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Chronic pelvic pain causes. Chronic pelvic pain syndrome in women. Complex etiotropic treatment of CP

Prevalence, causes, diagnostic search

Inna Wilhelmi

operating obstetrician-gynecologist of the Center of Urology and Gynecology of the ANO Clinic NIITO, Novosibirsk

Areas of interest: genital prolapse, urogynecology, aesthetic gynecology, laparoscopy, endometriosis

Every tenth patient who consults a gynecologist complains of chronic pain. The term “pelvic pain” refers to pain localized in the lower abdomen, lumbar region and sacrum, as well as in the perineum, external genitalia, vagina and rectum.

Usually this is a symptom of an underlying disease, but chronic pelvic pain syndrome (CPPS) itself is also distinguished. Currently, there is no uniform terminology, and increasingly, instead of the term CPPS, the term “chronic perineal-pelvic pain and dysfunction syndrome” is used, which better reflects the essence of this disease.

Definition

Chronic pelvic pain syndrome is a condition characterized by:

  • nonspecific pelvic pain of uncertain onset, present for at least 6 months
  • absence of changes in organs and tissues that can explain the severity of the pain syndrome
  • significant reduction in quality of life.

About 15–30 % of all medical consultations are for pain symptoms that are not medically explained points of view. Often, thorough studies conducted by doctors of related specialties: gynecologist, urologist, proctologist, neurologist, show the absolute norm.

Epidemiology

IN Russian Federation There are no statistics on CPPS, and according to the International Chronic Pelvic Pain Association, the prevalence of CPPS among women visiting a gynecologist reaches 15 %. CPPS is the indication for up to 40 % of laparoscopies and 10–15 % of hysterectomies performed annually in the United States.

Pathogenesis

The pelvic organs are closely connected to each other, have a common afferent and efferent innervation, blood circulation, so damage to one organ often involves neighboring organs in the pathological process. However, initially, women with chronic pelvic pain syndrome turn primarily to gynecologists. Sometimes, after an incorrect diagnosis, surgical treatment of pelvic pain is performed (hysterectomy, presacral neurectomy, dissection of the uterosacral ligaments), which leads to aggravation of the clinical picture.

A risk factor for chronic pain syndrome is previous ineffective treatment of the underlying disease. In case of untimely and insufficient relief of acute pain, the pain sensitivity threshold decreases, persistent generators of pathological impulses arise, and the nociceptive system is activated. Chronic pain loses its connection with damage to the pelvic organs and is maintained through complex central mechanisms, acquiring the status of a disease itself. Constant pain leads to the formation of psycho-emotional disorders, which, in turn, further stimulate the process of chronic pain syndrome.

Not all patients with predisposing factors develop chronic pelvic pain. What matters is a woman’s personality type, lifestyle characteristics, social status, level of intelligence, marital status, etc. Thus, single women with a low income, low social status, prone to depression, neuroses are typical patients at an appointment with a gynecologist, neurologist, urologist with complaints of pain of an unspecified nature.

In chronic pelvic pain syndrome, the autonomic nervous system plays a major role in conducting and intensifying pain impulses. Irritation of sensory receptors of the autonomic nervous system is perceived as a diffuse pain sensation, of unclear localization, with blurred boundaries.

Chronic pelvic pain syndrome in women: symptoms

Women suffering from pelvic pain typically have complaints such as:

  • heaviness, discomfort, pain in the lower abdomen or lumbar region
  • painful menstruation (dysmenorrhea)
  • dyspareunia (pain during, immediately before, or after sexual intercourse)
  • vulvodynia (burning or stabbing pain in the perineum and vestibule of the vagina)

The pain can be cyclical or constant. Communication with menstrual cycle most likely indicates a gynecological pathology (often endometriosis or inflammatory diseases). Ovulatory pain regularly appears in the middle of the menstrual cycle, dysmenorrhea is sometimes so severe that it deprives a woman of her ability to work these days. However, due to the presence of viscero-visceral connections, the cyclic nature of pain does not always exclude pathology of neighboring organs.

Particular attention is paid to the patient’s lifestyle, social status, financial situation, obstetric history, surgical interventions, sexual disorders. With the prolonged existence of pelvic pain, women become irritable, sleep disturbances appear, performance decreases, and ultimately they lose interest in life, up to the development of depressive, hypochondriacal conditions, decreased quality of life and social maladjustment. Therefore, in case of pronounced affective symptoms of chronic pelvic pain, it is advisable to immediately schedule a consultation with a medical psychologist, psychiatrist or psychotherapist.

Diagnostics

There is no single algorithm for the examination and treatment of patients with CPPS. A diagnostic search always begins with a thorough collection of complaints and anamnesis of the disease and life.

According to the International Association of Chronic Pelvic Pain, there are 6 obligate signs for this disease:

  1. duration of pain syndrome is at least 6 months
  2. low effectiveness of therapy
  3. discrepancy between the intensity of the patient's pain and the severity of tissue damage
  4. presence of signs of depressive disorder
  5. progressive limitation of physical activity
  6. presence of depression, hypochondria

The complex of basic examinations for CPPS includes:

  1. A thorough examination with bimanual vaginal and rectal examination, general clinical examination.
  2. Screening for STIs (especially herpes and chlamydial infections).
  3. Ultrasound of the pelvic organs, kidneys, bladder, abdominal cavity, including assessment of blood flow in the pelvic vessels with the Valsalva maneuver and with a change in body position; in some cases, MRI or MSCT of the pelvis is justified.
  4. X-ray examination of the lumbar, sacral spine, pelvic bones in two projections, irrigoscopy, urography, densitometry.
  5. Endoscopic examination methods: hysteroscopy, cystoscopy, fibrogastroscopy, colonoscopy.
  6. Consultation with related specialists: therapist, urologist, neurologist, surgeon, gastroenterologist, proctologist, psychologist.
  7. Diagnostic laparoscopy if less invasive diagnostic methods are unsuccessful.

Treatment of chronic pelvic pain

Treatment of chronic pelvic pain syndrome in women is a complex problem and is carried out based on the identified etiological factor. In addition, if the pain syndrome is severe, symptomatic therapy is necessary. The main goal of treatment is to improve the quality of life.

For symptomatic therapy, non-narcotic analgesics and physiotherapeutic methods of influencing the sources of pain impulses are most often used.

Despite wide application analgesic drugs for the treatment of CPPS, in particular non-steroidal anti-inflammatory drugs, there are no reliable studies on their effectiveness.

Considering the pathogenesis of pain, an interdisciplinary approach is always most appropriate in the treatment of CPPS. In the Russian Federation there are currently no specialized centers for the study of chronic pain and very few specialists dealing with this problem. To provide effective assistance to such patients, it is necessary to create specialized teams, which should include doctors of several specialties (gynecologists, urologists, neurologists, surgeons, gastroenterologists, proctologists, physiotherapists, rehabilitation specialists, psychologists, psychotherapists, sex therapists), armed not only with specific knowledge about the mechanisms pain syndrome, but also modern equipment, including diagnostic, endoscopic, electrophysiological.

List of sources

  1. Giamberardino M. A. Women and visceral pain: are the reproductive organs the main protagonists? Mini-review at the occasion of the “European week against pain in women 2007”. Eur. J. Pain. 2008; 12 (3): 257–60.
  2. Vorobyova O. V. Chronic pelvic pain: focus on myofascial pain syndrome pelvic floor muscles. Consilium medicum. 2012: 6 (14): 14–8.
  3. Yarotskaya E. L., Adamyan L. V. Features of tactics for managing gynecological patients suffering from pelvic pain. Reproduction problems. 2003; 3:17–26.
  4. Yarell J., Giamberardino M. A., Robert M., Nasr-Esfabani M. Bed-side testing for chronic pelvic pain: discriminating visceral from somatic pain. Pain Res. Treat. 2011; 11: 692–8.
  5. Chronic pelvic pain. ACOG American Congress of Obstetricians and Gynecologists. www.acog.org.
  6. Vulvodynia. ACOG American Congress of Obstetricians and Gynecologists. www.acog.org.
  7. Howard F. M. The role of laparoscopy in the chronic pelvic pain patient. Clin. Obstet. Gynecol. 2003; 46: 749–66.
  8. Missmer S. A., Cramer D. W. The epidemiology of endometriosis. Obstet. Gynecol. Clin. North Am. 2003; 30:1–19.
  9. Giudice L. C., Kao L. C. Endometriosis. Lancet. 2004; 364:1789–99.

It is considered separately from pain in the perineum and external genitalia.

Causes of pelvic pain in women

Pelvic pain can occur in the genitals or other organs. Sometimes the cause of the pain is unknown.

Gynecological disorders. Some gynecological disorders can cause cyclic pain. In other cases, pain is a discrete event not related to the menstrual cycle. The pain can be either sudden or gradually increasing.

Overall, the most common causes of pelvic pain include:

  • dysmenorrhea,
  • pain during ovulation,
  • endometriosis.

Non-gynecological diseases. These disorders may include:

  • gastrointestinal diseases;
  • diseases of the urinary system: (for example, cystitis, interstitial cystitis, pyelonephritis, urolithiasis);
  • musculoskeletal disorders;
  • psychogenic disorders.

Most often, the cause is difficult to determine.

Diagnosis of pelvic pain in women

The evaluation must be prompt because some causes of pelvic pain (eg, ectopic pregnancy, adnexal torsion) require immediate treatment.

Story. The history of the present disease should include a gynecological history (pregnancy and childbirth, menstrual history, history of sexually transmitted diseases), onset, duration, location and nature of pain, severity of pain and their relationship with the menstrual cycle. Important associated symptoms include vaginal bleeding or discharge, symptoms of hemodynamic compromise (eg, dizziness, syncope, or near-syncope).

Analysis of symptoms. You should look for symptoms that indicate possible reasons, including morning sickness, breast swelling and tenderness, or lack of menstruation (pregnancy); fever and chills (infection), abdominal pain, nausea, vomiting or changes in bowel movements (gastrointestinal upset), frequent urination(urinary disorders).

The history of past diseases should note previous infertility, ectopic pregnancy, urolithiasis, diverticulitis, cancer. All surgical procedures must be taken into account.

Physical examination. Begins with assessment of vital signs and signs of instability (eg, fever, hypotension) and focuses on the abdominal and pelvic areas.

The abdomen is palpated for tenderness, masses, and peritoneal symptoms. A rectal examination is done to check for tenderness, swelling, and hidden bleeding. The location of the pain and any associated findings may provide clues to the cause.

A gynecological examination includes examination of the external genitalia, speculum examination and bimanual examination. The cervix is ​​examined for discharge, uterine prolapse, stenosis, and focal lesions. During a bimanual examination, the sensitivity of the cervix during displacement, the sensitivity and presence of tumor-like formations of the appendages, and the enlargement or sensitivity of the uterus are assessed.

Risk indicators. The following data is of particular concern:

  • syncope or hemorrhagic shock (eg, tachycardia, hypotension).
  • Peritoneal symptoms (Shchetkin-Blumberg sign, rigidity, defense symptom).
  • Postmenopausal bleeding.
  • Fever or chills.
  • Sudden severe pain with nausea, vomiting, sweating.

Interpretation of symptoms. The severity and severity of pain and its relationship with the menstrual cycle suggests the most likely causes. Qualitative characteristics and location of pain may also indicate causes.

Study. All patients must undergo a urine pregnancy test. If the patient is pregnant, ectopic pregnancy should be assumed until this diagnosis is excluded by ultrasound or other methods. If the expected pregnancy period<5 нед, необходимо выполнить анализ крови на ХГЧ, т.к. анализ мочи может не показать положительных результатов из-за раннего срока.

Other tests depend on the suspected disease. If the patient cannot be adequately assessed (in case of severe pain or inability to cooperate) or if the presence of a mass is suspected, an ultrasound scan should be performed. If the cause of the pain remains unclear, laparoscopy is performed.

Pelvic ultrasound using a vaginal probe may be a useful adjunct to a gynecological examination, especially in the case of a tumor or pregnancy greater than 5 weeks. For example, a positive pregnancy test without signs of intrauterine pregnancy may help identify an ectopic pregnancy.

Treatment of pelvic pain in women

The underlying disease is treated whenever possible.

Pain treatment begins with oral NSAIDs. Patients for whom one NSAID is ineffective may respond favorably to another. If NSAIDs are ineffective, other analgesics or hypnosis may be used. Musculoskeletal pain may also require rest, warmth, physical therapy, or, in the case of fibromyalgia, local anesthetic blocks such as 0.5% bupivacaine or 1% lidocaine.

Patients with intractable pain due to dysmenorrhea or another disorder may benefit from uterosacral nerve ablation or presacral neurectomy. If these options are ineffective, a hysterectomy can be performed, but this may not be effective and may even make the pain worse.

Geriatrics

Symptoms of pelvic pain in older women can be vague. Careful examination of bowel and bladder function is very important.

Sexual activity needs to be assessed; Often experts do not take into account the fact that many women remain sexually active throughout their lives. In older women, vaginal irritation, itching, dysuria, or bleeding may occur secondary to sexual intercourse. Such problems are most often resolved after several days of sexual rest.

Acute loss of appetite, weight loss, dyspepsia, or a sudden change in bowel function may be signs of ovarian or uterine cancer and require careful clinical evaluation.

Pelvic pain in women and men is a widespread phenomenon that may indicate diseases, disorders in the functioning of the genitourinary system, and pathologies of the pelvic bone. Pelvic pain occurs due to the influence of various factors. A comprehensive medical examination will help determine the exact causes and prescribe appropriate treatment.

Brief anatomy of the pelvis

The pelvic area is formed by bones located in the lower part of the spinal column. The human pelvis includes:

  • coccyx;
  • sacrum;
  • ligaments;
  • pelvic bones (ilium, ischium, pubis);
  • muscles.

In the pelvic region in men there are:

  • bladder;
  • prostate;
  • vas deferens;
  • rectum.

In women, the pelvic region contains internal organs - the bladder, vagina, ovaries, uterus, and rectum.

Thus, pain occurs in various pathological processes. Pain in the pelvis can be acute or chronic. Chronic pelvic pain is commonly understood as unpleasant sensations that persist for 3 or more months.

Pain in the pelvic area may appear on the left or right:

  1. Right-sided pelvic pain is characteristic of liver pathologies, pancreatitis, and hepatitis. Based on certain accompanying signs, doctors can also diagnose kidney diseases, pyelonephritis, and urolithiasis.
  2. Pain in the pelvis on the left indicates disturbances in the functioning of the digestive system and an enlarged spleen.

This classification facilitates the diagnostic process and allows you to identify the exact factors that provoked the problem.

Causes of pelvic pain

The appearance of pelvic pain can be one of the clinical symptoms of other diseases related to gynecology, urology, and the musculoskeletal system.

Experts identify common provoking factors and specific causes that are characteristic exclusively for males or females.

Are common

Common causes of pelvic pain include:

  1. Tumors of a benign or malignant nature, localized in the pelvic bones. Pathology can also affect soft tissues. As the tumor grows, symptoms such as fever, excessive sweating, general weakness, and malaise appear.
  2. Injuries of the lower extremities and hip joint - various types of bruises, sprains, dislocations, fractures (violations of the integrity of the pelvic bone).
  3. Infections occurring in acute or chronic form. The cause of pelvic pain can be pathologies such as osteomyelitis and bone tuberculosis. They are accompanied by increased temperature, febrile syndrome, and changes in blood composition.
  4. Disturbance of metabolic processes in the pelvic bones. They occur when there is an incorrect, unbalanced diet, or a deficiency in the body of certain microelements and vitamins D.
  5. Kidney pathologies.
  6. Disorders in functioning gastrointestinal tract.
  7. Stressful situations and psycho-emotional shocks can trigger the occurrence of so-called stress pain.
  8. Inflammation of the anterior abdominal wall.
  9. Muscle pathologies – myofascial syndrome.

Severe pain with accompanying swelling occurs in most cases when the integrity of the pelvic bone is violated and requires immediate medical attention.

Among women

Pain in the pelvic area in women can occur as a result of gynecological diseases - lesions of the uterus, ovaries, and endometriosis. There are also other causes of pelvic pain that are specific to women:

  1. Varicose veins.
  2. The onset of an ectopic pregnancy. In this situation, the pain is sharp, acute, one-sided, accompanied by heavy uterine bleeding.
  3. Menstruation - pain in women can occur at different periods of the menstrual cycle and has a pulling, aching, periodic nature.
  4. Inflammation of the uterus or fallopian tubes, genitals, causing tissue scarring, which leads to pain.

Severe, sharp pelvic pain can be triggered by a ruptured cyst located in the ovarian area. Such a condition threatens with numerous complications and dangerous consequences such as peritonitis, blood poisoning, and therefore requires immediate medical intervention.

In men

Pelvic pain in men, according to statistical data, is somewhat less common than in women, which is due to certain physiological characteristics, structure and location of the genital organs. Pelvic pain can occur with inflammation of the urinary tract and prostate gland.

The following clinical symptoms are characteristic:

  • frequent urge to urinate, with a tendency to increase at night;
  • pain localized in the genital area;
  • erectile dysfunction;
  • pain in intimate contacts.

If the pathology progresses, signs characteristic of intoxication syndrome may appear: headaches, nausea, increased temperature.

With such symptoms, you need to consult a doctor and conduct a series of studies, since, in addition to prostatitis, pelvic pain in the stronger sex can be caused by the following dangerous factors:

  • sexually transmitted infectious diseases;
  • malignant tumors localized in the prostate or bladder;
  • urethritis.

Pathological processes develop quite quickly, threatening the health and sometimes the life of the patient.

What does pain in the pelvis from behind indicate?

Painful sensations in the pelvis from behind in most cases are a manifestation of pathological disorders occurring in the coccyx and sacral region. Pain in the back of the pelvis occurs as a result of hypothermia or traumatic injury.

The appearance of a dull pain often indicates overstrain of the spinal table.

Acute pelvic pain localized in the back often indicates kidney stones. This pathology is characterized by accompanying symptoms such as impaired urination and the appearance of bloody impurities in the urine.

Diagnostic methods

Diagnosis of pelvic pain begins with an analysis of the general clinical picture, the results of the collected anamnesis, and a patient interview. To make an accurate diagnosis and determine the necessary treatment, the following instrumental techniques may be recommended to patients:

  • radiography;
  • laboratory testing of urine and blood;
  • laparoscopy;
  • ultrasound examination of the pelvic organs;
  • taking urethral smears;
  • smears from the cervical canal.

In particularly difficult cases, computed tomography or magnetic resonance imaging or a biopsy may be required.

Based on the results of a comprehensive medical examination, the doctor will be able to give the patient an accurate diagnosis, determine the causes of pelvic pain and prescribe the optimal, most effective therapeutic course for a specific clinical case.

Which doctor should I contact?

When there is pain in the pelvic area and the discomfort does not go away for a long time, it is better not to self-medicate, but to seek help from a doctor. For pelvic pain, it is recommended to consult the following doctors:

  • rheumatologist;
  • gynecologist;
  • oncologist;
  • nephrologist;
  • gastroenterologist;
  • urologist;
  • neurologist.

If there are traumatic injuries, the help of a traumatologist and surgeon will be required.

You should immediately consult a doctor if pelvic pain is accompanied by the following alarming clinical symptoms:

  • a sharp and sudden pain symptom;
  • deformation of the pelvic bone;
  • impairment of motor activity and functionality of the musculoskeletal system;
  • increase in body temperature above 38.

Such conditions can be very dangerous, so the sooner treatment of the underlying disease is started, the higher the chances of achieving stable positive results and preventing possible complications.

In most cases, the patient is sent to a therapist, undergoes the necessary tests, after which he is given referrals to specialized specialists.

Treatment

Treatment of pelvic pain is selected individually depending on its causes and diseases that provoked the development of the pain syndrome. Therapy in some cases is carried out using conservative methods. In critical situations, during acute processes, surgical intervention may be required.

According to doctors, treatment of pain in the pelvic area should be comprehensive and include the use of medications, physiotherapy methods and traditional recipes.

Conservative

The basis of non-surgical treatment of pelvic pain is drug therapy. Depending on the causes of pain, the following drugs may be recommended for symptomatic treatment:

  • muscle relaxants;
  • non-steroidal anti-inflammatory drugs;
  • glucocorticosteroids;
  • chondroprotectors.

This type of medication is most effective for arthritis, atroses, and other joint diseases. Medicines can eliminate painful symptoms, swelling, inflammatory manifestations, and improve the general condition of the patient.

In order to normalize blood circulation in the pelvic area, dilate blood vessels, and control manifestations of a degenerative nature, drugs such as Trental and Xanthinol Nicotinate can be recommended.

It is mandatory to prescribe medications whose action is aimed at eliminating the underlying disease, the symptom of which is dull or acute pelvic pain.

In addition to drug treatment, the following physiotherapeutic procedures are prescribed to reduce pain, eliminate swelling and inflammation:

  • massages;
  • cryotherapy;
  • laser exposure;
  • electrophoresis;
  • physical therapy classes;
  • water procedures;
  • acupuncture;
  • manual therapy.

In some situations, nutritional correction, diet therapy, giving up bad habits, and lifestyle changes may be required.

Surgical

Surgical treatment is required for pathologies of the pelvic bone or hip joint, or the lack of proper effectiveness of conservative therapy methods. During the operation, doctors will partially replace the affected joint or perform a complete endoprosthetics.

Surgical intervention may also be required in such acute, life-threatening conditions as ectopic pregnancy, cyst rupture, ulcerative lesions of the gastrointestinal tract, and malignant diseases of a gastroenterological, gynecological, or urological nature.

Prevention of posterior pelvic pain

Following preventive medical recommendations will help prevent pain localized in the pelvic area:

  1. Avoid hypothermia.
  2. Regularly undergo preventive medical examinations.
  3. Treat gastroenterological, inflammatory, gynecological, and urological diseases in a timely manner.
  4. Avoid stress and psycho-emotional shocks.
  5. Regularly give yourself feasible physical activity.
  6. Avoid hazardous situations.
  7. Have a regular intimate life.
  8. Eat properly and balanced.
  9. Refrain from smoking, abusing alcoholic beverages and using medications without a doctor's prescription.

Pain in the pelvis from behind is a dangerous, alarming symptom that may indicate serious diseases that require professional, timely medical intervention. Such manifestations should not be ignored, especially if the pain is acute or prolonged chronic.

Timely contact with a specialist and an adequate course of treatment will relieve numerous, extremely unfavorable consequences. Treatment of pelvic pain is carried out by conservative and surgical methods, depending on the underlying causes of the disease.

Shulpekova Yu.O.

The term " pelvic pain"came to domestic medicine from foreign medical publications; in them, pelvic pain is considered as a syndrome that serves as the basis for further differential diagnosis. However, it should be recognized that pain itself, without describing other signs stereotypically associated with it, is only a separate symptom .

“Pelvic” refers to pain localized in the lower abdomen below the navel, in the lower back and sacrum, as well as in the perineum, in the area of ​​the external genitalia, vagina, and rectum. Irradiation along the anterior inner surface of the thighs and the lower edge of the buttocks is often observed. Typically, patients cannot indicate the exact localization of pain; it is rather diffuse in nature, and it is not always easy to separate the epicenter of pain from the zone of irradiation.

The temporal characteristics of pelvic pain - acute or chronic - are of fundamental importance for recognizing the causes and choosing treatment tactics.

Acute pelvic pain, usually sudden, severe, lasting up to several hours or days. Its causes are acute inflammatory diseases of the uterus and appendages, appendicitis, diverticulitis, acute colitis, acute urological diseases or conditions accompanied by ischemia of the pelvic organs or intraperitoneal bleeding - torsion or rupture of an ovarian cyst, ectopic pregnancy, complications of proctosigmoiditis. Acute pain is often accompanied by fever, reflex nausea, vomiting, signs of intestinal paresis, symptoms of general intoxication or internal bleeding. Patients with acute pelvic pain need immediate medical attention.

Chronic pelvic pain is recurrent or constant pain that bothers the patient for at least 6 months. The nature of the painful sensations can be different: burning, stinging, stabbing, aching pain, a feeling of pressure or heaviness. The intensity of pain in the same patient can vary significantly.

This article will focus on chronic pelvic pain in women due to the particular relevance of this problem. The prevalence of chronic pelvic pain among women, according to the US National Institutes of Health, reaches 15%. Other epidemiological studies are currently being conducted.

The studied causes of chronic pelvic pain in women combine various gynecological, urological diseases, as well as diseases of the intestines and musculoskeletal system. It is paradoxical that not all women suffering from these diseases develop chronic pelvic pain.

The question of the mechanism of pain chronization is urgent. In conditions of persistence of the pathological process, and sometimes in the absence of obvious organic pathology, chronic pain can be the result of a decrease in the threshold of perception, when the pain sensation occurs under the influence of non-damaging stimuli. In such cases, pathophysiologists use the following terms:

    hyperalgesia - the occurrence of pain when exposed to soft threshold stimuli;

    allodynia - pain when exposed to physiological stimuli that normally do not have an irritating effect;

    spontaneous painful spasms - pain that occurs generally in the absence of any influence on the sensory nerve endings.

The modern theory of pain explains the formation of chronic pain by dysfunction of the nerve pathways and centers that control the flow of pain impulses. In some cases, the main role is played by a decrease in the activity of the antinociceptive system, in others - the phenomenon of neuronal sensitization, in others - the development of neurogenic inflammation supported by constant nerve impulses and the production of substance P, a peptide encoded by the calcitonin gene related peptide (CGRP), and growth factor nerves and neurokinins in the affected organ.

Surgical interventions on the pelvic organs and rheumatic diseases predispose to the formation of chronic pain.

In maintaining painful sensations, great importance is attached to the phenomenon of hyperesthesia/hyperalgesia of soft tissues, manifested, in particular, by the formation of trigger points in the muscles and fascia of the pelvic floor. This phenomenon was first described by the English neurologist H. Head and the outstanding Russian clinician G.A. Zakharyin. Zakharyin-Ged zones, as a rule, correspond to certain dermatomes, at the level of which sensitive innervation of the affected organ and the corresponding area of ​​​​soft tissue is provided.

Pelvic muscle soreness often accompanies urological diseases, and physical therapy for myofascial pain often cures chronic pelvic pain.

Chronic pelvic pain is characterized by irradiation, which manifests itself as a feeling of pain, burning or itching in more distant areas simultaneously with the appearance of pain impulses from the affected organ. This phenomenon is, in fact, close to the phenomenon of hyperalgesia of the corresponding dermatome.

A number of researchers also point to the existence of visceral hyperalgesia - mutual strengthening of pain impulses due to partial intersection of the innervation paths of two affected organs. It has been shown, for example, that women with inflammatory diseases of the genitals are more likely to suffer from attacks of renal colic; in the same group of patients, pain in the back muscles is often observed at the ThX-LI level. .

The threshold for pain perception may be reduced under the influence of negative affective and social factors. Women suffering from chronic pelvic pain (usually in the form of dysmenorrhea, dysparenuria and vulvodynia) are more likely to have a history of physical or sexual abuse and show signs of post-traumatic stress disorder. Such patients are more prone to depression.

Due to the variety of causes of chronic pelvic pain in the United States, a multidisciplinary research group has been created based on large medical centers that register and thoroughly analyze the causes of each case.

Assessing associated symptoms can be a significant aid in recognizing the cause. Chronic pelvic pain rarely exists as an isolated symptom and is often combined with other complaints; it may be associated with defecation, urination, the menstrual cycle, and sexual intercourse.

The most important diagnostic value is the identification of obvious signs indicating, for example, damage to the excretory system (hematuria, dysuria, etc.), genital organs (pathological discharge, menstrual irregularities, infertility, rash herpetiformis, papillomatosis, etc.) or intestines ( diarrhea, constipation, pathological impurities in feces, etc.). But in many cases, the symptoms are nonspecific, which makes diagnosis difficult.

For women suffering from pelvic pain, the following complaints are quite “universal”: pain localized in the abdomen or lower back, very painful menstruation, dysparenuria (pain during sexual intercourse, as well as immediately before or after it), vulvodynia (burning or stabbing pain). pain in the perineum and vaginal opening).

In men, the nature of the complaints is somewhat different: the localization of pain in the lower back, difficult or painful urination, pain or discomfort at the base of the penis, around the anus, in the scrotum, pain during ejaculation, and blood in the seminal fluid are more typical. Often these symptoms are unreasonably interpreted as manifestations of infectious prostatitis.

There is often an “overlap” of symptoms, when the same complaints are noted in different pathological conditions. This is especially true for dysparenuria and vulvodynia.

For the purpose of differential diagnosis of chronic pelvic pain, it is important to establish whether it is cyclic (periodic) in nature. A connection with the menstrual cycle most likely indicates a gynecological pathology, in particular endometriosis or venous congestion in the pelvic cavity. "Algodysmenorrhea (syn. dysmenorrhea)" - pelvic pain during menstruation. “Ovulatory pain” is observed in the middle of the menstrual cycle, is associated with ovulation and occurs quite regularly in some women; pain may persist for up to 2-3 days, relieved by the use of heat or analgesics.

And yet, the cyclical nature of pain does not allow us to completely exclude the pathology of neighboring organs that are not related to the reproductive system, since the existence of viscero-visceral reflexes is possible.

From the point of view of some specialists, true chronic pelvic pain should mean only cases of non-cyclical pain of unknown origin, when all known organic causes have been excluded. This rigorous approach helps to identify a group of patients with functional pain, often associated with mental disorders - by analogy with functional abdominal pain, characterized in the Rome III criteria. It must be noted that the diagnosis of “functional pelvic pain” has not yet been reflected in the Rome criteria.

Some symptom complexes observed in certain pathological conditions are described below.

Chronic pelvic pain due to pathology of the urinary system is most typical for disorders such as interstitial cystitis, bladder stones and tumors, and obstructive uropathy. Symptoms can be very different:

    pain (a feeling of discomfort, a feeling of pressure) in the suprapubic region, intensifying as the bladder fills or after it is emptied.

    pain in the suprapubic region, urethra during urination;

    vaguely localized pain in the pelvic area, with possible irradiation;

    imperative calls to urinate and/or frequent urination;

    the presence of pathological impurities in the urine;

    dysparenuria.

Of particular interest is a disease such as interstitial cystitis ("irritated or painful bladder"). This is a fairly common disease, the causes of which are not well understood. Approximately 90% of patients suffering from this disease are women; worsening symptoms are observed during menstruation or after sexual intercourse. Pelvic pain with interstitial cystitis is often combined with fibromyalgia, chronic fatigue syndrome, and irritable bowel syndrome, which indicates a common pathogenetic mechanism for the formation of pain.

Chronic pelvic pain in gynecological pathology is characterized by a particularly frequent combination with dysparenuria, vulvodynia, and sometimes with dysuria and is often cyclical in nature. About 15% of visits to a gynecologist are due to chronic pelvic pain. Among the most common causes of pain are endometriosis, inflammation and venous congestion in the pelvis.

Chronic pelvic pain due to inflammation of the pubic symphysis (osteitis pubis) is localized in the pubic area and intensifies during physical activity, when squeezing the hips, climbing stairs or squatting.

Chronic pelvic pain with damage to the sensory nerves of the lower abdominal wall and pelvic area - n. Pudendus, n. ilio-inguinale, n. ilio-hypogastrum, n. genito-femoralis. Damage to these nerves can occur during childbirth, surgery, or systemic neuropathy. It is possible that in some cases neuropathy is caused by herpetiform viruses. The following symptoms may occur alone or in combination:

    dysparenuria;

    pain when urinating or defecating;

    pain when sitting;

    pain in the lower abdomen or back - constant or associated with changes in body position;

    pain in the genitals (vulvodynia) radiating along the posterior inner surface of the thighs and buttocks.

Chronic pelvic pain in diseases of the rectum. Chronic proctalgia is one of the most common types of pelvic pain. Its causes can be injuries, cracks in the mucous membrane of the rectum and skin around the anus, stercoral ulcers, hemorrhoids, rectal prolapse, recurrent herpetic and cytomegalovirus infections, human papillomavirus infection, tumor, chronic pararectal abscess. Proctalgia is a striking symptom of functional anorectal disorders: musculus levator ani syndrome or nonspecific functional anorectal pain, proctalgia fugax.

Proctalgia can be observed as part of ischemic colitis, stercoral, ulcerative colitis, irritable bowel syndrome. Pain may be associated with sexual intercourse, bowel movements and passing gas; You should pay attention to pathological impurities in the stool, changes in the perianal area.

Chronic pelvic pain against the background of inflammatory bowel diseases is characterized by a combination with tenesmus, diarrhea mixed with blood, mucus and pus, general weakness, and weight loss. Similar symptoms can be observed with ischemic colitis, which is also characterized by persistent flatulence, abdominal pain, and unstable stool.

Irritable bowel syndrome (IBS) is one of the most common causes of chronic pelvic pain in patients of both sexes. In typical cases, the pain is localized in the lower abdomen, mainly on the left, is spastic in nature and is combined with diarrhea, constipation, and bloating. The pain is worse after eating and relieved after defecation. According to the Rome criteria for functional disorders in IBS, periods of pain must necessarily be combined with changes in stool frequency and stool consistency. IBS is also characterized by a feeling of “obstruction” in the rectum when straining during bowel movements, a feeling of incomplete emptying of the rectum, and the release of mucus with feces.

When IBS is combined with proctalgia, there is severe stabbing pain in the rectum during bowel movements and the passage of gas.

Exacerbation of symptoms is observed against the background of stress, anxiety or depression.

Simultaneously with pelvic pain in IBS, a whole range of other symptoms can be observed: dysparenuria, algodismenorrhea, dysuric disorders. It is also very typical to have signs of autonomic dysfunction accompanying migraine and anxiety and depressive disorders.

The literature indicates a close relationship between the two most common types of pain in women - pelvic pain and migraine. According to a study by the US National Institutes of Health, chronic pelvic pain occurs in 15-24% of women of reproductive age, and migraine occurs in approximately 20%. There is an “overlap” of these conditions: no less than 67% of women with chronic pelvic pain have migraine. One possible explanation for this is the peculiarities of the metabolism of prostaglandins or serotonin and the regulation of smooth muscle cell tone, another is the peculiarities of pain perception in such patients.

Myofascial pelvic pain syndrome is a disorder in which painful “trigger” points form in the pelvic floor muscles. The pain is aching or burning in nature, its localization is varied. On palpation, the muscles of the pelvic floor and pelvic girdle appear tense, and points of sharp pain are identified in them. This is often accompanied by increased sensitivity or itching of the skin, making it difficult to wear clothes. Compression of sensory nerves by muscles also leads to itching and burning. Concomitant dysuric disorders, urgency, constipation, pain during defecation, and dysparenuria are often observed. Probably, myofascial syndrome is formed secondary to traumatic physical activity, joint diseases, frequent straining during bowel movements, repeated genitourinary infections as a consequence of injuries and childbirth - and makes a significant contribution to the persistence of pain. An analysis of medical records showed that in patients diagnosed with vulvodynia, interstitial cystitis, chronic pelvic pain, non-bacterial prostatitis, neuralgia, and IBS, signs of myofascial pelvic syndrome are often identified.

Dangerous symptoms indicating the likelihood of dangerous complications in patients with pelvic pain: intense or increasing pain, fever (>38.5 ° C) with chills, vomiting with blood, bleeding from the vagina or rectum, signs of blood loss, difficult or painful urination, increasing increase in abdominal size.

Diagnostic search. Because chronic pelvic pain and its associated symptoms can occur in different combinations and severity, diagnosis can often be difficult. Sometimes the cause of pain remains unrecognized.

Analysis of complaints and medical history involves a thorough assessment of the nature and localization of pain (lumbosacral region, coccyx region, sacroiliac joint, pelvic floor, groin area, abdominal wall), duration and frequency, and the influence of provoking factors. It is necessary to clarify complaints from all organs and systems, and analyze in detail the gynecological and drug history.

Particular attention should be paid to the description of the first episode of pain, which may serve as a key to identifying the “generator” of pain.

Rectal and vaginal examination are mandatory components of the examination of a patient with chronic pelvic pain. It allows you to identify diseases of the genital organs, rectum, changes in perirectal tissue and “trigger” points of the pelvic floor.

According to experts, a medical examination, supplemented by an ultrasound examination of the pelvic organs, in most cases makes it possible to recognize the gynecological pathology that is the cause of pain. Experience shows that to establish pathology in the intestines or urinary tract, it is often necessary to perform endoscopy with biopsy, irrigoscopy, urography, computed tomography or magnetic resonance imaging.

In difficult cases, the question of diagnostic laparoscopy is raised. Only with the help of this study can we reliably confirm the diagnosis of peritoneal endometriosis, adhesive disease and simultaneously carry out surgical treatment.

Effective treatment, of course, depends on a correctly established underlying diagnosis. Due to the wide variety of causes of pelvic pain, the author is not able to discuss in detail the treatment of each disease.

For cyclical pain, usually associated with premenstrual syndrome, menstruation or ovulation, the use of combined hormonal contraceptives or progesterone preparations is effective. For dysmenorrhea, symptomatic medications are prescribed - analgesics and antispasmodics. Appropriate treatment for genital infections is provided. For example, the use of acyclovir or valacyclovir for herpes infection and the prevention of relapses of candidiasis can lengthen periods of remission and alleviate the manifestations of vulvodynia and dysparenuria.

In some cases, physiotherapeutic treatment is effective, physiotherapy, acupuncture, especially when the causes of pain are associated with nerve damage, birth injuries, and impaired tone of the pelvic floor muscles. An open pilot study assessed the performance of a special device for identifying and neutralizing internal myofascial “trigger” points in patients suffering from urological diseases. The device applies dosed compression to the site of pain based on the indicators of the built-in algometer. For confirmed myofascial syndrome, muscle relaxants and blockade of “trigger” points can be used.

The use of tricyclic antidepressants and selective serotonin reuptake inhibitors not only eliminates depressive disorders, but also effectively supports the function of the antinociceptive system. Antidepressants are used in an individual dose, starting with a small one.

Surgical methods of treatment. If foci of endometriosis are detected on the peritoneum during diagnostic laparoscopy, they are ablated. Laparoscopic uterosacral nerve ablation and presacral neurectomy can be used to treat pelvic pain and unexplained dysparenuria, but these procedures are technically difficult and carry an increased risk of bleeding.

American researchers analyzed the experience of performing hysterectomy in patients suffering from endometriosis or chronic pelvic pain of unspecified origin, refractory to other treatment methods. In a large proportion of cases, after surgery, the quality of life of women improves, and the manifestations of dysparenuria decrease. But in 21-40% of women after a hysterectomy, pelvic pain persists, and in 5% it occurs for the first time. The chances of pain relief are lower if there is underlying depression.

Antispasmodics have an analgesic effect in situations where pain is caused by spasm or stretching of a hollow organ (in particular, the intestine) or an inflammatory process accompanied by reactive spasm of smooth muscles and impaired blood flow. Therefore, drugs of this class are very often used in the treatment of chronic pelvic pain.

Antispasmodics are perhaps an integral component of the treatment of patients with IBS, regardless of its severity. Taking into account the laws of chronic pain, the prescription of antispasmodics should be resorted to already at the earliest early stages illness in order to prevent the long-term existence of a flow of pain impulses from the affected organ. From this point of view, it is necessary to choose the safest and most effective antispasmodic that has high selectivity and power of action specifically on the smooth muscle cells of the pelvic cavity organs - the intestines, urinary tract, genitals.

Drotaverine hydrochloride (Ho-spa® manufactured by Sanofi-Aventis) is a selective inhibitor of phosphodiesterase (PDE) type IV, which controls the contractile activity of smooth muscle cells of the gastrointestinal tract and genitourinary system. Inhibition of type IV PDE is accompanied by an increase in the intracellular concentration of cAMP and disruption of the interaction between actin and myosin. Drotaverine also prevents the entry of calcium into smooth muscle cells and reduces the activity of calmodulin, a catalyst for muscle contraction. Since type IV PDE is actively involved in the development of inflammation, its inhibition is accompanied by an anti-edematous and anti-inflammatory effect. The high selectivity of the action of drotaverine compared to papaverine minimizes the likelihood of affecting blood vessels and myocardium. Drotaverine hydrochloride has no anticholinergic effects, which allows it to be prescribed without significant concerns. medicine both elderly patients and children.

The effectiveness of taking drotaverine hydrochloride (No-shpy®) at a dose of 80 mg 3 times a day. within 4-8 weeks. in the treatment of pain in IBS and its safety has been proven in randomized, double-blind, placebo-controlled studies involving 132 patients. The pronounced antispasmodic and analgesic effect of drotaverine in urolithiasis and gynecological pathology (painful menstruation, ovulatory pain, inflammatory diseases) is well known and confirmed in a number of studies.

A multicenter, open-label, prospective study of the safety and effectiveness of drotaverine hydrochloride tablets (No-shpa®) in the treatment of irritable bowel syndrome was conducted in China. The study involved 217 patients aged 18-70 years, 52% were women. Patients are divided into four subgroups: IBS with a predominance of diarrhea, constipation, mixed course or nonspecific type. The group of patients with IBS with a predominance of diarrhea was the largest and included 45.6% of participants. All patients were prescribed No-shpa® 80 mg 2 times a day. within 2 weeks. The primary endpoint was the severity of abdominal pain (on a 3-point scale, where 0 points corresponded to the absence of pain), and the secondary endpoint was changes in the frequency, shape of stool, and associated symptoms. After two weeks of treatment, the severity of pain decreased significantly in all subgroups of patients; the average score in the general group was from 1.42±0.42 to 0.66±0.59 points (p<0,0001). Результат действия в отношении облегчения боли в конце 2-й нед. лечения оценили как отличный - от 28 до 36%, как хороший - от 26 до 36% больных в разных подгруппах. Об отсутствии эффекта сообщили от 15 до 31% больных. По сравнению с концом 1-й нед. к концу 2-й нед. лечения число больных, отметивших существенное облегчение ("клиническое излечение"), увеличилось примерно вдвое. Дротаверина гидрохлорид оказывал положительное влияние на частоту и консистенцию стула. При CРК с преобладанием диареи средняя частота дефекаций в сутки уменьшилась с 2,8±1,2 до 1,6±0,8 (p<0,0001); при СРК с запором - увеличилась с 0,6±0,4 до 0,8±0,3 (р=0,0004). Последнее можно объяснить уменьшением спастической активности толстой кишки. Значительно уменьшилось число больных, испытывавших чувство затрудненной дефекации, неполного опорожнения прямой кишки, императивных позывов. Серьезных нежелательных явлений в ходе лечения не зафиксировано .

A pharmacoeconomic analysis of the use of antispasmodics for pain relief in IBS, published by A.V. Afonin, O.M. Drapkina, A.S. Kolbin, M.V. Pchelintsev, V.T. Ivashkin, showed that “drotaverine has faster dynamics to reduce signs of spasm and associated abdominal pain in comparison with mebeverine and hyoscine butyl bromide.No-spa has clear clinical and economic advantages in terms of pharmacoeconomic parameters “cost-effectiveness” and “cost minimization”.

In recent years, much attention has been devoted to the problem of magnesium deficiency in the pathogenesis of reproductive diseases in women, as well as emotional disorders and increased neuromuscular excitability. The effects that magnesium has in the body are closely related to the action of pyridoxine (vitamin B6). These substances, acting synergistically, regulate the functions of many enzymes, prevent the accumulation of homocysteine ​​and prevent thrombophilia. Magnesium is involved in maintaining the transmembrane potential and also reduces the production of thromboxane, exhibiting anti-inflammatory and antiplatelet effects.

In the modern diet of Russians, the magnesium content often does not correspond to physiological needs. The causes of iatrogenic magnesium deficiency can be the prescription of diuretics, cyclosporine, cardiac glycosides, antibiotics (especially aminoglycosides), adrenergic blockers, caffeine, theobromine, theophylline, anti-tuberculosis drugs, estrogen-containing contraceptives. Magnesium loss occurs with diarrhea. Under conditions of vitamin B6 and magnesium deficiency, pain sensitivity increases, probably partly due to impaired synthesis of neurotransmitters that regulate nociception - GABA, serotonin, dopamine.

With magnesium deficiency, pregnant women experience pelvic pain associated with impaired blood flow and tone of the uterus, as well as increased muscle excitability.

Organic magnesium salts (lactate, orotate, aspartate, citrate, pidolate) are absorbed significantly better than inorganic ones when taken orally. Combination with pyridoxine improves magnesium absorption. The combination of magnesium lactate 470 mg with vitamin B6 5 mg per tablet (MagneB6®) and magnesium citrate 618.34 mg with vitamin B6 10 mg per tablet (MagneB6 forte® produced by Sanofi-Aventis) can be used in the complex treatment of patients with chronic pelvic pain due to conditions accompanied by magnesium deficiency.

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Chronic pelvic pain syndrome (abbreviation: CPPS) is a significant concern for healthcare providers due to its unclear etiology, complex natural history, and poor response to therapy. In clinical practice, multimodal therapy is used to eliminate pain. The success of treatment depends on the doctor’s correct knowledge of all pelvic organs, the musculoskeletal system, neurological and mental systems. The prognosis is nonspecific and directly depends on the root cause that caused the pain syndrome.

Chronic pelvic pain syndrome is long-term (from 6 months) pain in the pelvic organs, the degree of which varies from mild to very severe. 44% of patients experience various associated problems, including bladder or bowel dysfunction and other systemic or constitutional symptoms.

In the United States, estimated direct medical costs for outpatient visits for chronic pelvic pain (women aged 18–50 years) are approximately $1 million per year.

Symptoms of chronic pelvic pain affect approximately 1 in 7 women. In one study of reproductive age women in a primary care practice, the prevalence of pelvic pain was 39%. Of all visits to gynecologists, 10% relate to chronic pelvic pain syndrome.

As with other chronic pain, chronic pelvic pain can lead to long-term suffering, family problems, job loss or disability, and various adverse medical reactions as a result of lifelong therapy.

Chronic pelvic pain is most common among women of reproductive age. Common causes of chronic pelvic pain in men include chronic (nonbacterial) prostatitis, chronic orchalgia, and prostatodynia.

Causes of occurrence and factors influencing the development of pathology

A variety of reproductive, gastrointestinal, urological, and neuromuscular disorders can cause or contribute to chronic pelvic pain. Sometimes there may be several contributing factors in one patient.

Ectopic reproductive disorders:

  • endometriosis;
  • ectopic pregnancy;
  • chlamydial endometritis or salpingitis;
  • Tuberculous salpingitis.

Symptomatic relaxation of the pelvic organs (genital prolapse):

  • intrauterine contraception.

Urological disorders:

  • bladder neoplasms;
  • chronic urinary tract infection;
  • interstitial cystitis;
  • urethritis;
  • urolithiasis disease;
  • chronic urethral syndrome.

Diseases of the musculoskeletal system:

  • compression fracture of the lumbar vertebrae;
  • incorrect or poor posture;
  • fibromyalgia;
  • mechanical pain in the lower back;
  • chronic coccygeal pain;
  • muscle strains and sprains;
  • hernias

Gastrointestinal disorders:

  • colon cancer;
  • chronic intermittent intestinal obstruction;
  • colitis;
  • chronic constipation;
  • diverticular disease;
  • inflammatory bowel disease;
  • irritable bowel syndrome.

Neurological disorders:

  • neuralgia;
  • shingles;
  • degenerative joint disease;
  • spondylosis;
  • epilepsy;
  • neoplasia of the spinal cord or sacral nerve.

Psychological and other disorders:

  • personality disorders;
  • depression;
  • sleep disorders.

If pain persists for more than 6 weeks, chronic pelvic pain or urethral pain is called "urethral syndrome." Contrary to popular belief, chronic pelvic pain syndrome is most often an organic disorder rather than a psychiatric one. Most patients have the above diseases.

Characteristic clinical manifestations

Symptoms are nonspecific and vary widely. In clinical practice, urological, gynecological, anorectal, neurological and muscular disorders of various etiologies are noted.

Urological symptoms

A detailed history to evaluate the urological system is essential. Patients with interstitial cystitis report increased frequency of urination as the most distressing symptom.

Gynecological symptoms

Excessive bleeding with menstruation suggests uterine leiomyomas or adenomyosis. A history of previous surgery may indicate intra-abdominal or pelvic adhesions.

Patients with cervical stenosis usually have a history of chronic infection of the cervix. Sometimes it is caused by treatment with cryosurgery/laser surgery or endometrial resection. Having multiple sexual partners is a risk factor for pelvic inflammatory disease.

Women with adenomyosis have higher rates of dysmenorrhea, pelvic pain, depression and endometriosis than people with fibroids. Women who have undergone hysterectomy with a histological diagnosis of adenomyosis have distinct symptoms and medical history compared with women with leiomyomas.

Anorectal symptoms

Deflecting sigmoid adhesions are common in women with chronic pelvic pain and are often associated with the gastrointestinal tract. Vaginal birth with prolonged episiotomy or second stage anal fissures may indicate a pelvic floor relaxation disorder.

Neurological symptoms

Constant burning pain is a common complaint in patients with neuralgia. Patients may report dysesthesia and vulvodynia, but usually not dyspareunia. A good psychosocial or psychosexual history is necessary to exclude organic diseases or concomitant mental disorders.


Vulvodynia is a neurological symptom of chronic pelvic pain syndrome

It is recommended to obtain a sufficiently detailed medical history to evaluate depression, anxiety disorder, medical illness, physical or sexual abuse, drug abuse or addiction, and family problems.

Sexual abuse before age 15 is associated with later development of chronic pelvic pain. Somatization is a common psychological disorder in women with chronic pelvic pain. Somatization scales can be used to assess the patient's condition.

Muscle pain syndrome

Various terms can be used to describe the quality of pain. Women often experience pulsation, tingling, spasms, colic, squeezing, stretching, pinching, burning, squeezing and dull pain.

In medical practice, special systems with a certain degree of objectivity and reproducibility are used to assess pain intensity. Various types of pain scales may also be used. The visual analogue scale is one of the most commonly used numerical methods for assessing muscle pain.

Diagnostic criteria

Tolerance and an open-minded approach are important when assessing any patient with chronic pain. A thorough systematic examination usually suggests appropriate diagnosis and therapy. Obstetrics, gynecology and other systemic examinations can be lengthy and stressful. A detailed examination of the obstetric-gynecological and other systems can be carried out in different positions. This usually involves standing, sitting and lying down.

Main types of research:

  • visual examination of the external genitalia;
  • basic sensory testing and trigger point assessment;
  • colposcopic assessment of the vulva and vestibule;
  • bimanual pelvic examination;
  • rectovaginal examination;
  • CT scan;
  • radiography.

Diagnoses that need to be excluded (differential diagnosis):

  • abdominal hernias;
  • acute bacterial prostatitis and prostate abscess;
  • acute intermittent porphyria;
  • anorectal abscess
  • benign ovarian lesions;
  • benign lesions of the vulva;
  • bipolar schizoaffective disorder;
  • bladder cancer;
  • carcinoma in the position of the bladder;
  • cervicitis;
  • chronic bacterial prostatitis.

Urinalysis and ultrasound often require imaging (CT or MRI of the abdomen), cystoscopy, and examination of the vagina and pelvic floor. Often the pain can be well localized when examining the genitals. Exclusion of the above causes leads to the diagnosis of chronic pelvic pain syndrome or interstitial cystitis.

Methods and basic principles of therapy

Treatment of chronic pelvic pain is complex in patients with multiple problems. Special treatment and simultaneous psychological and physical therapy are usually required. A good relationship between doctor and patient must be established. Treatment for chronic pelvic pain is tailored to the individual patient.

Treatment goals must be realistic. They should be aimed at restoring normal organ function (minimal disability), improving quality of life, and preventing recurrence of chronic symptoms.

Medication

Pharmacotherapy consists of symptomatic medications aimed at stopping or reducing the severity of acute exacerbations. Initially, the pain may respond to simple over-the-counter analgesics such as paracetamol, ibuprofen, aspirin or naproxen. If treatment results are unsatisfactory, the addition of other methods or the use of prescription medications is recommended.

If possible, it is recommended to avoid the use of barbiturates or opiate agonists completely. Long-term use and abuse of all symptomatic analgesics is also not recommended due to the risk of dependence.

Tizanidine can improve inhibitory function in the central nervous system and relieve pain. Tizanidine therapy is not considered standard of care. Amitriptyline (Elavil) and nortriptyline (Pamelor) are tricyclic antidepressants (TCAs) most commonly used for chronic pain.


Amitriptyline is a drug for the treatment of chronic pelvic pain syndrome

Selective serotonin reuptake inhibitors (SSRIs) are also commonly prescribed: fluoxetine (Prozac), paroxetine (Paxil), and sertraline (Zoloft). Other antidepressants such as doxepin, desipramine, protriptyline and buspirone may also be used.

Local administration of cortisone, anesthetics, vasodilating drugs, glycosaminoglycans also alleviates the condition of patients. Through a catheter with an electrical stimulation connection, the administered active ingredients can also reach the deeper layers of the pelvis.

In severe cases (bladder contraction), surgery is necessary in which most of the bladder is removed and replaced with intestinal components (supratrigonal cystectomy and bowel augmentation).

Physiotherapy

Physical therapy modalities include hot or cold applications, stretching exercises, massage, ultrasound therapy, transcutaneous electrical nerve stimulation (TENS), and manual therapy. Heat, massage and stretching can be used to relieve excess muscle contraction and pain. Pelvic floor training is also recommended in clinical practice.

In a Brazilian study, 58 women with pelvic pain of at least 6 months' duration who received multidisciplinary treatment for 6 months reported decreased sensitivity to skin pain using TENS. In the group that experienced a reduction in chronic pelvic pain after 6 months of multidisciplinary treatment, the therapeutic effect size was 40%.

Psychophysiological therapy

Psychophysiological therapy includes counseling, relaxation therapy, stress management program and biofeedback techniques. With these treatments, the frequency and severity of chronic pain can be reduced.

Biofeedback may be helpful for some patients in combination with medications. A Canadian study of 50 women with deep-penetrating endometriosis rated the effectiveness and safety of potentized estrogen relatively high compared to placebo.

The study reported that potentized estrogen at a dose of 3 drops twice daily for 24 weeks reduced the total pain score associated with pelvic endometriosis. The group that used potentized estrogen also experienced a reduction in dysmenorrhea, non-cyclic pelvic pain, and cyclic bowel pain.

Prevention measures

The patient and her family should have a good understanding of the multifactorial nature of chronic pain. Interdisciplinary and comprehensive treatment plans are needed. Therefore, self-medication is strictly prohibited.

The physician should instruct the patient to avoid uncomfortable stressful positions and poor posture. Experts also recommend regular exercise, a normal sleep schedule and a balanced diet. Hypovitaminosis should be avoided and plenty of fluids should be consumed.