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Overview
Pain is, as Paul Brand wrote, the gift nobody wants. It is given to us to signal injury to the body and cause us to change our behavior in some way to avoid the danger. Unfortunately, the physiological mechanisms that exist to keep us safe and healthy can backfire, causing us to do increasing damage to our bodies by responding to the pain. When human beings experience pain, signs are sent to very deep portions of the brain that also generate fear and anxiety. These emotions increase our sensation of pain. Women who have suffered sexual abuse, physical abuse or emotion abuse at any time in their lives are more susceptible to problems with pelvic pain. It may be that the body has a "physical memory" of that painful experience, and that triggers such as a smell, a particular phrase or even a holiday celebration can initiate an unconscious series of physical reactions. These sudden muscle spasms and abdominal tension may trigger severe pelvic pain. This, of course, is speculation. However, data is very clear in the medical literature on pelvic pain, that woman who have suffered from physical violence or emotional abuse make up as much as 60-75% of the patients we seen with chronic pelvic pain.

There are two types of nerves in the body that can "feel" pain. They are the somatic nerves - those that supply the skin, muscles, and external parts of the body - and the visceral nerves - those that supply our internal organs. These nerves respond to different types of signals. For example, the visceral nerves cannot feel temperature. The somatic nerves are very specific in their location while the visceral nerves are like a spider web within our organs - the same nerves supplying multiple structures.

Pelvic pain can arise from either the somatic nerves supplying the skin, muscles, and outer "housing" of the pelvis, or from visceral nerves supplying the uterus, tubes, ovaries, bladder, intestines, and blood vessels in the pelvis. Most women and many physicians tend to discount the abdominal wall and the pelvic floor musculature as a source of pelvic pain, however, these components are a significant source of pain in many people. It is important to carefully address ALL potential sources of pain when evaluating women for pelvic pain.

Pain in the pelvis can be acute - that is of rapid onset and severe in quality, or chronic - a sensation that has been present for longer than 3-6 months. Acute pain often signals an urgent medical condition such as pelvic infection, appendicitis, or an abnormal pregnancy. Acute pain that lasts more than a few hours requires immediate medical attention. Chronic pain, on the other hand, may well have begun with an insult to the body causing a series of responses that are now responsible for the chronic discomfort. It may be easier to understand an example from orthopedics. If I injure my right knee skiing, I will automatically adjust the way I walk and carry my body to protect that knee. In a few weeks my knee may have healed, however, I will often continue to walk with an unbalanced gait since I've become accustomed to it and in several months I may develop chronic back pain. When searching for the cause of my back pain, nothing structurally wrong with my back will be found. It is the abnormal use of muscles that has created my discomfort not something intrinsically wrong with the back. Similarly, women who have experienced severe pain in the pelvis develop a series of responses to protect the area and decrease their discomfort. Women with pelvic pain walk with a characteristic gait and often develop severe spasms in the muscles in the pelvic floor. Many women with chronic pelvic pain also suffer from irritable bowel symptoms related to this muscle spasm.

The evaluation and management of pelvic pain must encompass a careful search for severe and life-threatening processes which require immediate medical intervention, coupled with a comprehensive history and physical examination looking for ALL of the possible areas of malfunction - not just a problem with the female organs. Evaluation by a physician with a particular interest and expertise in pelvic pain is essential, especially for women with a long-standing problem. Because our bodies are "hard-wired" to experience fear and anxiety when we have pain, women often feel concern about the cause of their pain. Even when a thorough search has not uncovered a problem in the pelvis, women continue to seek attention and even surgery due to the fear that there is something terrible causing injury to the body that the doctors have been unable to find. Unfortunately, many gynecologists look only for sources of pain in the female reproductive organs and do not continue searching for the true cause of the pain. Just like severe headaches are rarely caused by brain tumors, so chronic pelvic pain is rarely caused by a specific structural problem within the pelvis. That is no way saying that the pain is not real or that it should not be treated. Rather it means that ultrasound and even laparoscopic surgery is often not very helpful in the evaluation of pelvic pain when the physical examination is normal.