Chronic Pelvic Pain

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Chronic low back pain and coccydynia are common in women with Chronic Pelvic Pain. Always consider conditions like endometriosis in women without a clear musculoskeletal cause pain. A high index of suspicion is needed because women may not think it is relevant and hence not disclose a pelvic pain history.

Definition

Key definitions include:

• American College of Obstetricians and Gynecologists (ACOG): Defines CPP as noncyclic pain lasting at least 6 months, located in the anatomic pelvis, anterior abdominal wall at or below the umbilicus, lumbosacral back, or buttocks, and severe enough to cause functional disability or lead to medical care.
• International Association for the Study of Pain (IASP): Defines CPP as chronic or persistent pain (often implying a duration of 3 months or more ) perceived in structures related to the pelvis. Crucially, this definition emphasizes associated negative cognitive, behavioral, sexual, and emotional consequences, as well as symptoms suggestive of lower urinary tract, sexual, bowel, pelvic floor, or gynecological dysfunction.
• Royal College of Obstetricians and Gynaecologists (RCOG): Characterizes CPP as intermittent or constant pain in the lower abdomen or pelvis lasting at least 6 months, not occurring exclusively with menstruation or intercourse, and not associated with pregnancy. It is explicitly viewed as a symptom, not a diagnosis.

Overlap with MSK

CPP frequently co-occurs with, or presents primarily as, CLBP or PGP. Studies on pregnancy-related lumbopelvic pain demonstrate this link clearly, with estimates suggesting around 45% of pregnant women experience lumbopelvic pain, and a significant proportion (around 25%) continue to experience pain postpartum, sometimes leading to severe disability. While pregnancy represents a specific physiological state, these findings highlight the intimate biomechanical and neurophysiological connections between the lumbar spine, pelvis, and pelvic organs in women.

Coccydynia can be a component of the CPP symptom complex or mimic pelvic pain originating from other sources. Somatic referred pain to the pelvis in chronic low back pain may also be common. Reinforcing this overlap, the anatomical location criteria used in CPP definitions often explicitly include the lumbosacral back and buttocks. The high prevalence of CPP combined with its common manifestation as LBP or PGP strongly suggests that MSK physicians are frequently evaluating patients whose symptoms are driven, at least in part, by underlying CPP mechanisms.

Myofascial Pain Syndrome (MPS) related to myofascial trigger points (TrPs) is a common and often overlooked contributor to CPP. TrPs are defined as hyperirritable spots located within palpable taut bands of skeletal muscle fibers. Palpation of an active TrP typically reproduces the patient's familiar pain, which often refers in characteristic patterns, sometimes distant from the TrP itself. Associated findings can include restricted range of motion, muscle weakness, and occasionally localized autonomic phenomena. The prevalence of pelvic floor myofascial pain in women with CPP may be as high as 85%.

Several muscle groups are frequently implicated in pelvic pain presentations:

• Pelvic Floor Muscles: TrPs in the levator ani (pubococcygeus, iliococcygeus, coccygeus), obturator internus, and piriformis muscles are common findings in women with CPP. These TrPs can refer pain to the vagina, rectum, coccyx, sacrum, bladder, urethra, lower abdomen, low back, buttock, and posterior thigh, often mimicking visceral or neuropathic pain.
• Abdominal Muscles: TrPs in the rectus abdominis, external and internal obliques , and transversus abdominis can refer pain into the pelvis, groin, and back. Abdominal wall pain, often identified by a positive Carnett's test (pain increases or remains unchanged when palpating a tender point while the patient tenses their abdominal muscles), is a recognized component of CPP. Palpation for specific TrPs in the abdominal wall is recommended.
• Gluteal Muscles: TrPs in the gluteus maximus, medius, and minimus, as well as the piriformis, commonly refer pain to the buttock, sacrum, coccyx, hip, and posterior thigh. Piriformis syndrome, involving TrPs or tightness leading to sciatic nerve irritation, can present with buttock and leg pain mimicking sciatica and contribute to pelvic discomfort.
• Quadratus Lumborum (QL): TrPs in the QL muscle can refer pain extensively, including to the SIJ region, buttock, hip, groin, and lower abdomen.

Pelvic Floor Muscle Dysfunction

PFMD is a broad term encompassing several abnormalities of the pelvic floor muscles, including hypertonicity (high tone, non-relaxing pelvic floor), hypotonicity (weakness), and incoordination. Pelvic floor muscle hypertonicity is particularly relevant as a contributor to CPP and associated symptoms.

PFMD is a very frequent finding in women with CPP and can exist as a primary MSK issue or, more commonly, secondary to other conditions. Potential triggers for pelvic floor hypertonicity include underlying visceral pain conditions (e.g., endometriosis, IC/BPS, IBS leading to guarding), direct trauma (childbirth, surgery), postural dysfunction, chronic constipation/straining, history of abuse, or psychosocial stress.

Symptoms associated with hypertonic or non-relaxing pelvic floor muscles often overlap significantly with CPP and can include localized pelvic or perineal pain, dyspareunia (particularly insertional or deep pain), constipation or pain/difficulty with defecation (dyschezia), and urinary symptoms such as urgency, frequency, hesitancy, incomplete emptying, or pain with urination (dysuria).

Assessment of PFMD typically requires specialized training and often involves an internal vaginal and/or rectal examination to directly palpate the muscles (levator ani complex, obturator internus, piriformis), assessing resting tone, tenderness (including trigger points), ability to contract and relax voluntarily, strength, and endurance. While this detailed internal examination is usually performed by pelvic health physiotherapists or gynaecologists, MSK physicians can contribute to screening through careful history taking (inquiring about the symptoms listed above) and external assessment. This may include palpation for tenderness around the perineum, ischial tuberosities, coccyx, and pubic symphysis, as well as palpation of accessible superficial muscles like the bulbocavernosus and ischiocavernosus. Functional tests that assess lumbopelvic stability, such as the Active Straight Leg Raise (ASLR) test, can provide indirect information about potential core and pelvic floor muscle dysfunction contributing to impaired load transfer. MSK physicians should recognize the indications for referral for a specialized internal pelvic floor assessment.

Clinical Assessment

Category	Key Questions / Areas to Cover	Rationale
Pain Onset & Timeline	"How and when did this pain start?" "Was it related to any event (surgery, childbirth, injury, illness)?" "Has it changed over time?" 14	Identifies potential triggers, chronicity, evolution of symptoms.
Pain Modifiers	"What makes the pain better or worse?" (Specifically ask about: sitting, standing, walking, posture, movement, intercourse, bladder filling/emptying, bowel movements, menstrual cycle) 23	Helps differentiate MSK vs. visceral vs. neuropathic patterns. Cyclical worsening is suggestive but not diagnostic of gyn causes. Sitting intolerance points towards pudendal nerve or coccyx issues.
Pain Location & Quality	"Can you point to exactly where you feel the pain?" "Does it stay in one place or travel?" "What does the pain feel like (ache, burn, sharp, pressure)?" 6	Maps somatic and potential referred pain areas. Quality can hint at origin (e.g., burning = neuropathic).
Gynaecological Screen	"Do you have painful periods (requiring time off work/school)?" "Do you experience pain during or after intercourse (superficial or deep)?" "Any unusual bleeding (between periods, after intercourse) or discharge?" "Have you ever been told you have endometriosis, fibroids, cysts, or pelvic infections?" 3	Screens for common gyn contributors often undisclosed in MSK settings.
Urological Screen	"Do you have pain with urination?" "Do you need to urinate very frequently or urgently?" "Does your pain change when your bladder is full or after you empty it?" 3	Screens for IC/BPS or other urinary tract involvement.
Gastrointestinal Screen	"Is your pain related to bowel movements?" "Have you noticed changes in your bowel habits (constipation/diarrhea)?" "Do you experience significant bloating?" 3	Screens for IBS or other GI contributors.
Neurological Screen	"Do you experience any numbness, tingling, burning, or shooting pain in your pelvis, groin, or legs?" 9	Screens for potential nerve entrapment or neuropathic pain component.
Functional Impact	"How does this pain affect your daily activities, work, sleep, mood, and relationships?"	Assesses pain burden and psychosocial impact, important for management planning.
Patient Beliefs	"What do you think might be causing this pain?"	Understands patient perspective and concerns, facilitates shared decision-making.

Red Flags

• Malignancy: New pelvic pain post-menopause, unexplained weight loss, palpable mass, rectal bleeding, postcoital bleeding, irregular vaginal bleeding >40 years, new bowel symptoms >50 years, persistent bloating/early satiety/urinary changes >50 years
• Acute Abdomen: Sudden severe intractable pain, peritonitis on exam, fever/chills/rigors, haemodynamic instability, suspected ectopic pregnancy
• Neurological: Cauda Equina Syndrome
• Psychosocial: Suicidal ideation

Differential Diagnosis

Condition Category	Specific Condition	Key History Clues	Key Exam Findings / Pain Pattern
Musculoskeletal	SIJ Dysfunction	Buttock/low back pain, +/- post. thigh radiation; Worse with sitting, stairs, transitions; +/- trauma/pregnancy history	Tenderness over SIJ/PSIS; +ve SIJ Provocation Cluster (≥3 tests); Potential LLD
	Hip Pathology (FAI/Labral/OA)	Groin/anterior hip pain (most common), +/- buttock/lateral pain; Worse with activity, flexion/IR, prolonged sitting; Clicking/locking	Limited hip Flex/IR; +ve FADIR, +ve FABER (may indicate hip or SIJ); Antalgic gait
	Lumbar Spine Referral	Back pain +/- radiation to buttock/leg; May follow dermatome; Worse with specific spinal movements/loading	Abnormal lumbar ROM/neuro screen; +ve SLR/Slump; Tenderness over lumbar structures
	Myofascial Pain (TrPs)	Aching pain, stiffness; Specific referred pain patterns (see text); May be related to posture, overuse, guarding	Palpable taut band with localized tender spot (TrP); Reproduction of familiar pain +/- referred pain on palpation; Restricted muscle length; +ve Carnett's (abdominal)
	Pelvic Floor Muscle Dysfunction (Hypertonicity)	Pelvic/perineal pain, dyspareunia (esp. insertional), constipation/dyschezia, urinary urgency/frequency/dysuria	External tenderness (perineum, ischial tuberosity); Internal exam (by trained provider): high resting tone, tenderness, TrPs, poor relaxation
	Coccydynia	Tailbone pain; Worse with sitting, rising from sitting; +/- trauma history	Localized tenderness over coccyx; +/- pain with mobility testing
Gynaecological	Endometriosis	Severe dysmenorrhea, deep dyspareunia, CPP, cyclical bowel/bladder symptoms (may become non-cyclical); Infertility	Often normal external exam; May have tenderness/nodularity on internal pelvic exam (Gyn); Diagnosis often requires laparoscopy
	Adenomyosis	Heavy/painful periods (dysmenorrhea), CPP	Tender, possibly enlarged uterus on pelvic exam (Gyn)
	PID (Chronic)	Persistent lower abdominal/pelvic pain, dyspareunia, +/- discharge; History of PID/STIs	Cervical motion tenderness, adnexal tenderness on pelvic exam (Gyn); May have signs of past infection
	Pelvic Congestion Syndrome	Dull, aching pelvic pain; Worse end of day, standing, activity	Diagnosis requires specialized imaging (venography/MRI)
Urological	IC/BPS	Bladder pain/pressure related to filling; Urinary urgency/frequency; Pain relief with voiding	Suprapubic tenderness; Often normal exam; Diagnosis based on symptoms +/- cystoscopy findings
Gastrointestinal	IBS	Abdominal pain related to defecation; Change in stool frequency/form; Bloating	Often normal exam; May have diffuse abdominal tenderness; Diagnosis based on Rome criteria
Neurological	Nerve Entrapment (e.g., Pudendal)	Burning, shooting, neuropathic pain in nerve distribution; Worse with sitting (pudendal), specific movements	Tenderness along nerve path; Sensory changes (allodynia/hyperalgesia) in distribution; +ve Tinel's sign (if accessible); Pain reproduction with specific maneuvers

Management

Management of pelvic floor myofascial pain, particularly hypertonicity, is a cornerstone of CPP treatment and typically involves referral to a pelvic health physiotherapist. Treatment modalities include manual therapy techniques (soft tissue release, trigger point therapy), biofeedback to improve awareness and control of muscle relaxation/contraction, specific relaxation and stretching exercises, therapeutic exercises to address underlying weakness or incoordination, bladder and bowel retraining, and extensive patient education. In refractory cases of persistent spasm, botulinum toxin injections into the pelvic floor muscles may be considered.

Endometriosis is common in women with chronic pelvic pain and referral to an endometriosis surgeon may be warranted. Diagnostic laparoscopy is not a perfectly reliable test, for example if it was done by a non-endometriosis surgeon then the patient may have had a false negative. Hence do not necessary let a previous negative diagnostic laparoscopy stop you from referring.

Resources

CPP referred pain.pdf - 904 KB (f)

Chronic Female Pelvic Pain Part 1 - apte 2011.pdf - 387 KB (f)

Chronic Female Pelvic Pain Part 2 - nelson 2011.pdf - 492 KB (f)

Pelvic floor myofascial pain physical examination - meister2018.pdf - 581 KB (f)