Chronic pelvic pain is defined as the presence of pain in the pelvic girdle of more than 6 months of evolution, which can affect the musculoskeletal, gynecological, urological and gastrointestinal systems.
It is more frequent in women and endometriosis is the most frequent cause of this pain.
The causes of chronic pelvic pain are different in men and women:
|
WOMAN |
MAN |
|
Infection |
Prostatitis |
|
Endometriosis |
Interstitial cystitis |
|
Dysmenorrhea |
Scrotal pain |
|
Dyspareunia |
Penile pain |
|
Myofascial syndrome |
Ureteral obstruction |
|
Vulvodynia |
Irritable bowel syndrome |
|
Interstitial cystitis |
Oncologic pain |
|
Pelvic congestion |
Proctalgia fugax |
|
Irritable bowel syndrome |
Post-tradiotherapy proctitis |
|
Oncologic pain |
Chronic orchialgia |
|
Post-surgical pain (adhesions, nerve entrapment) |
Post-surgical pain (adhesions. Nerve entrapments) |
|
Pudendal neuralgia |
Pudendal neuralgia |
Table 1. Causes of pelvic pain.
Are there treatments for pelvic pain?
In order to understand the complexity of pelvic pain and its treatment, it is necessary to know the structures and organs involved in the mechanism of pain production as shown in Table 2.
Therefore, the treatment of chronic pelvic pain should be multidisciplinary, that is, it should encompass different approaches that affect this syndrome and therefore it is necessary to receive treatment from:
- Psychologist
- Rehabilitator (physiotherapist)
- Pain specialist.
- Other specialist (gynecologist, urologist…).
The pharmacological treatment of pelvic pain differs little from that prescribed for other types of chronic pain. Perhaps, what sets it apart is the invasive treatment of pain, with radiofrequency, local anesthetics, steroid anit-inflammatory drugs and botulinum toxin being the most commonly used.
Within the pain units, different types of therapy aimed at infiltrating nerve structures, muscles and joints can be offered.
With regard to nerves, Table 3 shows the regions most frequently affected in pelvic pain and the nerves responsible for it.
|
Pudendal nerve |
|
Obturator nerve |
|
Cluneal nerves |
|
Posterior femoral cutaneous nerve |
|
Ilioinguinal nerve |
|
Iliohypogastric nerve |
|
Genitofemoral nerve |
Other times, it is necessary to address more complex and deeper structures such as the ganglion impar, hypogastric plexus, dorsal root ganglion T11-S3. They are shown in Table 4.
Having said all this, invasive treatment of pelvic pain will be directed towards those structures responsible for vehiculating the pain, i.e. infiltrate:
- The peripheral nerves
- The deeper nerve structures responsible for pain conveyed by the sympathetic nervous system: Ganglion impar, hypogastric, dorsal root.
- Muscles and joints involved: Table 5
- Pyramidal
- Obturator
- Levator ani
- Coccygeus
- Psoas-iliac
- Gluteus medius.
- Sacroiliac joint, lumbo-sacral facet joint, trochanteric bursa,…
Can pain recur after treatment?
Pelvic pain may recur after treatment. There are occasions when it is possible to reduce its intensity and the patient can live with a low degree of pain for some time. Other times it is necessary to repeat or maintain the aforementioned treatments.
In the case of pelvic pain and in women, as there is a hormonal component, cyclic pain is frequent, that is, it appears or is more intense with each menstrual cycle.
For this reason, behavioral therapies and physiotherapy are designed to complement the invasive treatment of pain as mentioned in previous paragraphs.
How can we avoid it?
The best way to avoid this pain is its knowledge on the part of all professionals and its rapid treatment to avoid great chronicity and the occurrence of central hypersensitization phenomena. When this happens, the brain creates a memory for the pain and even if the cause of the pain has disappeared, a memory that is difficult to eliminate has already been created.
It is not uncommon to see these patients wander through many specialists in search of a solution. Their knowledge and the alternatives that exist to mitigate it should be part of the knowledge of all specialists who come into contact with the patient at some point and not prolong his or her martyrdom.
This is one of the reasons why rare drugs are prescribed for the treatment of pain: antidepressants, antiepileptic drugs….. They are intended to “trick” the brain to avoid perpetuating the memory of pain.
More and more work is being done on this aspect and both gynecology, urology, proctology, psychiatry and rehabilitation services are working more in conjunction with pain units or clinics.