Women's Health

Pelvic Pain & Vulvar Disease Center

Chronic Pelvic Pain

Elements of Chronic Pelvic Pain and Pain Management

There are three basic elements that are crucial in causing chronic pain and that are important and treatment to the management of chronic pelvic pain:
1. Any pathology (tissue damage or disease) at the site of origin
2. Antidromic pain and/or referred pain
3. Central modulation by the brain

Pathology at the Site of Origin

If there is any disease or tissue damage in the pelvis that is stimulating nerve fibers and it is not dealt with, pain will continue. Our bodies have visceral and somatic nerves. Visceral nerves carry sensation or innervate internal organs (viscera) and their associated structures. Somatic nerves innervate muscles, skin, and superficial tissues. Nerve endings in the viscera and soma transmit the pain from the site of origin to the spinal cord and if tissue injury persists, these nerves will continue to be stimulated.

Antidromic Pain and/or Referred Pain

Antidromic pain is pain that is referred or directed to the abdominal wall or superficial tissues (subcutaneous fat, fascia, muscles). This may develop after visceral nerves have been stimulated over a long period of time. This occurs because the visceral nerves connect to (or synapse) on the same nerve cells in the spinal cord as the somatic nerves. After chronic stimulation of the visceral nerves, the somatic nerves may transmit the electrochemical impulse in a reverse manner down the nerve cells to the periphery (the fat, fascia, or muscle) and cause tender areas to develop in the abdominal wall and superficial tissues. This is called referred pain with hyperalgesia (excessive tenderness) and may result in trigger points (small areas of severe pain and tenderness in the fat, fascia, and muscle). Many patients with chronic pelvic pain will have antidromic or referred pain as a primary source of pain.

Central Modulation by the Brain

Our brains can modify the perception of pain by either inhibiting or increasing the central nervous system’s sensitivity to nerve impulses. This is called central modulation. It allows our brains, through our attitudes, moods, stress levels, tiredness, behavior, and so on, to alter or change the quality and severity of the pain we sense.

When dealing with chronic pelvic pain, treating all three of these elements of pain usually gets the best results. Therefore, ideal treatment includes treating any pelvic pathology, treating any antidromic or referred pain, and using central modulation to the patient’s advantage. Both physicians and patients need to realize that there is rarely one single or simple cause for chronic pain and that simultaneous evaluation and treatment of all contributing factors must take place. It is usually not possible to determine the amount of pain due to each factor. Optimal care requires an approach to the history and physical examination, diagnostic testing, medication management, and surgical management that is different from the usual gynecologic approach.

On taking a history, we are interested in the pattern of your pain (where it hurts), the intensity of the pain, and what activities increase or decrease the pain. We also need to know how and when the pain developed, and what type of body changes have occurred because of the pain, such as back pain, joint pain, muscle pain, or constipation. We need to know what previous diagnostic tests have been done so these will not be repeated unnecessarily. We also need to know what type of response you had to previous treatments. You will be asked to draw on a picture of a human body any and all areas where you feel pain (we call this a pain map). This can be very helpful, because it tells us what nerve areas and what level of the spinal cord are involved in your pain. Very often patients are able to exactly pinpoint the pain for us by carefully marking on this pain map which body areas are involved.