Chronic pelvic pain and the pelvic floor in Vienna
Chronic pelvic pain, known in medical terminology as CPP, means persistent or recurring pain in the lower abdomen and pelvis that has usually lasted for at least six months. There is often more than one cause behind the symptoms. Gynaecological, urological, gastrointestinal, muscular and nerve-related factors frequently act together. In my private practice in Vienna's 9th district, I take the time to understand your symptoms as a whole. This page also covers pelvic floor weakness with prolapse symptoms. Both conditions often call for individual treatment that takes several factors into account.
What is chronic pelvic pain and how does it develop?
The uterus (womb), ovaries, bladder, rectum, pelvic floor muscles and numerous nerves all lie close together in the pelvis. Pain signals from different structures can overlap and influence one another. This is why very different conditions can cause similar symptoms. Typically the pain is dragging, pressing, burning or cramping, and it is either constant or keeps coming back.
What are the possible causes?
Possible gynaecological causes include:
Pain during intercourse, when opening your bowels or when passing urine can also provide important clues. Causes outside gynaecology are possible too, for example conditions of the bladder or bowel, muscular problems or vulvodynia, which is persistent pain in the vulval area with no clearly identifiable cause.
Sometimes no single physical cause can be found. In that case it is especially important to assess the various possible factors systematically. You can read more about endometriosis under Endometriosis.
Why can pain become chronic?
When pain has been present for a long time, the way the nervous system processes pain signals can change. Doctors speak of peripheral or central sensitisation, among other terms. The nervous system then reacts more sensitively to stimuli, so that pain can persist or be felt more strongly even when the original trigger is no longer present to the same extent.
Stress, lack of sleep, muscle tension and the ongoing strain of being in pain can also make the symptoms worse. This is why, in chronic pelvic pain, looking for just one physical cause often falls short.
When should you come to see me about pelvic pain?
An assessment makes sense if lower abdominal or pelvic pain keeps returning or persists over a longer period. You should also be examined if your periods are so painful that they regularly interfere with your daily life or you often need painkillers. Pain during intercourse, when opening your bowels or when passing urine, and new symptoms after an operation, should be assessed as well.
If you already have earlier reports, operation notes or imaging results, please bring them with you. With chronic pain in particular, looking at all the previous investigations together can provide important clues.
How do I approach chronic pelvic pain?
Everything starts with a detailed conversation. I want to know when the pain began, whether it is linked to your cycle, what makes it better or worse, and how it affects your daily life, sleep and sexuality. Previous operations, inflammation and treatments you have already had are also important.
This is followed by a gynaecological examination, including a gentle internal examination by hand. I also check for painful or tense areas of the pelvic floor.
Transvaginal ultrasound allows me to assess the uterus and ovaries and can show, for example, fibroids, ovarian cysts or signs of deep endometriosis. Normal fallopian tubes, however, usually cannot be seen on ultrasound. Depending on your symptoms and the findings, further investigations such as magnetic resonance imaging (MRI), or an assessment by urology, gastroenterology, pain medicine or specialised physiotherapy, may be useful.
Today, a laparoscopy (keyhole surgery) is not necessary for every patient with suspected endometriosis. It can be useful, however, if imaging does not provide a sufficient explanation, if treatment with medication does not help, or if a finding is to be treated surgically at the same time. You can read more under Minimally invasive surgery in Vienna.
Which treatment helps with chronic pelvic pain?
Treatment depends on the suspected causes and can consist of several components. Depending on the situation, these include:
In chronic pain, regular exercise can have a positive effect on general well-being, physical resilience and the way pain is processed. It does not replace necessary medical treatment, however, and is adapted individually to your symptoms.
If the pelvic floor muscles are tense or painful, specialised pelvic floor physiotherapy can be particularly useful. Chronic pelvic pain is often an interdisciplinary problem. Where needed, I therefore coordinate the cooperation with the relevant specialties.
What does pelvic floor weakness have to do with prolapse?
The pelvic floor consists of muscles and connective tissue and supports the bladder, uterus, vagina and rectum, among other structures. If these structures are weakened, pelvic organs can shift downwards. This is called a prolapse, or pelvic organ prolapse.
Typical symptoms are a feeling of pressure or of something being in the vagina, which can get worse after standing for a long time or with physical exertion. Problems passing urine or opening your bowels can also occur. Leaking urine when coughing, laughing or exercising may be present at the same time, but does not occur with every prolapse.
The most important risk factors include pregnancy and vaginal births, increasing age and an individual weakness of the connective tissue. Being overweight, chronic constipation, frequent heavy lifting or a chronic cough can also play a part.
A prolapse is generally a benign condition, but it can considerably affect quality of life. It does not necessarily get worse. In some women it remains stable for a long time or even improves.
How do I treat pelvic floor weakness and prolapse?
For a mild to moderate prolapse, targeted pelvic floor training is an important treatment option. Structured training under expert guidance is particularly useful, so that the muscles really are contracted and trained correctly. For suitable patients, guidelines recommend supervised pelvic floor training over several months.
Regularity is key. I therefore also recommend forms of exercise that fit easily into daily life. Pilates can be a useful addition if the pelvic floor and core muscles are trained under good guidance. It does not, however, replace targeted pelvic floor training when a prolapse or incontinence is to be treated.
If that is not enough, pessaries can be used. These are, for example, rings or cubes that are placed in the vagina and support the organs that have dropped. They can be used alone or together with pelvic floor training.
For vaginal and urinary symptoms after the menopause, local oestrogen treatment can be useful in addition. It mainly improves symptoms affecting the vaginal and urinary lining, but is not a treatment for the prolapse in its own right.
If conservative measures do not help enough, or the patient does not want them, surgery can be discussed. Whether it makes sense depends mainly on how severe the symptoms are, the extent of the prolapse and your personal wishes.
Why should you come to Prof. Obwegeser about pelvic pain?
Chronic pelvic pain lies where several of my long-standing clinical specialisms meet. From 1989 to the end of 2023, I worked at the University Department of Obstetrics and Gynaecology at Vienna General Hospital (AKH Wien). In 2003, I founded the ZEM outpatient clinic for cysts, endometriosis and fibroids there and headed it until the end of 2023.
Over many years I have treated patients with endometriosis, fibroids, cysts and complex chronic pelvic pain. Minimally invasive surgery has also been one of my specialisms for decades. If an operation makes sense, it can be part of the treatment. In chronic pain, however, it is not automatically the right solution.
It is equally important to me not to look at physical and psychological factors separately. Chronic pain can be influenced by changes in pain processing, muscle tension, sleep problems and stress. This is why a treatment plan that takes several of these factors into account is often needed.
What about recurring vaginal symptoms?
Recurring symptoms in the vaginal area can have various causes. Besides recurring yeast infections (thrush), these include changes in the vaginal flora, bacterial infections, skin conditions and other causes.
When symptoms keep coming back, it therefore makes sense to review the diagnosis before repeatedly treating with vaginal suppositories or creams on suspicion alone. In recurrent vulvovaginal candidiasis, for example, a swab with culture or PCR can be useful to detect Candida and identify the exact species. Recurrent vulvovaginal candidiasis is usually defined as at least three symptomatic episodes within one year.
The aim is not only to treat the current symptoms, but to identify possible contributing factors and decide on a suitable longer-term treatment.
What does treatment cost and what does health insurance cover?
I run a private practice without a health insurance contract. After your appointment you will receive an invoice, which you can submit to your health insurer for reimbursement. The amount reimbursed depends on your insurer and on the services provided. For a private operation you will receive a cost estimate in advance, which you can submit to your supplementary private insurance where applicable. My team will be happy to tell you the specific amount for your concern in advance by telephone.
When is pelvic pain considered chronic?
Pelvic pain is often described as chronic when symptoms persist or recur over several months, frequently from a duration of about six months. You do not have to wait that long for an assessment, though. If pain keeps coming back or clearly interferes with your daily life, it should be examined.
Can the pain remain even though the cause has been treated?
Yes. When pain has been present for a long time, the way the nervous system processes pain can change. This so-called sensitisation can mean that symptoms persist even though the original trigger has been treated. It can therefore make sense to combine medical treatment with exercise, physiotherapy, pain therapy and, where appropriate, other supportive approaches.
Does a prolapse always need surgery?
No. For many women, pelvic floor training or a pessary can relieve the symptoms sufficiently. For symptoms after the menopause, local oestrogen treatment can be useful in addition. Surgery is an option if the symptoms persist despite conservative treatment or if a patient prefers a surgical solution.
Which type of exercise is suitable for pelvic pain or prolapse?
Regular exercise is useful in principle, but should be adapted to your symptoms. For pelvic floor weakness, I mainly recommend targeted pelvic floor training. Under expert guidance, Pilates can be a good addition.
If certain sports increase the feeling of pressure, urine leakage or prolapse symptoms, the training should be adapted accordingly. For general physical activity, there is currently insufficient evidence that it generally improves or worsens a prolapse.
What should I bring to my first appointment?
Please bring any existing reports, operation notes, ultrasound or MRI images and a list of your medication. For pelvic pain, a pain diary kept over a few weeks can also be helpful, in which you note the time, intensity, accompanying symptoms and, where relevant, the day of your cycle.
From 1989 to 2023 at the University Department of Obstetrics and Gynaecology at Vienna General Hospital (AKH Wien), senior consultant from 1994; founder and long-standing head of the ZEM outpatient clinic for cysts, endometriosis and fibroids.
If you suffer from pelvic pain, a prolapse or recurring symptoms in the vaginal area, make an appointment on +43 1 317 660 0 or by e-mail at ordination@prof-obwegeser.at. My private practice is at Hörlgasse 14, Top 11, 1090 Wien. Please note: the entrance is at Liechtensteinstraße 8.