Chronic pelvic pain (CPP) is a complex and often debilitating condition that affects a significant portion of the female population. It is commonly defined as pain perceived to originate from the pelvic region that has been present for longer than six months. This differs from acute pelvic pain, which usually has a clearly identifiable cause and often resolves after appropriate treatment or in some cases spontaneously (i.e., uncomplicated ruptured ovarian cyst). The persistence of CPP, however, poses substantial challenges for both patients and health care providers, making it a condition that demands careful management and comprehensive care.

CPP’s prevalence varies widely, with estimates ranging from 2.1% to 24% for noncyclic pain, 8% to 21.1% for dyspareunia, and 16.8% to 81% for dysmenorrhea. These figures highlight the widespread nature of CPP and the necessity for health care providers to be adept at recognizing and managing this condition.

“One of the most challenging aspects for clinicians arises from the complex innervation of the pelvis, in which several organs such as the bladder, uterus and intestines share nerve pathways and can influence each other’s sensory input and function. This phenomenon known as ‘cross-talk’ may cause a patient to report pain in a specific location, such as ‘the rectum’ or ‘the uterus,’ when in reality the issue may be somewhere else,” said Steven J. Radtke, M.D., FACOG, FMIGS, a minimally invasive gynecologic surgeon with Norton Urogynecology Center and Norton Women’s Care.

Endometriosis has been found to be present in approximately 70% of CPP patients,  which is significantly higher than the 10% prevalence in the general population. Other coexisting contributors in CPP are irritable bowel syndrome (IBS), interstitial cystitis (IC), pelvic floor muscle tenderness and depression.

The pathophysiology of CPP is complex, and, in addition to the pelvic component, it also can involve central sensitization. In this condition, pain signals are amplified, and patients may perceive pain from nonpainful stimuli. This is a result of changes in how the dorsal horn of the spinal cord, the somatosensory cortex and thalamus process pain. This explains why symptoms from conditions like endometriosis can persist in some cases even after seemingly successful treatment.

Diagnosing CPP requires a thorough and nuanced approach. A comprehensive history and physical are paramount. A pelvic exam and pain-mapping can identify potential trigger points in the pelvic floor versus uterine or cervical tenderness. Tools such as the FABER (flexion, abduction and external rotation) test and the Carnett test can be helpful in differentiating myofascial from visceral causes of pelvic pain. Other tests might include sexually transmitted diseases testing, dynamic pelvic ultrasound, pelvic MRI, endometrial biopsy and diagnostic laparoscopy. Evaluations for conditions such as IC, IBS or diverticulitis, and psychological factors like depression and anxiety are also essential. Ultimately, the goal is to identify a possible source for the pain, although in many cases, testing fails to reveal a specific cause.

Managing CPP requires a multifaceted approach, addressing the various contributors to the condition. Physical therapy plays a crucial role, incorporating techniques like internal and external tissue mobilization, myofascial release and pelvic floor retraining. Electrical stimulation and biofeedback also can be beneficial, helping patients regain control over their pelvic floor muscles. Cognitive behavioral therapy (CBT) is another cornerstone of CPP management. Given that chronic pain predisposes patients to depression, anxiety and social isolation, CBT can provide significant relief by teaching patients to modulate their thoughts and manipulate their environment to lessen pain perception. Similarly, professional counseling should be considered for all patients, offering them additional support and coping strategies. Sex therapy can be an adjuvant to treatment, especially for patients with female orgasmic disorder or genito-pelvic pain.

Medical management for CPP often includes neuromodulators such as serotonin and norepinephrine reuptake inhibitors, tricyclics, and anticonvulsants. Opioids are generally not recommended due to their risk profile and the potential for dependency, but nonsteroidal anti-inflammatory drugs can be considered in select cases. Muscle relaxants may offer some benefit as well, although evidence for their efficacy remains limited. If endometriosis is suspected, hormonal management either with oral contraceptive pills, progestins or gonadotropin hormone-releasing analogues can be considered.

Trigger-point injections and pudendal nerve blocks can provide immediate relief, especially for pelvic floor muscle spasms that are refractory to physical therapy and medications. This usually entails a combination of a medium- to high-potency steroid and a local anesthetic.

Laparoscopic surgery is an option for conditions such as endometriosis, ovarian tumors, adenomyosis, fibroids, etc. In the case of endometriosis, excision of the entire portion of affected peritoneum has been found to be markedly superior in terms of symptom relief and risk of recurrence when compared with ablation or “burning.” Procedures such as presacral neurectomy also can be valuable tools in select cases. Adhesiolysis is not recommended unless supported by specific intraoperative findings.

Given the complexity of CPP, practitioners must recognize when to refer patients to a pelvic health specialist, particularly in cases suspected of endometriosis. Signs warranting referral include persistent pelvic pain despite initial treatments, evidence of endometriosis on imaging or laparoscopy, and the presence of coexisting conditions like IC or severe dyspareunia. Endometriosis specialists can offer advanced diagnostic tools and treatment options, including laparoscopic surgery and hormonal therapies, which may be necessary for managing severe cases. Norton Women’s Care has a team of fellowship trained minimally invasive gynecologic surgeons who specialize in diagnosing and managing pelvic pain conditions such as endometriosis.

Chronic pelvic pain is a multifactorial and often challenging condition that requires a comprehensive and patient-centered approach. Health care providers must be aware that in most cases, effectively managing the condition requires addressing the “triad” of visceral, neuromuscular and psychosocial components. By incorporating this holistic approach, providers can significantly improve the quality of life for patients with CPP. For cases that are refractory or suggestive of underlying endometriosis, timely referral to a specialist is can help ensure optimal patient outcomes.