PELVIC PAIN

Pelvic pain is pain that occurs in the lower abdomen and pelvis.

The pelvic region is the area between the umbilicus (belly button) and the groin in the front and between the buttocks at the back. Pelvic area mainly consists of reproductive, urinary and digestive systems such as uterus, bladder and intestines.

Pelvic pain can be acute or chronic. Acute pelvic pain occurs suddenly and stays only for a short period of time.  Chronic pelvic pain lasts for more than six months and does not show any improvement with treatment.

Symptoms of Pelvic Pain

Pelvic pain may be dull or sharp; persistent or intermittent; mild to severe, and can extend to your lower back or thighs.

The common symptoms with pelvic pain are:

  • Pain in the hip and groin area

  • Pain and cramps during menstruation

  • Pain during urination, bowel movements, and intercourse

  • Fever or chills

  • Constipation or diarrhea

Causes of Pelvic Pain

Usually, pelvic pain is considered as an indication for infection or problem in the pelvic area. It is observed most commonly in women but can also occur in men.

The common causes of acute pelvic pain are:

  • Pelvic inflammatory disease (infection of the reproductive organs),

  • Urinary tract infection

  • Appendicitis (inflammation of appendix)

  • Ectopic pregnancy (pregnancy that occurs outside the uterus)

  • Twisted or ruptured ovarian cyst

  • Ruptured fallopian tube

  • Miscarriage or threatened miscarriage

  • Congestion or abscess (collection of pus) in the pelvic region

The common causes of chronic pelvic pain are:

Chronic pelvic inflammatory disease

  • Endometriosis (abnormal growth of uterus lining)

  • Interstitial cystitis (inflammation of urinary bladder)

  • Irritable bowel syndrome

  • Pelvic floor disorders (spasm or tension in the pelvic floor muscles)

  • Uterine fibroids (non-cancerous uterine growths)

  • Psychological factors such as stress, depression or a history of physical abuse

Diagnosis of Pelvic Pain

Your physician diagnoses pelvic pain by observing your pain symptoms, medical history, and by performing a pelvic examination.

For additional information, your physician may request

  • blood tests,

  • urine and culture test, pregnancy test, and

  • imaging studies.

The imaging studies such as X-ray, ultrasound, laparoscopy, CT (Contrast tomography) and Magnetic resonance imaging (MRI) scan are helpful in examining the pain source in the pelvic region.

Treatment of Pelvic Pain

Treatment for pelvic pain depends on the cause of pain, intensity and frequency of the pain.

Conservative management of pelvic pain includes

  • rest and

  • participating in regular physical therapy and

  • exercise.

Medication can be used to relieve

  • pain (pain killers),

  • muscle spasm/ contraction (muscle relaxants) and

  • to treat infection (antibiotics).

Dr Alexander may also instruct you to take hormonal medications for pain relief during ovulation and menstruation.

Surgery is considered for patients with chronic pelvic pain due to

  • endometriosis,

  • pelvic floor disorder, and

  • other chronic pelvic problems.

Laparoscopic surgery (removal of endometrial tissue or pelvic adhesion) and hysterectomy (removal of uterus) are the common surgical options for treating pelvic pain.

CHRONIC PELVIC PAIN

What is chronic pelvic pain?

Chronic pelvic pain is constant pain felt in the lower abdominal region and the pain may persist for longer duration, for more than six months.

What is the cause of chronic pelvic pain?

Chronic pelvic pain can be caused by different conditions that may or may not be related to reproductive organs such as pain due to urinary tract conditions. Cause for the pain may be unknown in some cases.

What are the symptoms?

The common symptoms include pain during periods, ovulation, intercourse, and pain when passing urine or bowel movements or lower back pain.

How is chronic pelvic pain diagnosed?

Chronic pelvic pain is diagnosed based on your medical history and pelvic examination. Certain tests such as

  • ultrasound,

  • laparoscopy,

  • cystoscopy,

  • colonoscopy and

  • sigmoidoscopy

are performed to find out the cause of your pain.

What are the treatment options for Pelvic Pain?

There are several treatment options to relieve chronic pelvic pain. They include

  • medications,

  • physical therapy,

  • nutrition and

  • surgery.

Lifestyle changes such as maintaining a good posture and regular exercise help reduce pain.

Pain medications such as nonsteroidal anti-inflammatory drugs may relieve pelvic pain. Vitamin B1 and magnesium supplements may help reduce pain.

Surgery to destroy nerves and block pain signals may be considered when all other treatment methods are unsuccessful.

Pelvic Floor Conditions

Pelvic floor is the group of muscles lining the pelvis. Any diseases or disorders that affect these pelvic floor muscles can lead to pelvic floor deformities. Local organs can also be affected including the bladder, urethra, vagina, anus, and rectum.

Some of the pelvic floor conditions are explained below

Urinary incontinence:  Refers to loss of bladder control resulting in involuntary leakage of urine. It commonly occurs in women due to pregnancy and childbirth, menopause and the structure of the female urinary tract. There are two types of urinary incontinence; stress incontinence and urge incontinence.

Stress incontinence – Refers to leakage of small amounts of urine during physical activities such as coughing, laughing, sneezing, or exercising that suddenly increases the pressure within the abdomen.

Urge incontinence – This condition refers to urine leakage with the sudden urge to urinate or unable to hold the urine.

Your physician diagnoses your condition through physical, pelvic and neurologic examination and suggests appropriate treatments.

Treatment for Pelvic Floor Conditions

The treatment options include

  • pelvic floor exercises,

  • bladder control techniques,

  • diet and

  • lifestyle changes,

  • urethral inserts,

  • sacral nerve stimulators, and

  • minimally invasive surgeries, and

  • biofeedback treatments.

PELVIC INFLAMMATORY DISEASE (PID)

Pelvic inflammatory disease (PID) is characterized by infection of the female reproductive organs, such as the uterus, fallopian tubes, and ovaries. It is mostly acquired through unsafe sexual practices and is one of the most serious consequences of sexually transmitted diseases (STD).

PID can cause permanent damage to the female reproductive system, and is one of the leading causes of infertility.

Causes of Pelvic inflammatory disease (PID)

PID can occur when your cervix is exposed to an STD, such as chlamydia or gonorrhea. The cervix loses its ability to protect the internal organs from bacteria and the infection eventually spreads to your uterus, ovaries, and fallopian tubes.

Ninety percent of PID occurs as a result of untreated chlamydia and gonorrhoea. Sexual practices that involve multiple partners and unprotected sex increase your chances of acquiring STDs, which can in turn lead to PID. Some of the other causes include:

  • Intrauterine device (IUD) use

  • Birthing

  • Miscarriage

  • Abortion

  • Endometrial biopsy (procedure to remove a piece of tissue from your uterine lining for examination)

  • Regular douching

  • Previous history of PID or STD

Symptoms of Pelvic inflammatory disease

Pelvic inflammatory disease PID can show minor symptoms or no symptoms at all (common with chlamydial infection). They can often vary, but may include:

  • Dull pain in your stomach and lower abdomen and pelvis

  • Green or yellow vaginal discharge, having a distinct and often unpleasant odor

  • Pain during urination

  • Irregular menses

  • Fever or chills

  • Nausea, vomiting or diarrhea

  • Pain in the lower back

  • Painful intercourse

If you notice these symptoms, it is important to stop having intercourse and visit Dr Alexander immediately, as prompt treatment is vital for PID.

Complications with Pelvic inflammatory disease

If left untreated, PID can cause scarring and collection of abscesses (infected fluid) in the fallopian tubes. PID can also lead to infertility or ectopic pregnancy (implantation of embryo outside the uterus). Scarring or damage can occur to other reproductive organs, which can cause chronic pelvic pain that can last for many months.

Diagnosis of Pelvic inflammatory disease

Based on your signs and symptoms, Dr Alexander may perform a pelvic examination, obtain a sample of your vaginal discharge, and perform cervical cultures and urine tests. Samples may be obtained from your cervix and vagina using a cotton swab, and sent to the laboratory to identify the bacteria causing the infection.

Dr Alexander may also recommend the following tests to confirm and determine the extent of your infection.

  • Blood tests,

  • Pelvic ultrasound to check your reproductive organs and exclude any abscesses ( pus collection ).

  • Endometrial biopsy

  • Laparoscopy, where a thin, lighted tube with a camera is inserted through a small cut in your abdomen to examine your pelvic organs

Treatment for Pelvic inflammatory disease

Confirmation of PID will be immediately followed by treatment. You will be started on oral antibiotic medications for mild cases of PID. For more severe cases, you may be treated with a combination of oral and intravenous medications, or hospitalized for more aggressive management. It is important that your partner also gets treated, even if he does not have any symptoms, in order to prevent future recurrence of the infection.

If antibiotics fail to clear the infection, and if the infection forms abscesses in your uterus or ovaries, you may be recommended to undergo laparoscopy for removal of abscess and pelvic wash, occasionally oophorectomy ( removal of the ovary ) is necessary or salpingectomy ( removal of tube ) if filled with pus..

When your infection, abscess, or inflammation has cleared, but you are still experiencing chronic pelvic pain, you may be recommended to undergo a nerve ablation surgery, where the nerves that provide sensation to your pelvic organs are surgically removed or destroyed.

Prevention of Pelvic inflammatory disease

Prevention is the best way to deal with PID.

  • Avoid unsafe sexual practices, multiple partners, and use barrier methods such as condoms and spermicides.

  • Avoid IUD if you have multiple partners.

  • Watch for symptoms and be prompt to get treatment.

  • Have regular follow up with Dr Alexander, as infections identified during the early stages can be prevented from spreading to your reproductive organs.

  • Avoid douching, as douching disturbs the fragile balance of bacteria in your vagina, masks your vaginal discharge, and pushes the bacteria up into the genital tract. 

PELVIC CONGESTION SYNDROME

Pelvic Congestion Syndrome (PCS), also known as pelvic venous insufficiency, is one of the causes of chronic pelvic pain in women.

Symptoms of Pelvic Congestion Syndrome

PCS is characterised by worsening pelvic pain on sitting or standing for a long time but is relieved on lying flat. The pain can also be worse following urination or menstrual periods or intercourse.

Causes of Pelvic Congestion Syndrome

The typical age of women with this condition ranges from 20 to 45 years and in women with multiple pregnancies. The weight gain and anatomic changes in the pelvic structures during pregnancy may cause enlarged ovarian and/or pelvic veins.

Hormonal changes associated with pregnancy are also known to weaken the walls of the ovarian and/or pelvic veins. The dilated veins cause dysfunction of the vein valves leading to backward flow of blood that pools within the pelvis. This pressure results in pain in the pelvic region and may also cause visible abnormal veins.

Diagnosis of Pelvic Congestion Syndrome

PCS may go undiagnosed in many cases as the lying down position of the individual during the pelvic examination relieves the pressure over the ovarian veins and hence may not be noticed during the examination.

PCS is best diagnosed based on the report of the symptoms experienced by the patient and a physical examination. Dr Alexander may recommend imaging techniques to detect the presence of abnormal veins.

These include:

  • Pelvic Venography - is an invasive diagnostic procedure most commonly used to diagnose PCS. To conduct the venography, the patient lies on a tilting table. During the test, X-rays are used to visualise the abnormal veins. A contrast dye is injected through a catheter (small tube) placed in the veins of the pelvic region and the images are captured.

  • Pelvic ultrasound and Transvaginal ultrasound may also be performed to exclude other causes of chronic pelvic pain.

Treatment for Ovarian vein embolization

Ovarian vein embolization (OVE) is a minimally invasive treatment for PCS.

This can be performed as an outpatient procedure, with most patients going home after a few hours of observation and returning to normal activity within 24 hours.

Ovarian vein embolization OVE is an effective and safe procedure to block blood flow to the veins causing pelvic congestion. The procedure is performed using X-rays and a contrast dye to visualise the abnormal veins. Under the imaging-guidance, a catheter is placed in the blood vessel and advanced to the treatment site. A dye is then injected through the IV (intravenous) line and a series of X-rays are taken to locate the abnormal area.

An embolic agent (medication) is then introduced into the catheter and additional X-rays are taken to confirm all the abnormal veins are embolized. This blocks the blood flow in these veins and subsequent pooling of blood within the pelvis is prevented.

PELVIC PAIN DIAGNOSIS & LAPAROSCOPY

Pelvic pain is one of the common gynaecological problems which may be caused by various conditions.

What Pelvic Pain Could Mean?

Pelvic pain is a characteristic symptom of various gynaecological conditions. Assessing the exact cause for pain is essential to treat the condition.

Laparoscopy helps in assessing the exact cause of the pain such as:

  • presence of scar tissue,

  • infections,

  • ovarian cysts,

  • gastrointestinal problems,

  • urinary problems,

  • musculoskeletal problems and

  • other conditions.

Assessing the exact cause for pain is essential to treat the condition.

During the procedure, the surgeon makes a small incision in the abdomen, usually at or below the belly button, and inserts a tube through which the laparoscope is introduced into the abdomen. Laparoscope helps in examining the pelvis and the images can be viewed on the large screen.

A special contrast dye may also be injected before the procedure for better visualization of the fallopian tubes. After the procedure, the incisions are closed with stitches and covered with bandages.

About Laparoscopy Procedure

During the procedure, the surgeon makes a small incision in the abdomen, usually at or below the belly button, and inserts a tube through which the laparoscope is introduced into the abdomen.

The laparoscope helps in examining the pelvis and the images from the camera are projected onto a large screen for the surgeon to view.

A special contrast dye may also be injected before the procedure for better visualization of the fallopian tubes. After the procedure, the incisions are closed with stitches and covered with bandages.

Laparoscopy Complications

Like all surgical procedures, laparoscopic procedures may be associated with certain complications, which include:

  • Bleeding

  • Urinary tract infection

  • Injury to bladder or urethra

  • Injury to bowels

  • Irritation or inflammation at the opening of the vagina

  • The advantages of laparoscopic procedures when compared to open laparotomy include:

  • Reduced hospital stay

  • Smaller incisions and less scarring

  • Less postoperative pain

  • Faster recovery