Chronic Pelvic Pain

Thursday, 28 April 2005 13:29


Note: This article cannot explore in depth all the various causes of chronic pelvic pain. It will deal briefly with the more common causes and those most relevant to arachnoiditis patients.

The term ?Chronic Pelvic Pain' is generally used with reference to women; however, men may also experience pelvic pain (though obviously the gynaecological causes are irrelevant): arising from the gut, a hernia, or from the spine.

?Perineal pain': in the saddle or crotch area and often affecting the rectum and/or genitals may be quite persistently troublesome for patients with arachnoiditis, regardless of their gender.

However, in the broad clinical context of this article, distinction will not be specified in the following information:

Causes of pelvic pain:   

Chronic pelvic pain may arise from a variety of different causes.

These may broadly be divided as follows:


In order to best appreciate the causes of pelvic pain of neurological origin, one must  understand the innervation of the pelvic organs.

  1. spinal level: T9-10: supplies the outer part of the fallopian tubes, the upper ureter (where it enters the kidney) and the ovaries. Sympathetic nerves(involved in involuntary processes) are also involved at this level.
  2. T11-12 : supplies: uterine fundus (top of the womb); inner third of the fallopian tube; broad ligament (supports the womb), upper bladder, proximal large bowel and appendix.
  3. S2-4 : supplies perineum (saddle or crotch area); vulva (opening of the vagina) ;vagina; lower uterus and cervix; posterior urethra; trigone area of the bladder (where ureters enter); lower ureter; rectosigmoid colon(lowest part of the large bowel).

One can now see that abnormalities in the nerve roots arising from these spinal levels have implication for most of the pelvic organs.

It is therefore unsurprising that in chronic Cauda Equina Syndrome, saddle sensation may be lost and there may be chronic neurogenic (burning) pain in the pelvic region (being neurogenic, it may be felt in numb areas). Also, there may be problems with bladder and bowel function, as well as sexual dysfunction.

The pudendal nerve may be implicated in abnormal sphincter function. It arises from S2-4. Pelvic and parasympathetic nerves also arise from this part of the sacral region.

Diagnostic Clues:

Specific conditions:

(please note that other articles in this series discuss gastrointestinal and musculoskeletal disorders; urinary tract disorders are discussed in more detail elsewhere in this article.)

Pelvic congestion syndrome:

Caused by varicose veins in the pelvis. Symptoms may include pelvic pain that worsens towards the end of the day or after long periods of standing, pain during or after intercourse or swollen veins in the vulva.

There may also be heavy periods and urinary frequency.

It is difficult to diagnose and many women will have been unable to find a diagnosis despite numerous consultations and tests, and may have been labelled as "psychosomatic" cases.

Special ultrasound and MRI tests may pick up this problem.

Once the diagnosis has been established, a venogram is performed: an X-ray of the pelvis with dye injected to show the abnormal veins; these can then be blocked by injecting tiny coils through the catheter into the vein, reducing the blood flow to the affected area and shrinking the varicose veins ("embolisation"); this is successful in around 80% of patients.  

Alternatively, non-invasive options include hormones to suppress ovulation.

Management of chronic pelvic pain:


Most women have a continuous discharge from the vagina which is greater in mid-cycle (between periods). It may become thick but usually has little smell and is not itchy.

Discharge is abnormal when:

Causes of abnormal discharge include:

There are 3 main types of infection:

Thrush is the commonest and is caused by a fungus that lives normally in the vagina but sometimes gets out of control due to hormonal changes or illness (especially if antibiotics are taken).

Diabetes may also be a precipitating factor. Recurrent thrush in a diabetic suggests the need for blood sugar levels to be checked. Any chronic illness may lower resistance and trigger episodes of thrush.

Wash daily with plain warm water, avoid long soaks in hot baths. Use cotton underwear. Pessaries can be obtained through your doctor to treat severe infections. Partners also need to be treated.

Recurrences can be prevented by regular soaks in slightly warm water with a couple of tablespoons of vinegar in it or by applying plain live yoghurt to the vagina (the lactobacillus combats the fungus). Note: douching does not help, and may in fact make matters far worse.

Discharge other than that due to thrush requires medical assessment (including swabs sent off for culture to identify the infecting organism).


You should not attempt to self-diagnose any of the conditions described in these articles; for persistent problems, seek medical advice. These embarrassing subjects should be dealt with prosaically but sensitively by medical and paramedical personnel. Don't let embarrassment deter you from seeking help! 

Sarah Smith (nee Andreae-Jones) MB BS,
Patron of the Arachnoiditis Support Groups March 2001.