Chronic Pelvic Pain
By Jill Menefee, PT
Chronic pelvic pain is defined in a variety of ways. A useful clinical definition of chronic pelvic pain is noncyclic pain that lasts six months or more; is localized to the pelvis, the anterior abdominal wall at or below the umbilicus, or the buttocks; and is of sufficient severity to cause functional disability or require medical care. As a Women’s Health physical therapist I have quite a bit of exposure to the diagnosis of chronic pelvic pain but I was quite shocked at the numbers associated with this condition upon reading an article recently while preparing for an in-service. Two to 10% of all gynecologic office consultations are for chronic pelvic pain. Twenty percent of all laparoscopies are performed for chronic pelvic pain. It is estimated that 10 million women suffer from this condition and that 7 million do not seek help. Up to 61% of patients are found to have no explanation for their pain. The economic impact of this condition is astonishing. The annual medical cost for diagnosis and treatment of chronic pelvic pain is estimated to be about $1.2 billion annually. The cost of lost productivity in these patients is estimated to be $15 billion annually. The most commonly made diagnosis in chronic pelvic pain is endometriosis (31%). The majority are undiagnosed or improperly diagnosed. (Ref. 1)
Initially the pelvic pain perception had been based on the theory that the level of pain should be proportional to the degree of tissue damage. So if your doctor could not see or palpate any masses or abnormal tissue-then you shouldn’t be feeling any pain. That notion in the medical community is changing. Studies show that at best only 60-70% of women undergoing laparoscopic surgery for endometriosis experience pain relief, showing that there is more to the story. (Ref. 2) More information is now showing the presence of one or more other chronic pain disorders such as interstitial cystitis, irritable bowel syndrome, TMJ disorder, migraines, pelvic congestion syndrome, ovarian remnant, vulvodynia, or fibromyalgia suggesting that pelvic pain should be treated as a disease rather than just as pathological changes.
Musculoskeletal dysfunction can be a driver for pelvic pain, either as the primary problem or a secondary reaction to pelvic pain. Issues such as overactive pelvic floor muscles or hip dysfunction can be contributors. According to a Clinical Expert Series article on chronic pelvic pain from the Journal of Obstetrics and Gynecology- “The mainstay of treatment of muscular components of pelvic pain is physical therapy, most commonly performed by a therapist with specialized training in the treatment of female pelvic pain. This subspecialty of the field has grown enormously over the pat 15 years in obvious response to growing recognition of muscular elements to pelvic pain and in recognition that it works.” (Ref. 2)
Hopefully attitudes towards chronic pelvic pain will continue to change and the medical community will move even further away from the “I can’t see it so you shouldn’t feel it” notion. It seems that more credence is now being given to treating the whole body and giving consideration to many factors such as anatomical, musculoskeletal, bowel and bladder function, and psychological issues. The multi-disciplinarian approach appears the best way to give women the support they need in dealing with this often misunderstood condition.
1. Scialli AR, Barbieri RL, Glasser MH, Olive DL, Winkel CA. Association of Professors of Gynecology and Obstetrics Educational Series on Women's Health Issues: chronic pelvic pain: an integrated approach. January 2000; 1–9
2. Steege JF, Siedhoff MT. ACOG Clinical Expert Series, Chronic Pelvic Pain. September 2014; 616-629.
www.pelvicpain.org International Pelvic Pain Society