Chronic Pelvic Pain (CPP)
Why do I have pain in my lower abdomen all the time?

West Maui Mountains

Definition 

• Non-cyclical pain in the pelvis lasting for 6 months or more.

How many women have it?

• In a large study done by the World Health Organization 15% of women in the US had pelvic pain for at least 3 months.  
• In this same study 45% of US women had pain with intercourse (dyspareunia).

Where is the cause of CPP usually located?

• 40% Gastrointestinal
• 30% Bladder
• 20% Reproductive Organs
• 10% Musculoskeletal

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What are the possible causes?

• pain in the muscles and joints
• painful bladder syndrome
• irritable bowel syndrome
• inflammatory bowel disease
• endometriosis
• adenomyosis
• pelvic adhesions
• dilated fallopian tubes
• chronic appendicitis
• post-tubal ablation syndrome

How does a doctor make a diagnosis?

• Most of making a diagnosis is taking a thorough history and doing a good physical exam.  If you have had pain for a long time it may take a long appointment just to take a good history.
• The basic questions that every doctor should start with are: where is the pain? how long have you had the pain?  how severe is the pain? is it constant or does it come and go? what does it feel like? does it spread anywhere? what makes it better? what makes it worse?
• The next questions in the case of pelvic pain are: is the pain worse with the period?  is the pain worse with intercourse? Do you have bloating, diarrhea, constipation? How many times at night do you pee? Do you have pain with a full bladder?
• The exam should try to locate and reproduce your pain.
• A pelvic ultrasound should be ordered.
• Referrals should be made to urology, gastroenterology, and physical therapy as needed.
• A follow up appointment should be made after the ultrasound and referrals.
• You may need a laparoscopy if endometriosis, pelvic adhesions, chronic appendicitis, or dilated fallopian tubes are thought to be contributing to your chronic pelvic pain.

What other problems do women with CPP have?

• Headaches
• Fibromyalgia
• TMJ
• Depression
• Anxiety
• Substance Abuse
• Vulvodynia

Bottom line. IT'S COMPLICATED.  Getting better will take patience and a multidisciplinary approach.  Most pelvic pain will not be resolved by taking out a normal uterus, tubes, or ovaries.  There will be a placebo effect in about 30% of women in which their pain will be better for a while even thought the removed organs were normal. If the pain comes back after surgery, then other organ systems need to be evaluated.  Abnormal organs, endometriosis, and adhesions do need to be removed, but even then there may also be some bladder pain or IBS to address.  Also, pain can be NEUROPATHIC (in the nerves) and not from an organ.  The approach to neuropathic pain is medical, physical therapy, and alternative therapies.  Untreated anxiety or depression will also keep you from getting better.  Additional techniques like cognitive behavioral therapy, mindfulness practice, meditation, or acupuncture can be used to help calm the mind.  Narcotic use should be short and goal directed, because overuse will lead to a change in pain threshold.  It takes persistence and a willingness to look for multiple causes to feel better. But it will be worth it when you are able to have improved function.  Not everyone will become 100% pain free, but everyone will be better than they were when they were without treatment

Maui after sunset

Sunset on Captiva Island

What is the treatment?

• pain in the muscles & joints -- This pain will tend to be worse with movement.  The pelvis is a complex 3-D structure supported by the muscles of the pelvis, abdomen, and back.  The best thing to do is to see a Women's Health physical therapist. The work will include work with the physical therapist and home exercises.  Biofeedback is a possible additional option. http://www.apta.org/
• painful bladder syndrome --Interstitial cystitis (IC) is part of this group of problems.  The lining of the bladder becomes inflamed and this leads to overactive nerves and chronic irritation due to a breakdown in the protective layer lining the bladder on the inside.  Women with IC tend to get up at night more than once to pee, pee small amounts, and have pain with a full bladder and/or intercourse.  Treatment includes: medicines to calm the nerve endings down (for example Elavil or Neurontin), antihistamines to decrease inflammation, Elmiron to recoat the bladder, or bladder installations with  a combination of medicines.  IC is diagnosed in the operating room with a cystoscopy done while you are asleep.  Overfilling the bladder while you are asleep can also be therapeutic.  If you have IC then installation into your bladder with a potassium solution in the office will be painful, or placement of a soothing rescue solution will relieve your chronic pain temporarily. 
• www.ncbi.nlm.nih.gov  
• http://www.ichelp.org
  
• http://kidney.niddk.nih.gov/kudiseases/pubs/interstitialcystitis/
  
• irritable bowel syndrome -- IBS is characterized by pain that improves with moving your bowels and/or is associated with a change in the consistency or frequency of your bowel movements.  Either diarrhea, constipation, or both can occur.  Pain may be triggered by foods.  Common triggers are: sorbitol, caffeine, alcohol, citrus fruit, gas forming vegetables, grain, gum chewing. Treatment is mostly geared at decreasing the pain the symptoms.  Immodium for diarrhea or stool softeners for constipation.  15 grams of soluble fiber (e.g., psyllium) a day is often recommended.  Some women have found help with products containing Bifidus Bacterium Infantis (probiotics like Align).  Sometimes antibiotics are prescribed.   As with other conditions a low dose of Elavil can sometimes help, sometimes another antidepressant, psychotherapy, cognitive behavioral therapy, and relaxation techniques can help.  http://www.ncbi.nlm.nih.gov
• inflammatory bowel disease -- Patients should be in the care of a gastro-enterologist. Crohn's disease and ulcerative colitis are chronic conditions that require good partnership with your doctor.http://www.ncbi.nlm.nih.gov
• endometriosis-- Endometriosis is implants in the pelvis of tissue that lines the uterus.  The pain will most likely be worse with the periods and have begun in the teen years, but not always.  This is best diagnosed by laparoscopy and treated with surgical resection.  Then a form of ovarian suppression (birth control) is needed to keep the endometriosis from recurring.  Patients may need repeat laparoscopy every 3 to 5 years for severe endometriosis.  There is alternative medical therapy that can be discussed with your doctor, but painful endometriosis needs to be in part surgically managed.  If the pain is mostly during the period, then suppressing the period with birth control pills, the hormonal intra-uterine device, or some other hormonal treatment options will minimize the pain.
• adenomyosis - Adenomyosis occurs when glands from the lining of the uterus are buried in the muscle of the uterus.  The pain often begins with the periods in a woman's thirtys.  The best and most definitive treatment is to remove the uterus. If you're not ready for this, then you can try suppression of the periods with birth control pills or a hormonal intra-uterine device.  The goal would be to get the periods as light as possible.
• pelvic adhesions -- It is important to consider adhesions as a possible source of pain if a woman has had surgery.  Small filmy adhesions after cesarean section in my experience are usually not a source of pain.  However, if a woman has a history of a complex infection in the pelvis from a ruptured appendix or tubo-ovarian abscess then she may have extensive adhesions that need to be removed.  The only way to find out if there are adhesions is to do a laparoscopy.  
• dilated fallopian tubes -- The fallopian tubes can become chronically dilated after infection in the pelvis.  They can not be repaired.  The only treatment if the tubes are causing pain is to remove the tubes surgically.  This can be done laparoscopically.  
• chronic appendicitis -- This is a very difficult diagnosis to make clinically.  If a woman has chronic right lower quadrant pain for several months and no relief with medical evaluation and treatment, then she needs a laparoscopy and the appendix should be visualized.  I have personally only seen this diagnosis twice, but the patients felt a lot better once the appendix was removed.
• post-tubal ablation syndrome -- This very painful condition can occur after an endometrial ablation for heavy menses in a woman who has had a tubal ligation.  The pain is crampy, severe, and midline.  The best treatment is removal of the uterus.  A laparoscopic hysterectomy can often be performed.