If it’s not PGP, then what is it?

By Madeleine Speed

As you may already know, pelvic pain in women can be difficult to diagnose. We always encourage women who believe their symptoms match those of PGP, to go and get a thorough assessment done through a referral to a manual therapist like a physio or a chiropractor. However, chronic pelvic pain can be caused by a number of different conditions; so it is important to seek professional help to try and sort out what the underlying cause of your symptoms might be.

As a rule of thumb, it’s PGP if the pain can be tracked down to pelvic joints that are not working efficiently and a misaligned pelvis. Yet, just going by the symptoms of pain and difficulty walking, it can be really difficult (and unwise) to work this out for yourself without involving you GP. We would suggest it is best to have a read through of this article for some ideas of what may be causing your pain and then to get yourself properly checked out by a healthcare professional. Don’t hang around and wait for the pain to go away, get your symptoms checked out as soon after they arise as possible.

With any diagnosis, you always have to exclude other possibilities – for example the cause of chest pain can be anything from indigestion to a heart attack. Something that appears to be PGP could also be another condition, although this is unusual if you have the classic symptoms of pain during or after pregnancy: pain when walking, turning over in bed, getting dressed, climbing stairs, etc.

The connection between the pain and a diagnosis

Talking about pelvic pain in a short article is hard to do without generalising but it is important to point out that as we are all individuals, we may experience pain very differently from each other. In addition, some pain is experienced by all women at some time in their lives and this is often associated with the normal functioning of organs and particularly the reproductive organs where changes at puberty, menstruation, pregnancy and childbirth (and later, the menopause) can all cause a certain amount of discomfort or pain even if some lucky women don’t get any uncomfortable symptoms.

When we think about pelvic pain, it might help to distinguish between chronic and acute pain. Chronic pelvic pain is often explained as pain that occurs in the abdomen or stomach area and continues for six months or longer; it may be less severe initially and slowly develop in intensity. The pain may also be intermittent. Acute pelvic pain can be described as lasting from a few minutes to several days and is often intense from the start. Acute pain is generally regarded as needing immediate attention from a healthcare professional, but both forms of pain should be investigated as early as possible. Acute pain can develop into chronic pain as often happens in PGP when you have had it for a long time – it then becomes a chronic, (longer term) pain. Individual women have a very good insight into what level of pain needs further investigation so if you are experiencing something that you know is different from how you normally feel, then make an appointment at your local surgery.

It goes without saying that in order to treat symptoms correctly, a diagnosis is going to be vital. It isn’t always easy to find the source of pain and even the same condition can have different symptoms in different women. These symptoms can include pain in the hips, groin, lower stomach, back, burning sensation around the genitals and discomfort down the inner thighs. Sometimes the pain can take
the form of a stabbing sensation or appear as a low – level ache. These symptoms can be alarming and do need checking out but often intermittent, chronic pain is less associated with a disease (which is a comfort) and more to do with a range of symptoms sometimes related to a problem in one or more of the female organs.

The range of symptoms indicated above is often associated with PGP. Sadly, there are still instances where PGP is not recognised by healthcare professionals and the appropriate manual treatment is not considered as a result. Thankfully, awareness of PGP is growing and more women are being assessed and treated early so that they make a full recovery or their PGP symptoms can be managed effectively. PGP affects one woman in five so it is very common and it arises during the early, middle or late phases of pregnancy. It can also occur as a result of a difficult delivery. However, not all pelvic pain is due to a mechanical problem as it is in PGP (where often the cause is an asymmetry in the pelvis where one or more of the pelvic joints have become stiff and are not functioning properly). There are a number of conditions that have very similar symptoms so diagnosis is often a matter of eliminating some of the most common causes of pelvic pain in women.

Potential causes of pelvic pain

Below is a list of the most common causes of pelvic pain that can be confused with PGP. The list is not exhaustive and it is important that if you are worried by a nagging pain of any kind in the abdomen, you see your GP.

Pelvic pain can be caused by an infection or inflammation and sometimes can be associated with the bladder, bowel or appendix, even when the pain may feel as if it is emanating from the reproductive organs. Kidney and bladder stones can cause a great deal of pain or discomfort, and pain may also stem from problems with the digestive system or possibly from straining muscles or nerves in the lower back.

Here are some relatively common, non-pregnancy-related causes of pelvic pain:

  • Urinary tract infection (UTI)
    Sometimes the symptoms of PGP can be very similar to those of a bladder infection. A UTI can occur when bacteria enter the urinary system through the urethra and then multiply. This can cause a sharp pain, an urgency to urinate and then a burning sensation when urine is passed. This problem is quite common in women as the urinary tract is shorter than in men and bacteria from the vagina or rectum can easily be passed to the into the urethra. Some women are more prone to these infections than others but about 50% of women will experience a UTI in the course of her life. This can be excluded as a diagnosis by a simple urine test. Drinking lots of water while you make an appointment to see your GP can help to ease the symptoms (and there may be some over-the-counter remedies for speedy relief if you ask your pharmacist which might avoid the need to see your GP).
  • Irritable bowel syndrome (IBS)
    This is a gastro-intestinal condition where chronic abdominal pain arises together with altered bowel habits (such as loose stools, increased frequency of bowel movements, more gas and pain) and often there is an absence of any obvious cause. One theory suggests that this may be because of a severe gastro-intestinal infection, whereas another attributes it to abnormal contractions of the colon and intestines. Stress might be responsible for heightened sensitivity in the intestines or it could be due to an intolerance of certain foods. It may be more difficult to diagnose this condition. Sometimes GPs prescribe simple measures to combat IBS such as taking peppermint capsules and these can be very effective. However, if you have been told that IBS is what you have and you continue to have symptoms such as difficulty walking, it is important to get a referral to a manual therapist to check that PGP is not being missed.
  • A lumbar disc problem
    Strained or pulled muscles in the lower back can cause a considerable amount of pain and impaired movement but a lumbar disc problem (or herniated disc) can be particularly painful. Misleadingly known as a slipped disc, this is actually where damage to the outer fibrous ring of an intervertebral disc allows the soft, central portion to bulge out. This can cause symptoms such as numbness, weakness and pain in the buttocks, genitals, legs and feet. A lumbar disc problem can be treated successfully through manual therapy so ask your GP for a referral as soon as possible.
  • Deep vein thrombosis (DVT)
    DVT has been in the news quite regularly as it has been linked to long haul flights. The main cause of DVT is slow circulation or a poor flow of blood. This can result in blood pooling and then forming clots. Certain medical procedures can also increase your risk of DVT. For example, it can result from major surgery or orthopaedic operations such a hip replacement. Although it is common, it can be difficult to recognise because it sometimes occurs without any obvious symptoms and when there are symptoms, these can be similar to other conditions. Symptoms can include swellings in one or both legs, pain or discomfort in one or both legs when standing or walking. There is often warmth in the skin of the affected leg and this can be accompanied by a red or discoloured appearance to the skin. Sometimes surface veins become very visible and often the legs feel heavy and tired. Your GP can use your medical history and various tests to help confirm or eliminate a diagnosis of DVT; these tests can include the use of ultra sound, special x-rays of your veins or magnetic resonance imaging (MRI) scans. DVT can be a serious condition and it is important to discuss this with your GP as soon as possible if you think you have these symptoms.
  • Diverticulitis
    Diverticulitis is an inflammation affecting diverticula within the colon or intestine. A diverticulum is a small protrusion that can form in the wall of the colon or intestine. Inflammation can occur if there is increased pressure on the diverticular wall or where hardened stools get stuck in the diverticulum. When inflammation occurs it can cause pain in the left side of the lower abdomen and, in some cases, it can cause nausea, vomiting and constipation. As with IBS, the diagnosis can be confusing, so again, if you have been told that this is what you have but you still have problems walking, ask for a referral to a manual therapist.

Common causes of pelvic pain that are more associated with the reproductive system include the following:

  • Dysmenorrhea (painful periods)
    Dysmenorrhea can cause many women to experience discomfort during their menstrual cycle. This pain can begin a few days before the period starts and then reduces as menstrual bleeding finishes. For a small percentage, the pain is severe and interferes with carrying out normal everyday tasks. There are two main types of dysmenorrhea: primary dysmenorrhea and secondary dysmenorrhea. In the first, the pain occurs within healthy women and is not related to any specific problem within the uterus or other pelvic organs. However, in the latter, the menstrual pain is linked to an underlying disease or structural abnormality within or outside the uterus such as endometriosis, fibroid tumours, ovarian cysts or by the use of an intrauterine device for birth control. If you find that you suddenly experience more pain than usually during your periods, it is worth letting your GP know. If you have had PGP, you may experience more pain during periods or after the birth of your baby. This is not normal and is different from Dysmenorrhea and it often means that you have an alignment problem (a common cause of PGP), so ask your GP for a referral to a physiotherapist, again to check your pelvic joints.
  • Endometriosis
    Endometriosis describes a condition where the lining of the uterus grows on the outside of the uterus. This can result in tissue attaching to the ovaries or fallopian tubes and sometimes to the bladder or intestines. This tissue is not shed during menstruation, unlike the lining of the uterus, and it can be accompanied by pain during sex or the menstrual cycle. Hormonal treatments that lower oestrogen levels can help to combat this condition and your GP can refer you to a gynaecologist for a diagnosis and treatment.
  • Uterine fibroids
    These are growths that can form on the inside walls of the uterus. They are non cancerous and can vary in size. Their presence can cause stabbing pain or cramps in the lower back and the intensity of pain can increase during the menstrual cycle or during sex.
  • Pelvic inflammatory disease (PID)
    PID is caused by an infection which can affect the pelvic organs such as the uterus, cervix and fallopian tubes. It usually involves sexual contact where bacteria canenter the cervix and then spread although it can develop as a result of childbirth, a termination of pregnancy or pelvic surgery. The symptoms include a fever, lower abdominal pain, and a high pulse. In most instances, PID develops as a result of untreated gonorrhoea and chlamydia. This can be a life-threatening condition so PID needs speedy medical attention.
  • Ectopic pregnancy
    An ectopic pregnancy is one that starts outside the uterus in, for example, the fallopian tubes. Ectopic pregnancies can be detected by pain on one side of the abdomen, spotting or more pronounced vaginal bleeding, symptoms that occur soon after a missed period. Again this can be life-threatening, so if an ectopic pregnancy is diagnosed, you will be referred for an urgent scan.
  • Ovarian cysts
    During ovulation, a follicle forms in the ovary which then matures and ruptures as part of the natural cycle, when an egg is released. A cyst can form if the natural cycle of the follicle doesn’t happen. There are various kinds of cysts and in some instances, they can cause infertility. Pain is often caused by the pressure of the cyst if it develops in size, bleeds or bursts which can irritate surrounding tissue. Ovarian cysts can also interfere with the normal cycle of periods and can make menstruation more painful than usual. If your GP believes that cysts are the cause of your symptoms, a scan can help to confirm the diagnosis and your will be referred to see a gynaecologist.

A painful coincidence

We probably can’t overstate that any pain or discomfort in the abdomen is worth checking out with your GP. Although this article is about causes of pelvic pain that are not because of PGP, there are sometimes instances where a woman can have PGP and experience a separate and painful infection or inflammation. For example, a woman might be unlucky enough to have an underlying pain from PGP and then suddenly experience a bladder infection at the same time. It is very unlucky but it is possible.
Seeing the doctor

The long list of possible causes of women’s pelvic pain can seem alarming. We haven’t provided this list to scare anyone. It is really to help women to keep an open mind about their symptoms and to encourage a quick visit to the GP. Even where you are pretty confident that your pain is likely to be as a result of PGP, it is worth getting the GP to eliminate some of the above conditions at the same time as you ask for a referral to be made to see a physiotherapist to assess whether PGP is the reason for the abdominal pain. The GP will be eliminating these conditions when he or she assesses you and this should not take long and is usually done by asking a few routine questions. Do make sure that once other conditions have been eliminated, you get your referral to a physiotherapist as this is the way to resolve PGP, by making sure your pelvic joints are well aligned and moving normally.

This article was produced after consulting a number of websites including:

My story – Jane Barnes
Useful sources of support & information

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The Pelvic Partnership consists of volunteers who have had Pelvic Girdle Pain (PGP) and wish to support other women. We aim to pass on information based on both research and the experience of other women with PGP. We are not medical professionals and cannot offer medical advice and the information we provide should not take the place of advice and guidance from your own health-care providers. Material on this site is provided for information and support purposes only.

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