Epidemiology.
Chronic Pelvic Pain (CPP) is one of the common symptoms in gynecology, a group of diseases or syndromes in which pain in the pelvis and surrounding tissues is the main symptom caused by organic or (and) functional causes for more than 6 months. the prevalence of CPP in the population is 3-15%, accounting for 16,9%-25,0% of gynecologic diseases. CPP is associated with 10%-15% of gynecologic visits and 12%-30% of total hysterectomies. Its insidious onset, complex etiology, difficult treatment, low cure rate, and recurrent disease seriously endanger the physical and mental health and quality of life of women, such as causing sexual discomfort, reducing the fertility of patients, and even accompanied by the emergence of depression or anxiety.
Patients suffer from long-term economic, physical and mental torment. In recent years, chronic pelvic pain has become a public health problem due to its increasing incidence. Therefore, it has become the responsibility and mission of gynecologic clinicians to find an effective clinical treatment. The high prevalence, the seriousness of its effects and the difficulty of its diagnosis and treatment have made CPP a worldwide health problem.
Definition.
Chronic pelvic pain (CPP) is defined as pelvic pain in the pelvis, umbilicus or anterior abdominal wall below the umbilicus, lumbosacral region or buttocks for more than six months that is not relieved by analgesic drugs and is not related to the physiological cycle. The pain can be constant or intermittent. It is common in women of childbearing age and not only impairs the patient’s physical and reproductive capacity and causes mental distress, but also seriously affects the patient’s psychosocial status and family relationships.
Classification.
Pelvic pain can be divided into visceral pain and somatic pain. Visceral pain comes from the bowel, bladder, uterus, fallopian tubes, and ovaries; somatic pain comes from the skin of the lower abdomen, vulva, anus, urethra, fascia, muscles, and wall peritoneum.
Etiology.
The etiology of CPP is complex, and many diseases such as pelvic inflammatory disease, endometriosis, pelvic stasis syndrome, postoperative adhesions, and certain medical and surgical diseases can cause chronic pelvic pain. Chronic pelvic pain can be caused by a single disease or by a combination of factors. 50% of patients have a combination of urologic disease or irritable bowel syndrome, while more than 30% of CPPs have no clear cause. Many gynecological diseases or psychological factors have been found to be associated with the occurrence of CPP, such as drug or alcohol abuse, abortion, excessive menstruation, pelvic inflammatory disease, history of previous cesarean section, abusive experiences, and psychological comorbidities, which can increase the incidence of CPP.
In summary, the etiology can be broadly categorized as: gynecologic and non-gynecologic factors.
Gynecologic factors: only 20% of chronic pelvic pain is due to gynecologic diseases such as endometriosis, pelvic inflammatory diseases, pelvic adhesions, uterine fibroids, pelvic stasis syndrome, adenomyosis, and pelvic floor dysfunction and its related surgical treatment.
a.
Pelvic inflammatory disease PID is the most common cause of CPP and is commonly found in women during their reproductive years, mostly caused by retrograde infection. The probability of chronic pelvic pain caused by pelvic inflammatory disease is 20%, while the probability of chronic pelvic pain caused by 3 or more PIDs increases to 67%. It can cause pain due to adhesions, congestion and edema, and distortion of pelvic organs, and can lead to infertility and ectopic pregnancy because the local inflammatory pelvic environment interferes with reproductive processes such as fertilization, gamete and fertilized egg transport, and embryo implantation. CPP in chronic pelvic inflammatory disease is mainly related to abnormalities of the fallopian tubes, ovaries, pelvic tissues and morphological structures due to inflammation. Repeated episodes of chronic pelvic inflammatory disease can significantly increase the incidence of CPP.
b. Adenomyosis and endometriosis: it is one of the main causes of pelvic pain. The incidence of endometriosis has increased significantly in recent years and has become a common disease in gynecology. Abdominal pain in endometriosis is characterized by secondary, progressive dysmenorrhea, which can be accompanied by menstrual disorders, infertility, and mental and psychological changes. Eighty percent of patients with endometriosis suffer from chronic pelvic pain. Clinicopathophysiological studies have found that the cause of CPP in pelvic endometriosis is related to recurrent bleeding from the ectopic lesion and the resulting tissue adhesions. Deeply infiltrating endometriotic lesions can infiltrate the subperitoneal nerves leading to severe CPP, while adenomyosis is caused by extensive bleeding from endometriotic lesions in the myometrium during menstruation, which stimulates abnormal contractions of the uterus, produces large amounts of prostaglandins, destroys uterine smooth muscle cells, produces inflammatory mediators, and stimulates or damages nerve endings and produces pain.
c.Pelvic adhesion (Pelvic
Adhesions may be one of the causes of pelvic pain, but it does not mean that all adhesions cause pelvic pain, only about 20% to 50% of CPP patients have adhesions.
～Adhesions are present in about 20% to 50% of CPP patients. Postoperative adhesions do not have a constant proportional relationship with pelvic pain, but if adhesions restrict the free movement of pelvic organs, they can cause pelvic pain. Depending on the site of adhesions, they can cause pain in various parts of the pelvic and abdominal cavity. It also correlates with the patient’s age, degree of pelvic inflammation, and surgical history. Among the inflammatory conditions pelvic tuberculosis and adnexal abscess are the most common. Postoperative adhesions are also one of the etiologies of chronic pelvic pain. According to laparoscopic or autopsy data, women with a history of pelvic and abdominal surgery have an intra-abdominal adhesion rate of 60% or 69%, respectively.
d. Pelvic stasis syndrome (PCS) is a specific syndrome caused by chronic stasis in the pelvic veins, with chronic pelvic pain as the main clinical manifestation.
The majority of PCS patients have ovarian varicose veins, so it is also called ovarian venous insufficiency or ovarian venous syndrome. p C S clinical characteristic symptoms are ” three pains, two more, one less”, namely: lower abdominal pain, low back pain, deep intercourse pain; more menstrual volume, more vaginal discharge; less positive signs. The pain is mostly seen in young menstruating women
The pain can sometimes radiate to the lower limbs, perineum and lumbosacral region, and is aggravated by increased pelvic vein congestion before or during menstruation, fatigue, uprightness, etc., and can be relieved by lying down and elevating the thighs.
e. Pelvic pain caused by tumor, adnexal torsion, endometriosis cyst, adnexal tumor, etc. can easily lead to acute pelvic pain. When fibroids compress the surrounding organs, they can cause pain and pressure symptoms. Pelvic symptoms are related to the size and location of fibroids. There are 5 kinds of causes of pain caused by tumor: ① pain caused by tumor itself; ② pain caused by tumor treatment; ③ pain indirectly related to tumor; ④ concomitant diseases not related to tumor; ⑤ psychological and social factors.
f.
Uterine prolapse and retroflexed uterus Uterine prolapse changes the normal anatomical relationship of pelvic floor tissues, fascia and ligaments. Retroflexed uterus tends to cause tortuous pelvic plexus, which affects venous reflux and can be accompanied by CPP; retroflexed uterus can be accompanied by chronic pelvic pain, lower back pain, excessive menstruation, painful intercourse, and occasionally bladder or bowel dysfunction.
g. Residual ovarian syndrome Ovarian residual syndrome (ORS)
Remnant Syndrome (ORS) is a condition in which a small amount of cortical tissue unintentionally remains in the pelvis after complete ovariectomy, resulting in a range of symptoms such as chronic pelvic pain.
Non-gynecological factors: including digestive system diseases, urological system diseases, musculoskeletal system diseases, neurological system diseases and psychological factors, etc.
a. Urinary system diseases CPP caused by urinary system diseases is often aggravated when the bladder is full and relieved after urination. It mainly includes interstitial cystitis (IC), neurogenic pain, and urethral syndrome (US).
b.
Digestive system disorders Because of the diffuse nociception and inaccurate localization of the gastrointestinal tract, many CPPs are often confused with some gastrointestinal tracts, so it is also important to be familiar with the anatomical and physiological characteristics of the digestive system. Patients mostly have a history of abnormal bowel movements.
c.
Diseases of the neurological, muscular and skeletal systems Skeletal muscle-derived CPP is significantly characterized by pain relief at rest and aggravation after exercise or exertion, without nocturnal pain or rest pain.
d.
Psychological studies increasingly suggest that chronic stress and catastrophic life events (including sexual and somatic injuries) are associated with CPP, and many patients do not have pathological changes, and the probability of psychological aspects causing the disease is about 5%-25%. Pain can be caused by psychological factors and is characterized as not triggered or aggravated by examination, episodes in the presence of psychosocial factors, diffuse, persistent, and dull pain. 60% of patients with chronic pelvic pain may have had premature sex, or have been abused, or feel disappointed, anxious, or have experienced marital discord, or material deprivation, or sexual dysfunction. are closely related.
Diagnosis.
Often, pelvic pain is often characterized by chronic symptoms and it is not easy to find the exact cause, when the relationship between symptoms and etiology is difficult to determine. Therefore a thorough history and a comprehensive examination are important steps in the diagnosis of chronic pelvic pain.
For those with chronic pelvic pain as the main complaint, detailed questions should be asked about the nature of pain, duration, relationship with menstrual cycle and relationship with body position, etc., and the diagnosis should be made by combining history, physical signs and auxiliary examinations to facilitate treatment. First, a series of examinations such as barium meal to exclude gastrointestinal diseases, intravenous pyelogram to exclude urinary tract diseases, pelvic ultrasound to exclude gynecological diseases, and blood routine and blood sedimentation to exclude chronic pelvic inflammatory diseases should be performed based on medical history and physical examination. If patients are found to have gastrointestinal, urinary tract or skeletal and muscular symptoms and signs, they should be consulted and treated by the relevant specialists, and those with combined psychoneurological symptoms should undergo psychological counseling at the same time. For patients with chronic pelvic pain of complex etiology, it is often necessary to include gynecology, urology, gastroenterology, psychiatry, pain department and other related departments to work together to reach a clear diagnosis.
4. What is done in chronic pelvic pain clinic.
Pain is influenced by many factors, including physical, social and psychosocial aspects. In modern medical concept, CPP can be understood as a comprehensive disease model with three levels of “social-psycho-biological”. Improper management at any level can affect the outcome of treatment. Our team is dedicated to helping you find the causes of your pain that may be increasing your perception of pain. Every woman’s experience of pain is different, so we conduct a thorough and comprehensive assessment of the patient’s pain during the initial consultation. The evaluation includes a thorough history and physical examination, appropriate imaging, and a multidisciplinary approach that takes into account and intervenes appropriately with the patient’s psychological status and social and family relationships. After a thorough evaluation of the patient, our team members discuss and decide on an individualized treatment plan for each patient.
5. The composition of our team.
Pain Specialists.
Medication: The pain physician may use medication to relieve your pain. Principles of medication include the following: (1) Combine treatment of the cause with pain relief. (2) Emphasis on functional improvement. (3) Use of medications to improve mental and psychological status when neuropathic factors are involved. （The pharmacological treatment of CPP includes analgesics, hormonal drugs, antidepressants and psychological adjustment drugs. Pain relief is often the main treatment objective in clinical practice. The pain specialist will also instill in the patient knowledge about pain, such as how it arises, why it persists, etc. If the pain physician believes that your pain is neurological in nature, then we may treat you with a nerve block.
Surgical treatment: Patients with chronic pelvic pain that has been untreated for a long time and whose cause is difficult to define may be considered for laparoscopy. Laparoscopy is an important tool for clinical gynecologists to diagnose CPP, which is minimally invasive, less painful for patients, good clinical compliance, less surgical complications, less chance of postoperative pelvic adhesions, and low recurrence rate after surgery. The positive diagnostic rate can reach 83%, which is the main diagnostic basis for clinical diagnosis of CPP, and 80% of CPP can be clinically resolved after microscopic treatment. Laparoscopy provides direct visualization of the general changes in pelvic tissues and organs, and if necessary, biopsies can be taken for pathological examination, which can provide strong evidence for the etiological diagnosis of CPP, while surgery can be performed for treatment. Laparoscopy is currently considered the gold standard for the diagnosis of unexplained CPP, and laparoscopic surgery is also the best option.
Physiotherapists: When the pelvic floor is abnormal, patients may experience lower abdominal pain, vulvar pain, urinary symptoms (e.g., frequent urination) or bowel symptoms (e.g., constipation and painful bowel movements). The physiotherapist will also provide advice on lifestyle changes and enhance pelvic floor function training to reduce pain and improve the patient’s ability to perform daily tasks.
Psychological counselor: Numerous studies have demonstrated that patients with CPP have emotional, cognitive, behavioral, sexual, and social problems, and the more severe the patient’s presentation, the worse the prognosis. Chronic pelvic pain caused by psychosocial factors accounts for 5-25% of cases. Therefore, the impact of psychological and social factors on CPP cannot be ignored. Our counselors will help you find a better way to deal with chronic pelvic pain. Treatments offered include Cognitive Behavior Therapy (CBT).
The goal of CBT is to help the patient understand that she has the ability to control her thoughts, emotions and behaviors, and the evidence shows that CBT is an effective treatment for chronic pelvic pain.
In summary, treatment should be symptomatic, fully assessing the role of psychotherapy and physical therapy, and should be multidisciplinary and comprehensive, including organic, functional, and psychological conditions.