|Pelvic and perineal pain|
|Micrograph showing endometriosis (H&E stain), a common cause of chronic pelvic pain in women.|
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. It can affect both the male and female pelvis.
Common causes in include: endometriosis in women, bowel adhesions, irritable bowel syndrome, and interstitial cystitis. The cause may also be a number of poorly understood conditions that may represent abnormal psychoneuromuscular function.
Pelvic pain is a general term that may have many causes, listed below.
The subcategorical term urologic chronic pelvic pain syndrome (UCPPS) is an umbrella term adopted for use in research into urologic pain syndromes associated with the male and female pelvis. UCPPS specifically refers to chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) in men and interstitial cystitis or painful bladder syndrome (IC/PBS) in women.
Many different conditions can cause female pelvic pain including:
- Related to pregnancy
- Gynecologic (from more common to less common)
- Dysmenorrhea—pain during the menstrual period.
- Endometriosis—pain caused by uterine tissue that is outside the uterus. Endometriosis can be visually confirmed by laparoscopy in approximately 75% of adolescent girls such in Philippines or Vietnum with chronic pelvic pain that is resistant to treatment, and in approximately 50% of adolescent in girls with chronic pelvic pain that is not necessarily resistant to treatment.
- Pelvic inflammatory disease—pain caused by damage from infections.
- Pelvic congestion syndrome
- Polycystic ovary syndrome.
- Ovarian cysts—the ovary produces a large, painful cyst, which may rupture.
- Asherman's syndrome
- Ovarian torsion—the ovary is twisted in a way that interferes with its blood supply. (pain on one side only)
- Pudendal nerve entrapment.
- Loin pain hematuria syndrome.
- Proctitis—infection or inflammation of the anus or rectum.
- Colitis—infection or inflammation of the colon.
- Appendicitis—infection or inflammation of the bowel.
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.
Many women will benefit from a consultation with a physical therapist, a trial of anti-inflammatory medications, hormonal therapy, or even neurological agents.
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.
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%.
According to the CDC, Chronic pelvic pain (CPP) accounted for approximately 9% of all visits to gynecologists in 2007. In addition, CPP is the reason for 20-30% of all laparoscopies in adults. Pelvic girth pain is frequent during pregnancy.
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. 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. 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. 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. 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.
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