Pelvic Pain | Johns Hopkins Medicine

What is pelvic pain?

Pelvic pain is a common problem among women. Its nature and intensity may fluctuate, and its cause is often unclear. In some cases, no disease is evident. Pelvic pain can be categorized as either acute, meaning the pain is sudden and severe, or chronic, meaning the pain either comes and goes or is constant, lasting for a period of months or longer. Pelvic pain that lasts longer than 6 months and shows no improvement with treatment is known as chronic pelvic pain. Pelvic pain may originate in genital or other organs in and around the pelvis, or it may be psychological. This can make pain feel worse or actually cause a sensation of pain, when no physical problem is present.

What causes pelvic pain?

Pelvic pain may have multiple causes, including:

• Inflammation or direct irritation of nerves caused by injury, fibrosis, pressure, or intraperitoneal inflammation

• Contractions or cramps of both smooth and skeletal muscles

• Some of the more common sources of acute pelvic pain, or pain that happens very suddenly, may include:

  • Ectopic pregnancy (a pregnancy that happens outside the uterus)

  • Pelvic inflammatory disease (also called PID, an infection of the reproductive organs)

  • Twisted or ruptured ovarian cyst

  • Miscarriage or threatened miscarriage

  • Urinary tract infection

  • Appendicitis

  • Ruptured fallopian tube

Some of the conditions that can lead to chronic pelvic pain may include:

• Menstrual cramps

• Endometriosis

• Uterine fibroids (abnormal growths on or in the uterine wall)

• Scar tissue between the internal organs in the pelvic cavity

• Endometrial polyps

• Cancers of the reproductive tract

Other causes may be related to problems in the digestive, urinary, or nervous systems.

What are the symptoms of pelvic pain?

The following are examples of the different types of pelvic pain most commonly described by women, and their possible cause or origin. Always talk with your healthcare provider for a diagnosis.

How is pelvic pain diagnosed?

Tests will be done to determine the cause of the pelvic pain. In addition, your healthcare provider may ask you questions regarding the pain such as:

• When and where does the pain happen?

• How long does the pain last?

• Is the pain related to your menstrual cycle, urination, and/or sexual activity?

• What does the pain feel like (for example, sharp or dull)?

• Under what circumstances did the pain begin?

• How suddenly did the pain begin?

Additional information about the timing of the pain and the presence of other symptoms related to activities such as eating, sleeping, sexual activity, and movement can also help your healthcare provider in determining a diagnosis.

In addition to a complete medical history and physical and pelvic exam, you may have other tests including:

• Blood tests

• Pregnancy test

• Urinalysis

• Culture of cells from the cervix

• Ultrasound. A diagnostic imaging technique that uses high-frequency sound waves to create an image of the internal organs.

• Computed tomography (CT or CT scan). This is an imaging test that uses X-rays and a computer to make detailed images of the body. A CT scan shows details of the bones, muscles, fat, and organs, and any abnormalities that may not show up on an ordinary X-ray.

• Magnetic resonance imaging (MRI). A noninvasive procedure that produces a two-dimensional view of an internal organ or structure.

• Laparoscopy. A minor surgical procedure in which a laparoscope, a thin tube with a lens and a light, is inserted into an incision in the abdominal wall. Using the laparoscope to see into the pelvic area, the healthcare provider can determine the locations, extent, and size of any endometrial growths.

• X-ray. Electromagnetic energy used to produce images of bones and internal organs onto film.

• Colonoscopy. In this test, the healthcare provider can view the entire length of the large intestine, and can often help identify abnormal growths, inflamed tissue, ulcers, and bleeding. It involves inserting a colonoscope, a long, flexible, lighted tube, in through the rectum up into the colon. The colonoscope allows the healthcare provider to see the lining of the colon, remove tissue for further exam, and possibly treat some problems that are discovered.

• Sigmoidoscopy. A diagnostic procedure that allows the healthcare provider to examine the inside of a portion of the large intestine. It is helpful in identifying the causes of diarrhea, abdominal pain, constipation, abnormal growths, and bleeding. A short, flexible, lighted tube, called a sigmoidoscope, is inserted into the intestine through the rectum. The scope blows air into the intestine to inflate it and make viewing the inside easier.

How is pelvic pain treated?

Specific treatment for pelvic pain will depend on the cause of the pain and will be discussed with you by your healthcare provider based on:

• Your overall health and medical history

• Extent of condition

• Cause of the condition

• Your tolerance for specific medicines, procedures or therapies

• Expectations for the course of the condition

• Your opinion or preference

Treatment may include:

• Antibiotic medicines

• Anti-inflammatory and/or pain medicines

• Relaxation exercises

• Oral contraceptives

• Surgery

• Physical therapy

If a physical cause can’t be found, your healthcare provider may refer you for counseling to help you better cope with chronic pain. In other cases, healthcare providers may recommend a multidisciplinary treatment using a number of different approaches, including nutritional modifications, environmental changes, physical therapy, and pain management.

Key points about pelvic pain

• Pelvic pain is a common problem among women. Its nature and intensity may fluctuate, and its cause is often unclear.

• Pain can be acute or chronic.

• Specific treatment will depend on the cause as determined by the physical exam and tests.

• Treatment may include medicines, surgery, physical therapy and pain management techniques.

18 Possible Causes of Pelvic Pain in Women

If you have pain below your belly button and above your legs, it counts as pelvic pain. It can be caused by a lot of things. It may be a harmless sign that you’re fertile, a digestive disorder, or a red flag that you need to go to the hospital.

If you have a sharp pain in the lower right part of your belly, are vomiting, and have a fever, it could be appendicitis. If you have these symptoms, go to the ER. An infected appendix may need surgery. If it bursts, it can spread the infection inside your body. This can cause serious complications.

Do you have belly pain, cramps, bloating, and diarrhea or constipation that keeps coming back? Talk to your doctor to figure out the problem. It could be IBS, sometimes called spastic colon. Doctors aren’t sure what causes it. Diet changes, stress management, and medications may help.

Ever feel a painful twinge between periods? You may be feeling your body ovulate. When you do, the ovary releases an egg along with some fluid and blood. It can cause irritation. This feeling is called mittelschmerz — German for “middle” and “pain.” That’s because it happens midway through your monthly cycle. The pain may switch sides from month to month. It isn’t harmful and usually goes away in a few hours.

You can usually feel these cramps in your lower belly or back. They typically last 1 to 3 days. Why the pain? Every month, your uterus builds up a lining of tissue. That’s where an embryo can implant and grow. If you don’t get pregnant, the lining breaks down and is shed during your period. When the uterus tightens to push it out, you get a cramp. Try a heating pad and over-the-counter pain relievers to ease pain. Exercise and de-stressing can help, too. You can also talk to your doctor about PMS pain. Certain birth control pills or antidepressants may help.

This happens when an embryo implants somewhere outside of the uterus and begins to grow. This usually happens in the fallopian tubes. Sharp pelvic pain or cramps (particularly on one side), vaginal bleeding, nausea, and dizziness are symptoms. Get medical help right away. This is a life-threatening emergency. 

Pelvic pain is a warning sign of some STDs. Two of the most common are chlamydia and gonorrhea (shown here through a microscope). You often get both at the same time. They don’t always cause symptoms. But when they do, you may have pain when you pee, bleeding between periods, and abnormal vaginal discharge. See your doctor. It’s also important to get partners checked and treated, too, so you don’t pass the infection back and forth.

This is a complication of sexually transmitted diseases. It’s the No. 1 preventable cause of infertility in women. It can cause permanent damage to the uterus, ovaries, and fallopian tubes. Belly pain, fever, abnormal vaginal discharge, and pain during sex or urination can be symptoms. Get it treated right away to avoid damage. It is treated with antibiotics. In severe cases, you may need to be hospitalized. Get your partner treated, too.

Ovaries release eggs when you ovulate. Sometimes a follicle doesn’t open to release the egg. Or it recloses after it does and swells with fluid. This causes an ovarian cyst. They’re usually harmless and go away on their own. But they may cause pelvic pain, pressure, swelling, and bloating. And if a cyst bursts or twists, it can cause sudden, severe pain, sending you to the emergency room. Doctors can spot them during a pelvic exam or ultrasound.

These grow on or in the wall of the uterus. While they’re sometimes called fibroid tumors, they are not cancerous. Fibroids are common in women in their 30s and 40s. They usually don’t cause problems. But some women may have pressure in the belly, low back pain, heavy periods, painful sex, or trouble getting pregnant. Talk with your doctor if you need treatments to shrink or remove them.

In some women, there is tissue growing outside the uterus that is similar to tissue that lines the uterus. It can happen on the ovaries, fallopian tubes, bladder, intestines, and other parts of the body. When it’s time for your period, these clumps of tissue break down. But the tissue has no way to leave the body. While this is rarely dangerous, it can cause pain and form scar tissue that may make it tough to get pregnant. There are several treatment options. Pain medications, birth control pills, hormones to stop periods, surgery with small incisions, and even a hysterectomy (taking out your uterus) are options.

Do you have to pee often, or does it hurt when you do? Or do you feel like your bladder is full? It could be a UTI. This happens when germs get into your urinary tract. Treating it quickly can keep it from it getting serious. But if it spreads to the kidneys, it can cause serious damage. Signs of a kidney infection include fever, nausea, vomiting, and pain in one side of the lower back.

These are globs of salt and minerals that your body tries to get rid of in urine. They can be as tiny as a grain of sand or as large as a golf ball. And boy can they hurt! Your urine may turn pink or red from blood. See your doctor if you think you have a kidney stone. Most will pass out of your system on their own, but some need treatment. Even if they can pass on their own, your doctor can help with pain medication and will tell you to drink lots of water.

This condition causes ongoing pain and is related to inflammation of the bladder (illustrated here). It’s most common in women in their 30s and 40s. Doctors aren’t sure why it happens. People with severe IC may need to pee several times an hour. You might also feel pressure above the pubic area, pain when you urinate, and pain during sex. Although this can be a long-term condition, there are ways to ease the symptoms and avoid flares.

As you get older, this may happen. Your bladder or uterus drops into a lower position. It usually isn’t a serious health problem, but it can be uncomfortable. You may feel pressure against the vaginal wall, or your lower belly may feel full. It may also give you an uncomfortable feeling in the groin or lower back and make sex hurt. Special exercises like Kegel’s or surgery may help.

We’ve all seen varicose veins in legs. (This is a picture of one in the upper thigh.) They can sometimes happen in the pelvis, too. When blood backs up in veins, they become swollen and painful. This is known as pelvic congestion syndrome. This is a condition that’s difficult to diagnose and treat. It tends to hurt worse when you sit or stand. Lying down may feel better. But because the best treatment is still unclear, you need to work with your doctor to learn what the options are and to find what works well for you.

If you’ve had surgery or an infection, you could have ongoing pain from this. Adhesions are a type of scar tissue inside your body. They form between organs or structures that aren’t meant to be connected. Adhesions in your belly can cause pain and other problems, depending on where they are. In some cases, you may need a procedure or surgery to get rid of them.

Does it hurt when you ride a bike or have sex? If it burns, stings, or throbs around the opening of your vagina, it could be this. The feelings can be ongoing or come and go. Before you’re diagnosed with this, your doctor will rule out other causes. This isn’t caused by an infection. Treatment options range from medication to physical therapy.

This can be caused by many things. Most are treatable. It could be a vaginal infection, or you just may need more lubrication. The medical name is dyspareunia. Sometimes the pain gets better after sexual therapy. This type of talk therapy can focus on inner conflicts about sex or past abuse.

If you have pain that lasts at least 6 months, it’s considered chronic. It may be so bad it messes with your sleep, career, or relationships. See your doctor. Most of the conditions we’ve covered get better with treatment. Sometimes, even after a lot of testing, the cause of pelvic pain remains a mystery. But your doctor can still help you find ways to feel better.

Article “Chronic pelvic pain in women”

The problem of chronic pelvic pain in women of reproductive age occupies a special place in gynecology. Almost half of the patients who turn to the specialists of the EMC Department of Gynecology and Oncogynecology have complaints of chronic pelvic pain – discomfort for a long time in the lower abdomen, in the area below the navel. Long-term, despite the fact that conventional painkillers are ineffective, pelvic pain changes the psyche, the behavior of women, reduces the ability to work and quality of life.

Pain may be constant or intermittent, even paroxysmal, may be cyclical or not at all related to the menstrual cycle. Pain impulses arising in the genitals and surrounding tissues as a result of irritation of nerve endings are transmitted to the central nervous system, which in most women is accompanied by general weakness, irritability, anxiety, excitability, emotional lability, attention disorders, memory loss, sleep disturbances.

Chronic pelvic pain is characterized by:

• persistent pain in the lower abdomen and lower back of varying intensity and character (pulling, dull, burning, etc.), prone to irradiation, lasting more than 6 months;

• periodic exacerbations – pain crises arising in connection with cooling, overwork, stress, etc. ;

• psycho-emotional disorders, manifested by insomnia, irritability, disability, anxiety and depression, decreased sexual function up to a complete lack of interest and sexual response;

• no or little effect of conventional pain and antispasmodic therapy.

In some cases, it is not possible to identify its causes even with in-depth examination – this is the so-called “inexplicable” pain. For such patients, the “triangle” route – gynecologist-urologist-neurologist – becomes familiar, and pain and fear force them to turn to an oncologist. Often, for years, these patients have been treated for “inflammation of the uterus and appendages” with large doses of antibacterial drugs, and such irrational treatment aggravates the situation even more.

Pain is one of the most common symptoms in many gynecological diseases. External genital endometriosis, adhesions in the pelvic cavity, chronic inflammatory diseases of the internal genital organs, internal endometriosis of the uterine body, Allen-Masters syndrome, genital tuberculosis, uterine fibroids, benign and malignant ovarian tumors, malignant neoplasms of the body and cervix, developmental anomalies genital organs with a violation of the outflow of menstrual blood – this is not a complete list of diseases and conditions that may be accompanied by chronic pelvic pain.

The most common misconceptions about chronic pelvic pain

Chronic pelvic pain in women can only be caused by gynecological diseases

syndromes, arthrosis of the sacro- coccygeal articulation, primary tumors of the pelvic bones, metastases to the pelvic bones and spine, bone forms of tuberculosis, pathology of the symphysis), retroperitoneal neoplasms, diseases of the peripheral nervous system (plexitis), diseases of the gastrointestinal tract (chronic colitis, irritable bowel syndrome, nonspecific ulcerative colitis, proctitis, adhesive disease), diseases of the urinary system (chronic cystitis, urolithiasis, pelvic location of the kidney, prolapse of the kidney), vascular disease (varicose veins of the small pelvis). The causes of chronic pain syndrome can also be mental illness (abdominal epileptic seizures, depressive syndrome, schizophrenia).

Pain is usually caused by one factor, eliminating which, you can get rid of pain

In fact, in most gynecological diseases, the origin of pain is caused by several irritants at once, and it is often impossible to single out the leading factor. With uterine fibroids, pain can be caused by an increase in this organ, a violation of its blood supply and contractility of the uterine muscle, deformation of the uterine cavity by nodes, compression of the enlarged uterus or individual nodes of neighboring organs – the intestines, urinary tract, nerve plexuses, blood vessels.

With tumors and ovarian cysts are exposed to the tissue and bunch of ovaries (up to twist), the maturation of follicles is disturbed, microwaves with inflammation and formation of adhesions are possible, and squeezing of neighboring organs

Pancous pains are characteristic of the development of genitals (normal or repented a functioning uterus with aplasia of the cervix or vagina, a rudimentary uterine horn, a closed cavity of a bicornuate or doubled uterus) and other conditions accompanied by a violation of the outflow of menstrual blood (intrauterine synechia, stenosis of the cervical canal or cicatricial changes in the vagina). In these cases, the onset of pain is due to the expansion of closed cavities with blood and irritation of the peritoneum with almost constant hemoperitoneum, inflammation, and adhesions. Incorrect positions of the internal genital organs (bends of the uterus, prolapse, prolapse) also cause pelvic pain.

As a rule, most patients have a combined gynecological pathology, and each of the diseases can cause pain. External endometriosis often accompanies any other gynecological disease, and uterine fibroids are combined with internal endometriosis of the uterine body. Often there is a prolapse of the uterus, affected by fibroids or adenomyosis. The presence of a combined gynecological and extragenital pathology (hernias, diseases of the gastrointestinal tract, urinary tract, osteochondrosis of the spine) can significantly complicate the determination of the true cause of pain.

Periodic pain in women is normal

This myth has been around since the 19th century. Doctors then explained menstrual pain by the instability and delicacy of the physiology of women and believed that pain during menstruation is the norm, which is very characteristic of the female body. Another “cause” of pain in women during menstruation is, according to some, a low pain threshold.

In fact, many women and girls experience pain during their periods. However, severe pain that disrupts the habitual lifestyle and level of activity cannot be the norm, and usually they are based on some kind of disease, for example, endometriosis, a hormone-dependent disease in which the lining of the uterus (endometrium) grows in other parts of the body. This is the third most common gynecological disease after uterine fibroids and various inflammatory processes in the genitals.

Therefore, every woman with severe pain during menstruation should be fully examined to identify their cause.

Early identification of the causes of pain determines the success of treatment. To establish the possible causes of pelvic pain, we work as a team with doctors of other specialties – general surgeons, oncologists, urologists, neurologists, psychologists.

For the treatment of chronic pelvic pain, EMC gynecologists-surgeons use an approach based on reducing the invasiveness of surgical intervention, avoiding excessive radicalism, and expectant management in certain diseases of the genital area.

Laparoscopy and hysteroscopy provide us with unique diagnostic and therapeutic opportunities, which allow us to identify and eliminate possible causes of pain that are not diagnosed by other examination methods: endometriosis of the pelvic peritoneum, adhesions, anatomical disorders – hernia, peritoneal defects (Allen-Masters syndrome).

From the patient’s point of view, laparoscopic intervention, unlike laparotomy, is not perceived as a “big and difficult” operation, and the absence of intense and prolonged postoperative pain associated with the surgical wound of the anterior abdominal wall eliminates the aggravation of the initial pain due to layering on them operating rooms. And, finally, early activation and return to physical activity, the almost absence of cosmetic defects also contribute to a quick recovery.

The volume of surgical intervention is chosen by EMC gynecologists depending on the age of the patient, her plans for childbearing, the severity of the detected pathology, the severity of pain. In young women, organ-preserving surgeries are performed, warning patients about the likelihood of recurrence of diseases such as endometriosis and uterine fibroids. Patients of older age groups with adenomyosis, multiple uterine fibroids, accompanied by severe pain, bleeding and leading to anemia, tumor growth and its significant size, dysfunction of neighboring organs, are shown radical operations in the volume of removal of the uterus, which we perform by laparoscopy or from a vaginal access .

In case of prolapse and prolapse of the pelvic organs accompanied by pelvic pain, EMC gynecologists use surgical correction technologies that are fundamentally different from each other, depending on the age of the patient, to effectively eliminate gynecological pathology and restore the disturbed pelvic anatomy. For pelvic varicose veins, we perform laparoscopic ovarian vein ligation, which is highly effective for pelvic pain due to congestion in the pelvic veins, without adversely affecting ovarian function.

The efficiency of surgical interventions performed by specialists of the EMC Department of Gynecology and Oncogynecology varies from 60 to 95%, which indicates the effectiveness of the treatment and the high level of training of specialists, whose experience allows them to take on even the most complex cases.

EMC Clinic of Gynecology and Oncogynecology works in accordance with evidence-based medicine protocols practiced in the USA and Western Europe. The EMC clinic is one of the few in Moscow whose level of medical services meets international standards.

The doctors of the Clinic work under the guidance of Vladimir Nosov, an experienced surgeon-gynecologist and obstetrician-gynecologist, certified by the US National Commission (Board Certified) in obstetrics-gynecology and oncogynecology, and also certified in Russia in obstetrics-gynecology and oncology.

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