Access to the PPM Journal and newsletters is FREE for clinicians.
12 Articles in Volume 21, Issue #2
Advanced Practice Matters with Theresa & Jeremy: MAT and the DATA Waiver Debate
Analgesics of the Future: The Potential of Vocacapsaicin Injections for Knee Pain
Authorities Update Opioid and Naloxone Prescribing Policies as Overdoses Soar
Autologous Adipose-Derived Biocellular (Stem Cell-Rich) Prolotherapy into Hoffa’s Fat Pad Improves Knee Osteoarthritis
Behavioral Medicine: How to Utilize Acceptance and Commitment Therapy in Primary Care
Case Report: How We Grew Our Pain Practice Amidst Pandemic, Opioid Crisis
Chronic Overlapping Pelvic Pain Disorders: Differential Diagnoses and Treatment
Fentanyl Transdermal Patch: Variability is Key When Prescribing
Optimizing Opioid Therapy with Pharmacogenetics
Research Insights: Advances in Shoulder Arthroplasty and Revision Surgery
Research Insights: How to Address Osteoarthritis Treatment Gaps in Women
Topical Anti-Inflammatories: Analgesic Options for Arthritis Beyond NSAIDs

Chronic Overlapping Pelvic Pain Disorders: Differential Diagnoses and Treatment

To effect a paradigm change in treating this under-recognized yet prevalent condition, clinicians must understand the multifactorial nature and neuroanatomy of chronic pelvic pain.

Imagine you check your patient schedule for tomorrow and see three females lined up for the afternoon – all with pelvic pain as their chief complaint. Unusual for you? What thoughts cross your mind…

I better block out some extra time; Oh no… I won’t make my evening appointment; or, Pelvic pain truly is a common problem.

If your sentiments align with any of those thoughts, you are not alone. According to numerous studies conducted over the past three decades, medical providers of many disciplines and backgrounds express negative attitudes and difficulty in both diagnosis and management of patients with chronic pelvic pain (CPP).1-6

In general, medical education regarding chronic or persistent female pelvic pain disorders is inconsistent and many healthcare providers feel inadequately prepared by their training to manage this challenging and complex patient population. In a 2014 survey, OB/GYN residents reported feeling overwhelmed by patients with CPP and inadequately prepared to address the needs of women presenting with CPP.7

More than half a decade later, those outlooks have not changed, yet CPP prevalence for women of reproductive age has been reported between 14% and 24%, with about 14% of women experiencing CPP at least one time during their life. CPP affects women of all races, socioeconomic and cultural backgrounds worldwide, although there is a paucity of studies in some regions.8,9

The term “chronic pelvic pain” – also called persistent chronic pain – is used frequently in the literature and for medical coding, but does little to help a clinician discern what may be contributing to a patient’s symptoms or what care recommendations to make. It only describes how long and where your patient feels pain.

As a result, CPP is commonly under-recognized and under-treated by frontline HCPs, leading to prolongation of symptoms and increased suffering. Multifactorial in nature, CPP has a major impact on quality of life (QoL), commonly involving not only gynecological causes but also urological, gastrointestinal, musculoskeletal, neurological, and psychopathological and sexual dysfunction contributions.8

Chronic pelvic pain (CPP) is commonly under-recognized and under-treated by frontline HCPs, leading to prolongation of symptoms and increased suffering. Multifactorial in nature, CPP has a major impact on quality of life, involving not only gynecological causes but also urological, GI, MSK, neurological, and psychopathological and sexual dysfunction contributions. (Image: iSTock)

Differing Definitions for Chronic Pelvic Pain

The American College of Obstetricians and Gynecologists (ACOG) describes CPP as “noncyclical pain of at least 6 months’ duration that appears in locations such as the pelvis, anterior abdominal wall, lower back, or buttocks and that is serious enough to cause disability or lead to medical care.”9

However, the International Association for the Study of Pain (IASP) defines CPP as “chronic or persistent pain perceivedin structures related to the pelvis of either men or women. It is often associated with negative cognitive, behavioral, sexual and emotional consequences as well as with symptoms suggestive of lower urinary tract, sexual, bowel, pelvic floor or gynecological dysfunction.”10See Table I for a categorized list of potential causes.

A growing body of literature recognizes the comorbid and overlapping nature of abdominopelvic pain disorders including dysmenorrhea, irritable bowel syndrome (IBS), interstitial cystitis/painful bladder syndrome, vulvodynia, and lumbopelvic myofascial pain.11-14Additionally, anxiety and depressive disorders as well as sleep disorders are strongly associated with pelvic pain disorders.15-17



Enter Chronic Overlapping Pain Conditions (COPCs)

The concept of coexisting pain conditions has now been recognized by the National Institutes of Health and the US Congress as a set of disorders that co-aggregate and include, but should not be limited to, temporomandibular disorder (TMD), fibromyalgia (FM), IBS, vulvodynia, myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), interstitial cystitis/painful bladder syndrome (IC/PBS), endometriosis, chronic tension-type headache, migraine headache, and chronic lower back pain and dry eye syndrome. Collectively, these conditions are increasingly referred to as chronic overlapping pain conditions (COPCs).18Interestingly, almost half of these conditions occur in the abdominopelvic region. Why might this be? Let’s consider the anatomy.

Clinically Relevant Neuroanatomy to Chronic Pelvic Pain (CPP)

The neuromuscular anatomy of the urogenital floor (synonymous with pelvic floor) is, in a word, complex. Compared to other areas of the body, there has been fairly little research on both the neuroanatomy and neurophysiology of the pelvic floor and, thus, is typically poorly taught in most medical education fields.

The pelvic floor is responsible for executing many daily and necessary biologic activities including micturition, defecation, copulation, as well as support of the pelvic viscera, association with balance, and use of the pelvic girdle and lower extremities.

The pelvic floor is innervated by both the autonomic nervous system (sympathetic and parasympathetic divisions) and the somatic nervous system (sensory and motor divisions). Sensation is primarily conveyed via the sacral afferent parasympathetic system and somewhat via the afferents traveling with the thoracolumbar sympathetics. The inferior hypogastric plexus is thought to be the neuronal integrative center and innervates multiple pelvic organs including the bladder, proximal urethra, distal ureters, rectum (both internal and external sphincters) as well as the genital and reproductive tract structures. The inferior hypogastric plexus receives both sympathetic and parasympathetic input.

Sympathetics originate in the thoracolumbar spinal segments of the spinal cord (T10-L2) and then condense into the superior hypogastric plexus just inferior to the bifurcation of the aorta.19

It is no wonder why so many patients may get sensations from these pelvic organs confused when they have persistent pelvic pain.

Somatic efferent and afferent innervation to the pelvic floor muscles originate from the sacral spinal cord (S2-4) with roots emerging to form the sacral plexus and then give rise to the pudendal nerve. The pudendal nerve also receives sympathetic input, hence, carries both somatic and autonomic fibers. The pudendal nerve takes a circuitous route through the pelvis running medial to the internal pudendal vessels on the lateral side of the ischiorectal fossa dorsal to the sacrospinous ligament. It then branches to become the dorsal nerve to the clitoris (or penis) and then also arborizes to distribute branches to the anal canal, urethral sphincter, vulvar vestibule and the perineal musculature.10, 20

Now consider, how the abdominopelvic region may be impacted when the autonomic nervous system becomes dysregulated, particularly with sympathetic up-regulation.

Chronic Overlapping Pain Conditions: How to Differentiate a Multifactorial Condition

With this complex neuroanatomy in mind, it’s important to revisit COPCs. In general, there are two defining features of COPCs:

  • etiologies of COPCs are multifactorial
  • clinical manifestations of COPCs are diverse and present with a mosaic of risk determinants.

Practically speaking, these features make this concept clear as mud. We can, however, describe these characteristics as a mosaic to emphasize our expectation that no single risk determinate is necessary or sufficient to cause one or more of the COPCs – just as multiple tiles are needed to depict the image in a mosaic. Understanding the interactions among multiple risk determinates, and/or their grouping into clusters, is required to better comprehend the etiological factors at play.21

Many individuals with one condition also tend to meet diagnostic criteria for other conditions, however, this is not the case for every patient. So, clinicians may question:

  •  Is each singular condition a primary problem – with some patients exhibiting a secondary disorder (ie, a person with endometriosis who also meets criteria for interstitial cystitis/painful IBS) that appears to overlap with the primary condition(s)?


  • Do all of the patient’s conditions share a common underlying mechanism, with the severity varying along a continuum where some individuals display only a singular manifestation and others exhibit more severe cases dictated by genetic susceptibility and the nature of specific environmental exposures?21 (eg, consider a person diagnosed with TMD, fibromyalgia, migraine, vulvodynia, and chronic low back pain – this patient may lie at the more severe end of the continuum).

At the end of the day, there is still much controversy regarding the underpinnings despite agreement on the frequency of overlapping chronic pain conditions.

Treatment Approaches to Chronic Overlapping Pain Conditions

When a condition or conditions are multifactorial, the most successful approaches to management and treatment address all of the contributing factors. We know this is true of hypertension and diabetes, for instance, as treating only with medications does not typically lead to optimal management or improvement in QoL.

COPCs are likely no different – clinicians must address the underlying contributing factors.

Evidenced-based approaches suggest utilizing a combination of both traditional and centrally acting medications, however, they produce only modest benefits for COPCs. The combination of medications with non-pharmacologic interventions can lead to greater benefits in pain relief and functional outcomes for people with COPCs.22

Of note, acute and chronic pain are inherently different. Acute pelvic pain should be evaluated to rule out or diagnose acute causes such as active infection, obstruction of outflow tracts, anatomical abnormalities, etc.)  Once pelvic pain is found to be persistent, lasting longer than 3 months, one should begin to look for common underlying contributors such as stress, inflammation, biomechanics or problematic nutrition, or association with prior trauma.

If you find yourself struggling with the complexity and challenging presentations of people with persistent or chronic pelvic pain disorders, you are not alone. To learn more, check out additional resources available through the International Pelvic Pain Society (IPPS) .

This article is part of a new series on chronic/persistent pelvic pain disorders by Dr. Witzeman to be published throughout 2021. Part 2 discusses overlapping pelvic pain and mental health disorders in women.

Last updated on: August 25, 2021
close X