Pelvic pain is a complicated topic and a clinical challenge,
because the very definition of this pain can vary. The pelvis has
a formal anatomic description; however, pelvic pain can refer to
pain experienced in the general pelvic cavity or pain that is synonymous
with gynecologic pain. In addition, gynecologic pelvic pain, although
potentially acute or chronic, can refer to chronic pain with or
without an anatomic lesion. Under these circumstances the parameters
for describing pelvic pain also fluctuate. In the most general context,
pelvic pain can be visceral, somatic, and neuropathic. Causal categories
are traumatic, mechanical, and psychological. Organ systems include the
genitourinary, gastrointestinal, neurologic, and musculoskeletal.
The treatment of pelvic pain encompasses not only discoveries in
clinical physiology and pharmacology, but also the social and intellectual
assumptions behind the clinical practice.
It is estimated that 9.2 million women in United States have
pelvic pain. Ten percent of all gynecologic office visits are for
pelvic pain; 44% of all laparoscopies and 10% to
15% of hysterectomies are for chronic pelvic pain; and
30% of women presenting to a pain clinic have already undergone
hysterectomy. The male pelvic pain syndrome comprises of 8% of
all urologic visits and 1% of all visits to primary care
physicians. The economic impact is enormous, with medical costs
of $1.2 billion per year and missed work and productivity
totalling $15 billion per year.
Any discussion of pelvic pain requires an appreciation of the
spatial relations of the pelvic viscera, along with their vascular
supply and innervation. The pelvis has as its walls the bony pelvis and
as its floor the pelvic diaphragm. It is lined by a complex vascular
structure and traversed by sympathetic and parasympathetic afferent,
visceral afferent, and efferent nerves from the lumbar and sacral
plexes. The pelvis is divided into a major pelvis and a minor pelvis,
separated by the pelvic brim, which also is the boundary between
the abdominal and pelvic cavities. The pelvis contains the bladder
and the paravesical fossae in front, the rectum and the pararectal
fossae in back, and the internal genital organs in the middle.
The bony pelvis includes two hip bones formed from the fusion
of the ischium, ilium and pubis, the sacrum, and coccyx. The two
innominate bones form the sides of the pelvis. They are joined in front
at the symphysis pubis and articulate with the sacrum and coccyx
The pelvic diaphragm, or floor of the pelvis, arises in front
from the body of the pubis and continues behind to the coccyx. It
includes the levator ani muscles and the coccygeus muscles. The
diaphragm holds the lower part of the rectum and supports the bladder,
vagina, and prostate by maintaining sufficient intraabdominal pressure.
Beneath the diaphragm is the perineum, with the external genitalia.
Although the bony pelvis can be compared to a basin, the pelvic
vasculature resembles a woven lining composed of large, ...