Persistent pelvic pain in women: unraveling diagnostic challenges and the overlooked role of pelvic congestion syndrome

Persistent pelvic pain (PPP) is one of the most frequently encountered yet diagnostically complex conditions in women’s health. By definition, PPP is noncyclical pain located in the pelvis, persisting for at least 6 months, and severe enough to interfere with daily activities. The prevalence of PPP is striking, but it is often under-recognized, leading to delayed diagnoses and misdirected therapies. Among its many causes, pelvic congestion syndrome (PCS) has re-emerged as a significant but often overlooked contributor. First described more than a century ago, PCS involves dilated venous complexes of reproductive tissues with impaired venous drainage. Richet was credited with identifying this illness as tubo-ovarian varicocele, and in the 1950s, Howard Taylor gave further clinical descriptions, gaining limited acceptance before the era of laparoscopy and venography. However, due to longstanding misconceptions and emphasis on psychosexual origins of pain, many physicians considered PCS a psychosomatic illness. This belief contributed to women being denied appropriate treatment and instead being subjected to years of uncertainty and ineffective therapies [ 1 , 2 ] . PPP is not just a medical condition, it is a major public health issue. It significantly impacts quality of life, employment, relationships, and mental health. The purpose of this article is to clarify the meaning of PPP as a diagnostic challenge, to highlight PCS in the differential diagnosis, and to present a structured approach that can help clinicians avoid misdiagnoses, reduce unnecessary therapies, and improve patient outcomes. This manuscript has been written in line with TITAN guidelines [ 3 ] .

Chronic pelvic pain is both common and debilitating. Women affected by PPP frequently experience disruption of social life, sexual function, and occupational roles. Globally, it is estimated that nearly 10 million women suffer from PPP, with 7 million remaining untreated [ 3 ] . In gynecology, PPP accounts for 2–10% of all office consultations and up to 30% of diagnostic laparoscopies [ 4 ] . The burden extends beyond the physical. Unlike episodic acute pain, PPP is continuous, often resistant to conventional treatments, and can progress to secondary consequences such as depression, central sensitization, and permanent impairment [ 3 , 4 ] . This condition frequently coexists with psychological dysfunction, including anxiety, post-traumatic stress, and a history of abuse [ 4 ] . Importantly, patients often endure years of medical visits before receiving a correct diagnosis. The overlap with gynecologic, gastrointestinal, urinary, musculoskeletal, and psychosomatic disorders contributes to frequent misdiagnosis. As a result, some women undergo unnecessary surgeries or receive inappropriate medications without addressing the underlying cause [ 5 , 6 ] .

PPP represents a diagnostic and therapeutic dilemma. Historically, many women were told their pain was “psychogenic,” delaying recognition of legitimate organic causes [ 2 ] . Misdiagnosis is harmful: for example, patients without endometriosis or adhesions may still suffer from PCS or musculoskeletal dysfunctions. Without systematic evaluation, these women may undergo repeated surgeries or receive inappropriate pharmacological regimens [ 5 , 6 , 9 ] . Management requires multidisciplinary care. Gynecologists, gastroenterologists, urologists, neurologists, and mental health specialists should collaborate in a patient-centered framework. Evidence-based management strategies include the following: pharmacological therapies, such as tricyclic antidepressants (amitriptyline, nortriptyline), which are effective for neuropathic pain [ 5 , 15 – 18 ] ; lifestyle interventions, including physical therapy for musculoskeletal contributions [ 11 ] ; and psychological interventions, which support coping mechanisms and reduce catastrophizing [ 5 ] . Surgical or interventional approaches, such as ovarian vein embolization, may relieve PCS when conservative treatments fail. A growing body of evidence supports integrated care. For example, interdisciplinary management of endometriosis-associated pain demonstrates superior outcomes compared to isolated specialty care [ 15 , 19 ] . Similarly, lifestyle modifications and multidisciplinary counseling improve quality of life in women with chronic pelvic pain [ 11 , 14 ] . By systematically considering all possible etiologies, clinicians can avoid unnecessary therapies and ensure targeted management. This approach not only alleviates symptoms but also reduces healthcare costs and psychological burden.

Persistent pelvic pain is a multifaceted and often misunderstood condition affecting millions of women. Its clinical burden is enormous, with significant consequences for quality of life, productivity, and psychological well-being. A structured diagnostic framework integrating gynecologic, urologic, gastrointestinal, musculoskeletal, neurological, vascular, and psychosomatic causes is essential. PCS must be recognized as a legitimate and clinically relevant etiology, not dismissed as psychosomatic. By emphasizing differential diagnosis and adopting a multidisciplinary strategy, clinicians can reduce misdiagnoses, avoid unnecessary interventions, and provide effective, evidence-based care. The key message is that PPP should not be treated merely as a “common” problem. It is a significant diagnostic challenge, demanding systematic evaluation and integrated management. Addressing this appropriately can profoundly impact women’s health, offering accurate diagnoses, better therapies, and improved outcomes.

To manage PPP effectively, a systematic evaluation of differential diagnoses is crucial. A structured framework helps prevent overlooking important conditions: Gynecologic causes: Endometriosis, the most common gynecologic contributor, often produces pain due to ectopic endometrial implants [ 7 ] . Pelvic adhesions, usually post-surgical, are associated with chronic pain [ 3 ] . Adnexal tumors, benign or malignant, can mimic PPP. Fibroids cause bulk-related pain and bleeding. Ectopic pregnancy must always be considered in reproductive-age women with pelvic pain [ 8 ] . Ovarian torsion and cyst rupture may present with acute or chronic pain episodes [ 9 ] . Urologic causes : Urinary tract infections and cystitis are common and recurrent [ 3 ] . Interstitial cystitis/bladder pain syndrome leads to persistent pain with urinary frequency [ 9 ] . Ureteric calculi can produce referred pelvic discomfort [ 9 ] . Gastrointestinal causes : Appendicitis, acute or chronic, is a well-known mimic [ 9 ] . Gynecologic causes: Endometriosis, the most common gynecologic contributor, often produces pain due to ectopic endometrial implants [ 7 ] . Pelvic adhesions, usually post-surgical, are associated with chronic pain [ 3 ] . Adnexal tumors, benign or malignant, can mimic PPP. Fibroids cause bulk-related pain and bleeding. Ectopic pregnancy must always be considered in reproductive-age women with pelvic pain [ 8 ] . Ovarian torsion and cyst rupture may present with acute or chronic pain episodes [ 9 ] . Urologic causes : Urinary tract infections and cystitis are common and recurrent [ 3 ] . Interstitial cystitis/bladder pain syndrome leads to persistent pain with urinary frequency [ 9 ] . Ureteric calculi can produce referred pelvic discomfort [ 9 ] . Gastrointestinal causes : Appendicitis, acute or chronic, is a well-known mimic [ 9 ] . Diverticulitis may cause pelvic tenderness [ 10 ] . Irritable bowel syndrome frequently overlaps with gynecologic pain disorders [ 6 ] . Colorectal malignancy, though less common, must be excluded in older patients. Musculoskeletal causes : Pelvic floor muscle spasms and dysfunction can drive chronic pain [ 5 , 7 ] . Lumbar disc disease and spinal pathologies often refer pain to the pelvis [ 11 ] . Obesity-related strain exacerbates musculoskeletal contributions. Neurological causes : Nerve entrapments, particularly pudendal neuralgia, produce neuropathic pain [ 12 ] . Neurological dysfunctions secondary to trauma or surgery contribute significantly [ 3 ] . Vascular Causes : PCS, varicosities, and reflux, is a hallmark finding [ 5 , 6 ] . Vascular malformations may rarely be involved. Psychosomatic and psychiatric causes : Depression, anxiety, and personality disorders may exacerbate PPP [ 3 , 5 ] . Trauma history, including sexual or emotional abuse, strongly correlates with pelvic pain [ 3 ] . Musculoskeletal causes : Pelvic floor muscle spasms and dysfunction can drive chronic pain [ 5 , 7 ] . Lumbar disc disease and spinal pathologies often refer pain to the pelvis [ 11 ] . Obesity-related strain exacerbates musculoskeletal contributions. Neurological causes : Nerve entrapments, particularly pudendal neuralgia, produce neuropathic pain [ 12 ] . Neurological dysfunctions secondary to trauma or surgery contribute significantly [ 3 ] . Vascular Causes : PCS, varicosities, and reflux, is a hallmark finding [ 5 , 6 ] . Vascular malformations may rarely be involved. Psychosomatic and psychiatric causes : Depression, anxiety, and personality disorders may exacerbate PPP [ 3 , 5 ] . Trauma history, including sexual or emotional abuse, strongly correlates with pelvic pain [ 3 ] . A pregnancy test is mandatory in the acute setting to exclude ectopic pregnancy. Acute pelvic pain in pregnancy requires differentiation from spontaneous or septic abortion, abruptio placentae, and ectopic pregnancy [ 13 , 14 ] . Laparoscopy and ultrasound remain essential tools to delineate acute versus chronic etiologies [ 10 ] .

The mechanisms underlying PPP are multifactorial. PCS represents a leading vascular cause, characterized by venous incompetence and varicosities in ovarian and uterine veins. Retroversion of the uterus can worsen venous pooling, while hormonal influences such as elevated estrogen levels may cause venous dilation. Importantly, fetal vein capacity rises by approximately 60% during pregnancy, predisposing to venous stasis, reflux, and varicosities when coupled with uterine enlargement and venous kinking [ 5 , 6 ] . Multiparity is a significant risk factor. Beyond vascular causes, PPP may arise from anatomic dysfunctions such as endometriosis or adhesions, hormonal factors influencing tissue sensitivity, musculoskeletal abnormalities such as pelvic floor hypertonicity, neuropathic processes, including pudendal nerve entrapment, and psychological influences, with stress amplifying pain perception [ 2 , 3 ] . This complex interplay explains why no single investigation or treatment can address PPP universally. A nuanced approach is required to identify primary drivers in each patient.