Pelvic pain is a common symptom of endometriosis – accurate diagnosis and effective treatment of the underlying cause can provide long term relief.
What causes chronic pelvic pain?
The most simple and explicable example of chronic pelvic pain, which applies to patients with endometriosis is the presence of persistent nerve compression by an expanding or infiltrating lesion of endometriotic scar tissue. In the vast majority of women, meticulously removing the lesion creating adverse nerve pressure will resolve this pain.
Some patients with deep infiltrating endometriosis (DIE) have fixation of the uterus, vagina or bowel (rectum), and to a lesser degree, the bladder. These patients will have not just cyclical pain but functional pain too, during sex, bowel or bladder function. Most often the pain can be addressed by targeted surgery.
What does chronic pelvic pain feel like?
Pelvic pain from endometriosis is most often cyclical, significantly worse with menstruation or ovulation. Patients with endometriosis however often experience virtually continuous pain with at most short relief of pain symptoms immediately after a period.
In uncommon circumstances, women with endometriosis (and or chronic nerve damage) can experience pain distant from the site where the pathology is confined; the management of “Chronic Regional Pain Syndrome” requires not just careful surgery, but ongoing management with a multidisciplinary team.
When is pelvic pain serious?
The most common issue we see in the surgical practice is patients with cyclical back pain, worsening progressively over the years. Such patients have probably already seen a physio, chiropractor, acupuncturist, and maybe even a yoga specialist. These patients most often have endometriosis affecting the uterosacral ligaments, with extension of endometriosis into the pelvic wall. With correct surgery, they return to normal function, with resolution of pain completely in the weeks after laparoscopic excision surgery.
When should I see a doctor for pelvic pain?
All patients with progressively worsening chronic pelvic pain should seek a referral for gynaecological assessment, especially when the symptoms are cyclical. Patients with chronic back pain should have, as part of their work up, X rays and or CT scans of the lower back, hip and spine if there is acute pain (eg, from disc prolapse).
Diagnosing pelvic pain associated with endometriosis
Patients who can tolerate a transvaginal ultrasound scan can have a clearer picture of endometriosis (either superficial markers or DIE)
Those who cannot tolerate a vaginal scan can have an MRI scan for an equally good pre-operative assessment.
The gold standard however is planned surgery with the above information at hand, where photographs are taken at surgery before and after removing all visible evidence of pelvic endometriosis.
Treating chronic pelvic pain from endometriosis
Treating the symptoms of pelvic pain with medication does not change the underlying pathology of endometriosis.
Locally acting pharmacological remedies (paracetamol) assist by reducing the inflammatory response. Centrally acting agents (codeine) work on the central nervous system. Other medications are more specific modulators of nerve pain to provide temporary relief until surgery can be affected.
Many patients also find symptomatic relief with non-pharmacological remedies (acupuncture, herbal and Chinese medicine).
All of these pain relief methods, however, are temporary measures until definitive surgical treatment is arranged to permanently treat the source of your pain.
In all of these circumstances, the role of surgery is to restore anatomy, and relieve pressure on pelvic nerves. Preserving these nerves is essential, and although time-consuming, the benefits are enormous, particularly in those patients with chronic bowel or bladder dysfunction. Many patients who have had “IBS” and “overactive bladder” are pleasantly surprised to return to normal function when the endometriosis is removed, and nerves preserved.
