Chronic Pelvic Pain

Defining Pelvic Pain

Persistent pelvic pain refers to constant or recurrent pain that occurs in the lower abdomen and pelvis, lasting for at least six months or longer.

It is a complex condition with a variety of potential causes, and it can significantly impact a person’s quality of life.

Persistent pelvic pain may be dull, sharp, intermittent, or constant, and it may be accompanied by other symptoms such as discomfort during urination, bowel movements, or sexual activity.

Where Does Pelvic Pain Occur?

Pelvic pain can occur in the lower part of the abdomen, below the belly button, and between the hip bones.

It encompasses the region of the pelvis, which is the area of the body located between the abdomen and the thighs.

Pelvic pain can be felt in various areas within the pelvic region, including:

• Lower Abdomen. Pelvic pain commonly occurs in the lower abdomen, particularly in the area below the belly button. The pain may be localised to one side of the abdomen or may be felt centrally.
• Pelvic Area. The pain can be felt deep within the pelvic cavity, often described as a dull ache or pressure. It may feel like it originates from the reproductive organs (uterus, ovaries, fallopian tubes) or other pelvic structures (bladder, bowel, pelvic floor muscles).
• Groin. Pelvic pain may radiate to the groin area, or the crease where the abdomen meets the thigh. This can occur on one or both sides and may be associated with conditions affecting the pelvic organs, pelvic floor muscles or the hip joints.
• Lower Back. Pelvic pain may extend to the lower back, particularly in cases where pelvic inflammation, muscle tension, or nerve irritation is involved. The pain may be centralised or may radiate from the pelvis to the lower back. The pain may also originate from structures of the lumbar spine such as the discs, nerves, muscles and facet joints.
• Perineum. The perineum is the area of tissue between the anus and the genitals. Pelvic pain may be felt in this region, particularly in cases of pelvic floor dysfunction or nerve-related pain.
• Buttocks. Some individuals with pelvic pain may experience discomfort in the buttocks, especially if the pain radiates from the pelvis to the surrounding muscles or nerves. The pain may also originate from structures such as the sacroiliac joints due to inflammation or sacroiliac joint dysfunction.
• Genitals. Pelvic pain may also be felt in the genitals, including the vagina, vulva, or penis. This can occur with conditions affecting the reproductive organs or pelvic floor muscles.

Pelvic pain can vary in intensity, duration, and quality, ranging from mild discomfort to severe, debilitating pain.

It may be constant or intermittent and may worsen with certain activities, such as menstruation, sexual intercourse, or bowel movements. 

The location and characteristics of pelvic pain can provide valuable clues about its underlying cause, but a thorough medical evaluation is often necessary to determine the specific source of the pain and develop an appropriate treatment plan.

Often there is an interplay between the various structures and organ systems and it is common to identify more than one cause leading to pelvic pain.

What Causes Persistent Pelvic Pain?

There are numerous potential causes of persistent pelvic pain, including but not limited to:

• Endometriosis. Endometriosis, a condition where tissue similar to the lining of the uterus grows outside the uterus, is a common cause of persistent pelvic pain in women of reproductive age.
• Pelvic Inflammatory Disease (PID). PID is an infection of the female reproductive organs, often caused by sexually transmitted infections (STIs) such as chlamydia or gonorrhoea. It can lead to persistent pelvic pain if left untreated.
• Interstitial Cystitis/Bladder Pain Syndrome (IC/BPS). IC/BPS is a chronic bladder condition characterised by bladder pain, urinary urgency, and frequency. It can cause pelvic pain that may worsen as the bladder fills.
• Pelvic Floor Dysfunction. Pelvic floor dysfunction involves abnormalities or weakness in the muscles, ligaments, and connective tissues of the pelvic floor. This dysfunction can lead to persistent pelvic pain and may be associated with conditions such as pelvic floor tension, myalgia or pelvic floor hypertonicity.
• Adenomyosis. Adenomyosis is a condition characterised by the presence of endometrial tissue within the muscular wall of the uterus. It can cause persistent pelvic pain, heavy menstrual bleeding, and other symptoms similar to those of endometriosis.
• Fibroids. Uterine fibroids are noncancerous growths that develop in or on the uterus. Large or numerous fibroids can cause persistent pelvic pain, pressure, and discomfort.
• Chronic Pelvic Inflammatory Conditions. Chronic inflammatory conditions affecting the pelvic organs, such as chronic appendicitis or diverticulitis, can cause ongoing pelvic pain.
• Gastroenterological causes. Conditions such as Inflammatory bowel disease (Crohn’s disease/ Ulcerative Colitis), adhesions, irritable bowel syndrome can cause persistent pelvic pain, often associated with change in bowel motions.
• Pelvic Congestion Syndrome. Pelvic congestion syndrome occurs when varicose veins develop in the pelvic area, leading to persistent pelvic pain, particularly in women who have had multiple pregnancies.
• Nerve Compression or Entrapment. Nerves in the pelvic region can become compressed or entrapped, leading to persistent pelvic pain. Conditions such as pudendal neuralgia or ilioinguinal neuralgia can cause this type of pain.
• Post-surgical pain. Patients can develop pelvic pain after major abdominal surgeries such as hysterectomy, bowel resections, laparotomies, hernia repairs etc, due to nerve damage and development of adhesions. 
• Psychological Factors. Emotional stress, anxiety, depression, post traumatic stress disorder and other psychological factors can contribute to or exacerbate persistent pelvic pain.

Diagnosing the underlying cause of persistent pelvic pain can be challenging and may require a thorough medical evaluation, including a physical examination, imaging tests, and possibly diagnostic procedures such as laparoscopy or cystoscopy. 

Treatment approaches for persistent pelvic pain vary depending on the underlying cause but may include medications, physical therapy, lifestyle modifications, and in some cases, surgical intervention. 

A multidisciplinary approach involving experts from various specialties may be beneficial in managing persistent pelvic pain effectively.

What is a Pelvic Pain Specialist?

A pelvic pain specialist is a healthcare provider who specialises in the diagnosis and treatment of persistent pelvic pain.

These types of physicians typically have general expertise in various medical disciplines, including gynaecology, urology, gastroenterology, colorectal surgery, pain medicine, physical therapy, and psychology. 

They are trained to evaluate and manage a wide range of conditions that can cause pelvic pain, utilising a multidisciplinary approach to address the complex nature of persistent pelvic pain.

Multidisciplinary Teams for Persistent Pelvic Pain

A multidisciplinary team for persistent pelvic pain typically includes healthcare professionals from various specialties who collaborate to provide comprehensive care tailored to the individual needs of patients. 

The composition of the team may vary depending on the specific needs and circumstances of each patient, but it often includes professionals with expertise in the following areas:

• Pain Management Specialists. Pain management specialists are physicians with specialised training in the diagnosis and treatment of chronic pain conditions. They may employ a variety of approaches to manage pelvic pain, including medication management, interventional procedures (e.g., nerve blocks), physical therapy, and psychological interventions.
• Gynaecologists or Gynaecological Surgeons. Gynaecologists specialising in women’s reproductive health are often involved in the diagnosis and management of conditions such as endometriosis, pelvic inflammatory disease (PID), and other gynaecological causes of pelvic pain. Gynaecological surgeons may perform minimally invasive procedures, such as laparoscopic surgery, to diagnose and treat pelvic pain.
• Urologists or Functional Urologists. Urologists specialise in the diagnosis and treatment of conditions affecting the urinary tract, including the bladder and urethra. They may be involved in evaluating and managing pelvic pain associated with conditions such as interstitial cystitis/bladder pain syndrome (IC/BPS) or urinary tract infections (UTIs). Functional Urologists may provide specific treatment including medications, physical therapy and neuromodulation for certain bladder conditions.
• Gastroenterologists. Gastroenterologists specialise in the diagnosis and treatment of conditions affecting the digestive system, including the intestines, colon, and rectum. They may be involved in evaluating and managing pelvic pain associated with gastrointestinal disorders such as irritable bowel syndrome (IBS), inflammatory bowel disease (IBD), or pelvic floor dysfunction affecting bowel function.
• Colorectal surgeons. Colorectal surgeons specialise in the diagnosis and treatment of various conditions affecting the colon, rectum and anus. This may include disorders such as inflammatory bowel disease, carcinomas, benign tumours and painful perianal conditions.
• Physical Therapists. Pelvic floor physiotherapists specialise in the evaluation and treatment of pelvic floor dysfunction, including muscle imbalances, tension, and weakness that may contribute to pelvic pain. They may provide specialised exercises, manual therapy techniques, biofeedback, and education to improve pelvic floor function and alleviate pain.
• Psychologists or Mental Health Professionals. Psychologists or mental health professionals may be involved in providing counselling, cognitive-behavioural therapy (CBT), stress management techniques, or other psychological interventions to help patients cope with persistent pelvic pain and its impact on emotional well-being.
• Pain Psychologists/ Hypnotherapists. Pain psychologists and Hypnotherapists specialise in the assessment and treatment of psychological factors contributing to chronic pain conditions. They may work with patients to address issues such as pain catastrophising, depression, anxiety, and coping skills to improve pain management and overall functioning.

Dr Mittal is the Director of the Pelvic Pain Collaborative Group which comprises all of the above specialists who are experts in their field and are well averse with the complexities of persistent pelvic pain.

By bringing together professionals from multiple disciplines, Dr Mittal and her staff at Persistent Pain Solutions can offer comprehensive care that addresses the complex interplay of physical, psychological, and social factors contributing to persistent pelvic pain. 

Collaboration among team members allows for individualised treatment plans tailored to each patient’s unique needs and preferences, with the goal of improving pain management, functionality, and everyday life. 

How Does a Pain Specialist Treat Pelvic Pain?

Here’s how a pelvic pain specialist may approach the diagnosis and treatment of chronic pelvic pain:

1. Comprehensive Evaluation and Assessment. The specialist will conduct a thorough medical history and physical examination to assess the patient’s symptoms, medical history, and potential risk factors for pelvic pain. Diagnostic tests, such as imaging studies (Ultrasound, CT, MRI and pathology blood tests) may be ordered to identify the underlying cause of the pain.
2. Collaboration with other specialists. Often the cause of persistent pelvic pain is multifactorial in nature. Early involvement of other specialists will assist in obtaining a targeted diagnosis and identifying the various organ systems that are involved in the evolution of the pelvic pain. This will enable a more specific treatment plan depending on the causes identified.
3. Individualised Treatment Plan. Based on the evaluation findings, the specialist will develop a personalised treatment plan tailored to the patient’s specific needs and circumstances. The treatment plan may involve a combination of medical, surgical, and non-invasive therapies aimed at relieving pain and improving quality of life.
4. Medication Management. Pelvic pain specialists may prescribe medications to help manage persistent pelvic pain, depending on the underlying cause and the patient’s symptoms. This may include pain relievers, muscle relaxants, hormone therapy, antidepressants, or anticonvulsants to target neuropathic pain.
5. Interventional Procedures. For patients with severe or refractory pelvic pain, pelvic pain specialists may perform interventional procedures to provide targeted pain relief. These procedures may include nerve blocks, trigger point injections, corticosteroid injections, radiofrequency denervation treatments, sacral neuromodulation or spinal cord stimulation. 
6. Physical Therapy. Pelvic floor physical therapy is often a key component of treatment for persistent pelvic pain. Pelvic pain specialists may refer patients to physical therapists specialising in pelvic floor rehabilitation to address muscle imbalances, tension, and dysfunction contributing to pelvic pain.
7. Surgical Intervention. In some cases, surgical intervention may be necessary to address underlying anatomical abnormalities, endometriosis, pelvic adhesions, or other conditions contributing to pelvic pain. Pelvic pain specialists may refer patients to other specialists to perform minimally invasive procedures, such as laparoscopic surgery, to diagnose and treat pelvic pain while minimising surgical risks and recovery time.
8. Psychological and Mental Health Support. Persistent pelvic pain can have a significant impact on a patient’s emotional well-being and quality of life. Pelvic pain specialists may collaborate with psychologists or mental health professionals to provide counselling, cognitive-behavioural therapy, stress management techniques, or other psychological interventions to help patients cope with pain and improve their overall functioning.

Overall, pelvic pain specialists take a holistic and multidisciplinary approach to the management of persistent pelvic pain, addressing the physical, psychological, and social aspects of the condition to optimise treatment outcomes and improve your outlook on life. 

What Does a Treatment Plan for Persistent Pelvic Pain Involve?

A holistic treatment plan for persistent pelvic pain involves a variety of methods and techniques aimed at addressing the underlying causes of pain, relieving symptoms, and improving overall quality of life. 

The specific approach to treatment may vary depending on the underlying cause of pelvic pain, as well as individual patient factors such as medical history, severity of symptoms, and treatment preferences. 

Here are some common methods and techniques used in the treatment of persistent pelvic pain:

• Medication Management. Medications may be prescribed to help manage pelvic pain and associated symptoms. These may include:
  • Nonsteroidal anti-inflammatory drugs (NSAIDs) to reduce inflammation and relieve pain.
  • Analgesics or opioids for severe pain that is not adequately controlled with other medications (used cautiously and only temporarily due to the risk of dependence, tolerance and other long term side effects).
  • Muscle relaxants to alleviate pelvic floor muscle tension and spasms.
  • Hormonal medications (e.g., birth control pills, GnRH agonists) to regulate hormonal fluctuations and reduce pain associated with conditions like endometriosis or adenomyosis.
  • Antidepressants or anticonvulsants for neuropathic pain management.
• Physical Therapy. Pelvic floor physical therapy is a key component of treatment for many individuals with persistent pelvic pain. Physical therapists specialising in pelvic floor rehabilitation can provide:
  • Pelvic floor muscle relaxation techniques.
  • Manual therapy to release trigger points and muscle tension.
  • Biofeedback to improve awareness and control of pelvic floor muscles.
  • Therapeutic exercises to strengthen weak muscles and improve pelvic stability.
  • Education on posture, body mechanics, and lifestyle modifications.
• Interventional Procedures. For patients with severe or refractory pelvic pain, interventional procedures may be considered to provide targeted pain relief. These may include:
  • Nerve blocks or injections of local anaesthetics and/or corticosteroids to block pain signals from specific nerves or trigger points.
  • Trigger point injections to release tension and alleviate pain in specific pelvic floor muscles.
  • Radiofrequency denervation treatment to block pain signals from various pelvic structures.
  • Sacral neuromodulation or spinal cord stimulation, which involves the implantation of a device to modulate nerve activity and reduce pelvic pain.
• Surgical Intervention. In cases where conservative treatments are ineffective or the underlying cause of pelvic pain requires surgical intervention, surgical options may be considered. These may include:
  • Laparoscopic surgery to diagnose and treat conditions such as endometriosis, adhesions, ovarian cysts, or fibroids.
  • Hysterectomy (removal of the uterus) or other surgical procedures to remove diseased tissue or structures contributing to pelvic pain.
• Psychological Support. Persistent pelvic pain can have a significant impact on a patient’s emotional well-being. Psychological support and interventions may include:
  • Counselling or psychotherapy to address psychological factors contributing to pain, such as stress, anxiety, or depression.
  • Cognitive-behavioural therapy (CBT) to help patients develop coping strategies, change negative thought patterns, and manage pain-related emotions.
  • Mindfulness-based stress reduction (MBSR) or relaxation techniques to promote relaxation and reduce stress.
• Lifestyle Modifications. Certain lifestyle modifications may help manage persistent pelvic pain and improve overall well-being. These may include:
  • Dietary changes to reduce inflammation and promote digestive health.
  • Regular exercise to improve pelvic muscle strength, flexibility, and circulation.
  • Stress management techniques such as yoga, meditation, or deep breathing exercises.
  • Avoiding activities or positions that exacerbate pelvic pain.
  • Cessation of smoking and reduction of alcohol consumption to reduce inflammation in the body and hence reduce pelvic pain.
  • Sleep hygiene techniques to assist with regulation of the circadian rhythm and hence manage pain more effectively during the day.

Overall, the treatment of persistent pelvic pain often involves a multimodal and individualised approach that addresses the complex interplay of physical, psychological, and social factors contributing to pain. 

Collaboration among healthcare providers from various disciplines is essential to develop comprehensive treatment plans tailored to your specific needs and goals.

Regular follow-up and ongoing adjustments to the treatment plan may be necessary to optimise pain management and improve overall quality of life.

The Challenges of Living with Persistent Pelvic Pain

Living with persistent pelvic pain presents numerous challenges that can significantly impact a person’s physical, emotional, and social well-being. 

Here are some of the key challenges individuals with persistent pelvic pain may face:

• Persistent Pain.  Persistent Pelvic pain is characterised by constant or recurrent pain in the lower abdomen and pelvis, lasting for at least six months or longer. The constant or intermittent nature of the pain can make it difficult to engage in daily activities, work, or social events.
• Physical Limitations. Persistent pelvic pain can lead to physical limitations, such as reduced mobility, muscle weakness, and fatigue. Activities that involve sitting, standing, walking, or lifting may exacerbate pain and discomfort, making it challenging to perform tasks both at home and in the workplace.
• Impact on Sexual Health. Pelvic pain can interfere with sexual intimacy and enjoyment, leading to decreased libido, discomfort during intercourse (dyspareunia), and relationship strain. The fear of pain during sexual activity may contribute to feelings of anxiety, frustration, or guilt.
• Fertility Concerns. For individuals of reproductive age who wish to become pregnant, persistent pelvic pain may be associated with underlying conditions such as endometriosis or pelvic inflammatory disease (PID) that can affect fertility. Fertility challenges and concerns about infertility treatment may add to the emotional burden of living with pelvic pain.
• Mental Health Effects. Persistent pelvic pain can have a profound impact on mental health, contributing to feelings of depression, anxiety, stress, and social isolation. Coping with ongoing pain, uncertainty about the future, and the challenges of managing daily life can exacerbate psychological distress.
• Financial Strain. Managing persistent pelvic pain often involves frequent medical appointments, diagnostic tests, treatments, and medications, which can be costly. Additionally, reduced ability to work or participate in daily activities due to pain may result in financial strain, loss of income, or difficulties accessing healthcare resources.
• Social Isolation. Persistent pelvic pain can lead to social isolation and withdrawal from social activities, hobbies, and relationships. Participating in events or gatherings may be challenging due to pain, fatigue, or discomfort, leading to feelings of loneliness and disconnection from others.
• Stigma and Misunderstanding. Pelvic pain is often misunderstood or stigmatised, leading to feelings of shame, embarrassment, or frustration for individuals living with persistent pelvic pain. Lack of awareness among the general public and healthcare providers may contribute to delays in diagnosis, mismanagement of symptoms, or dismissal of pain complaints.
• Challenges in Obtaining Diagnosis and Treatment. Obtaining an accurate diagnosis and effective treatment for persistent pelvic pain can be challenging due to the complexity of the condition and the lack of standardised diagnostic criteria. Patients may face barriers such as long wait times for specialist appointments, limited access to knowledgeable healthcare providers, and disparities in healthcare resources.

Living with persistent pelvic pain requires resilience, patience, and a strong support system.

It’s important for persistent pelvic pain patients to be their own best advocates, seek compassionate and knowledgeable healthcare providers, and access appropriate resources for pain management, psychological support, and social connections.

How do I Find a Pelvic Pain Specialist Near Me?

To find a pelvic pain specialist in or around Melbourne, you can start by asking your general practitioner for referrals to a pain management doctor.

Look for a doctor with access to a network of healthcare professionals who have experience treating patients with persistent pelvic pain and related conditions for more ideal outcomes.

Ensure that the doctor has adequate training and years of local experience in managing a complex condition such as persistent pelvic pain.

If you’re comfortable with speaking about your pelvic pain, reaching out to friends, family, and even support groups (both online or in-person) for referrals to appropriate physicians may help in your search. 

Persistent Pain Solutions for Chronic Pelvic Pain in Melbourne 

Dr Mittal and her collaborative team of multidisciplinary healthcare professionals at Persistent Pain Solutions are deeply committed to providing compassionate care to individuals suffering from pelvic pain and other chronic pain conditions.

Persistent pelvic pain affects both the patient and their loved ones, taking a significant physical and psychological toll.

It goes to follow that finding relief from pelvic pain can truly change your life. 

Dr Mittal offers a caring environment where empathy, understanding, and support are prioritised.

She listens to your concerns and understands your needs and health goals — and most importantly, looks for ways to manage your pelvic pain and reduce the ways that it can negatively affect your life. .

Dr Mittal views compassion as a fundamental aspect of pain relief, and is committed to alleviating your persistent pelvic pain and restoring your quality of life.