Pelvic pain

Pelvic pain is defined as a nonmalignant pain perceived in structures related to the pelvis. Acute pain is more common than chronic pain. If the pain lasts for more than six months, it is deemed to be chronic pelvic pain. On the other hand, acute pain is referred as pain lasting less than three months. It can affect both women and men. Patients frequently suffer from pelvic pain throughout their reproductive ages, for very long periods of time; in women more rarely a premenarche (the stage of life immediately preceding menarche) or postmenopause onset is referred.

Pelvic pain is a main issue for patients and health care systems. It not only significantly deteriorates the quality of life of patient himself/herself, but also affects the relationships with the partner, relatives, and colleagues thus representing a consistent social burden. 

Several causes may be at the basis of pelvic pain; however, not always an organic disorder is present as a pain cause. In this case pain perception is usually due to a “functional pathology,” often with a neuropathic basis. As a consequence, only few physicians specialized and trained in pelvic pain disorders, can easily recognize what the etiology of pelvic pain is, and the treatment is often exclusively symptomatic, frequently with fewer efficacies.

The most commonly identified causes of pain in the pelvic region are gynecologic, urologic, gastrointestinal, neurological, and musculoskeletal. However, in up to 33% of patients the source of this symptom is not identified, frustrating both patients and health-care professionals. Pelvic pain may involve both the somatic and visceral systems, making the differential diagnosing challenging. 

Most common causes of pelvic pain are:

gynecologic:

• endometriosis
• adenomyosis 
• pelvic inflammatory disease
• adhesions
• fibroids
• pelvic congestion syndrome - a chronic medical condition in women caused by varicose veins in the lower abdomen

urologic:

• painful bladder syndrome – a chronic inflammation of the bladder 

gastrointestinal:

• irritable bowel syndrome - a group of symptoms including abdominal pain and changes in the pattern of bowel movements without any evidence of underlying damage
• inflammatory bowel diseases - a chronic intestinal inflammatory condition

musculoskeletal:

• fibromyalgia - a medical condition characterized by chronic widespread pain and a heightened pain response to pressure
• pelvic floor myalgia (piriformis syndrome) – a pain caused by piriformis muscle which spasms and causes buttock pain

other:

• neuralgia (pain in the distribution of a nerve) in pelvic area
• depression
• visceral pain - pressure-like, intermittently squeezing or cramp, not well localized, vague in character, and difficult for patients to describe
• somatisation disorders
• psychosexual dysfunction (including previous or current sexual abuse)
• porphyria - metabolic disorders related to heme biosynthesis pathway enzyme dysfunction

The mechanisms underlying the onset and the persistence of pelvic pain are linked to the existence of complex circuits, which involve peripheral neural pathways, the spinal cord, and brain areas. There are numerous interconnections among the nervous system and the anatomical structures of the pelvis and through the different pelvic organs themselves. 

Pelvic pain may be treated by several ways:

• drugs - pain relievers, muscle relaxants, antidepressants
• hormonal treatment – especially in case of endometriosis or menstruation, including birth control pills, hormonal injections or intrauterine devices
• lifestyle changes – changed diet, improved posture, regular physical activity
• physical therapy – massage, stretching, strengthening, pelvic muscle controlling and relaxing therapies
• surgery – removing adhesions, fibroids, endometriosis
• counseling – “talk therapy” improves medical treatment

Endometriosis

Endometriosis is a disease in which tissue that normally grows inside the uterus grows outside it. The main symptoms are pelvic pain and infertility. The pain can range from mild to severe cramping or stabbing pain that occurs on both sides of the pelvis, in the lower back and rectal area, and even down the legs. The amount of pain a woman feels correlates poorly with the extent or stage (1 through 4) of endometriosis, with some women having little or no pain despite having extensive endometriosis or endometriosis with scarring, while other women may have severe pain even though they have only a few small areas of endometriosis.

Pelvic inflammatory disease

Pelvic inflammatory disease (PID) is an inflammation of the uterus, fallopian tubes and/or the ovaries. It should be treated promptly to avoid permanent damage to the affected organs which can cause scarring and adhesions and subsequent infertility, ectopic pregnancy and chronic pelvic pain.

Adenomyosis

Adenomyosis is a medical condition characterized by the presence of ectopic glandular tissue found in the muscular wall of the uterus (myometrium). Patients with adenomyosis often present with painful and/or profuse menses (dysmenorrheal (painful menstrual period) & menorrhagia (heavy menstrual bleeding), respectively). Other possible symptoms are pain during sexual intercourse, chronic pelvic pain because of scars and adhesions and irritation of the urinary bladder.

Fibroids

Uterine fibroids, also known as uterine leiomyomas or fibroids, are benign smooth muscle tumors of the uterus. Most women have no symptoms while others may have painful or heavy periods. Bleeding and pelvic pain symptoms are frequently reported as main symptoms related to uterine fibroids. Pelvic pain is caused by pressure exerted fibroids on the surrounding organs. 

Prostatitis

Prostatitis is inflammation of the prostate gland. Prostatitis is classified into acute, chronic, asymptomatic inflammatory prostatitis, and chronic pelvic pain syndrome.

The initiator of the inflammatory process in pelvic pain within the prostate is thought to be a local infection. Regardless of the triggering factor, the resultant inflammatory process causes tissue swelling and increased pressure of prostate leading to local hypoxia (tissues are not oxygenated adequately) and varied tissue damage. This leads to the pain and other symptoms associated with the condition.