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Medical Description

There is no universally accepted definition for chronic pelvic pain (CPP). However, there are three important elements, which characterize CPP:

  • Long-term pain
    To be deemed chronic, the pelvic pain must have been present for at least six months (or by some definitions, at least three months). Generally, CPP is not affected by a woman's menstrual cycle although some women with CPP do experience severe cramping during their period. The pain is often more pronounced during sexual activity.
  • Other conditions have been ruled out
    The pain experienced by women with CPP is not due to measurable damage to the pelvic organs and no other condition or abnormality can account for the pain. If abnormalities are present, the pain is out of proportion to what would be expected.
  • Limitations on life activities
    The pain is severe enough to limit a woman's physical activities, interfere with her occupation, affect her sexual life, and/or have an impact on her relationships and her emotional state.

CPP symptoms vary from woman to woman. Some women experience severe, even disabling, pain; others, a dull pain or mild feeling of pressure in the pelvis. For some women, the pain is steady; for others, it comes and goes. For some women, urinating, having a bowel movement or having sex can cause the pain to intensify; for others, they do not.

How We Perceive Pain
To understand what is happening in women with CPP, it is important to understand how the body perceives pain.

Understanding Pain

Our understanding of chronic pelvic pain (CPP) is based on our understanding of how pain works. When a body part is damaged or adversely stimulated, it sends a pain signal through specialized nerve cells, called sensory neurons. These neurons carry the signals from the body to the spinal cord and brain.

Even though we may feel pain on our hand, in our pelvis or somewhere else on the body, it is our brain that creates the experience of pain. It usually does so in response to sensory input (for example, a hot element, an injury or a disease), but our brains can also perceive pain independent of sensory input (that is, independent of tissue damage or disease).

Because the brain plays a central role in processing pain signals, other things that influence the brain, such as a person's mood, hormones and stress level, can also affect a person's experience of pain.

Neuropathic Pain

When the nerves that carry messages between the body, spinal cord and brain are damaged or send incorrect signals, a person may continue to experience pain, even though the original damage has been repaired. This type of pain is sometimes described as a switch that is stuck in the “on” position. This type of pain is called neuropathic pain. Researchers believe that many women with chronic pelvic pain are experiencing neuropathic pain. Neuropathic pain can also prompt further problems such as muscle spasms and incontinence.

Referred Pain

Sometimes people perceive pain at a site that is at a distance from the pain’s origin. This is called referred pain.

There are two types of neurons that carry pain signals from the pelvis.

  • Somatic Neurons
    Somatic neurons respond to damage or stimulation to the skin and the muscles in the abdominal wall. Rapid response to pain that is external to the body helps protect us, so this pain is often intense and easy to locate! Feeling pain can be a useful way to protect ourselves. For example, when we feel a burning pain on our hand, we know to immediately pull our hand away from the hot element.
  • Visceral Neurons
    Visceral neurons respond to damage or swelling deep inside the body, in the reproductive system and other internal organs. This type of pain might be caused by endometriosis, or infection or by a variety of other causes. Much less is known about visceral pain and how these neurons process pain signals; however; it does seem different than somatic pain. Damage does not always cause pain. For example, cutting the intestines does not cause pain but stretching them does. Visceral pain is sometimes less intense than somatic pain and it may be difficult to describe exactly where the pain is.

The way a pain signal is processed may be influenced by signals sent by other neurons. Both visceral and somatic neurons may meet in a single cell in the spinal cord. If one neuron is chronically stimulated with pain, these nerve impulses will spill over to the other neurons. This is called referred pain. This is why a person having a heart attack, for example, often has pain in the arm. Similarly, an abnormality in an organ deep in the body may cause intense pain in the abdominal wall. These painful spots, which are not the actual source of the pain, are called trigger points.

Referred pain may also be neuropathic, which means that a woman may continue to have painful trigger points after whatever is causing the visceral pain has been resolved.

To effectively treat CPP, treatment strategies must address all three levels of the pain process: physical damage to tissue, pain originating from damage to the nerves or central nervous system, and the processing of pain impulses by the brain.


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