Chronic pelvic pain is one of the most common symptoms in women, and generally refers to non-cyclical pelvic pain that lasts for more than 6 months. The pelvic cavity is the lowest part of the abdominal cavity, and the pain caused by organ lesions in the pelvic cavity mainly manifests in the lower abdomen, so clinically pelvic pain is also called lower abdominal pain. There are acute and chronic pelvic pains. Acute pelvic pain is caused by organ lesions or tissue damage in the pelvis, and the location and intensity of the pain are directly related to the damaged organ and the scope of the lesion. It has an acute onset, obvious clinical manifestations, no difficulty in diagnosis, and can usually be cured in a short time. Chronic pelvic pain is different from acute pelvic pain, it has the following characteristics:
1, there are many diseases that cause pain, but sometimes it is difficult to find any organic lesion even with various diagnostic methods, including laparoscopy and even abdominal dissection;
2. the degree of pain is not always proportional to the degree of lesion.
3, psychological factors may play an important role in the development of the disease process.
4, patients may be accompanied by depression, anxiety, paranoia and other symptoms;
5, where the cause is unknown and the longer the course of the disease, the less effective the treatment.
The common diseases of chronic pelvic pain
1, chronic pelvic inflammatory disease: is the most common cause of pelvic pain, including endometritis, fallopian tube ovarian inflammation, pelvic connective tissue inflammation and pelvic peritonitis. Chronic pelvic inflammatory disease accounts for about 23-30% of chronic pelvic pain.
Symptoms: pelvic pain is characterized by persistent dull pain and vague pain in the lower abdomen, but it can also be manifested as distension, cramping or lumbosacral cramping in the lower abdomen, aggravated by exertion or during menstruation, often accompanied by increased leucorrhea, excessive menstruation or dysmenorrhea. Long-term disease may cause systemic symptoms, such as fatigue, depression, insomnia, poor appetite and even wasting. When the patient’s resistance is poor, there may be acute or subacute attacks.
Signs: Signs of chronic endometritis are often not obvious, and if necessary, hysteroscopy can be performed to understand the endometrial condition. In chronic tubal-ovarian inflammation, in mild cases, thickened tubules may be palpated in one or both adnexal areas, with mild tenderness; in severe cases, cystic masses of varying size and irregular shape may be palpated in the bilateral adnexal areas or in the posterior side of the uterus, which are inactive and have tenderness. In cases of tubal effusion, the masses are mostly of the salami type. In the case of pelvic connective tissue inflammation, the uterus is posteriorly fixed with limited activity, bilateral parametrial tissue is lamellar thickened and painful, and the main ligament and uterosacral ligament are thickened and hardened. In severe cases, it is frozen, called “frozen pelvis”.
2, endometriosis: In women with chronic pelvic pain, laparoscopic examination reveals that 25% to 38% of them are endometriosis (endometriosis). As endometriosis often leads to pelvic adhesions and pelvic congestion, lower abdominal pain and lumbosacral cramping between menstrual periods may occur, which is aggravated before and during menstruation, and is often confused with pelvic pain caused by chronic pelvic inflammatory disease.
Symptoms: pelvic pain is characterized by secondary dysmenorrhea, progressive aggravation, often appearing at the beginning of menstruation and continuing throughout the menstrual period. The pain is mostly located in the deep lower abdomen and rectal area, mostly in the middle of the pelvis, but can also involve both sides of the pelvis and the pelvic wall, often accompanied by menstrual disorders, painful intercourse, infertility, intestinal or urinary tract symptoms, etc. Women of childbearing age or premenopausal with pelvic pain should be on high alert for endometriosis.
Signs: Signs of palpable nodules in the uterosacral ligament, lower posterior uterine wall, or vaginal rectal septum are easily missed during pelvic examination. The palm of the hand facing backward and palpation with the finger belly is more conducive to detecting positive signs, which can also be combined with triple diagnosis. If a cystic, inactive mass is palpated on one or both adnexa of the uterus and is closely adherent to the uterus, with light pressure pain, it is usually an ovarian endometriosis cyst.
3, pelvic vein stasis syndrome: is due to pelvic veins or plexus varicose, stasis of blood, resulting in chronic lower abdominal pain, post-coital pain, low back pain and other syndromes.
Symptoms: The pain is characterized by diffuse lower abdominal cramping, light in the morning and heavy in the evening, aggravated by prolonged standing and relieved or disappeared by lying on one side; the symptoms may also be heavier on one side; it may be accompanied by dysmenorrhea, painful intercourse, menstrual changes, bladder and rectal irritation and vegetative symptoms.
Signs: Mild deep pressure pain in the lower abdomen is the only positive sign in the abdominal examination of pelvic venous stasis syndrome. The signs are not obvious during gynecological examination and do not correspond to the severity of subjective symptoms. Abnormal filling of the labia majora, purple-blue vaginal and cervical mucosa, cervical hypertrophy, posterior position of the uterus, softness and fullness, and tenderness of the cervix and posterior vault can be found. It is easily misdiagnosed as chronic pelvic inflammatory disease.
4, pelvic tumor: if the ovarian malignant tumor infiltrates the surrounding tissues or compresses the nerves, it can cause abdominal pain, lumbago or lower limb pain.
Symptoms: The pain is characterized by persistent dull pain. It is often accompanied by abdominal distension, abdominal mass, ascites, etc. In the late stage, it can appear wasting, severe anemia and other cachectic signs.
In the advanced stage, cachexia, severe anemia and other signs of cachexia may appear.
Signs: Solid or semi-solid, irregular and inactive masses can be palpated in one or both adnexal areas on triage examination. Tubal cancer has the “triad” of intermittent vaginal discharge, cramping abdominal pain and cystic adnexal masses.
5.Pelvic adhesions: often caused by pelvic and abdominal surgery and its inflammation, the adhesions restrict the normal physiological activities of the pelvic cavity and its organs, thus causing pelvic pain.
Symptoms: Due to the different sites of adhesions, it can cause pain in different parts of the pelvis, and its pain characteristics: non-periodic, chronic persistent dull pain.
Signs: During physical examination, there may be a feeling of thickening in the adnexal area or poor mobility of the pelvic organs.
6. Residual ovarian syndrome: It is a syndrome caused by a small amount of functional ovarian tissue remaining after removal of the uterus and both adnexa.
Symptoms: Pain is periodic or frequent, mostly dull, non-radiating pain in the lower abdomen or lumbar ribs or pain during intercourse, a few are sharp, knife-like pain, and can also be manifested as irritable bowel syndrome or urinary frequency and urgency, the cause of which is difficult to explain.
Signs: No abnormal findings on pelvic examination.
7, interstitial cystitis: is a chronic non-bacterial bladder dysfunction, not accompanied by histological changes. Surveys show that 90% of patients with interstitial cystitis are female patients with an average age of 40-46 years.
Symptoms: The common symptoms of interstitial cystitis are urinary frequency, urgency, difficulty with intercourse and pelvic pain. Early symptoms are not obvious, but as the disease progresses and the bladder epithelium is damaged, chronic pelvic pain can occur, leading to decreased quality of life, depression, anxiety, and even suicidal tendencies.
Signs: Clinical examination reveals negative cervical culture results, positive cervical tenderness, and positive bladder pressure pain;
8, intestinal irritation syndrome: refers to the involvement of the small intestine and large intestine motor dysfunction, the cause of abdominal pain is not clear.
Symptoms: its pain characteristics: abdominal pain diffuse, no fixed pain points, the left lower abdomen is common, paroxysmal or continuous spasmodic pain, anxiety, tension, after eating and premenstrual pain, mostly accompanied by chronic constipation, and occasionally diarrhea.
Signs: Gynecological triage often reveals pressure pain in the sigmoid colon, but no other signs of intestinal inflammatory diseases.
9.Myofascial pain: It refers to pelvic pain involving active myofascial trigger points or nociceptive allergy points. Myofascial pain is characterized by chronic lower abdominal pain, which on examination is confined to a fixed point and appears as pressure pain when the finger is pressed on the point, and then the pain recurs or worsens;
10, musculoskeletal abnormalities: is one of the causes of chronic pelvic pain. The pain is characterized by the following: the degree and location of musculoskeletal pain often changes with the change of position or after activity, the pain is relieved significantly after rest, and the pain increases when the affected muscle is exerted. There are no abnormal findings in the pelvic examination, the patient often has some bad movement habits, correcting bad movement habits after the patient’s pain symptoms can be improved.
11, psychological factors: because many patients with chronic pelvic pain do not have histopathological changes, researchers have turned to the study of psychological factors, and found that chronic pelvic pain may be caused by emotional disorders, such as depression, anxiety, sexual dysfunction and other factors. Investigations showed that the etiology of chronic pelvic pain was caused by social factors in 5%-25% of cases. The pain is persistent, dull, non-radioactive, diffuse and easily changed, and it can be attacked when there are psychosocial factors, and the same pain is maintained for a long time without improvement or worsening after treatment. No abnormal findings on pelvic examination.