Chronic Pelvic Pain
Chronic pelvic pain (‘CPP’) is one of the most common medical problems of women. Twenty-five percent of women with CPP may spend 2-3 days in bed each month. More than half of the women with CPP must cut down on their daily activities one or more days a month and 90% have pain with intercourse (sex). Almost half of the women with CPP feel sad or depressed some of the time.
Despite all the suffering CPP causes, often doctors are not able to come up with a diagnosis or treatments to help these women. Often the problem that originally caused the pain has lessened or gone away completely but the pain continues.
A woman who has had CPP long-term may notice that she begins to have symptoms in other muscles and organs of her body as well. It is common for pain to cause muscle tension. CPP sufferers may notice lasting changes in the muscles of the pelvis and even the tissue and skin of the pelvis. Tension in the pelvic muscles can affect the bladder and the bowel. Patients also may notice pain involving the back and legs due to muscle and nerve involvement. Once these problems have started, they may become more painful and troublesome than the pelvic pain that started them.
What are the characteristics of chronic pelvic pain?
There are 4 main factors of chronic pain
1 - Pathology at the site of origin.
There is or was an injury (pathology) at the place (site of origin) where the pain first started. This injury may be
endometriosis,
ovarian cysts, pain from the bowel or bladder, infection, or
adhesions (scar tissue from surgery).
2 - Referred pain.
Your body has two types of nerves.
Visceral nerves carry impulses from the organs and structures within your abdomen and chest (stomach, intestines, lungs, heart.).
Somatic nerves bring messages from the skin and muscles. Both types of nerves travel to the same sites on the spinal cord. When your visceral nerves are stimulated for long periods with chronic, ongoing pain, some of this stimulation may spill over into the somatic nerves, which then carry the pain back to the muscles and skin. In CPP, the somatic nerves may carry the pain back to your pelvic and abdominal muscles and skin. That means that your pain may start in your bladder and spread to your skin and muscles, or the other way around.
3 - Trigger points
are specific areas of tenderness occurring in the muscle wall of the abdomen. Trigger points may start out as just one symptom of your pelvic pain or they may be the major source of pain for you. For this reason, treating the trigger points, for some women, may significantly reduce the pain. For other women, the original source of injury as well as the trigger points must be treated.
4 - Action of the Brain
.
Your brain influences your emotions and behaviour. It also interacts with your spinal cord and affects how you feel the visceral and referred pain. For instance, if you are depressed, your brain will allow more pain signals to cross the gates of the spinal cord and you will feel more pain. This influence or modulation by the brain must also be treated. Treatment can include psychological counselling, physical therapy and medications.
What is the content of a consultation?
A/Prof Reyftmann will take a thorough history of your problem. It is very important to give your physician a detailed and accurate description of the problem. He will also do a physical examination. From this, the doctor will be able to determine what lab tests and procedures might be needed to find the reasons for your pain.
There are a number of things you can do to help your doctor diagnose and treat you:
1 - Get Copies of Your Medical Records
Get copies of your medical records, including doctor visits, lab tests, x-rays, and surgical testing. If you have had surgeries, records of the surgical treatments including videotapes are very helpful.
2 - Carefully Fill Out the IPPS Questionnaire
Carefully fill out the
IPPS questionnaire. Take your time and try to remember all the details and the order in which they happened. Just filling out the questionnaire may help you remember details you had forgotten. Also, it may easier to write out personal information that is difficult or embarrassing to talk about. Remember that the more information you give the doctor, the easier it will be for him to help you.
What can you expect?
First off, you need to be realistic in your expectations and hopes for treatment. Some CPP can never be completely cured. Some women are so uncomfortable with the evaluation and testing process that they are never able to get a significant amount of pain relief.
Don't expect instant results. Be patient with your treatment, follow all your doctor's instructions. Treatments may take up to 3-6 months to work, so continue to follow instructions even if you don't see results right away.
During your treatment and therapies, you will have set appointments with your doctor and therapist rather than just coming in when the pain is particularly bad. You may start with weekly or monthly visits. You and your doctor will decide whether these should be more or less frequent based on your progress. Be sure not to miss an appointment as this can interfere with your treatment. If you miss an appointment and your pain becomes worse it may take time to get it under control again.
Remember that the treatment of chronic pelvic pain is a slow process using many different kinds of therapy. It may not be possible to totally eliminate your pain.
Successful treatment means decreasing your pain to a low level so that you are able to enjoy doing the things you want to do again. It means being able to be a wife, mother, or career woman with a minimum of discomfort.
Additional Resources
IPPS questionnaire
IPPS patient information leaflet
Website of the IPPS (international pelvic pain society)
Pelvic pain 2012 (an e-book from Dr Susan Evans)
