Causes of chronic pelvic pain in women

Author:
Robert L Barbieri, MD
Section Editor:
Howard T Sharp, MD
Deputy Editor:
Kristen Eckler, MD, FACOG

Contributor Disclosures

All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Feb 2017. | This topic last updated: Jul 30, 2013.

INTRODUCTION Chronic pelvic pain (CPP) refers to pain of at least six months' duration that occurs below
the umbilicus and is severe enough to cause functional disability or require treatment. In the United States, this
problem accounts for approximately 10 percent of all ambulatory referrals to a gynecologist and is a common
indication for diagnostic and therapeutic surgery [1]. It is considered the principal indication for approximately
20 percent of hysterectomies performed for benign disease and at least 40 percent of gynecological
laparoscopies [2,3].

The causes of CPP will be reviewed here. Evaluation and treatment of this disorder are discussed separately.
(See "Evaluation of chronic pelvic pain in women" and "Treatment of chronic pelvic pain in women".)

PREVALENCE The prevalence of CPP ranges from 4 to 16 percent, but only about one-third of women with
CPP seek medical care [4-7]. Representative examples of surveys that have attempted to determine the
prevalence of CPP in specific populations are described below:

A study of 635 women aged 20 to 50 years living in Seveso, Italy reported a prevalence of 4 percent for
moderate to severe CPP [4].
A survey of patient records of 136 primary care practitioners in the United Kingdom also observed a 4
percent prevalence of CPP among 284,162 women aged 12 to 70 years [5]. The prevalence of CPP in this
population was similar to that of migraine, back pain, and asthma.
A population-based study in New Zealand designed to investigate the prevalence of CPP in women
between the ages of 18 and 50 years noted that 25 percent of the 1160 women surveyed reported CPP
over a three- month interval [6].
In the United States, the Gallup organization performed a population-wide survey of women 18 to 50
years of age and found that of eligible women who agreed to participate, 15 percent reported they had
experienced CPP within the past three months [7]. The prevalence of pain sufficiently severe to miss work
was 4 percent, similar to the prevalence reported in the Italian and United Kingdom studies.
Characteristics of women with CPP in this study are described in the table (table 1).

ETIOLOGY Potential causes of CPP are listed in the table (table 2). The relative frequency of the various
causes of CPP is significantly influenced by the local patient population, referral patterns, and specialty focus of
the practice. In fact, one population-based study found that gastrointestinal and urologic problems were more
common than gynecological conditions in women with CPP; gynecologic conditions accounted for
approximately 20 percent of cases of CPP in this population [8].
Although any one disorder may be the cause of CPP, pain can also be the end result of several medical
conditions, with each contributing to the generation of pain and requiring management. As an example, a
woman may have endometriosis, interstitial cystitis, emotional stress, and pelvic floor pain related to muscular
spasm. Women with more than one medical condition tend to have greater pain than women with only one
disorder [9]. In some women, no diagnosis other than chronic pain can be established; this is often a source of
frustration for both the patient and clinician.

Some causes of CPP are discussed below by system.

Gynecologic etiologies

Endometriosis Endometriosis is the most common diagnosis made at the time of gynecological laparoscopy
for the evaluation of CPP. Overall, about one-third of women who undergo laparoscopy because of CPP are
diagnosed with endometriosis; however, in practices specializing in the treatment of endometriosis, 70 percent
or more of patients with CPP are given this diagnosis [10]. (See "Endometriosis: Pathogenesis, clinical features,
and diagnosis".)

Pelvic inflammatory disease As many as 30 percent of women with pelvic inflammatory disease (PID)
subsequently develop CPP [11]. Therefore, PID is a common cause of CPP in settings with a high prevalence of
sexually transmitted disease. (See "Pelvic inflammatory disease: Clinical manifestations and diagnosis".)

Two factors correlate with the likelihood of developing CPP after an episode of acute PID: (1) severity of
adhesive disease and tubal damage (eg, hydrosalpinx) and (2) persistent pelvic tenderness 30 days after
diagnosis and treatment [12]. However, the underlying reason that PID often leads to CPP has not been clearly
established. In one study of 780 predominantly black urban women with recently diagnosed PID, those most
likely to develop CPP were smokers, women with a history of two or more episodes of PID, and women with a
low composite mental health score on standardized tests [13].

Adhesions The relationship between CPP and presence of adhesions is poorly defined. There is some
evidence that dense adhesions that limit organ mobility cause visceral pain [14], and evidence from conscious
laparoscopic pain mapping that adhesions may account for pelvic pain in some patients [15].

Pelvic congestion syndrome Pelvic congestion syndrome is a controversial entity. It refers to a condition in
which characteristic symptoms of shifting location of pain, deep dyspareunia, post-coital pain, and exacerbation
of pain after prolonged standing are associated with radiological findings of pelvic varicosities (dilated uterine
and ovarian veins) that display reduced blood flow [16]. One theory is that damage to the valves in the ovarian
veins results in valvular incompetence leading to reflux and chronic dilation; however, incompetent and dilated
pelvic veins are a common finding in asymptomatic women [17].

Adenomyosis Abnormal uterine bleeding and dysmenorrhea are the major symptoms of adenomyosis. Pain
may be due to bleeding and swelling of endometrial islands confined by myometrium. Symptoms typically
develop between the ages of 40 and 50 years. (See "Uterine adenomyosis".)

Ovarian cancer Ovarian cancer is not truly a "silent killer." Most affected women have one or more
nonspecific symptoms, such as lower abdominal pain/discomfort/pressure/bloating, increased abdominal size,
constipation, lack of appetite/nausea/indigestion, irregular menstrual cycles/abnormal vaginal bleeding, low
back pain, fatigue, urinary frequency, or dyspareunia. (See "Epithelial carcinoma of the ovary, fallopian tube,
and peritoneum: Clinical features and diagnosis".)

Ovarian remnant and residual ovary syndrome The ovarian remnant syndrome (ORS) occurs in patients who
have undergone bilateral oophorectomy and subsequently present with symptoms related to ovulatory
function from ovarian tissue inadvertently left behind. It should be distinguished from the residual ovary
syndrome (ROS), in which the ovary was intentionally preserved and subsequently developed pathology. The
typical patient presents with cyclic pelvic pain and a mass, although the pain may be persistent with acute flare-
ups. Occasionally, an asymptomatic mass is detected on pelvic or sonographic examination. Ureteral
obstruction may occur. (See "Ovarian remnant syndrome".)

Leiomyoma Uterine leiomyomas may cause pressure symptoms. Acute pain occurs with degeneration,
torsion, or expulsion through the cervix. Chronic pain is uncommon [4]. (See "Uterine leiomyomas (fibroids):
Epidemiology, clinical features, diagnosis, and natural history".)

Dysmenorrhea Dysmenorrhea commonly occurs in women with CPP. (See "Primary dysmenorrhea in adult
women: Clinical features and diagnosis".)

Other CPP is often associated with vulvar pain and dyspareunia. (See "Clinical manifestations and diagnosis
of localized vulvar pain syndrome (formerly vulvodynia, vestibulodynia, vulvar vestibulitis, or focal
vulvitis)" and "Clinical manifestations and diagnosis of generalized vulvodynia" and "Differential diagnosis of
sexual pain in women".)

It can also be due to postsurgical a neuropathy, such as nerve entrapment. (See "Nerve injury associated with
pelvic surgery".)

Urinary tract

Interstitial cystitis/painful bladder syndrome Interstitial cystitis/painful bladder syndrome may be a

common cause of CPP [18]. It is a chronic inflammatory condition of the bladder that causes pelvic pain and
irritable bladder dysfunction with exaggerated urge to void and urinary frequency. Incontinence is not usually a
symptom. The syndrome is often referred to as interstitial cystitis/painful bladder syndrome (IC/PBS), reflecting
the importance of bladder pain as a primary characteristic of the syndrome. (See "Pathogenesis, clinical
features, and diagnosis of interstitial cystitis/bladder pain syndrome".)

Other Chronic suprapubic pain, especially in association with frequency, urgency, and/or hematuria suggests
recurrent urinary tract infection. The possibility of a urethral diverticulum should be considered if there is a
suburethral mass, fullness, or tenderness. (See "Recurrent urinary tract infection in women" and "Urethral
diverticulum in women".)

Bladder neoplasia (carcinoma-in-situ and carcinoma) may present with symptoms similar to those of interstitial
cystitis. Neoplasia should be considered in women with hematuria, a history of smoking, or who are over 60
years of age.

Chronic urethral syndrome also presents with symptoms resembling those of interstitial cystitis, and many
experts no longer recognize chronic urethral syndrome as a diagnosis distinct from
interstitial cystitis/painful bladder syndrome.
Gastrointestinal tract

Irritable bowel syndrome Irritable bowel syndrome (IBS, sometimes also called visceral hyperalgesia [19]) is
a gastrointestinal pain syndrome characterized by chronic or intermittent abdominal pain that is associated with
bowel function, in the absence of any organic cause. Most patients with IBS also have bowel dysfunction. About
10 percent of the general population has symptoms compatible with IBS; women are diagnosed with IBS more
than twice as often as men [20-22].

IBS is probably the most common diagnosis in primary care populations with CPP, occurring in up to 35 percent
of these women [9,23]. However, in many women with CPP and IBS, the IBS has not been diagnosed or treated
[23].

The diagnosis of IBS is based upon specific criteria in the patient's history; physical examination is generally
unremarkable. The clinical manifestations, diagnosis, and treatment of IBS are discussed in detail separately.
(See "Clinical manifestations and diagnosis of irritable bowel syndrome in adults" and "Treatment of irritable
bowel syndrome in adults".)

In children and adolescents, functional abdominal pain is the most common cause of chronic abdominal pain. It
is a diagnosis of exclusion after anatomic, infectious, inflammatory, and metabolic causes of abdominal pain
have been ruled out [24]. Specific functional abdominal pain disorders include functional dyspepsia, IBS,
abdominal migraine, and functional abdominal pain syndrome.

Inflammatory bowel disease Fatigue, diarrhea with crampy abdominal pain, weight loss, and fever, with or
without gross bleeding, are the hallmarks of Crohn's disease. The transmural nature of the inflammatory
process leads to fibrotic strictures that often lead to repeated episodes of small bowel or less commonly colonic
obstruction. Ulcerative colitis, as well as other causes of colitis, have a similar presentation; however, rectal
bleeding is more common with ulcerative colitis than with Crohn's disease. (See "Clinical manifestations,
diagnosis and prognosis of Crohn disease in adults" and "Clinical manifestations, diagnosis, and prognosis of
ulcerative colitis in adults".)

Diverticular colitis Infrequent patients with diverticular disease develop a segmental colitis most commonly
in the sigmoid colon. The endoscopic and histologic features vary, ranging from mild inflammatory changes with
submucosal hemorrhages (peridiverticular red spots on colonoscopy) to florid, chronic active inflammation
resembling (histologically and endoscopically) inflammatory bowel disease. The pathogenesis is incompletely
understood. The cause may be multifactorial, related to mucosal prolapse, fecal stasis, or localized ischemia.
(See "Segmental colitis associated with diverticulosis".)

Colon cancer The majority of patients with colorectal cancer have hematochezia or melena, abdominal
pain, and/or a change in bowel habits. (See "Clinical presentation, diagnosis, and staging of colorectal cancer".)

Chronic intestinal pseudo-obstruction The clinical symptoms of chronic intestinal pseudo-obstruction

include distension (75 percent), abdominal pain (58 percent), nausea (49 percent), constipation (48
percent), heartburn/regurgitation (46 percent), fullness (44 percent), epigastric pain/burning (34 percent), early
satiety (37 percent), and vomiting (36 percent). (See "Chronic intestinal pseudo-obstruction".)

Chronic constipation Although chronic constipation is common in women, chronic pain is not a common
symptom. (See "Etiology and evaluation of chronic constipation in adults".)
Celiac disease Celiac disease (or sprue) is a disorder caused by an immune reaction to gluten. Impaired
absorption and digestion of nutrients by the small intestine typically result in recurrent diarrhea and weight
loss, but chronic pelvic pain may be the presenting complaint [25].

Musculoskeletal system

Fibromyalgia Women with fibromyalgia sometimes present to their gynecologists with CPP as the primary
complaint. Fibromyalgia is a poorly characterized disorder with substantial overlap with systemic exertion
intolerance disease, also known as chronic fatigue syndrome; depression; somatization; and IBS [22]. The
American College of Rheumatology has two criteria which must be present for diagnosing fibromyalgia:

The patient reports pain in all four quadrants of the body, and
Detection of at least 11 (of a possible 18) separate areas (eg, knees, shoulders, elbows, neck) that are
tender to physical pressure stimulus applied by the clinician [26].

(See "Clinical manifestations and diagnosis of fibromyalgia in adults".)

Coccydynia, piriformis/levator ani syndrome, pelvic floor tension myalgia Coccydynia, pelvic floor tension
myalgia, or pelvic myofascial pain is caused by involuntary spasm of the pelvic floor muscles (eg, piriformis,
levator ani, iliopsoas, obturator internus). In particular, the levator ani muscle group can undergo pain
processes observed in other muscle groups, such as hypertonus, myalgia, overuse, and fatigue. The etiology
includes any inflammatory painful disorder, childbirth, pelvic surgery, and trauma. In addition to dyspareunia,
there may be aching pelvic pain, which is aggravated by sitting for prolonged periods, and relieved by heat and
lying down with the hips flexed.

There is evidence that women with CPP have decreased thresholds to pain in the pelvic floor muscles,
suggesting that pelvic floor tension myalgia may sometimes be a direct sequela of CPP due to other disorders,
such as endometriosis or IC/PBS [27].

Posture Faulty posture can cause muscle imbalance involving the abdominal muscles, thoracolumbar fascia,
lumbar extensors, or hip flexors and abductors leading to local or referred pain.

Chronic abdominal wall pain Chronic pain emanating from the abdominal wall is frequently unrecognized or
confused with visceral pain, often leading to extensive diagnostic testing before an accurate diagnosis is
achieved. (See "Anterior cutaneous nerve entrapment syndrome".)

It may be related to muscular injury or strain (eg, rectus abdominis, pyramidalis, external obliques, transversus
abdominus) or nerve injury (iliohypogastric, ilioinguinal, genitofemoral, lateral femoral cutaneous, pudendal).
Pathology of these nerves can also result in pain referred to visceral organs. Chronic abdominal wall pain occurs
in 7 to 9 percent of women after a Pfannenstiel incision [28]. (See "Nerve injury associated with pelvic
surgery".)

Myofascial pain syndrome is pain that originates from myofascial trigger points in skeletal muscle. Compression
of the hyperirritable spot results in local as well as referred pain, sometimes accompanied by autonomic
phenomena (piloerection, hyperhidrosis, vasodilation or vasoconstriction) and visceral symptoms (eg, diarrhea,
vomiting) [29]. It may develop after an injury (direct muscular injury or overuse strain), or it may be related to
scoliosis or other postural/joint abnormalities.
Abdominal wall hernias can also cause CPP. (See "Overview of abdominal wall hernias in adults".)

Osteitis pubis Osteitis pubis refers to lower abdominal and pelvic pain due to noninfectious inflammation of
the pubic symphysis. It can be a complication of surgery (eg, urogynecologic procedures) or related
to pregnancy/childbirth, athletic activities, trauma, or rheumatological disorders. The pain is aggravated by
movements such as walking, stair climbing, and coughing. On examination, the pubis symphysis is tender to
palpation. (See "Sports-related groin pain or 'sports hernia'" and "Musculoskeletal changes and pain during
pregnancy and postpartum".)

Mental health issues Mental health disorders, especially somatization, drug seeking behavior and opiate
dependency, physical and sexual abuse experiences, and depression are commonly diagnosed in women with
CPP. Somatization may be the cause of CPP, other mental health disorders are more likely to represent
comorbidities.

Somatization Somatization is a syndrome of nonspecific physical symptoms, such as CPP, that are distressing
and may not be fully explained by a known medical condition after appropriate investigation.
(See "Somatization: Epidemiology, pathogenesis, clinical features, medical evaluation, and diagnosis".)

Opiate dependency Patients treated with opioids for chronic pain have a 3 to 7 percent risk of manifesting
an addiction disorder. Additionally, patients with chronic pain have a decreased responsiveness to opioid
analgesics, such that higher than normal doses are required for adequate analgesia. Because of these factors,
the decision to treat women with CPP with opioids should be made only after a thorough evaluation, failure of
other treatment modalities, and appropriate counseling of risks. (See "Substance use disorder: Principles for
recognition and assessment in general medical care" and "Overview of the treatment of chronic non-cancer
pain".)

Physical and sexual abuse Patients with chronic pain appear to have a higher incidence of prior physical or
sexual abuse, and this appears to be the case for CPP, as well: up to 47 percent of women with CPP disclose a
history of physical and sexual abuse [30-32]. Past traumatic experiences may alter neuropsychological
processing of pain signals and can permanently alter pituitary-adrenal and autonomic responses to stress.

In one study, women with a childhood history of sexual or physical abuse had a five-fold greater increase of
adrenocorticotropic hormone to a standardized social stress intervention compared to women without a
history of abuse [33]. In another series, 713 consecutive women seen in a referral-based pelvic pain clinic were
given a questionnaire; 47 percent reported having either a sexual or physical abuse history and 31 percent had
a positive screen for posttraumatic stress disorder [32]. (See "Intimate partner violence: Epidemiology and
health consequences".)

Depression Depression, which is prevalent in the general population, appears to occur even more frequently
in women with CPP [34]. It is not clear if depression and CPP are causally related. A few authorities believe that
some cases of CPP are a variant of depression [35], while others feel that stressful experiences, such as
childhood sexual abuse, could cause both CPP and depression [36]. Alternatively, depression might increase the
risk that a stressful trauma, such as childhood sexual abuse, leads to CPP [37].

Some women presenting with CPP have histories of primary psychiatric comorbidity. It is important to
distinguish them from patients who are developing secondary psychological problems, that is, patients who are
developing symptoms of anxiety, depression, or other expressions of psychopathology in reaction to their pain.
Since nociceptive pathways are modulated by psychological processes, this mechanism probably plays an
important role in amplifying pain symptomatology [38]. (See "Unipolar depression in adults: Assessment and
diagnosis" and "Unipolar major depression in adults: Choosing initial treatment".)

Sleep disorders Women with CPP can have sleep disorders that both result from and contribute to their
pain and/or depression [39]. (See "Classification of sleep disorders".)

Abdominal pain Abdominal pain may be distinguished from pelvic pain by its location: the abdomen is the
area above the umbilicus, while the pelvic is the area below the umbilicus. Some causes of abdominal pain may
also cause pelvic pain. Abdominal pain is reviewed separately. (See "Causes of abdominal pain in adults".)

INFORMATION FOR PATIENTS UpToDate offers two types of patient education materials, The Basics and
Beyond the Basics. The Basics patient education pieces are written in plain language, at the 5 th to 6th grade
reading level, and they answer the four or five key questions a patient might have about a given condition.
These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.
Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles
are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and
are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these
topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on
patient info and the keyword(s) of interest.)

Basics topics (see "Patient education: Chronic pelvic pain in women (The Basics)" and "Patient education:
Bladder pain syndrome (interstitial cystitis) (The Basics)")
Beyond the Basics topics (see "Patient education: Chronic pelvic pain in women (Beyond the
Basics)" and "Patient education: Diagnosis of interstitial cystitis/bladder pain syndrome (Beyond the
Basics)")

SUMMARY AND RECOMMENDATIONS

Chronic pelvic pain (CPP) refers to pain below the umbilicus of at least six months' duration that is severe
enough to cause functional disability or require treatment. (See 'Introduction' above.)
The prevalence of CPP ranges from 4 to 16 percent. (See 'Prevalence' above.)
Potential causes of CPP are listed in the table (table 2). The relative frequency of the various causes of
CPP is significantly influenced by the local patient population, referral patterns, and specialty focus of the
practice. Although any one disorder may be the cause of CPP, pain can also be the end result of several
medical conditions, with each contributing to the generation of pain and requiring management. Women
with more than one medical condition tend to have greater pain than women with only one disorder. In
some women, no diagnosis other than chronic pain can be established. (See 'Etiology' above.)
The gastrointestinal and urinary tracts are the organ systems most often affected by disorders causing
CPP. Endometriosis is the most common gynecological cause of CPP. (See 'Etiology' above.)

ACKNOWLEDGMENT The editorial staff at UpToDate would like to acknowledge Fred Howard, MD, who
contributed to an earlier version of this topic review.

Use of UpToDate is subject to the Subscription and License Agreement.

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