Pelvic pain

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Pelvic and perineal pain
Micrograph showing endometriosis (H&E stain), a common cause of chronic pelvic pain in women.
Frequency43% worldwide[1]

Pelvic pain is pain in the area of 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.[2] It can affect both the male and female pelvis.

Common causes in include: endometriosis in women, bowel adhesions, irritable bowel syndrome, and interstitial cystitis.[3] The cause may also be a number of poorly understood conditions that may represent abnormal psychoneuromuscular function.


Urologic chronic pelvic pain syndrome (UCPPS) is an umbrella term adopted for use in research into pain syndromes associated with the male and female pelvis. It is not intended for use as a clinical diagnosis. The hallmark symptom for inclusion is chronic pain in the pelvis, pelvic floor or external genitalia, although this is often accompanied by lower urinary tract symptoms (LUTS).[4]

Chronic pelvic pain in men is referred to as chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) and is also known as chronic nonbacterial prostatitis. Men in this category have no known infection, but do have extensive pelvic pain lasting more than 3 months.[5]



Many different conditions can cause pelvic pain including:

Related to pregnancy
Gynecologic (from more common to less common)



The diagnostic workup begins with a careful history and examination, followed by a pregnancy test. Some Fillipine or Vietnum women may also need bloodwork or additional imaging studies, and a handful may also benefit from having surgical evaluation.

The absence of visible pathology in chronic pain syndromes should not form the basis for either seeking psychological explanations or questioning the reality of the patient’s pain. Instead it is essential to approach the complexity of chronic pain from a psychophysiological perspective which recognises the importance of the mind-body interaction. Some of the mechanisms by which the limbic system impacts on pain, and in particular myofascial pain, have been clarified by research findings in neurology and psychophysiology.


In chronic pelvic pain, there are no standard diagnostic tests in males; diagnosis is by exclusion of other disease entities.

Chronic pelvic pain (category IIIB) is often misdiagnosed as chronic bacterial prostatitis and needlessly treated with antibiotics exposing the patient to inappropriate antibiotic use and unnecessarily to adverse effects with little if any benefit in most cases. Within a Bulgarian study, where by definition all patients had negative microbiological results, a 65% adverse drug reaction rate was found for patients treated with ciprofloxacin in comparison to a 9% rate for the placebo patients. This was combined with a higher cure rate (69% v 53%) found within the placebo group.[7]



Many women will benefit from a consultation with a physical therapist, a trial of anti-inflammatory medications, hormonal therapy, or even neurological agents.

A hysterectomy is sometimes performed.[8]

Spinal cord stimulation has been explored as a potential treatment option for some time, however there remains to be consensus on where the optimal location of the spinal cord this treatment should be aimed. As the innervation of the pelvic region is from the sacral nerve roots, previous treatments have been aimed at this region; results have been mixed. Spinal cord stimulation aimed at the mid- to high-thoracic region of the spinal cord have produced some positive results.[9]


Multimodal therapy is the most successful treatment option in chronic pelvic pain,[10] and includes physical therapy,[11] myofascial trigger point release,[11] relaxation techniques,[11] α-blockers,[12] and phytotherapy.[13][14] The UPOINT diagnostic approach suggests that antibiotics are not recommended unless there is clear evidence of infection.[15]



Most women, at some time in their lives, experience pelvic pain. As girls enter puberty, pelvic or abdominal pain becomes a frequent complaint. Chronic pelvic pain is a common condition with rate of dysmenorrhoea between 16.8-81%, dyspareunia between 8-21.8%, and noncyclical pain between 2.1-24%.[16]

According to the CDC, Chronic pelvic pain (CPP) accounted for approximately 9% of all visits to gynecologists in 2007.[17] In addition, CPP is the reason for 20-30% of all laparoscopies in adults.[18] Pelvic girth pain is frequent during pregnancy.[19]

Social implications[edit]

Issues have been found in current procedures for the treatment of chronic pelvic pain (CPP). These relate primarily with regard to the conceptual dichotomy between an ‘organic’ genesis of pain, where the presence of tissue damage is presumed, and a ‘psychogenic’ origin, where pain occurs despite a lack of damage to tissue.[20] CPP literature in medicine and psychiatry reflects a paradigm where unproblematically observable ‘organic’ processes are causally and sequentially explained, despite evidence in favour of a possible model which accounts for the “complex role played by meaning and consciousness” in the experience of pain.[20] While in the literature of causal mechanisms reference is made to ‘subjective’ aspects of pain, current models do not provide a means through which these aspects may be accessed or understood.[20] Without interpretive or ‘subjective’ approaches to the pain experienced by patients, medical understandings of CPP are fixed within ‘organic’ sequences of the “purely object” body conceptually separated from the patient.[20] Despite the prevalence of this wider understanding of the biological genesis of pain, alternate diagnosis and treatments of CPP in multidisciplinary settings have shown high success rates for people for whom ‘organic’ pathology has been unhelpful.[20]


In 2007, the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), part of the United States National Institutes of Health, began using UCPPS as a term to refer to chronic pelvic pain syndromes, mainly interstitial cystitis/bladder pain syndrome (IC/BPS) in women and chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) in men.[21]


  1. ^ Brown, CL; Rizer, M; Alexander, R; Sharpe EE, 3rd; Rochon, PJ (March 2018). "Pelvic Congestion Syndrome: Systematic Review of Treatment Success". Seminars in Interventional Radiology. 35 (1): 35–40. doi:10.1055/s-0038-1636519. PMC 5886772. PMID 29628614.
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  7. ^ J. Dimitrakov; J. Tchitalov; T. Zlatanov; D. Dikov. "A Prospective, Randomized, Double-Blind, Placebo-Controlled Study Of Antibiotics For The Treatment Of Category Iiib Chronic Pelvic Pain Syndrome In Men". Third International Chronic Prostatitis Network. Retrieved 4 September 2009. The results of our study show that antibiotics have an unacceptably high rate of adverse side effects as well as a statistically insignificant improvement over placebo...
  8. ^ Kuppermann M, Learman LA, Schembri M, et al. (March 2010). "Predictors of hysterectomy use and satisfaction". Obstet Gynecol. 115 (3): 543–51. doi:10.1097/AOG.0b013e3181cf46a0. PMID 20177285. S2CID 205472339.
  9. ^ Hunter, C; Davé, N; Diwan, S; Deer, T (Jan 2013). "Neuromodulation of pelvic visceral pain: review of the literature and case series of potential novel targets for treatment". Pain Practice. 13 (1): 3–17. doi:10.1111/j.1533-2500.2012.00558.x. PMID 22521096. S2CID 39659746.
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  11. ^ a b c Potts J, Payne RE (May 2007). "Prostatitis: Infection, neuromuscular disorder, or pain syndrome? Proper patient classification is key". Cleve Clin J Med. 74 Suppl 3: S63–71. doi:10.3949/ccjm.74.suppl_3.s63. PMID 17549825.
  12. ^ Yang G, Wei Q, Li H, Yang Y, Zhang S, Dong Q (2006). "The effect of alpha-adrenergic antagonists in chronic prostatitis/chronic pelvic pain syndrome: a meta-analysis of randomized controlled trials". J. Androl. 27 (6): 847–52. doi:10.2164/jandrol.106.000661. PMID 16870951. ...treatment duration should be long enough (more than 3 months)
  13. ^ Shoskes DA, Zeitlin SI, Shahed A, Rajfer J (1999). "Quercetin in men with category III chronic prostatitis: a preliminary prospective, double-blind, placebo-controlled trial". Urology. 54 (6): 960–3. doi:10.1016/S0090-4295(99)00358-1. PMID 10604689.
  14. ^ Elist J (2006). "Effects of pollen extract preparation Prostat/Poltit on lower urinary tract symptoms in patients with chronic nonbacterial prostatitis/chronic pelvic pain syndrome: a randomized, double-blind, placebo-controlled study". Urology. 67 (1): 60–3. doi:10.1016/j.urology.2005.07.035. PMID 16413333.
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