine are experts in managing and treating pelvic pain. Remarkable improvements are possible with the right treatment. The sooner treatment is started, the better the chances of success. Schedule an appointment now with one of our board-certified pain management experts.
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