Women's Health

Pelvic Pain & Vulvar Disease Center

Chronic Pelvic Pain

Some Causes of Chronic Pelvic Pain

Endometriosis is one of the most common problems in women with chronic pelvic pain. The name is derived from endometrium, the tissue that lines the inside of the uterus (or womb) and that normally builds up and sheds each month during the menstrual cycle. With endometriosis, endometrium is found outside the uterus, in other areas of the body. It may be found on the ligaments that support the uterus and on nearby organs such as the ovaries, bladder, or bowel. It can sometimes also be found in more distant organs, such as the lungs or navel. The areas of endometiosis are usually referred to as implants, nodules, or lesions. On the ovaries it may cause cysts, referred to as endometriomas. These may be smaller than a pea, or larger than a grapefruit. Women with endometriosis may have only a few isolated implants or the disease may be present throughout the pelvis. It can irritate surrounding tissues and produce web-like scar tissue known as adhesions. Endometriosis almost exclusively affects women in the reproductive years. Most women with endometriosis-associated pelvic pain suffer with painful periods and pain during intercourse before they develop continuous pelvic pain.

Trigger points may cause pelvic pain. Trigger points can be discovered by distinguishing deep areas of tenderness from superficial areas of tenderness in the abdominal wall. The "abdominal wall tenderness test" allows us to look for pain from the skin, muscle, and subcutaneous tissue, as occurs with trigger points. With this test we press on the abdominal wall while you raise your head so there is no pressure on the internal organs. If tenderness is present while raising the head, the source of the pain is somatic (from the skin, muscle, and subcutaneous tissue) rather than visceral (from the internal organs). This test often helps find trigger points and nerve entrapments. Occasionally, abdominal and pelvic hernias may be responsible for the pain instead.

Adhesions, an abnormal type of scar tissue may binds organs or tissue together, may be a source of pelvic pain. In particular, the uterus, tubes, ovaries and nearby intestines may be stuck together by adhesions in women with chronic pelvic pain, and in some cases the adhesions cover these organs completely.

Vulvar vestibulitis is a common component of pelvic pain. With this syndrome the vestibular glands, small glands on the outer aspect of the vagina inside the minor lips of the vulva, are extremely painful. They can be checked for tenderness at the time of the physical examination. Vulvar vestibulitis most commonly causes painful intercourse, specifically pain on initial penetration. It may also cause tampon insertion to be painful.

Pelvic Floor Pain Syndrome - The pelvic floor muscles can be in spasm and cause pelvic pain. It si also referred to as levator ani syndrome (the levator ani muscles are the major muscles of the pelvic floor), or pelvic tension myalgia. These muscles must be examined carefully, with each muscle palpated separately, to gain some idea about their tenderness or spasm. They may sometimes have trigger points as well. One of the pelvic muscles often affected is the piriformis muscle (sometimes called piriformis syndrome). This muscle lies high in the pelvis and can be palpated with some difficulty through the vagina. It can also be evaluated by examining the lower buttocks. Most patients who have piriformis spasm experience pain in their buttocks and down the back of the leg, as well as discomfort with intercourse.

Nerve Entrapment Pain - The ilioinguinal and the iliohypogastric nerves, nerves that run in a downward fashion from the hipbone toward the vulva, are sometimes involved in chronic pain. In cases of entrapment these nerves may be trapped by old scar tissue from prior surgery or injuries, or they may be trapped due to congenital tightness of the openings by which they enter the abdominal wall. Occasionally these nerves are painful due to antidromic pain because problems with the pelvic organs, such as the uterus, cervix, or fallopian tubes.