Pelvic pain causes - diagnosis starts with your symptoms
Pelvic pain is felt in the lower abdomen and over the sacrum, below the lumbar spine.
Clues to gynecological origin are pain in the second half of the menstrual cycle, the two weeks prior to menstruation and/or during it.
Pain deep inside during sexual intercourse and ache afterwards, is another strong clue.
Pelvic pain which increases with a full bladder or during passage of urine, suggests a problem in or against the outside of your bladder.
See at bottom of page re urine collection.
Keeping a diary in female pelvic pain diagnosis
Do you have a problem of recurrent pain like this, but are not sure about when in your menstrual cycle you are most likely to have pain?
It may help to record your symptoms daily, over a few months if necessary, looking for a pattern.
Ideally use a large sheet of paper, ruled into squares, so one month occupies one row of squares.
Record the months one under another, each on a separate row, menstruating days first. This will make it easier to see a pattern emerge.
Record a 1 to 10 score for the severity of your pain, a rough duration (or proportion of the day you had it.) Record anything that obviously affected the pain for better or worse.
Also record any PMS symptoms experienced, of the following...
bloating/weight gain sensation
breast fullness, tenderness, pain
tiredness, low energy
anxiety, tension, feeling on edge
continual irritability or anger
mood changes (eg. suddenly tearful)
feeling flat, down in mood, hopeless
appetite changes, craving certain foods
general joint or muscle pains
losss of interest in usual activities
Pelvic pain causes
It is worth knowing a little about the various conditions which can be responsible, if you have pelvic pain. This will help you to ensure that you are getting properly invesigated and help you understand the advice you are given.
Remember always that common things will coexist frequently, by chance. Gynaecological and bowel conditions can be seen together. Chronic constipatiion, irritable bowel syndrome and diverticular disease are common and will be seen with gynaecological problems.
Our body is very economical, and will frequently make just the one complaint, when multiple factors are contributing to it.
My gynaecologist informant has seen women with low grade endometriosis, having constipation, diarrhoea and bloating only in their premenstrual fortnight. They have responded to dietary fruit and fiber, sometimes with mebervine or laxative medication.
Endometriosis - pelvic pain cause
Endometriosis is the number one suspect as a cause of pelvic pain. It is easily overlooked and the average duration of symptoms to the time of diagnosis is 7 years!
The pain can be at any time of the cycle, and menstrual pain here is commonly severe. It can be more related to bowel or bladder use.
You really need to be quite sure about this and it is one time when a gynaecologist with a special interest in this particular area, may be better. It can be mistaken for irritable bowel syndrome or pelvic inflammatory disease. It is quite easy to overlook even at laparoscopy.
Any suspicious areas on peritoneal surfaces need to be biopsied, and the pathologist needs to be alerted to this concern.
Endometriosis develops because of the body's immune cells (natural killer cells) not functioning well. During menstruation, some of the lining of the womb can easily go the wrong way, up your fallopian tubes instead of out. Your immune system cells are supposed to prevent these aberrant cells from thriving wherever they end up.
Prevention of endometriosis therefore depends on ensuring that you have a healthy immune system.
This in turn depends on good nutrition and lifestyle.
Treatment of endometriosis can be conventional, with hormone medications and surgery, or using traditional Chinese medicine and naturopathy. A gynaecologist trained in TCM would be ideal, and in Melbourne we are fortunate to have such a person in Steven Clavey. (See
If you have found out about this because of infertility, surgery is a better option if the disease is found to be not very extensive. The aim then is to remove it all, to improve fertility.4
Adenomyosis - another cause of pelvic pain
Adenomyosis used to be called internal endometriosis. This is the same condition within the muscular wall of the uterus.
If you have pelvic pain in the lead up to a period, which eases off when menstruation begins, this is a possibility. You may have a bulky, tender uterus when you are examined.
It used to be diagnosed mainly by the pathologist after a hysterectomy, but even then was easily overlooked. Now modern ultrasound machines are capable of picking it up using a transvaginal probe.
Medical treatment is NSAID drugs during the premenstrual week or so. These drugs are less of a worry when used intermittently, as here.
pcos pelvic pain ( polycystic ovary syndrome )
Another underdiagnosed cause is polycystic ovaries. These will often be under reported on pelvic ultrasound done by radiologists. This is again an area when a gynaecologist with a special interest may be better.
You need to have the pelvic ultrasound done through your vagina. It really is worth while, as it is more accurate in this case.
Hormone tests are then used to confirm the diagnosis.
Polycystic ovaries are found in 15% of women. They can cause pain due to stretching of the capsule of the ovary. It is a really important thing to check for, because it may mean you need to have a major lifstyle change to avoid diabetes.
Two to four months of medical treatment may be needed before people with polycystic ovary disease are feeling partly better.
Pelvic vein congestion
Pelvic vein congestion is another cause of pelvic pain, in the second half of the menstrual cycle. This is also easier to diagnose now because of major improvements in US equipment. The distended veins in the broad ligaments, can now be seen on transvaginal US.
A lot of the good results from hysterectomy, are probably due to inadvertent treatment of these congested veins.
Professor Carl Wood, one of the pioneers of IVF in Australia, used to get good results for a year or so, from operating and tying off some of these veins. Like varicose veins in the legs, however, they recurr after this surgery.
This condition tends to recover after the menopause.
Pelvic pain in uterine prolapse symptoms
Early stages of prolapse of your uterus can cause you to have a dull sacral backache. You will not be aware of this, as the condition is only evident if your doctor uses an instrument to pull down on the cervix.
This is seen in the 35 to 50 age group, after 2-3 pregnancies with vaginal deliveries.
The pain is caused by the bulky uterus stretching the cardinal and utero-sacral ligaments. Deep pain on sexual intecourse, is caused by hitting these tender ligaments.
Holding your uterus up with a Portex ring pessary, will relieve the pain. Surgical treatment of this condition (level 1 pelvic suspension procedure,) can be very satisfactory.
Infection as a cause of chronic pelvic pain after childbirth or as a STD
Chronic pelvic inflammatory disease, due to low grade infection, can cause pelvic pain.
This is likely to have followed a termination of pregnancy or induction of labour by artificial rupture of the babies' membranes especially if followed by instrumental delivery (with obstetric forceps.)
PID can also be due to sexually transmitted chlamydia germs. If you have pelvic pain and this cause is possible, make sure you have a swab taken from your cervix and a urine sample, to check.
This is one area of medicine where antibiotics have made a wonderful difference. When I started in family medical practice, I joined doctor Alister Hinchley, who had been working in the 1930's, before there were any antibiotics.
He recounted how women with PID would be so sick for so long, that they became mentally unbalanced. He said that when the sulphonamide drugs were introduced, giving doctors the first effective means of fighting infections, it was like a miracle!
Sulphonamide drugs are very little use for anything these days, due to germs becoming used to them. We should all be very careful in our use of antibiotics, to avoid encouraging the development of germs resistant to more of them.
See further notes on the
pelvic inflammatory disease page
PID additional case history page
Dysmenorrhoea - period pain
Primary spasmodic dysmenorrhoea is common from late teenage years, starting 6 months to 2 years after the menses, until first pregnancy. It is there on the first day (or two) of bleeding, is cramping pain in the lower abdomen and can be accompanied by giddiness, fainting, nausea and vomiting.
It is not something to just accept.
Increase omega 3 oil, reduce dietary omega 6 and take a multi mineral supplement to get your eicosanoid metabolism right.
Acupuncture is very effective for relief while you're doing that.
Secondary spasmodic dysmenorrhoea starts later in the reproductive years, due to the uterus trying to expel fibromyomata, intrauterine contraceptive devices or heavy periods with clots.
Congestive dysmenorrhoea (from pelvic congestion) also appears years after the menarche, and is a constant "heavy" pain, starting days before and lasting often until the third day of the bleeding. This can come from lots of pelvic organ problems.
Pelvic bone pain
Osteoporosis can lead to spontaneous fractures of the pelvic bones, either sacrum or the more delicate bones at the front.
This comes on suddenly, and takes weeks or months to settle.
Bone cancer, often from breast or prostate, can cause fairly constant pain, day and night, which may be worse standing up.
A very good resource for conventional information on cancer, is
, and for alternative therapies,
Paget's disease of bone, probably a slow virus infection, weakens the pelvic (or other) bones and eventually can cause insidious deep aching.
Diagnosis of these conditions is by X-ray or bone scan.
Pelvic pain in males - prostatitis
Same pain, different gender.
Some of the same (microbial) causes too.
Here accompanied by difficulty initiating passage of urine, or extreme urgency sometimes; diminished urinary stream; dribbling at the end and getting up at night.
The pain in chronic prostatitis can actually be felt as high as the kidneys and as low as just below one's knees.
The two tube test referred to below is for finding white blood cells in the first drops, but not in the midstream specimen. This tells one the infection is in the urethra or prostate rather the bladder or kidneys.
The three-glass test includes the clear midstream specimen and pus cells in a further specimen taken after prostatic massage. This is more certain.
Also,evidence of chronic prostatitis is frequently seen on pathological examination of benign prostate hypertrophy specimens after TURP.
is probably an important cause of both conditions.
If antibiotics are used here, a prolonged course is needed, but probably not because of the "blood genital tract barrier." This is a blood testis barrier only, designed to protect the sperm production from waste substances in the blood stream.
Combined antibiotic plus alpha-adrenergic-blocker drug therapy, gives better results1.
A case history of this problem illustrates some points...
In the 1980's, Mr. X, 24, was seen with a recurrence of his prostatitis from 2 years earlier. He was tender over nearly all his abdomen, more so below tummy button level. On rectal examination his prostate gland was tender, compared to pressing on the Obturator internus muscle on each side of the pelvis.
It is usually uncomfortable having one's prostate examined, and it always makes one feel as though one wants to pass urine. The same pressure applied to prostate and muscles at the sides, should however cause the same degree of tenderness.
Urine microscopy confirmed infection.
He was given intravenous rolitetracycline plus oral metronidazole and started to improve within two days. After 4 days the injections were changed to oral doxycycline, combined with the metronidazole.
He improved progressively over the first 2 weeks, by which time his abdominal tenderness was confined o a small spot near his tummy button.
At the 3 week mark, his prostate was no longer tender and the small area near his umbilicus was only slightly tender.
He reported however feeling "totally run down, not eating, tired." I gave him an injection of B complex vitamins and prescribed Lactobacillus acidophilus.
Antibiotics can run our body short of vitamins, and did so here.
Two weeks later he reported that he had "virtually cleared up, (but) last few days having pain again." He had a sore throat for a week, during this time. This is very likely to have been an
antibiotic sore mouth
It had already cleared up.
Examination revealed extensive abdominal tenderness gain.
Because of the bad reaction to the antibiotics, this time I gave him vitamin C 15gm intravenously to be followed by oral vitamin C in megadoses.
Interstitial cystitis, bladder pain syndrome
This causes pain, pressure and discomfort felt in your bladder as well as marked urinary urgency and frequency, in the absence of infection, overactive bladder or (in men) chronic prostatitis.
With any complaints down here, always take a small sample of urine to your doctors appointment, to encourage them to test it.
The cause of this condition is unknown and there is no curative treatment in conventional medicine2. Botulin toxin injections into the base of the bladder can help for a time3. As always in this sort of situation, look elsewhere for help as well.
There are no cystoscopic or urodynamic findings specific for IC/BPS, but new guidelines state that these tests can be valuable in identifying Hunner's lesions) in the bladder, and in ruling out overactive bladder, bladder cancer or urethral diverticula.
pelvic pain back to home page
pelvic joint pain -sacroiliac and pubic symphysis
Under your pelvis - anal conditions
Underneath at the front - vulva pain in women
Around the front - groin pain conditions
Broken hip - avoiding disaster.
Hip pain in young people - slipped epiphysis etc
How to do a midstream specimen of urine (MSSU)
You will need a sterile urine collection container and a full bladder. Men may need two containers.
Men - pull back foreskin, wash end with water only, catch the first few drops of urine for a "two tube test" and a separate midstream sample caught without stopping.
Women - Shower to wash perineum, no soap, just face washer. Insert a tampon or a ball of cotton wool to block off your vagina. Sit on the edge of a short stool, hold your labia apart with one hand, and be ready with the urine collection container in the other.
Pass urine into a dish on the floor, and towards the end, while it is still flowing quickly, catch the sample without stopping.
Immediately place the container in your refrigerator. Leave it there for as long as possible before your visit to the doctor. It will be OK there overnight if need be.
References for pelvic pain page
1. Thunyarat Anothaisintawee et al Management of Chronic Prostatitis/ Chronic Pelvic Pain Syndrome
A Systematic Review and Network Meta-analysis JAMA. 2011;305(1):78-86
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