Chronic pelvic pain in women is a pathological condition lasting more than 6 months and manifested by constant pain in the lower abdomen, the subjective sensation of which does not correspond to the degree of organic disorders. Depressive and behavioral disorders are observed. For diagnosis, physical methods, ultrasound of the pelvic organs, radiography, endoscopic and laboratory techniques, laparoscopy are used. The treatment regimen involves the therapy of the underlying disease, the appointment of drugs that normalize the work of the peripheral and central parts of the nervous system responsible for the perception of pain.
Chronic pelvic pain in women (CPP) is characteristic of many gynecological and non-gynecological diseases diagnosed in women. According to research in the field of gynecology, more than 60% of patients who have applied for specialized help complain of pelvic pain. About 14% of diagnostic hysteroscopies and 40% of laparoscopies are prescribed to patients with abdominal pain. At the same time, chronic pelvic pain is not established in all cases, but only if there are certain diagnostic criteria. The disease is usually detected in women of reproductive and menopausal age with a certain temperament — prone to hypochondria, anxiety, violent emotional reaction. According to gynecologists, up to 5-15% of patients aged 18-50 years suffer from this disorder.
Pain in the pelvic region usually occurs against the background of actual pathologies of the pelvic organs, primarily reproductive. There are gynecological and non-gynecological causes of chronic pelvic pain in women. In 75-77% of patients, the following diseases of the female genital sphere become the morphological basis:
- Inflammatory pathologies. Periodic and constant pain syndrome is accompanied by chronic endometritis, salpingitis, adnexitis, oophoritis.
- Adhesive processes. Pelvic pain is one of the characteristic signs of plastic pelvioperitonitis and uterine tube adhesions.
- Volumetric neoplasms. Pain occurs with sactosalpinx, ovarian cyst, submucous fibroids, ovarian cancer or uterine body, other benign and malignant neoplasms.
- Genital and extragenital endometriosis. Aseptic inflammation of tissues due to cyclic rejection of endometrioid growths can provoke pain.
- Varicose veins of the pelvic veins. Pathological expansion of the vessels of the pelvis and venous stagnation arising on its background have a stimulating effect on the nerve endings located in the pelvic cavity.
- Allen-Masters syndrome. Characteristic pelvic pains appear in women who have suffered a trauma with rupture of the uterine ligaments during childbirth.
In 21-22% of cases, chronic pain has an organic non-gynecological basis. These reasons include:
- Urological pathology. Pain is observed in urolithiasis, kidney prolapse, their dystopia and developmental abnormalities, chronic cystitis.
- Pathology of the peripheral nervous system. Chronic pain is characteristic of inflammatory and other lesions of the intra-phase nerve plexuses.
- Gastrointestinal diseases. Painful sensations are expressed in irritable bowel syndrome, chronic colitis and proctitis, appendicular-genital syndrome, adhesive disease.
- Retroperitoneal neoplasia. Pelvic pain occurs with neoplasms of the kidneys, ganglioneuromas and other volumetric processes localized behind the peritoneum.
- Diseases of the osteoarticular apparatus. Pain syndrome is manifested by lumbosacral osteochondrosis, damage to the pubic symphysis, tumors and metastases in the pelvic bones, bone tuberculosis, etc.
In 1.1-1.4% of patients, the causes of chronic pain syndrome are inorganic: pain can be disturbed by mental and some other disorders — abdominal epilepsy, depressive states, psychogenias, hyperventilation syndrome, spasmophilia. In less than 2% of clinical cases, the specific causes of chronic pelvic pain in women remain unidentified.
The initial link in the occurrence of chronic pain is local hemodynamic, metabolic, dystrophic and functional changes that occur in the peripheral nerve endings and nodes of the sympathetic nervous system. Such disorders are accompanied by an increase in the intensity and frequency of pathological afferent impulses. Local disorders are complemented by increased excitability of spinal cord structures and pathological changes in the central nervous system, in which even ordinary impulses from the pelvic organs begin to be perceived as painful. Against the background of innervation disorders, hyperemia and stagnation of blood in the pelvis increases, the tone of the pelvic floor muscles increases pathologically, which triggers the mechanism of a “vicious circle”, causing even greater changes in the peripheral and central nervous system. At the later stages of the development of the syndrome, the ganglia and plexuses located above are involved in the process.
The disorder develops gradually and has a stage character. There are three stages of chronic pelvic pain in women.
- Stage I (organ). Painful sensations are localized in the lower abdomen. The intensity of pain corresponds to the severity of the disease that caused it, or slightly exceeds it. Psychoemotional disorders are minimal.
- Stage II (supra-organ). Pelvic pain is complemented by reflected pain in the upper abdomen. The pathological process extends to paravertebral and paraaortic nerve formations. At this stage, most diagnostic errors are allowed.
- Stage III (polysystem). Various parts of the nervous system are involved in the process. Menstrual, secretory and sexual functions, digestion, metabolism are disrupted. The pain is characterized by high intensity, accompanied by pronounced psychoemotional disorders.
For six months or more, the patient is concerned about constant dull aching pain or pronounced discomfort in the lower abdomen, behind the pubis, in the groin, vagina, sacrum, coccyx, perineum. Painful sensations usually do not have a clear localization, often “migrate”. Their irradiation into one or both hip joints, buttocks, thighs, labia majora and minora is possible. The severity of the pain syndrome increases with urination, defecation, hypothermia, static and dynamic physical exertion, after stressful situations. Intense pain is also noted during vaginal examination. The clinical picture of CPP is characterized by algodismenorrhea, ovulatory syndrome, and deep dyspareunia.
Women with chronic pelvic pain have insomnia and other sleep disorders, reduced efficiency and productivity, mood gradually worsens to the level of depression. Some patients have signs of hypochondria and carcinophobia: they express thoughts about the presence of oncological or other incurable disease, undergo numerous examinations by doctors of different specialties. The increase in anxiety-depressive disorders is accompanied by a deterioration in the subjective perception of pain, which begins to seem unbearable, exhausting, absorbing all the attention of a woman.
The transition of CPP to the multi-organ stage is accompanied by hormonal disorders, violation of menstrual and sexual functions, functional insufficiency of various organs and systems. However, the main consequence of chronic pelvic pain is increasing social maladaptation with signs of behavioral disorders. The patient becomes withdrawn, irritable, tearful, restricts physical activity. Behavioral disorders can provoke family and sexual problems, cause work maladaptation. With the development of depression, suicidal thoughts and intentions may appear.
Since in more than 95% of cases, chronic pain occurs against the background of other disorders, the key task of the diagnostic stage is to determine the causes of the pain syndrome and an objective assessment of the severity of the underlying disease. To make a diagnosis , the following are shown:
- Examination on the chair. During the bimanual examination, soreness was expressed with minor changes on the part of the uterus and appendages. When examined in mirrors, cyanosis of the mucous membrane of the cervix and vagina is sometimes observed.
- Ultrasound of the pelvic organs. It is used as a screening to identify possible developmental abnormalities, inflammations, volumetric processes, fluid accumulation in the cavities of the urinary and reproductive system organs.
- X-ray examinations. In the course of contrast-free and contrast radiography, it is possible to confirm or detect diseases of the internal organs and the musculoskeletal system.
- Laboratory diagnostics. Examination of a vaginal smear, its sowing on flora with an antibioticogram, PCR, ELISA allow to determine the pathogen in non-specific and specific inflammatory processes.
- Endoscopic methods. When examining organs with the help of hysteroscopy, cystoscopy, ureteroscopy, rectoromanoscopy, rectosigmoscopy, colonoscopy and other techniques, it is possible to visually assess the condition of the mucous membranes, to identify volumetric neoplasms.
- Laparoscopy. The method is used to detect adhesions, foci of endometriosis, hydrosalpinx, pyosalpinx, subserous fibroids, ovarian cysts and other neoplasms, varicose veins, Allen-Masters syndrome.
In complex diagnostic cases, the examination plan is supplemented with MRI, computed tomography, absorption densitometry and other techniques. Urologists, surgeons, neuropathologists, psychiatrists, gastroenterologists, orthopedic traumatologists, phthisiologists, oncologists are involved in the examination of the patient.
According to experts of international medical associations involved in the study of this pathology, the presence of chronic pelvic pain syndrome in women can be said only with a combination of several criteria. Such pain lasts for six months or more. The patient’s subjective feelings do not correspond to the nature and severity of tissue and organ damage. Therapy of the underlying disease is ineffective. There are signs of depression, behavioral disorders, increasing restriction of physical activity.
Complex therapy combining etiotropic and pathogenetic approach is recommended for chronic pelvic pain syndrome. For the treatment of the disease that provoked the appearance of pain, the patient is prescribed antibacterial, antiviral, antifungal, hormonal and other medications according to indications, and the necessary surgical interventions are performed. In parallel, therapy is carried out aimed at reducing or completely eliminating pathological pain impulses. The goals of pathogenetic treatment are:
- Normalization of local biochemical processes. Hormone replacement therapy, antioxidants, vitamins, enzymes, nonsteroidal anti-inflammatory drugs and drugs that improve blood flow in tissues are effective in solving this problem. It is recommended to combine drug therapy with physiotherapy techniques (the action of an alternating magnetic field, etc.).
- Blockade of pathological impulses. To stop the flow of pathological pain impulses into the brain, various types of intra-phase blockades, alcoholization of nerve fibers, acupuncture are prescribed. It is possible to carry out small neurosurgical interventions — presacral neurotomy, paracervical denervation of the uterus.
- Effects on the central nervous system. Sedatives, vegetative correction agents, suggestive and rational psychotherapy are used to influence the central link of the nociception system and the correction of concomitant neurotic disorders. This approach makes it possible to restore or significantly improve the balance of activation and inhibition processes in the corresponding areas of the brain.
An important role in the treatment of the disease is played by the nature of the relationship between the doctor and the patient. With the proper level of trust in a specialist, a detailed explanation to a woman of the causes and mechanisms of her painful condition allows you to rationalize sensations and thereby significantly reduce the intensity of pain even with minimal drug therapy.
Prognosis and prevention
CPP is characterized by a long, therapy-resistant course. Its prognosis is determined by the characteristics of the underlying disease. Adequate comprehensive treatment can significantly reduce pain disorders and improve the quality of life of the patient. To prevent the chronization of pain, timely therapy of disorders leading to the development of pain syndrome is recommended. For preventive purposes, it is recommended to normalize the sleep and rest regime, reduce mental and physical exertion, exercise, and compliance with the principles of rational nutrition.