Gynaecological causes:
A variety of gynaecological problems may be associated with pelvic pain.
- Endometriosis: Endometriosis is one of the leading gynaecological causes of pelvic pain. It may be associated with constant pain or with pain that is exacerbated during the periods (dysmenorrhoea). Pain may also occur during sex (dyspareunia) or when opening the bowels (dyschezia). For more information, see my section on Endometriosis.
- Adenomyosis: This refers to the invasion of womb lining tissue into the muscle of the wall of the womb. Adenomyosis is most often found in women who are in their thirties and forties and have had children.
- Scarring (Adhesions): Adhesions are “scar tissue” that may be caused by previous surgery, endometriosis or previous pelvic infection. Very fine adhesions are not thought to be a cause for pain. Dense adhesions that have a blood supply and which restrict free movement of structures such as bowel may be associated with pain.
- Pelvic inflammatory disease (PID): Studies indicate that chronic pelvic pain may occur in 18-33% of women after an episode of PID. PID is caused by sexually transmitted infections brought about by agents such as Chlamydia and Gonorrhoea. It is not clear exactly what causes pain once the acute inflammatory episode of PID is over but adhesions have been suggested as one cause.
- Ovarian cysts
- Pelvic congestion syndrome: This refers to swelling (or dilatation) of the pelvic veins.
- Fibroids: Typically, fibroids are thought to cause pain with periods (cyclical pain) and a feeling of pressure, rather than persistent pain throughout the cycle.
Problems with the urinary system:
- Bladder inflammation (Interstitial Cystitis): This is a common contributor to pelvic pain and often co-exists with endometriosis.
- Chronic urinary tract infections
- Bladder stones
Problems with the gut (gastrointestinal problems):
- Irritable Bowel Syndrome (IBS): As many as 50-80% of women with pelvic pain have symptoms suggestive of IBS. Pain associated with IBS may be cyclical as bowel symptoms worsen during menstruation in 50% of women.
- Inflammatory bowel disease
- Chronic constipation
- Chronic appendicitis: Around 20% of women with endometriosis also have appendiceal disease.
- Diverticular disease
- Chronic intermittent bowel obstruction
Problems with the musculoskeletal and/or nervous system:
- Myofascial pain and spasm of pelvic floor muscles: In one study of women who had had a normal laparoscopy, pain was related to a myofascial problem in 30% of cases. Pain arises from excessive muscle spasm that may produce a tight band of muscle in the pelvic floor.
A myofascial trigger point is a focus of excessive sensitivity located within the muscle or it’s covering tissue (known as fascia) that causes pain. Trigger points may occur in response to misalignment of the pelvic bones, injury to pelvic floor muscles, endometriosis, sleep disorders, fatigue and psychosocial stress. - Nerve entrapment: Nerves may become trapped leading to pain. This pain is usually very localised over the area supplied by the nerve. Nerves may become trapped within scar tissue arising from previous operations. Nerve entrapment could also lead to the development of myofascial trigger points.
- Changes to the nervous system: The activity of nerves carrying pain sensations, or the perception of nervous impulses by the brain, may be altered in some women leading to an increased sensation of pain. Changes in nerve activity may be triggered by damage brought about, for instance, by surgery or infection. Pain due to changes in nerves is known as “neuropathic pain” and often produces pain that is burning or shooting in nature.
- Spinal disc problems
- Hernias
Psychological problems:
Pre-existing psychological issues can exacerbate pain. The converse is also often seen; pain brings on psychological problems that further intensifies the pain, leading to a vicious cycle.
- Anxiety and depression: Clinical depression develops in 25-50% of patients with chronic pain and if left untreated can be an obstacle to pain control.
- Sleep disturbance
- Sexual or physical abuse: 25-50% of women with chronic pelvic pain have abuse histories
- Substance abuse: Alcohol, narcotics or other drugs.
- Psychological stress related to marital problems or work.