Chronic Pelvic Pain (CPP)

Chronic Pelvic Pain (CPP) is defined as non-cyclic pain in your pelvic region (below your belly button) that lasts for six months or more. It is a complex condition, not a disease itself, but a symptom that can arise from many different sources gynaecological, urological, gastrointestinal, musculoskeletal, or nervous system related.

CPP can significantly impact your quality of life, work, relationships, and mental health. A “cure” is not always possible, but effective management and significant improvement in pain and function are achievable goals. It often requires a multidisciplinary team approach for diagnosis and treatment.

Common Symptoms & Experiences

Pain is the main symptom, but its nature and associated symptoms vary widely.

• The Pain Itself: May be dull, sharp, cramping, burning, aching, or a feeling of heaviness/pressure. It can be constant or come and go.
• Pain Triggers: Often worsened by prolonged sitting, sexual activity, bowel movements, urination, menstruation, or certain movements.
• Associated Symptoms:
  • Gynaecological: Painful periods, pain during/after sex, abnormal bleeding.
  • Urinary: Urgent/frequent need to urinate, painful urination, recurrent UTIs.
  • Bowel: Bloating, constipation, diarrhoea, painful bowel movements.
  • Musculoskeletal: Lower back pain, hip pain, pain in the buttocks or thighs.
  • General: Fatigue, sleep disturbances, anxiety, and depression.

CPP is often multifactorial, meaning several issues may be contributing at once.

Common Underlying & Associated Conditions:

• Gynaecological: Endometriosis, Adenomyosis, Persistent Ovarian Cysts, Pelvic Inflammatory Disease (PID) aftermath, Pelvic Congestion Syndrome.
• Urological/Pelvic Floor: Interstitial Cystitis/Bladder Pain Syndrome (IC/BPS), Overactive Bladder, Pelvic Floor Muscle Dysfunction (overly tight or weak muscles), Urethral Syndrome.
• Gastrointestinal: Irritable Bowel Syndrome (IBS), Inflammatory Bowel Disease (IBD), Chronic Constipation.
• Musculoskeletal & Nerve-Related: Pelvic joint dysfunction, abdominal wall pain (like nerve entrapment), Fibromyalgia, Nerve damage (e.g., pudendal neuralgia).
• Central Sensitization: Over time, the nervous system can become “wound up,” amplifying pain signals long after an initial injury has healed. This is a common feature of chronic pain.

Diagnosing CPP involves a detailed “detective” process to identify all contributors.

• Detailed History: You will be asked in-depth questions about your pain pattern, medical history, and life experiences.
• Physical Examination: Includes a gentle pelvic exam, assessment of pelvic floor muscle tone, and checking for tender points in your abdomen, back, and hips.
• Investigations (to rule out specific causes):
  • Ultrasound Scan: To check uterus, ovaries, and bladder.
  • Laparoscopy: A keyhole surgery sometimes used to diagnose endometriosis or adhesions.
  • Cystoscopy: To look inside the bladder if IC/BPS is suspected.
  • Blood & Urine Tests: To rule out infection or other conditions.
• Multidisciplinary Review: Your case may be discussed by a team including a gynaecologist, urologist, gastroenterologist, pain specialist, and physiotherapist.

Management & Treatment Strategies

Treatment is personalized and focuses on improving function and quality of life, not just eliminating pain. It often combines several approaches.

Physical & Behavioural Therapies (Core Foundation)

• Pelvic Floor Physiotherapy: Essential for treating muscle-related pain. A specialist physio will teach you to relax, coordinate, and strengthen pelvic muscles.
• Psychology/Cognitive Behavioural Therapy (CBT): Helps develop coping strategies, manage stress/anxiety, and address the impact of pain on your life.
• Pain Management Techniques: Mindfulness, meditation, pacing activities.

Medications:

• Pain Relievers: NSAIDs (e.g., ibuprofen) for flare-ups.
• Medications for Nerve Pain: Amitriptyline, Gabapentin, or Pregabalin.
• Hormonal Treatments: The contraceptive pill, progestogens, or GnRH agonists can help if pain is linked to menstruation or endometriosis.
• Muscle Relaxants: For pelvic floor spasms.

Interventions & Procedures:

• Nerve Blocks: Injections (e.g., pudendal nerve block) to temporarily block pain signals.
• Botox Injections: Into tight pelvic floor muscles.
• Acupuncture.
• Surgery: To treat a specific, confirmed cause (e.g., excision of endometriosis, hysterectomy for adenomyosis). Surgery is not a first-line treatment for CPP without a clear target.

Frequently Asked Questions (FAQs)

Q: Is the pain all in my head?
A: No. The pain is very real. While stress and emotions can worsen pain perception (this is true for all pain conditions), they are not the cause of the initial problem. CPP has physical origins, even if they are complex.

Q: Will I ever get better?
A: Complete cure may not be the goal for everyone, but significant improvement is absolutely possible. The aim is to reduce pain to a manageable level, restore function, and help you live a full life.

Q: Do I just have to learn to live with it?
A: “Living with it” doesn’t mean giving up. It means actively managing it with the right tools and support team to minimize its impact on your life.

Q: Why is it so hard for doctors to find what’s wrong?
A: The pelvis is a crowded area with many overlapping systems. Pain from one organ can be felt in another, and multiple conditions often co-exist. This complexity requires a specialist, holistic approach.

Q: Should I just have a hysterectomy?
A: A hysterectomy is a treatment for specific conditions like adenomyosis or fibroids, but it is not a guaranteed cure for CPP unless the uterus is the confirmed sole source of pain.

eGynaecologist Advice

• You should seek care from a dedicated Pelvic Pain Clinic or a gynaecologist with a specialist interest in CPP. A standard gynaecology clinic may not have the resources for the holistic assessment you need.
• You must become an active partner in your care for chronic pelvic pain. Keeping a pain diary (tracking pain levels, triggers, diet, menstrual cycle) provides invaluable clues for your medical team.
• You should pursue a combination of physical (physiotherapy) and psychological (CBT) therapies as a first-line approach to address core components of chronic pain, even while undergoing diagnostic tests.