Pain in the lower abdomen that keeps coming back, pain during intercourse, periods that have become very painful, or pelvic discomfort present for several months can have a considerable impact on daily life.
Yet chronic pelvic pain is sometimes dismissed as normal, particularly when it has been present for a long time or when initial investigations do not immediately reveal a cause.
But persistent pain is not "normal" simply because it is long-standing.
Chronic pelvic pain can be related to a gynaecological condition, but also to a urinary, digestive, muscular, or neurological one. Several mechanisms can sometimes coexist in the same patient.
The aim of the assessment is therefore not only to look for "a lesion", but to understand which mechanisms are actually contributing to the pain.
What is chronic pelvic pain?
Chronic pelvic pain refers to persistent or recurrent pain located in the pelvic region, present for several months.
It can be:
- constant;
- intermittent;
- cyclical, notably linked to periods;
- triggered by sexual intercourse;
- associated with defecation or urination;
- brought on by certain positions or movements.
It can be superficial or deep, localised or diffuse.
The intensity felt is not always proportional to the size of any lesion visible on imaging.
Why is chronic pelvic pain sometimes difficult to diagnose?
Because the pelvis brings together several organs and systems that are very close to one another:
- the genital tract;
- the bladder and urinary tract;
- the bowel and rectum;
- the pelvic floor muscles;
- the abdominal wall;
- joints and musculoskeletal structures;
- pelvic nerves.
Pain perceived as "gynaecological" can therefore sometimes come from another system.
Conversely, a gynaecological condition can cause urinary or digestive symptoms.
In some patients, several causes are present simultaneously.
What are the main possible gynaecological causes?
Several gynaecological conditions can be associated with chronic pelvic pain, notably:
- endometriosis;
- adenomyosis;
- certain fibroids;
- certain cysts or ovarian conditions;
- after-effects of pelvic infection;
- certain post-surgical adhesions;
- certain vulvar or vaginal conditions;
- pelvic floor disorders.
This list is not exhaustive.
Whether the pain is cyclical, and its relationship with periods, intercourse, defecation, or urination, provides important information to guide the diagnosis.
When should endometriosis be considered?
The Haute Autorité de Santé notably recommends considering endometriosis in the presence of chronic pelvic pain symptoms such as:
- significant dysmenorrhoea;
- deep dyspareunia;
- non-menstrual pelvic pain.
Pain on defecation, cyclical urinary symptoms, or certain localising signs can also point towards deep endometriosis.
The presence of several associated symptoms strengthens the case for an appropriate assessment.
Does a normal ultrasound rule out endometriosis?
No.
This is an essential point.
Pelvic ultrasound is an important examination, particularly when performed by a professional experienced in endometriosis imaging.
However, normal imaging does not rule out all forms of the disease.
The HAS notably specifies that superficial or minimal endometriosis lesions may not be detected by imaging.
When symptoms remain suggestive despite inconclusive initial imaging, the next steps in the assessment depend on the clinical context.
What about adenomyosis?
Adenomyosis corresponds to the presence of endometrial tissue within the uterine muscle.
It can notably be associated with:
- painful periods;
- heavy periods;
- pelvic pain;
- sometimes a feeling of heaviness.
Ultrasound and MRI can contribute to the diagnosis depending on the situation.
Endometriosis and adenomyosis can coexist.
Do fibroids always cause pain?
No.
Many fibroids are asymptomatic.
When they do cause symptoms, these depend notably on their size, number, and location.
They can be associated with:
- heavy periods;
- a feeling of pelvic pressure or heaviness;
- certain pain;
- urinary or digestive symptoms due to a mass effect.
Discovering a fibroid does not, therefore, automatically mean it explains all pelvic pain.
Can a past infection cause chronic pain?
Yes, in certain situations.
An upper genital tract infection, called pelvic inflammatory disease, can lead to long-term complications.
The ACOG notably states that pelvic inflammatory disease can subsequently be associated with persistent pelvic pain.
A current or past infection should nevertheless not be assumed without appropriate clinical or laboratory evidence.
Can the bladder be responsible for pelvic pain?
Yes.
Some pelvic pain can be associated with urinary symptoms:
- frequent urges to urinate;
- urinary urgency;
- pain or pressure that increases as the bladder fills;
- pain related to urination.
Bladder pain syndrome, sometimes called interstitial cystitis depending on classification and situation, is among the diagnoses that can be discussed after excluding other causes.
A urinary tract infection should be investigated when the context suggests it.
Can the bowel cause pain felt in the pelvis?
Yes.
Certain digestive or functional conditions can cause pelvic or lower abdominal pain.
Irritable bowel syndrome can notably coexist with chronic pelvic pain syndromes.
Pain related to defecation, changes in bowel habits, blood in the stool, or other digestive symptoms should be reported to the doctor.
Pain on defecation that varies markedly with the menstrual cycle can also suggest endometriosis and deserves a targeted gynaecological assessment.
Can the pelvic floor be painful?
Yes.
The pelvic floor muscles can themselves become a source of pain.
Some patients have hypertonia, myofascial trigger points, or poor muscle coordination.
These disorders can be associated with:
- pain during intercourse;
- vaginal or perineal pain;
- discomfort after prolonged sitting;
- urinary or digestive symptoms;
- pain triggered during examination.
When a pelvic floor dysfunction is identified, specialised rehabilitation can be part of the management.
Can pelvic pain be of nerve origin?
Yes.
Some pelvi-perineal pain can have a neuropathic component.
It can be described as:
- burning;
- electric shocks;
- numbness;
- hypersensitivity;
- pain worsened in certain positions.
Different nerves can be involved depending on the location and history.
A specialised examination may be necessary when the characteristics of the pain suggest a neuropathic origin.
What is central sensitisation?
When pain persists for a long time, the nervous system can sometimes change the way it processes pain signals.
Central sensitisation refers to mechanisms that can contribute to amplification and persistence of pain.
It is studied notably in endometriosis, vulvodynia, fibromyalgia, and certain chronic pelvic pain conditions.
This does not mean the pain is "imaginary".
It means that the nervous system can itself become a participant in the pain phenomenon.
And above all, identifying central sensitisation does not exempt from also looking for a gynaecological, urinary, digestive, or muscular cause.
Why can pain persist after surgery?
Several reasons are possible.
An intervention may have correctly treated a lesion without necessarily removing all pain mechanisms.
There may persist:
- another source of pain;
- myofascial pain;
- a pelvic floor disorder;
- a neuropathic component;
- sensitisation of the nervous system;
- an associated condition that was not the target of the intervention.
In endometriosis, the literature indeed describes multiple pain mechanisms, including inflammation, nociception, and changes in the peripheral and central processing of pain.
Persistent pain therefore requires re-assessment rather than automatic repetition of interventions.
Can stress or emotions explain the pain?
Stress, sleep, anxiety, and emotional state can change the intensity and impact of many chronic pains.
But this does not mean the pain is "psychological" or invented.
The ACOG recommends a multidisciplinary approach to chronic pelvic pain precisely because it can be influenced by several biological, physical, and psychosocial dimensions.
Looking for an organic cause and taking into account factors that modulate pain are not mutually exclusive.
What signs should prompt you to consult quickly?
Chronic pain can sometimes be accompanied by an acute episode requiring prompt assessment.
You should notably seek medical advice quickly in the event of:
- sudden or very intense pain;
- possible pregnancy associated with pain or bleeding;
- feeling faint or loss of consciousness;
- high fever;
- persistent vomiting;
- heavy genital bleeding;
- significant deterioration in general condition.
These situations can correspond to very different causes, some of which require urgent management.
How is the assessment of chronic pelvic pain carried out?
It begins with a detailed interview.
The doctor notably seeks to understand:
- where the pain is located;
- how long it has been present;
- whether it is constant or intermittent;
- its possible relationship with periods;
- its relationship with sexual intercourse;
- its relationship with urination or defecation;
- associated urinary or digestive symptoms;
- treatments already tried;
- medical, gynaecological, and surgical history;
- its impact on sleep, sexuality, work, and daily life.
This mapping of symptoms is often as important as the intensity of the pain itself.
What examinations might be proposed?
They depend on the situation.
The assessment may include, when indicated:
- abdominal and gynaecological clinical examination;
- pelvic ultrasound;
- pelvic MRI;
- blood tests;
- pregnancy tests depending on the context;
- infection screening;
- urinary tests;
- digestive investigations;
- pelvic floor assessment;
- specialised examinations depending on symptoms.
There is no single "standard assessment" identical for all patients.
Do you always need a laparoscopy?
No.
Laparoscopy is not automatically necessary for every case of chronic pelvic pain.
Regarding endometriosis, ESHRE guidelines have significantly changed the diagnostic strategy: laparoscopy is no longer considered the sole diagnostic reference for all patients, and it may be considered notably when imaging is negative but suspicion remains high, or when empirical treatments are unsuitable or ineffective.
In France, the HAS also states that when imaging shows characteristic endometriosis, laparoscopy performed solely to confirm the diagnosis is not recommended.
The decision to operate should therefore be part of an overall diagnostic and therapeutic strategy.
Why keep a pain diary?
Recording symptoms over several weeks can help identify patterns.
It can be useful to note:
- days with pain;
- intensity;
- periods;
- sexual intercourse;
- urination;
- defecation;
- digestive symptoms;
- medications taken and their effectiveness.
A repeated link with the cycle can guide diagnostic reasoning.
Can management require several specialists?
Yes.
When pain is multifactorial, a multidisciplinary approach can be particularly useful.
Depending on the situation, it can involve:
- a gynaecologist;
- a general practitioner;
- a specialised radiologist;
- a urologist;
- a gastroenterologist;
- a pain specialist;
- a physiotherapist specialised in the pelvic floor;
- other professionals according to needs.
The aim is to avoid each symptom being analysed in isolation when several intertwined mechanisms are sometimes present.
Key points to remember
Chronic pelvic pain should not be dismissed as normal simply because it has lasted a long time.
It can be related to endometriosis, adenomyosis, an ovarian or uterine condition, but also to the bladder, the bowel, the pelvic floor, or the nervous system.
Several causes can coexist.
A normal ultrasound does not rule out all causes of pelvic pain and does not mean the pain is imaginary.
Analysis of the cyclical pattern, urinary or digestive symptoms, pain during intercourse, and the clinical examination help guide investigations.
When pain becomes complex or persistent, multidisciplinary management can be more relevant than the repeated search for a single cause.
Medical information: this article provides general information and does not replace a consultation. Sudden or intense pain, pain associated with a possible pregnancy, feeling faint, high fever, or heavy bleeding require prompt medical assessment.
Medical and Scientific Sources
American College of Obstetricians and Gynecologists (ACOG). Chronic Pelvic Pain. Practice Bulletin No. 218. Obstet Gynecol. 2020;135:e98-e109. https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2020/03/chronic-pelvic-pain
Haute Autorité de Santé (HAS) / CNGOF. Prise en charge de l'endométriose — démarche diagnostique et traitement médical. https://www.has-sante.fr/jcms/c_2820456/fr/prise-en-charge-de-l-endometriose-demarche-diagnostique-et-traitement-medical-fiche-de-synthese
Haute Autorité de Santé (HAS). Actualisation de la place des différents examens d'imagerie pour le diagnostic d'endométriose. 15 mai 2025. https://www.has-sante.fr/jcms/p_3607756/fr/actualisation-de-la-place-des-differents-examens-d-imagerie-pour-le-diagnostic-d-endometriose-recommandations
ESHRE Guideline Development Group. ESHRE guideline: endometriosis. European Society of Human Reproduction and Embryology. 2022. https://www.eshre.eu/guideline/endometriosis
Morotti M, Vincent K, Becker CM. Mechanisms of pain in endometriosis. Eur J Obstet Gynecol Reprod Biol. 2017;209:8-13. PMID: 27522645. https://pubmed.ncbi.nlm.nih.gov/27522645/
Kaya S, Hermans L, Willems T, Roussel N, Meeus M. Central sensitization in urogynecological chronic pelvic pain: a systematic literature review. Pain Physician. 2013;16(4):291-308. PMID: 23877446. https://pubmed.ncbi.nlm.nih.gov/23877446/
Cetera GE, et al. Central Sensitization in Vulvodynia and Endometriosis: What Have We Been Overlooking So Far? 2023. PMID: 38134340. https://pubmed.ncbi.nlm.nih.gov/38134340/
Consult Dr. Yasmine Maazouzi at the Hôpital Privé Beauregard (23 Rue des Linots, Bât. B5 ICOGM, Marseille 13004) for a full assessment of your pelvic pain.