Chronic pelvic pain

Symptoms that raise suspicion

• Constant or intermittent pain in the lower abdomen, pelvis or perineum
• Pain that gets worse with your period, with physical effort or at the end of the day
• Pain during or after sex (dyspareunia)
• Stinging, pressure or a foreign-body sensation in the vulva or vagina
• Pain when urinating or urinary urgency without a confirmed infection
• Pain with bowel movements, constipation, or constipation alternating with diarrhea
• Pain that radiates to the groin, inner thigh or lower back
• Pain that gets worse when sitting for a long time

You don't need to have all the symptoms. If you have two or three that affect your life, it is worth looking into.

What is chronic pelvic pain

We speak of chronic pelvic pain when pain in the pelvis, lower abdomen or perineum lasts more than six months and affects daily life: work, rest, physical activity or sex.

The key difference from acute pain is that here it is not enough to find a lesion and remove it. When pain persists for months or years, several mechanisms usually coexist: an underlying gynecological cause (endometriosis, adenomyosis), hypertonic, painful pelvic floor muscles, an irritated nerve, a hypersensitive bowel or bladder, and a central nervous system that amplifies pain signals (central sensitization).

That is why a patient can have a normal ultrasound and MRI and still suffer real pain that has an explanation. Not seeing it on an image does not mean it is not there.

Three types of pain that can coexist

The International Association for the Study of Pain (IASP) distinguishes three pain mechanisms. In chronic pelvic pain, it is common for them to coexist in the same patient:

• Nociceptive pain: caused by tissue injury or inflammation, such as endometriosis lesions. It usually improves when the cause is treated.
• Neuropathic pain: caused by an injury to or irritation of a nerve, such as the pudendal nerve. It is often described as burning, cramping or electric shocks.
• Nociplastic pain: occurs when the nervous system processes pain abnormally, without an injury that fully explains it. Its main mechanism is central sensitization: the nervous system amplifies pain signals and loses part of its ability to dampen them.

Identifying which type of pain predominates in each patient is what makes it possible to choose the right treatment. This approach, known as pain phenotyping, is the focus of my doctoral research at Hospital Clínic.

What are the most common causes

In the clinic, it is unusual to find a single cause; usually there are several at once. These are the ones that need to be assessed systematically:

Why it takes so long to diagnose

Because the usual healthcare pathway is designed to find lesions, not to analyze the mechanisms of pain. A patient with chronic pelvic pain often goes through gynecology, gastroenterology, urology and orthopedics, and each visit rules out the disease specific to that specialty. When all the tests come back normal, the pain often ends up being attributed to stress or psychological factors.

The problem is not that the tests are done badly, but that muscle pain, neuropathic pain and central sensitization do not show up on any imaging test. They are diagnosed with a targeted medical history and a physical examination that includes the pelvic floor, something that is still not done systematically.

How we assess it in the clinic

1. Targeted medical history

This is the longest part of the first visit and the one that provides the most information. We map the pain: location, type, intensity, what triggers it and what relieves it, its relationship with the cycle, urination, bowel movements and sex, sleep quality, previous treatments and the response to each one.

2. Complete physical examination

It includes examination of the abdomen and abdominal wall, a gynecological examination and, crucially, palpation of the pelvic floor muscles to detect hypertonicity and trigger points, as well as the exit points of the nerves involved. Reproducing during the examination the pain the patient recognizes as her own is often the key to the diagnosis.

3. Expert gynecological ultrasound

Transvaginal ultrasound aimed at detecting deep endometriosis and adenomyosis, which also assesses the mobility of the organs and the pelvic compartments. It is a different examination from a routine gynecological ultrasound.

4. Additional tests only if they add information

MRI, urodynamic testing, a gastrointestinal assessment or guided diagnostic nerve blocks, depending on what is suspected. Tests are not ordered “just in case”: they are ordered to answer a specific question.

Treatment: in layers and with follow-up

There is no single treatment for chronic pelvic pain. What does exist is a reasonable order of intervention based on the mechanisms that predominate in your case.

• Medical treatment of the gynecological cause when there is one: hormonal control of the cycle in endometriosis or adenomyosis to reduce the repeated painful stimulus.
• Specialized pelvic floor physical therapy: the piece that is most often forgotten and one of those that most improve the outlook when there is a myofascial component. I work with specialized physical therapists and coordinate the plan with them.
• Treatment of neuropathic pain: pain-modulating medications, injections or nerve blocks when a nerve territory is clearly involved.
• Addressing central sensitization: pain neuroscience education, sleep hygiene, gradual physical activity and, when needed, psychological support specialized in chronic pain. This does not mean the pain is “psychological”: it is the treatment of a real neurophysiological mechanism.
• Surgery: indicated when there is a lesion that justifies it and after the other treatments have been optimized. Operating without having understood the mechanism of the pain increases the risk that the pain will persist after the procedure.

Follow-up is not optional. Chronic pain requires reviewing what works, stopping what does not help and adjusting doses and goals.

Frequently asked questions about chronic pelvic pain

References

1. Lamvu G, Carrillo J, Ouyang C, Rapkin A. Chronic pelvic pain in women: a review. JAMA. 2021;325(23):2381-91. doi:10.1001/jama.2021.2631 · PubMed
2. Kosek E, Cohen M, Baron R, et al. Do we need a third mechanistic descriptor for chronic pain states? Pain. 2016;157(7):1382-6. doi:10.1097/j.pain.0000000000000507 · PubMed
3. Quintas-Marquès L, Valdés-Bango M, Box C, et al. Multidimensional evaluation of myofascial pelvic pain and other comorbidities in endometriosis patients. J Clin Med. 2025;14(10):3455. doi:10.3390/jcm14103455 · PubMed

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