CHRONIC PELVIC PAIN

WHAT IS CHRONIC PELVIC PAIN?

Chronic pelvic pain is defined as severe pain that lies below the umbilicus for at least six months. This pain can cause disruption in daily lifestyle functioning and may require treatment.

WHAT CAUSES CHRONIC PELVIC PAIN?

There are several entities that can be a cause of chronic pelvic pain. Several major body systems comprise of causes of chronic pelvic pain. These are most commonly the gynecologic, urologic, musculoskeletal, gastrointestinal, psychological and neurologic systems. In each system there are several causes as well. Below is a list of probable causes by body systems, in no particular order for cause of pain.

Fibroid symptoms vary from woman to woman, but they include:

• Heavy menstrual bleeding (normal menses last up to 7 days).
• Pelvic or abdominal pain.
• Pelvic pressure on the bladder which can cause the bladder to feel full with little urine or require frequent urination.
• Pressure on the rectum, and in some can cause constipation or difficulty with bowel movements.
• Lower back pain.
• Pain during sexual intercourse.
• Difficulty achieving pregnancy.
• Pelvic or abdominal swelling or bloating.
• Potential complications during pregnancy, including
  • Preterm labor or preterm Contractions.
  • Fetus in breech presentation requiring cesarean section.

DIAGNOSIS

• Sometimes fibroids can be palpated on pelvic or abdominal exam as large, firm masses.
• Fibroids can be seen on Ultrasound, CT Scan and MRI.
• Sometimes we will also perform a fluid-filled ultrasound (Hysterosonogram/Sonohysterogram) to better identify the location and number of all of the fibroids, especially if they are located inside the uterus.

TREATMENT

Treatment depends on the symptoms that you are experiencing, whether they are bleeding symptoms or symptoms associated to the bulk effect of fibroids.

 If your main symptom is bleeding, there are some medication options including:

• Non-steroidal Anti-inflammatory (Ibuprofen etc)
• Tranexamic Acid
• Birth Control Pills, Ring, Patch
• Birth Control Shot
• Intrauterine Device
• GnRH Agonist, also known as Lupron
• GnRH Antagonist (Oriahnn)

Surgical procedures can resolve bleeding and bulk symptoms. Options vary depending upon whether you desire future pregnancy.

Myomectomy, or surgical removal of the fibroids and preserves the uterus. Depending upon the location, number and size, this procedure may be performed via different routes.

• Hysteroscopy (only for fibroid located within the uterus): fibroids removed via a camera placed through the cervix (no incisions are made).
• Laparoscopy: fibroids removed via 3-4 small incisions made on the abdomen.
• Robotic: Fibroids removed again with 3-4 small incisions with the assistance of a surgical robot.
• Laparotomy: Fibroids removed via a larger incision on the abdomen.
• Radiofrequency Fibroid Ablation (shrinks the fibroids and preserves the uterus).
  • Accessa- Performed via 3-4 abdominal incisions.
  • Sonata (link)- Performed via a handpiece placed through the cervix. This is an incision-free treatment that shrinks fibroids to reduce symptoms. Charles E. Miller, MD & Associates is the only team in Chicago that offers the Sonata Treatment through Lutheran General Hospital.
• MRI guided High Intensity Focused Ultrasound: Uses high intensity ultrasound waves to shrink the fibroids. It is only available at certain centers in the United States.
• Uterine Fibroid Embolization (UFE): Performed by an interventional radiologist to block the blood vessels that feed the fibroid and cause them to shrink over time.
• Hysterectomy: Removal of the uterus and fibroids.
  • Resolves current symptoms and risk of future fibroid growth. At Charles E. Miller, MD & Associates, we perform these procedures almost entirely laparoscopically (through 3-4 small abdominal incisions approximately 1cm each).

What are the reasons to have a Hysterectomy?

Hysterectomy is the most common gynecologic procedure performed in the United States. However, the numbers of cases seem to be decreasing due to advances in medicine allowing patients less invasive options.

If these less invasive options fail or are not recommended on an individual basis, women may be offered a hysterectomy for:

• uterine fibroids
• pelvic pain
• endometriosis
• pelvic adhesions
• abnormal uterine bleeding
• uterine prolapse
• pre-cancerous/cancerous disease. 

A hysterectomy is rarely performed on an emergent basis and the decision to proceed with this surgery should be mutually agreed upon by the woman and her surgeon after discussing hysterectomy risks and benefits, alternatives, fertility desires and expectations after the surgery.

What are the risks/benefits to a Hysterectomy?

Please refer to the link Surgical Risks on the home page.

The benefit to having a hysterectomy is that it is allows for complete resolution of any symptoms caused by the uterus without the risk of the symptoms coming back. It is a definitive approach to managing symptoms if other treatment options have failed or a woman is not a candidate for other therapies.

Are there different ways to perform a Hysterectomy?

There are three different approaches to a hysterectomy:

Abdominal incision. The most traditional technique is through a single, approximately 4-6 inch, abdominal incision. If the indication for surgery is non-cancerous or the uterus is not too large, the incision is made horizontally about 2 finger-breadths above the pubic bone, also known as the “bikini incision”, otherwise, a midline, vertical incision may be recommended.

The hospital stay is about 2 to 4 days long and the recovery is about 6 to 8 weeks long.  This technique can be applied to both total and subtotal hysterectomies.

Vaginal approach. There are no abdominal incisions, however, only a total hysterectomy can be performed. The uterus also has to be mobile and small enough to fit through the vaginal canal.  The hospital stay is usually one night. The postoperative pain is significantly less than an abdominal hysterectomy.

However, recovery is still about 6 weeks long so that the vaginal cuff, where the cervix once use to be, can heal from the sutures. Most women resume daily activities, other than intercourse at about 2 weeks.

 Laparoscopic approach.  This technique involves 3 to 4, less than ½ an inch skin incisions to perform.  The patient may go home the same day or stay overnight. Postoperative pain is significantly less than the abdominal approach.

The recovery is about 2 weeks long if a subtotal hysterectomy is performed. If a total hysterectomy is performed, 6 weeks of no intercourse is recommended if the cervix is removed so that the vaginal cuff can heal. Most women resume other daily activities within 2 weeks.

Advantages of the laparoscopic approach versus the vaginal approach

Large uteri can be removed as well as other abdominal pathology, such as endometriosis, ovarian cysts, etc.  Laparoscopy is a newer approach to hysterectomy and involves a surgeon skilled in this technique.  In our practice, our surgeons are well trained in laparoscopy and can safely perform simple and difficult hysterectomies using this approach.

• Endometriosis – Implants of cells of the lining of the uterine cavity (endometrium) outside of the uterus in the pelvis, potentially causing inflammation, scarring, and/or pain.
• Adenomyosis – Implants of cells of the lining of the uterine cavity (endometrium) growing into the muscle of the uterus causing painful periods and abnormal uterine bleeding.
• Pelvic Adhesions – Scar tissue formed from an inflammatory process, such as endometriosis, chronic infection, bowel disease, or previous surgery, that distorts the normal pelvic anatomy limiting its natural mobility.
• Pelvic Congestion – Pooling of blood in the veins (varicosities) of the uterus and ovaries causing pain after long periods of standing, deep penetration with intercourse and pain after intercourse. With this condition, pain seems to improve with laying down and rest.
• Pelvic Inflammatory Disease – Infection causing inflammation and possibly scar tissue. It is caused by sexually transmitted bacteria that spreads to your uterus, fallopian tubes or ovaries.
  • How it’s treated: Antibiotics may be prescribed. Surgery may be recommended if an abscess has formed in the fallopian tube and/or ovary and symptoms are not improving on antibiotics.
• Uterine Fibroids – Non-cancerous growths of the uterine muscle causing space-occupying symptoms, such as pressure and pain.
• Cancer of the pelvic organs – Abnormal cell growth of the pelvic organs can cause increasing inflammation and scarring as it continues to grow.
• Ovarian Remnant Syndrome or Residual Ovarian Syndrome – Part of the ovary is left behind from a previous surgery causing ovarian function to continue, which may have been the source of pain initially.

Urologic

• Interstitial Cystitis or Painful Bladder Syndrome – Chronic inflammation of the bladder causing pain, urgency and frequency
• Urinary Tract Infections – If recurrent, can cause chronic pain

Musculoskeletal

• Pelvic Myofascial Pain – Pain occurring from the pelvic floor muscles that involuntary spasm, usually during intercourse or from prolonged periods of sitting.
  • How it’s treated: Pelvic floor physical therapy may be recommended to help identify the muscles involved and provide feedback for pelvic relaxation. Trigger point injections may also be recommended. A small amount of local anesthetic is injected into the muscle at the site of tenderness. A few treatments may be necessary to see a significant improvement.

Gastrointestinal

• Inflammatory Bowel Disease– Abdominal pain and altered bowel habits with potentially rectal bleeding; 2 disease processes- Ulcerative Colitis and Crohn’s Disease
• Irritable Bowel Syndrome – Changed bowel habits with or without diarrhea and/or constipation with chronic abdominal pain in the absence of any other cause

Psychologic

• Depression – No exact correlation with chronic pelvic pain, but may stressful events in the presence of depression may worsen pelvic pain
• Prior physical or sexual abuse – May alter brain signals of pain and cause pelvic pain especially during stress

Neurologic

• Neuropathic Pain – Dysfunction of the nervous system in the absence of any other cause

HOW IS CHRONIC PELVIC PAIN DIAGNOSED?

Diagnosing the cause of chronic pelvic pain is difficult because the pain may be due to one or a combination of causes of chronic pain. Therefore, diagnosing the cause of chronic pelvic pain can take a few months.

The most important steps in diagnosing the cause of chronic pelvic pain is obtaining a medical history and performing a physical exam. To aid in the diagnosis of your chronic pelvic pain, other tools, such as lab tests and radiologic imaging, may be added to your evaluation along with a questionnaire.

HOW IS CHRONIC PELVIC PAIN TREATED?

Chronic pelvic pain is difficult to diagnose and treat since there can be a single cause or multiple causes. Some of these causes are diagnoses of exclusion, so treatment can be empiric with or without resolution of symptoms. A step by step treatment plan will be made when you see your physician for a consultation, however, time is necessary to help treat chronic pelvic pain.

Treatment plans may vary based on age and childbearing plans.