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I Have Pelvic Pain: Is It Cancer?

When women post to the Women’s Health message board about pelvic pain they can describe symptoms which have recently started, or pain which has been present for six months or more. Despite the difference in duration of pain, everyone wants to know if cancer is a possible cause — and if cancer is not the cause then what is the culprit?

Fortunately cancer is not the usual suspect. Yet the list of possible causes extends beyond uterus, Fallopian tubes, and ovaries. The “female organs” are near the intestines, the bladder sits in front of the uterus, and there are networks of nerves which can conduct pain sensations from the actual site of pain to a more distant location (“referred pain”). The purpose of this post and the ones following is to share with you with some possible causes of pelvic pain. The information will be organized into recent pelvic pain, and pain of longer duration. Within those two categories pain sources from different body systems can be designated.

Acute Pelvic Pain

Acute pelvic pain is the medical term for pain that has recently started. Sometimes the onset can be very abrupt, in other conditions the pain builds slowly. Then too the pain can be present only at one time of the menstrual month. Let’s look at true OB/GYN pain first.

Pregnancy caused pain:

  • Miscarriage
  • Tubal pregnancy (“ectopic”) which has ruptured. This usually occurs before 7-10 weeks from the first day of the last period.
  • Breakdown (“degeneration”) of fibroid whose blood supply has been cut off. This can occur in the later part of pregnancy.

Gynecologic pain:

  • Ruptured ovarian cyst. This can onset very suddenly, and if an ultrasound is done promptly it can image “free fluid in the “cul de sac” or fluid leaked by the cyst now present in the lowest part of the abdominal cavity.
  • Large intact ovarian cyst. While this can prompt discomfort, the greatest pain occurs when a large cyst twists the ovary like a too heavy flower on a thin stalk. “Ovarian torsion” creates severe pain as the ovary’s blood supply is twisted off leading to the ovary’s death.
  • Pelvic infection. This can be an infection of the lining of the uterus (“endometritis”), or a generalized infection of the uterus/tubes/ovaries (“pelvic inflammatory disease”/”PID”). If an infection has been present for a while the Fallopian tubes and/or the ovaries can develop an abscess or become fluid filled (“hydrosalpinx”).
  • Painful ovulation (“Mittelschmertz “). This pain generally occurs around midcycle (eg cycle day 14). It is prompted by the release of the egg/oocycte. As the oocyte is ejected from its follicle, the fluid from the follicle splashes the lining of the abdomen and creates a sharp sudden pain. Mittleschmertz generally resolves on its own after 48-72 hours.
  • Cramps of menstruation (“primary dysmenorrhea”). Common menstrual cramps are caused by the release of prostaglandins from the lining of the uterus. Prostaglandins create both the cramps of labor and menstrual cramps by making the uterus contract. Common cramps may start prior to the onset of flow and usually last 72 hours. Cramps that increase in intensity, last increasingly longer over time, and start later in life suggest that endometriosis, not just prostaglandins, may be the villain.

Bladder & kidney sources of pain:

  • Bladder infection (Urinary tract infection – UTI). Pain from a sudden bladder infection may be described as cramping, with burning during urination. Frequency, urgency, and small amounts of urine passed are common symptoms.
  • Kidney infections (“pyelonephritis”) will often start with UTI symptoms and progress to back pain at the level of the lower ribs.
  • Kidney stone. Pain from a kidney stone can be sudden and so severe that the woman begins to vomit. There may be blood in the urine.

Bowel caused pain:

  • Irritable bowel syndrome (“IBS”) can start up after eating, or during stressful events. Bloating, gas, and constipation or diarrhea may be present.
  • Infection (“gastroenteritis”) of the intestines can be caused by bacteria, viruses, or even parasites. Diarrhea and nausea may accompany the painful cramping.
  • Diverticulitis is a localized infection in a pouching out section of the bowel.
  • Appendicitis pain may manifest with a fever, loss of appetite, and pain focused in the right lower part of the abdomen.
  • Crohns disease or inflammatory bowel syndrome may have bloody diarrhea along with the pain.

Less common sources of acute pain include:

  • Abdominal aortic aneurysm
  • Blood clot in the large pelvic blood vessels
  • Acute intermittent poryphyia

Chronic Pelvic Pain

When used as a medical diagnosis, chronic pelvic pain indicates that the pain has been more or less constant for at least six months. The same general body systems, except for pregnancy, that produce acute pain can be a source of chronic pain. Additionally, problems with muscles and nerves can create pain in the pelvis. Let’s look at some of the more common causes.

Gynecologic pain:

  • Endometriosis (bits of uterine lining tissue growing on the bowel, bladder, ovaries, etc). The endometriosis implants go through the same cycle as uterine lining–they slough off and bleed monthly. Because there is no outflow for the bleeding, the body creates bands of filmy scar tissue (“adhesions”) as a response to the inflammation of monthly bleeding into the abdomen. These adhesions can “glue” together organs in the abdomen.
  • Adhesions can also be formed if a woman has had an abdominal surgery or a serious abdominal infection (eg PID or ruptured appendix).
  • Ovarian remnant syndrome is an ovarian cyst that occurs after oophorectomy. Despite the removal of an ovary, a small bit of ovarian tissue remains behind. This tissue can still produce ovarian cysts. Ovarian remnants tend to be more common in women who have multiple adhesions which “web together” ovaries to the intestines making it more difficult to be sure that all the ovary was removed.
  • Adenomyosis is endometriosis that has grown into the muscular walls of the uterus. In addition to pain it can produce a uterus that is enlarged, tender, and boggy. Unfortunately, adenomyosis is usually diagnosed only after hysterectomy has been performed. One could have a suspicion for adenomyosis if the woman, or her family, has a history of endometriosis.
  • Pelvic congestion syndrome is also more difficult condition to diagnosis. It involves varicose veins of the uterus or ovaries.
  • Uterine prolapse can create a dragging, heavy pain. The supportive tissues become relaxed and the uterus drops down into the vaginal canal.
  • Large uterine or ovarian masses. Even benign masses such as large external uterine fibroids, or large dermoid cysts, can put pressure on surrounding organs.

Bladder & kidney sources of pain:

  • Interstitial cystitis (“IC”) can present like a urinary tract infection (UTI) with urgency, frequency, and pain with urination. Unlike a UTI there can be pain in the vagina, urethra, or pelvis; there can be pain with intercourse. Unlike a UTI pain may be less at the end of urination. Urine cultures are negative for bacteria, and antibiotics do not relieve the symptoms.
  • Urethral syndrome will also have urinary urgency, frequency, pain with urination, and no evidence of bacteria in the urine. Sometimes women are given a longer than normal duration of broad spectrum antibiotics as a trial treatment. If the woman is postmenopausal she may be prescribed estrogen therapy.
  • Problems with the ureters leading from the kidney to the bladder can include obstructions or diverticulum (a pouch in the walls). These are an uncommon source of pain.

Bowel caused pain:

  • Irritable bowel syndrome (“IBS“) can start up after eating, or during stressful events. Bloating, gas, and constipation or diarrhea may be present. Excluding GYN causes, IBS is the most common cause of chronic pelvic pain.
  • Infection (“gastroenteritis”) of the intestines can be caused by bacteria, viruses, or even parasites. Diarrhea and nausea may accompany the painful cramping.
  • Diverticulitis is a localized infection in a pouching out section of the bowel.
  • Appendicitis pain may manifest with a fever, loss of appetite, and pain focused in the right lower part of the abdomen.
  • Crohn’s disease or inflammatory bowel syndrome may have bloody diarrhea along with the pain.
  • Hernias may be evident and uncomfortable when the woman is standing upright, then not apparent when she is lying flat on the exam table.
  • Cancer of the bowel, while not a common cause of pelvic pain, needs to be ruled out with a sigmoidoscopy. This is especially important if there are other bowel symptoms such as blood in the stool.

Neurologic sources:

  • Myofascial pain creates abdominal wall pain along the lines of major nerve pathways. The area of pain can often be identified very specifically with a finger tip. It is believed that the pain can be instigated by a deeper organ which then refers the pain to the area served by the shared nerve. Performing a straight leg raise (tightens the abdomen) can make the pain worse. Treatment involves injection of the shared nerve with a local anesthetic at the specific site of pain identified by the finger tip.
  • Nerve entrapment or injury may follow a GYN surgical incision (eg laparoscope or C-section scar). The pain may be described as burning, or aching and like myofacial pain follows the shared pathway of a nerve (“dermatome”). As noted above abdominal tightening or exercise can make the pain worse, and treatment includes injection with a local anesthetic at the specific site of pain on the outside of the abdomen.
  • Neuroma is a mass, or thickening, of nerve tissue. Often these can arise where there has been trauma to a nerve. In pelvic pain a neuroma can occur in the area of a hysterectomy scar (including inside the vagina), or other surgical scars.
  • Pudendal neuropathy results from damage to the pudendal nerve. Women may experience vaginal pain with sex, rectal pain with bowel movements, bladder pain with urination, and pain with sitting.

Finally, less common sources of chronic pain can include:

  • Systemic lupus erythematosis
  • Low back injury with pain referred to the abdomen
  • Acute intermittent porphyria

Given this long list of reasons to have pelvic or lower abdominal pain, one can see why it may take more than a single office visit to get an accurate diagnosis. It may take more than one type of imaging technique. If a GYN cause is strongly suspected, an ultrasound is usually performed first. If the ultrasound results are equivocal then either a CT or MRI scan may be ordered. More than one specialist may be needed to examine specific organs in the abdomen–for example a gastroenterologist, or urologist.

WebMD has an extensive library of information here. If you are interested in more information consider visiting these sites. The International Pelvic Pain Society has a list of pelvic pain specialists indexed by geographic location. One can also review the lectures from past conferences on a variety of pelvic pain issues. Also, the NIH has an extensive list of resources.

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