In the branch of obstetrics and gynecology, especially low back pain, back and leg pain are frequently encountered.

Transient or acute infections are the most common infections. Infections of the upper genital tract, such as endometritis (infection of the lining of the uterus), salpingitis (infection in the tubes), are often seen with pain in the groin and waist. Pelvic region pain is also seen due to reasons such as ovarian cysts, ovarian cyst ruptures, leiomyomas (fibroids, benign tumoral growths in the uterus), menstrual pains (primary dysmenorrhea), cervix uteri stenosis (the cervix is ​​extremely narrow and can hardly expel the dirty blood during menstruation). .

Pain in the lower back or leg may occur during pregnancy. In particular, the onset of uterine contractions (delivery, premature birth) is felt by the pregnant as a pain in the lower back. In addition, low back pain due to the musculoskeletal system is common in pregnant women, factors such as increasing hormones loosening the joint ligaments and changing the body’s center of gravity can often cause low back pain. In a woman who is pregnant or not, large ovarian cysts can cause pain that radiates to the leg.

Chronic Pelvic Pain (CPA)

Although there is no fully accepted definition, we define such cases as chronic pelvic pain (CPA) when there is pain in the groin and abdomen that lasts longer than 3-6 months or attacks for 6 months or persists for 3 months. When there is an acute event, there is usually enough tissue damage and irritation to explain the clinical picture. In chronic pelvic pain, there may not be enough pathological tissue changes to explain the pain in general. In general, physical activity limitation, bodily changes due to depression, and pain-perceiving systems are affected by mood changes.

Chronic pelvic pain is a common condition in women and its treatment may require a multidisciplinary process. CPA is detected in 15-40% of gynecological laparoscopies (the operation performed on the abdomen with a camera, where we can see the internal organs clearly) in one of 10 patients who come to the gynecological examination. The cause is detected in an average of 12% of all hysterectomies (uterus removal surgery).

To summarize, the clinical findings generally seen in CPA;

• last longer than 6 months
• Failure to relieve symptoms with most treatments
• Disruptions in home or work life
• Appearance of symptoms such as depression, anorexia, weight loss

Common causes of chronic pelvic pain and common coexisting conditions

There are many causes of chronic pelvic pain. Many gynecological pathologies are involved in KPA, however, the occurrence of chronic pain is multifactorial. Therefore, clinical evaluation should be based on medical, surgical and psychological evaluation. For example, a patient with dyspareunia (painful sexual intercourse) diagnosed with endometriosis (chronic pelvic inflammation caused by the tissue in the inner lining of the uterus being around the ovaries, uterus) was diagnosed with vaginusmus (inability to have intercourse, involuntary contractions in the muscles around the vagina during intercourse) and vestibulitis (vagina) secondary to dyspareunia (painful sexual intercourse). non-inflammatory inflammation in the tissue at the entrance of the tissue, pain) and in the later stages, for example, it may give symptoms of irritable bowel syndrome and finally give psychological symptoms. The diseases that make up KPA can be seen together at the same time or can occur over time.

The role of the obstetrician and gynecologist in chronic pelvic pain; To determine whether there is an acute event, to diagnose and treat the cause of chronic pelvic pain.

A good history questioning is essential in evaluating chronic pelvic pain. The frequency, persistence, intensity of the pain, the reasons that increase and decrease the pain, and the connection between urination and menstruation should be investigated well. Any previous surgeries, physical sexual abuse, alcohol and other habits should be considered.

Some clues can guide us in evaluating the patient.

Blunt diffuse pain suggests bowel pain, recurrent pain with menstruation suggests endometriosis or adenomyosis. Pain that begins with pregnancy is usually related to the musculoskeletal system. Painful intercourse or painful menstruation makes us think more of endometriosis. Nerve compression pain is often like a heat, cold, or electric shock. Pain with sudden urge to urinate is usually related to interstitial cystitis. Pain associated with losing weight may be due to carcinogenic causes.

Obstetrics examination is important in diagnostic methods. Transvaginal ultrasound is a highly sensitive method for detecting pelvic masses and adenomyosis. Ultrasound also serves to distinguish cystic masses from solid masses. Doppler studies give information about whether the lesion is benign or malignant.

MRI (EMAR) can be used to evaluate more complex pelvic masses. Although it is insufficient to see small implants, it can give findings in the diagnosis of deep endometriosis. It is a method that can be preferred in the diagnosis of adenomyosis. Diagnostic laparoscopy is the most important diagnostic intervention. We can see the intra-abdominal organs with a half-inch incision from the navel.

Causes of chronic pelvic pain

Endometriosis

Endometriosis is the lining of the uterus outside the uterus. The inner lining of the uterus is a tissue that allows the woman to become pregnant and the baby is placed. If there is no pregnancy, it is thrown out with a menstrual bleeding in that month. The reason is unknown. Severe dysmonea (menstrual pain), dyspareunia (painful intercourse) are common in the clinic, sometimes the disease may not cause any complaints.

Adenomyosis

The embedding of the uterine lining in the deep interior of the uterus is called adenomyosis. The reason is unknown. The uterus is usually large and soft, and the incidence of adenomyosis varies between 5 and 70%. It is especially common in women between the ages of 40-50 who have given birth. Not all women with adenomyosis have complaints. The most common symptoms in adenomyosis are pelvic pain, painful menstruation, and excessive menstrual bleeding.

Adhesions

Intra-abdominal adhesions are called peritoneal adhesions. It mostly occurs in surgeries, endometriosis, pelvic inflammation and infections. Adhesions are found in 25-50% of patients with chronic pelvic pain.

Pelvic inflammatory disease

PID is a common disease that can cause chronic pelvic pain as long-term consequences. It most commonly occurs with sexually transmitted infections. Microbes passed during intercourse reach the uterus and tubes from the cervix and cause inflammation. They can cause obstruction, adhesion, intra-abdominal infections in the tubes.

Ovarian cysts

Unilateral chronic pelvic pain may be due to ovarian cysts. They generally do not cause pain, adhesions with surrounding tissues may cause pain.

Uterine fibroids (fibroids)

Monoclonal tumors arising from the muscle tissue of the uterus are called fibroids (leiomyomas). They are benign growths. Although painful menstruation and a feeling of pressure in the pelvis are common, it should not be forgotten that if there is significant pelvic pain, it can be seen together with other painful causes. Surgically removing submucosal ones can improve symptoms such as menorrhagia and dysmenorrhea, while performing myomectomy or hysterectomy for larger and symptomatic myomas reduces chronic pain.

Gastrointestinal and urological causes of chronic pain

A good gynecological, urological, gastroenterological and psychological evaluation is required to evaluate a woman with chronic pelvic pain. Appropriate evaluation is necessary for the patient to receive the most appropriate treatment.