Chronic Pelvic Pain

What counts as chronic pelvic pain

ACOG defines chronic pelvic pain as pain originating from pelvic organs or structures that lasts for more than 6 months. It may be:

• cyclical: linked to the menstrual cycle, such as endometriosis
• non-cyclical: constant or unrelated to periods
• related to activities: sex, urination, bowel movements, sitting or standing

Chronic pelvic pain affects an estimated 1 in 7 women of reproductive age and a significant number of men. It often involves more than one organ system.

Causes in women

Gynecological

• Endometriosis: tissue similar to the womb lining grows outside the womb, causing painful periods, pain with sex, bowel and bladder symptoms, and infertility
• Adenomyosis: womb lining tissue in the womb muscle, causing heavy painful periods and an enlarged tender uterus
• Pelvic adhesions: scar tissue after surgery or infection
• Chronic pelvic inflammatory disease and its after-effects
• Ovarian cysts and pelvic congestion syndrome (enlarged pelvic veins)
• Fibroids: usually pressure and heavy bleeding rather than pain
• Vulvodynia: chronic vulvar pain

Bladder

Interstitial cystitis/bladder pain syndrome causes pelvic pain that builds as the bladder fills and eases after urinating, with urgency and frequency, and normal urine cultures.

Bowel

Irritable bowel syndrome causes cramping pain related to bowel movements, with diarrhea, constipation or both, and bloating.

Musculoskeletal and nerve causes

• Pelvic floor dysfunction: tight, tender pelvic floor muscles causing aching, pain with sex and difficulty emptying
• Pudendal neuralgia: burning pain in the perineum, worse sitting
• Abdominal wall pain: trapped nerves after surgery, myofascial trigger points
• Pelvic girdle pain and hip or lower back problems

Causes in men

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is the most common. It causes pain in the perineum, testicles, penis tip or lower abdomen, pain with ejaculation and urinary symptoms, without evidence of bacterial infection. See chronic prostatitis. Other causes include pelvic floor dysfunction, bladder pain syndrome, IBS and nerve entrapment.

Contributing factors

• Central sensitization: long-standing pain makes the nervous system more sensitive, so normal sensations become painful
• Overlapping pain conditions: fibromyalgia, migraine and chronic fatigue are more common
• Psychological factors: anxiety, depression and past trauma, including sexual trauma, do not mean pain is "in your head" but can amplify it and need attention
• Sleep disturbance

Diagnosis

History and examination

Your doctor will ask about the pain's location, timing, triggers, menstrual pattern, bowel, bladder and sexual symptoms, previous surgeries, infections and mental health. A pain diary over 2 to 3 cycles helps. Examination includes the abdomen, pelvic floor muscles and a pelvic exam.

Tests

• urine tests and STI swabs
• pregnancy test
• pelvic ultrasound, ideally transvaginal
• MRI for suspected deep endometriosis or adenomyosis
• laparoscopy: keyhole surgery to look for and treat endometriosis and adhesions, when other tests and treatments have not helped
• cystoscopy, colonoscopy or other tests when bladder or bowel causes are suspected

Treatment

A combined approach works best.

Medicines

• NSAIDs such as ibuprofen or naproxen, following the label dose, especially for period-related pain
• Hormonal treatments: combined hormonal contraception, progestins, the levonorgestrel IUD, and GnRH analogues or antagonists for endometriosis and adenomyosis
• Nerve pain medicines: amitriptyline, duloxetine, gabapentin or pregabalin
• Bladder-specific treatments for bladder pain syndrome
• IBS treatments such as antispasmodics, fiber and diet changes
• Alpha blockers and other medicines for some men with CP/CPPS

Long-term opioids are not recommended for chronic pelvic pain.

Pelvic floor physical therapy

Specialist physical therapists treat tight pelvic floor muscles with manual therapy, relaxation training, biofeedback and exercise. It is one of the most effective treatments for many people.

Psychological therapies

Cognitive behavioral therapy, pain education, mindfulness and sex therapy reduce pain and its impact.

Procedures and surgery

• laparoscopic excision of endometriosis or division of adhesions
• trigger point and nerve block injections
• hysterectomy for adenomyosis or severe endometriosis when other options fail and childbearing is complete
• neuromodulation in selected cases

Living with chronic pelvic pain

• keep active with gentle exercise such as walking, swimming or yoga
• use heat packs for cramps and muscle tension
• pace activities and plan rest
• seek a clinic or team with pelvic pain expertise if progress is slow
• connect with support groups

Frequently asked questions

What is the most common cause of chronic pelvic pain in women?

Endometriosis is one of the most common gynecological causes, but irritable bowel syndrome, painful bladder syndrome and pelvic floor muscle dysfunction are also very common. Many women have more than one contributing cause.

Can men have chronic pelvic pain?

Yes. Chronic prostatitis/chronic pelvic pain syndrome causes pain in the perineum, testicles, penis or lower belly, often with urinary symptoms and pain during ejaculation. Pelvic floor muscle problems are a frequent contributor.

How is chronic pelvic pain diagnosed?

It is diagnosed through a careful history, examination, urine and swab tests, and imaging such as transvaginal ultrasound or MRI. Laparoscopy may be used to look for endometriosis or adhesions when other tests are normal.

Can chronic pelvic pain be cured?

Some causes, such as endometriosis or adhesions, may be treated surgically with lasting relief. For many people, a combination of medicines, pelvic floor therapy and psychological support greatly reduces pain, even if it does not disappear entirely.

Does pelvic floor physical therapy help chronic pelvic pain?

Yes. Many people with chronic pelvic pain have tight, tender pelvic floor muscles. Specialist physical therapy using relaxation, manual therapy and biofeedback can significantly reduce pain, including pain during sex and urination.