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Pelvic pain in women

by Diane K. Newman, DNP, FAAN, BCB-PMD

Pelvic pain is a growing area of concern for health care providers as well as women with disorders that involve the pelvic area (bladder, pelvic floor muscle, rectum and uterus.) Chronic pelvic pain and vulvodynia, two frustrating pelvic disorders seen in young adult women, are not well understood. Research on these two conditions, which are often linked under the umbrella of "chronic pain syndromes", is scarce, especially as it relates to successful treatments.

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Women with chronic pelvic pain or vulvodynia tend to visit specialists who provide non-surgical treatments for urinary incontinence and other pelvic disorders because they seem appropriate. This article will provide an overview of the clinical picture of both conditions, describe specific evaluation techniques, and outline practical treatment options that can be provided.

Chronic Pelvic Pain

Chronic pelvic pain (CPP) is most often seen in adult white women and is defined as any pelvic pain that continues for more than six months. Chronic pelvic pain can be identified clinically by six common characteristics.

  • Duration of six months or longer
  • Incomplete relief with most treatment
  • Significantly impaired function at home or work
  • Signs of depression (e.g. early morning awakenings, weight loss, anorexia)
  • Pain out of proportion to pathology
  • Altered family and social roles

The pain of chronic pelvic pain originates in the lower abdomen and pelvis, although it may extend downwards to involve the lower extremities or upwards to the thoracolumbar (chest) area. Chronic pelvic pain can be intermittent (cyclic) or continual in duration and change in relation to physical and mental fatigue, depression and anxiety; dyspareunia (painful sex /intercourse) causing decreased sexual activity, and interruptions in sleep. Activities such as changing position, sitting or standing for long periods, and exercise can trigger pain. Rectal itching and burning on when having a bowel movement associated with irritable bowel syndrome (IBS) are other typical symptoms. Other medical conditions that may present as chronic pelvic pain syndrome include interstitial cystitis, overactive bladder (OAB), and urethral syndrome. Irritable bowel syndrome and other colorectal problems may also give rise to symptoms that mimic chronic pelvic pain, and may even coexist to produce a confusing overall picture. Chronic pelvic pain often encompasses psychological and environmental factors along with a collection of physical factors. Because a single concise cause is rarely identified, treatment of just one aspect of the syndrome will not necessarily produce a cure.

Chronic pelvic pain and sexual abuse

Studies have shown that women with chronic pelvic pain are more likely to have a history of sexual abuse compared to other groups of women. These women are often referred to many different specialists and, in the process, they may be subjected to expensive tests and exploratory surgery only to be told that 'nothing is wrong' because no underlying pathology was discovered or identified.

Many women consent to hysterectomy or other major surgery and still experience chronic pelvic pain. Chronic pelvic pain is often intractable and unremitting and may lead to lifestyle changes that affect work, recreation and personal relationships. An integrated multidisciplinary team approach to treatment is often the best way to give the woman the greatest chance of a long-term cure.

Symptoms of Chronic Pelvic Pain in Women:

  • Anxiety and depression.
  • Involuntary contractions (spasms)of the levator ani and perineal muscles can lead to pelvic pain and is called vaginismus. This condition is often called pelvic floor tension myalgia and is accompanied by painful and difficult penetration of the vagina.
  • Fatigue, both mental and physical.
  • Rectal itching.
  • Burning during the frequent bowel movements associated with Irritable Bowel Syndrome.
  • Sleep interruptions.
  • Low back pain and a feeling of heaviness in the lower abdomen.
  • Leg pain that radiates from the groin.
  • Constipation or diarrhea.
  • Irregular or painful menstrual cycles. 

What is Vulvodynia?

The International Society for the Study of Vulvar Disease (ISSVD) defines vulvodynia as chronic vulvar discomfort or pain, especially characterized by complaints of perineal burning, stinging, irritation, or rawness. The most common symptoms are dyspareunia (pain during intercourse), severe point tenderness upon touch, perineal irritation and vestibular erythema (redness and inflammation). Women with vulvodynia also complain of perineal hypersensitivity to clothing or touch and often report urological symptoms such as urgency, frequency, and dysuria, all of which are similar to those seen with interstitial cystitis.

Vulvodynia that has persisted for more than six months has more in common with chronic pelvic pain than with other gynecologic disorders. Unexplained vulvar pain is often accompanied by physical disabilities, limitation of simple daily activities (such as sitting and walking), sexual dysfunction and psychologic disability. When vulvodynia is accompanied by pain during intercourse, many factors may be at work including psychologic causes. Vulvodynia and self-esteem issues are often interrelated.

Since vulvodynia is a relatively new diagnosis, its incidence and prevalence have not been well studied. Before the 1980s, very little about the condition had been published in the medical literature. Vulvodynia is distributed across a wide age group, from the twenties to the sixties, and it is limited almost exclusively to white women. The obstetric and gynecologic history of women with the condition is usually unremarkable. The onset of vulvar pain is usually acute (sudden) and may be associated with episodes of vaginitis or certain therapeutic procedures of the vulva (cryotherapy or laser therapy). In general, causes of the condition are unknown. Even in those women who complain of vaginitis or itching, bacterial and fungal infections are uncommon causes of vulvar discomfort though vulvar pain is sometimes triggered by bacterial and viral infections.

Vulvodynia often becomes a chronic problem lasting months to years. Furthermore, many patients with vulvodynia suffer from other chronic neurological problems such as burning and pain of the tongue and chronic facial pain. Most women with vulvodynia consult several physicians before being diagnosed and may be treated with multiple topical or systemic medications while experiencing minimal relief. Sometimes an inappropriate therapy may actually make the symptoms worse. Since physical findings, including the results of cultures and biopsies, are frequently inconclusive, women may be told that the problem is primarily psychologic. 

Types of Vulvodynia

Vulvodynia has been classified into three basic types:

  1. Cyclical vulvitis (cyclical vulvodynia), where symptoms come and go, often responds to anti-Candida therapy given over a long period. This group of problems includes herpes simplex infections, severe yeast infections, thinning and cracking of vaginal skin due to decreased estrogen after menopause, lichen sclerosis, and lichen planus. If symptoms persist in spite of appropriate therapy for the specific problem, the patient is often "graduated" to the next category.

  2. Dysesthetic vulvodynia is characterized by constant pelvic pain, usually burning pain when touched lightly or spasmodic stabbing pains with extreme skin sensitivity. Most often seen in post-menopausal women, this type of pain is usually not increased by sexual intercourse or examination and can be more generalized to the groin and inner thighs. The pain seems to be associated directly with the nerves in the area.

  3. Vulvar vestibulitis is defined as burning, stinging, irritation of the vaginal area on a chronic basis. These patients are usually young and have had many visits and examinations with doctors that don't result in a real treatment plan. Most often association with interstitial cystitis, this type produces pain on intercourse and when the skin is touched. Patients describe the pain as having had their vaginal opening rubbed with sandpaper. 

Typical Symptoms of Vulvodynia

  • Pain during intercourse.
  • Irritation of the perineum that feels like burning, stinging or rawness.
  • Extreme tenderness of trigger points when touched.
  • Redness and inflammation of the skin around the vaginal opening.
  • Increased sensitivity of the skin to clothing and touch.
  • Urinary urgency, frequency and painful urination.

Conclusion to Chronic Pelvic Pain and Vulvodynia

Commonly seen in clinical practice, chronic pelvic pain and vulvodynia are pelvic disorders that are frustrating to both clinicians and woman. Clinicians should understand the type and number of symptoms in order to comprehensively assess and evaluate women with these conditions. Many non-invasive treatments can be implemented in clinical practice; however, more research is needed to understand causes and appropriate treatments.

References

Baker, PK. (1993) Musculoskeletal Origins of Chronic Pelvic Pain. Contemporary Management of Chronic Pelvic Pain, 20(4) December:719-742.05-227.

Duleba, A.J., Keltz, M.D., Olive, D.L. (1996) Evaluation and Management of Chronic Pelvic Pain. Journal American Association Gynecologic Laparoscopists, February 1996, 3 (2), 205-227.

Glazer,H.I.,Rodke,G.,Swencionis,C., Hertz,R.,Young,A.W.(2000) "Treatment of Vulvar Vestibulitis Syndrome with Electromyographic Biofeedback of Pelvic Floor Musculature". Journal of Reproductive Medicine, 40(4),11 pp.

Metts, J.F. (1999) Vulvodynia and Vulvar Vestibulitis: Challenges in Diagnosis and Management. American Family Physician, 59(6),1547-1556.

Newman, DK. (2000) "Pelvic Disorders in Women: Chronic Pelvic Pain and Vulvodynia". OstomyWound Management: December 46(12): 48-54.

Paavonen, J. (1995) "Vulvodynia - a complex syndrome of vulvar pain". Acta Obstet Gynecol Scand. 74,243-247.

Steege,J.F. (1997) Office Assessment of Chronic Pelvic Pain. Clinical Obstetrics and Gynecology, Vol.40(3),554-563.

Steege,J.F.,Metzger,D.A.,Levy, B.S. (1998) Chronic Pelvic Pain: An Integrated Approach. W.B.Saunders,Philadelphia, PA.

Yount,J.J. Solomons, C.C.,Willems, J.J., St. Amand, R.P. (1997) "Effective Nonsurgical Treatments for Vulvar Pain". Women's Health Digest, 3(2),88-93.

Posted October 2007
Updated August 2009

See Also: Vulvar/vaginal Disease

 See also Patient Tip Sheets:

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