Chronic Pelvic Pain: Why It Happens and What You Can Do About It
- malavikajp10
- 1 day ago
- 6 min read
At some point in our lives, the majority of us—women in particular—have experienced pain or discomfort in the lower abdomen, between the hips. This pain could be due to underlying causes like menstrual cramps, urinary tract infections, endometriosis, or digestive issues like irritable bowel syndrome. While most of the time the pain may resolve on its own, in some cases, it persists for months.
So, when can pelvic pain be considered chronic pelvic pain syndrome (CPPS)? It occurs when the pelvic pain persists for more than six months and does not get better with treatment. Compared to acute pelvic pain, which is an indication of a more serious problem, chronic pain may continue even after the initial cause has been addressed or is still unknown. CPPS is a complex condition influenced by multiple factors and the pain you experience might originate from the urogynaecological, gastrointestinal, pelvic musculoskeletal, or nervous systems.
Having CPPS can significantly reduce your quality of life, making simple tasks like sitting for a long duration or exercising painful. It can also cause pain during sex and difficulties with urination or bowel movements. Moreover, since its symptoms often overlap with other conditions, diagnosing this condition is difficult, causing women to go through many physical and mental challenges before obtaining the right treatment.
What Causes Chronic Pelvic Pain Syndrome?
CPPS likely results from a combination of factors affecting the immune system, nerves, muscles, and blood flow in the pelvic area. Therefore, it is important to understand these factors, as they help guide and choose appropriate treatment. Here are some key mechanisms by which you may experience CPPS:
Nerve-Related Inflammation
CPPS can result from neurogenic inflammation due to overactive nerve signals. We have a complex system of nerves throughout the body that transmit signals from the brain to various organs. However, when nerve signals become overactive, they can cause inflammation, leading to the release of certain chemicals such as substance P, acetylcholine, and vasoactive intestinal peptides, which amplify pain signals and contribute to tissue irritation. This heightened pain sensitivity manifests as chronic discomfort in your bladder and pelvic tissues.
Infections
Sometimes, if you have CPPS, you may exhibit symptoms similar to an infection, such as bladder pain or discomfort during urination. However, a study by Grinberg and Sela suggests that there is no conclusive evidence that ink infections to CPPS, which explains why antibiotics do not work as a long-term treatment.
Hypoxia
Another reason is hypoxia or poor blood flow. This happens due to weak circulation in your pelvic area. Poor blood flow leads to lower oxygen levels and irritation of tissues, causing pain and discomfort. Studies have shown that when hyperbaric oxygen therapy was performed to increase oxygen supply to the pelvic tissues, symptoms improved, confirming that problems with blood flow could contribute to the pain.
Pelvic Floor Muscle Dysfunction
Weak or overly tight pelvic floor muscles can cause cramps, spasms, and pain, just like muscle knots occurring in your neck or knee body. If you have pelvic floor muscle dysfunction, activities like sitting, walking, and sexual activity can become uncomfortable.
GAG Layer Dysfunction
Damage to the protective bladder and vaginal lining can also cause CPPS. The glycosaminoglycan (GAG) layer acts as a barrier that normally protects the bladder and vaginal walls. However, if this layer is damaged, urine solutes (waste particles) can leak through, irritating nerve endings and triggering inflammation. As a result, histamine is released, which intensifies inflammation, heightens pain perception, and contributes to bladder irritation. Prolonged inflammation can eventually result in fibrosis (tissue scarring), which causes the pelvic tissues to become stiff, potentially worsening pain and dysfunction.
How Does CPPS Affect Your Body's Pain System?
Studies have shown that women with CPPS may experience increased pain sensitivity in other body parts, not just in the pelvis. An important contributing factor is a more sensitive nervous system. Research has indicated that women with CPPS may experience pain from stimuli that are normally not painful, a condition known as allodynia. They may also experience an exaggerated pain response, known as hyperalgesia. When the brains of these patients were examined using imaging studies, results showed that certain brain regions—such as the amygdala, thalamus, anterior cingulate cortex, prefrontal cortex, and insula—were overactive in response to pain. Since these areas are involved in pain perception and emotional processing, these findings suggest that CPPS could be associated with changes in how the brain processes and regulates pain. Moreover, many individuals with CPPS are also diagnosed with fibromyalgia, irritable bowel syndrome, and other chronic pain disorders, suggesting a common underlying pain system dysfunction. Women with CPPS and fibromyalgia were reported to experience more intense pain, anxiety, and depression, which in turn can worsen overall symptoms.
Treatment Approaches
Since CPPS involves abnormal pain processing, treatment should not only target the pelvic area but also focus on managing the nervous system's response to pain. Therefore, it requires a multidisciplinary approach. Some common approaches include:
Cognitive Behavioural Therapy (CBT) and Bladder Training
In cognitive behavioural therapy, a mind-body approach is used to manage pain. This includes performing deep breathing exercises to help relax tense pelvic muscles and learning how to contract and release pelvic muscles to reduce muscle spasms.
Bladder training involves slowly increasing the time between urinations using distraction techniques. This helps you hold more urine and reduce urination frequency.
Medications
A healthcare professional may prescribe you medication depending on the underlying causes. This includes pain-relieving medications, such as tricyclic antidepressants, which help calm overactive nerves and improve pain regulation. They may also suggest anti-inflammatory drugs if inflammation is the underlying cause. It may also involve bladder treatments using medications like glycosaminoglycans, capsaicin, and resiniferatoxin, which can be injected directly into the bladder to restore its protective lining and reduce nerve sensitivity.
Botox is another approach, which helps relax overactive pelvic muscles and block pain signals, whereas hormone therapy in the form of creams, pills, or injections may provide relief for some women.
Physical Therapy for Pelvic Floor Muscles
Since pelvic floor muscle dysfunction is a common cause of CPPS, physical therapy is considered an important step in treatment. A therapist can help relax tight pelvic muscles to relieve tension and pain. Myofascial physical therapy is a safe and recommended treatment for CPPS.
Surgery
Surgery is only considered a last option when all other treatments have failed. Surgical options may include performing a nerve surgery to block pain signals from the bladder or using electrical stimulation implants to help regulate nerve activity.
Overall, treating CPPS frequently requires a combination of therapies rather than a single approach, as it is a complex disorder involving nerves, muscles, and the brain’s pain processing system. Future studies will continue to explore more effective ways of identifying the underlying causes of CPPS and developing better treatments.
Sources
1. Grinberg K, Sela Y, Nissanholtz-Gannot R. New Insights about Chronic Pelvic Pain Syndrome (CPPS). IJERPH [Internet]. 2020 [cited 2025 Mar 18]; 17(9):3005. Available from: https://www.mdpi.com/1660-4601/17/9/3005.
2. Grinberg K, Granot M, Lowenstein L, Abramov L, Weissman-Fogel I. A common pronociceptive pain modulation profile typifying subgroups of chronic pelvic pain syndromes is interrelated with enhanced clinical pain. Pain [Internet]. 2017 [cited 2025 Mar 18]; 158(6):1021–9. Available from: https://journals.lww.com/00006396-201706000-00006.
3. Pukall CF, Baron M, Amsel R, Khalifé S, Binik YM. Tender Point Examination in Women With Vulvar Vestibulitis Syndrome. The Clinical Journal of Pain [Internet]. 2006 [cited 2025 Mar 18]; 22(7):601–9. Available from: https://journals.lww.com/00002508-200609000-00002.
4. Hampson JP, Reed BD, Clauw DJ, Bhavsar R, Gracely RH, Haefner HK, et al. Augmented Central Pain Processing in Vulvodynia. The Journal of Pain [Internet]. 2013 [cited 2025 Mar 18]; 14(6):579–89. Available from:
5. As-Sanie S, Harris RE, Napadow V, Kim J, Neshewat G, Kairys A, et al. Changes in regional gray matter volume in women with chronic pelvic pain: A voxel-based morphometry study. Pain [Internet]. 2012 [cited 2025 Mar 18]; 153(5):1006–14. Available from:
6. Klotz SGR, Ketels G, Richardsen B, Löwe B, Brünahl CA. Physiotherapeutische Befunderhebung bei „chronic pelvic pain syndrome“. Manuelle Medizin [Internet]. 2019 [cited 2025 Mar 18]; 57(3):181–7. Available from: https://doi.org/10.1007/s00337-019-0537-3.
7. Stones W, Cheong YC, Howard FM, Singh S. Interventions for treating chronic pelvic pain in women. Cochrane Database of Systematic Reviews [Internet]. 2005 [cited 2025 Mar 18]; (2). Available from:
Assessed and Endorsed by the MedReport Medical Review Board
