Chronic pelvic pain in women

Chronic pelvic pain (CPP) is defined as non-cyclic pain in the lower abdomen or pelvis lasting at least six months, sufficient to cause functional disability or require medical care. It is one of the most common and challenging conditions in women's health — affecting an estimated 15–25% of women at some point in their lives.

**Causes**

CPP is frequently multifactorial. Common underlying conditions include:

- *Endometriosis:* endometrial-like tissue growing outside the uterus responds to the menstrual cycle — thickening and bleeding each month. Blood cannot exit through the vagina, accumulating as painful cysts and adhesions in the abdomen. Causes dysmenorrhoea, deep dyspareunia, and chronic pelvic pain - *Pelvic floor muscle dysfunction:* hypertonic (overactive) pelvic floor muscles produce persistent pain, pain with touch or penetration (vulvodynia, vaginismus), and referred pain to the lower back, hips, and thighs - *Chronic pelvic inflammatory disease:* long-term or incompletely treated pelvic infection causes scarring and adhesions involving pelvic organs - *Interstitial cystitis (painful bladder syndrome):* recurrent bladder pain with urinary urgency and frequency; pain worsens as the bladder fills and temporarily improves after voiding - *Uterine fibroids:* non-cancerous uterine growths causing pelvic pressure, heaviness, and — when blood supply is compromised — acute-on-chronic pain - *Ovarian remnant syndrome:* residual ovarian tissue after surgical removal develops painful cysts - *Pelvic congestion syndrome:* dilated, varicose-like pelvic veins causing a dull, aching heaviness that worsens with standing, walking, and at the end of the day - *Musculoskeletal causes:* pubic symphysis dysfunction, sacroiliac joint dysfunction, hip pathology, and abdominal wall trigger points can all produce pain perceived as pelvic - *Irritable bowel syndrome:* bloating, altered bowel habit, and visceral hypersensitivity contribute to lower abdominal and pelvic pain - *Psychological and central sensitisation:* chronic pain remodels central pain processing; depression, anxiety, and a history of trauma increase pain intensity and chronicity

**Assessment**

A thorough history, examination, and targeted investigations (pelvic ultrasound, laparoscopy for endometriosis, cystoscopy for bladder symptoms, pelvic floor physiotherapy assessment) are needed to identify contributing conditions and guide treatment.

**Management principles**

Identifying and treating specific causes — hormonal therapy for endometriosis, physiotherapy for pelvic floor dysfunction, antibiotic treatment for PID — is the starting point. However, because CPP is commonly multifactorial and involves central sensitisation, a combination approach is usually required:

- *Neuromodulation:* spinal cord stimulation and rTMS for refractory pain; pulsed radiofrequency for specific nerve targets - *Interventional:* hypogastric plexus block, ganglion impar block, and superior hypogastric nerve block for visceral pelvic pain; Botox injections into hypertonic pelvic floor muscles - *Regenerative:* prolotherapy and ozone injections for ligamentous and fascial pelvic pain - *Physiotherapy:* pelvic floor downtraining, manual therapy, and therapeutic exercise - *Psychological support:* pain psychology, cognitive behavioural therapy, and mindfulness significantly improve outcomes in CPP with central sensitisation