Chronic Pelvic Pain in Women: Causes, Interventions & Reclaiming Your Life

Why a multidisciplinary pain team not a single doctor holds the key to lasting relief, and how advanced non-surgical interventions are transforming outcomes for women across India.

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The Scale of Chronic Pelvic Pain in India

42M

Women in India estimated to have endometriosis

Approx. 10% of reproductive-age women globally

1 in 7

Women affected by chronic pelvic pain worldwide

WHO systematic review, CPP prevalence 4–43%

7–10

Years average diagnostic delay in India

Symptoms dismissed as “normal period pain”

78%

Maximum co-occurrence of endometriosis & IC/BPS in CPP patients

Healthcare 2024 systematic review, Inzoli et al.

10+

Interventional pain procedures available without surgery

At IBAP Clinics, Hyderabad

Chronic Pelvic Pain

Every day across India, millions of women go to work, raise families, and carry on whilst silently bearing chronic pelvic pain. The pain is real, disabling, and profoundly life-altering. Yet it is routinely normalised, dismissed as “just periods,” or handed between specialists without resolution. This must change.

Chronic pelvic pain (CPP) is defined as persistent or recurrent pain in the lower abdomen or pelvis lasting at least six months, severe enough to affect daily function. It is not a single diagnosis it is a complex, multisystem symptom syndrome driven by overlapping causes, demanding a multidisciplinary response. At Indo British Advanced Pain Clinics (IBAP), Hyderabad, we believe that with the right diagnosis, the right team, and the right interventions, most women with pelvic pain can reclaim their lives without surgery.

"Pelvic pain is not 'one organ, one doctor' — it is 'one woman, one team.'"

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The Many Faces of Chronic Pelvic Pain

One of the greatest clinical challenges in CPP is that it is almost never single-cause. Multiple conditions coexist in the same patient each requiring targeted management. Identifying which conditions are present, and which is dominant at any given time, is the very foundation of effective treatment.

Endometriosis — The Leading Cause

Endometriosis occurs when tissue resembling the uterine lining grows outside the uterus on the ovaries, fallopian tubes, bladder, bowel, or pelvic lining. Each menstrual cycle, this misplaced tissue bleeds with nowhere for the blood to escape, creating inflammation, scarring, and intense pain. An estimated 42 million women in India are affected, yet diagnosis is routinely delayed by 7–10 years, symptoms dismissed as “bad periods.”

Critically, endometriosis involves both peripheral sensitisation where local nerve endings become hypersensitive and central sensitisation where the brain and spinal cord become amplified in their pain processing. This means that even after surgical removal of lesions, pain may persist if the nervous system is not separately addressed. This is precisely why a pelvic pain physician, alongside the gynaecologist, is essential.

🔥Think of endometriosis pain as a fire that has burned so long it has scorched the walls of the room itself. Removing the fuel (the lesions) helps enormously — but the scorched walls (the sensitised nerves) need separate treatment before the room is truly safe again.

Adenomyosis — The Silent Sister

Adenomyosis occurs when endometrial glands invade the muscular wall of the uterus. The uterus becomes bulky and chronically inflamed, producing relentless heavy cramping and pelvic aching. It frequently coexists with endometriosis, doubling the pain burden. Many women with adenomyosis are told to “wait for menopause” a response that is neither acceptable nor necessary given the range of available interventions.

The "Evil Twins": Interstitial Cystitis & Endometriosis

Interstitial cystitis/bladder pain syndrome (IC/BPS) is a chronic bladder condition causing pelvic pain, urinary urgency, and frequency routinely mistaken for recurring urinary tract infections. A landmark 2024 systematic review found that endometriosis and IC/BPS coexist in 15.5–78.3% of women with CPP nicknamed the “evil twins” because each condition masks the other, causing years of diagnostic delay and inappropriate surgery.¹

Other Key Causes at a Glance

Pelvic Inflammatory Disease (PID) & AdhesionsPast infections (including pelvic TB, common in India) create internal scar tissue tethering organs together. Pain worsens with movement and is often misread as ongoing infection.
Pelvic Congestion SyndromeVaricose veins inside the pelvis produce a dull, throbbing ache worsening with prolonged standing or after sexual intercourse. Invisible on routine ultrasound; requires dedicated Doppler assessment.
Pudendal NeuralgiaEntrapment of the pudendal nerve causes burning, electric perineal pain classically worse with sitting. One of the most under-diagnosed causes of chronic pelvic and perineal pain.
Irritable Bowel Syndrome (IBS)The gut and uterus share overlapping autonomic nerve pathways. Bowel pain is frequently perceived in the pelvis, creating a complex diagnostic picture requiring both gastroenterology and pain medicine expertise.
Hypertonic Pelvic Floor DysfunctionChronically overactive pelvic floor muscles generate constant pelvic and perineal pain without visible pathology on any scan. Commonly missed because it requires clinical assessment, not just imaging.

The Most Overlooked Cause: Lumbar Spinal Problems

The L4, L5, and S1 nerve roots supply the uterus, bladder, perineum, and inner thigh. A herniated disc or inflamed facet joint at these levels refers pain directly into the pelvis and groin perfectly mimicking gynaecological disease, with no obvious back pain. A 2024 systematic review confirmed that “referred pain related to lumbar spine diseases tends to spread to the lower abdomen, groin, and pelvic regions.” Approximately 95% of lumbar disc herniations occur at L4–L5 or L5–S1 the very levels that innervate pelvic structures.

📞 The lumbar nerve roots are like telephone cables running into the pelvis. A fault in the cable at L5–S1 makes the phone (the pelvis) ring — even though the fault is in the cable, not the phone. Treating only the pelvis whilst ignoring the spine means replacing the phone when the wiring is the actual problem.

Why Pelvic Pain Demands a Team, Not a Single Doctor

The most dangerous phrase in pelvic pain medicine is: “All your tests are normal.” This usually means no single specialist found a cause within their own domain not that no cause exists. CPP crosses every specialty boundary: gynaecology, urology, gastroenterology, orthopaedics, neurology, psychology, and pain medicine. A structured multidisciplinary team is not a luxury; it is clinical necessity.

Gynaecologist / Endometriosis Surgeon

Hormonal therapy, fertility planning, laparoscopic excision

Interventional Pain Physician

Nerve blocks, RF ablation, neuromodulation, analgesic optimisation

Radiologist

Pelvic MRI (DIE protocol), dynamic TVS, pelvic vein Doppler

Pelvic Floor Physiotherapist

Myofascial release, downtraining, biofeedback specialist-trained only

Psychologist / Psychiatrist

CBT, pain catastrophising, trauma psychiatric comorbidity in ~1 in 10 with endometriosis

Urologist

Bladder pain syndrome, urodynamics, IC/BPS management

Gastroenterologist

IBS, bowel-related CPP, inflammatory bowel disease exclusion

At IBAP Clinics, we are the interventional pain hub in this team working alongside gynaecologists, urologists, and physiotherapists across both our Banjara Hills and Madeenaguda sites, with senior consultant roles at Apollo Hospitals and Care Hospitals.

The Foundation: Getting the Diagnosis Right

No treatment works when the diagnosis is incomplete. Our diagnostic process goes far beyond routine scans and includes:

Detailed Structured Pain History

Character, timing, triggers, urinary and bowel symptoms, sexual function, psychological history, and prior treatment history.

Pelvic MRI with DIE Protocol

Deep infiltrating endometriosis-specific sequences not routine MRI. Dynamic transvaginal ultrasound using the FOGSI-endorsed IDEA protocol.

Lumbar Spine MRI

Mandatory when spinal contribution is suspected especially in women with back pain, buttock pain, or leg symptoms alongside pelvic pain.

Pelvic Vein Doppler

Specifically for pelvic congestion syndrome, which is invisible on routine ultrasound.

Diagnostic Nerve Blocks

A superior hypogastric plexus block that relieves 70% of pain within 30 minutes confirms the visceral sympathetic pathway as dominant driver immediately directing the entire treatment plan. These are simultaneously diagnostic AND therapeutic.

Psychological Assessment

PHQ-9, GAD-7, and Pelvic Pain Impact Questionnaire because central sensitisation and psychological factors are active pain drivers, not incidental findings.

Interventional Procedures for Pelvic Pain

Interventional procedures for pelvic pain are minimally invasive, image-guided, and performed as outpatient procedures. They complement and in many cases substantially reduce the need for surgery. Below is the complete procedural toolkit available at IBAP Clinics.

Superior Hypogastric Plexus Block

Targets sympathetic nerves at L5–S1 carrying pain from uterus, bladder, and colon. Diagnostic and therapeutic. Can be combined with RF ablation for lasting relief. Indicated for endometriosis, PID, cancer pain.

Ganglion of Impar Block

Targets the terminal sympathetic ganglion at the sacrococcyx, supplying the vulva, perineum, lower rectum, and vagina. Key for perineal pain, coccydynia, vulvodynia, post-surgical pelvic pain.

Pudendal Nerve Block

Image-guided injection at Alcock’s canal. Treats pudendal neuralgia, vulvodynia, perineal burning, post-sling pain. Both diagnostic and therapeutic.

Peripheral Nerve Blocks

Ilioinguinal, iliohypogastric, genitofemoral, obturator, and cluneal nerve blocks for groin, inguinal, and posterior pelvic pain especially after surgery or hernia repair.

Caudal Epidural

Anti-inflammatory delivery to sacral nerve roots S1–S5 via the sacral hiatus. Safe first-line option for sacral nerve irritation contributing to pelvic and perineal pain.

RF Ablation

Radiofrequency ablation of the superior hypogastric plexus; pulsed RF of pudendal and sacral nerve roots; facet joint RF for the spinal component. Provides extended relief well beyond nerve blocks alone.

Botox Injections

Botulinum toxin A into hypertonic pelvic floor muscles relieves vaginismus, dyspareunia, and myofascial pain. Intravesical Botox for IC/BPS reduces bladder pain. A 2024 multi-study review of 1,108 patients confirmed efficacy for sexual pain disorders.

Sacral Nerve Stimulation

Implanted electrode at S3 sacral nerve root delivers continuous neuromodulation. Established (NICE-endorsed) for IC/BPS and bladder pain. Staged trial ensures ≥50% improvement before permanent implant.

Pudendal Nerve Stimulation

Miniaturised wireless leads at the pudendal nerve more targeted than sacral neuromodulation for perineal-specific pain. Refractory pudendal neuralgia, vulvodynia, post-sling pain

The IBAP Non-Surgical Philosophy: These ten procedures represent a complete toolkit for addressing pelvic pain at every level from the sympathetic plexus to the peripheral nerve to the spinal cord without a single surgical incision. Our clinical tilt is always toward safely exhausting this toolkit before any consideration of surgery

Pelvic Physiotherapy: Why "Just Do Kegels" Is Dangerous Advice

2 types

of pelvic floor dysfunction hypotonic (weak) and hypertonic (overactive)

Most

women with chronic pelvic pain have a hypertonic (too tight) pelvic floor

Kegels

are ONLY correct for weak pelvic floors — and actively worsen hypertonic ones

The pelvic floor is a complex hammock of muscles, ligaments, and fascia forming the base of the pelvis. In health, these muscles must contract (to maintain continence), relax (to allow comfortable intercourse and voiding), and coordinate precisely with the diaphragm. Pelvic floor dysfunction exists on a spectrum: hypotonic (too weak) and hypertonic (too tight, overactive, unable to relax).

The Kegel Myth

Kegel exercises developed by Dr Arnold Kegel in the 1940s are pelvic floor strengthening exercises. They are appropriate only when the pelvic floor is weak and underactive. The critical truth is that most women with chronic pelvic pain have an overactive, hypertonic pelvic floor muscles in chronic, painful spasm.

⚠️ Clinical Warning

Performing Kegel exercises on an already-hypertonic pelvic floor increases muscle tension and worsens pain, urinary urgency, and dyspareunia. Clinical evidence confirms this. Harvard Health (2024) explicitly states that women with hypertonic pelvic floors who try Kegels “have actually made things worse.” If you have been prescribed Kegels for pelvic pain — please ask whether your pelvic floor has been assessed as hypertonic or hypotonic before continuing.

⚠️Giving Kegel exercises to a woman with a hypertonic pelvic floor is like telling someone with a severe leg cramp to do calf raises. It feels logical from the outside — but it forces an already-contracted muscle to contract further, deepening the very problem.

Pelvic Floor Relaxation: The Correct Approach

For hypertonic pelvic floors the norm in CPP treatment must focus on relaxation and release, not strengthening. Evidence-based physiotherapy includes:

Diaphragmatic breathing and downtraining: consciously releasing pelvic tension through breath-led techniques.
Internal and external myofascial manual release: performed by a trained pelvic physiotherapist, not a generic sports physiotherapist.
Reverse Kegels: actively and mindfully opening rather than contracting the pelvic floor.
Biofeedback: real-time visual display of pelvic floor muscle activity, helping patients learn voluntary relaxation of muscles they cannot otherwise feel.
Hip flexor, piriformis, and adductor stretching: pelvic floor tension is often maintained by surrounding muscle tightness.
Yoga and mindfulness: stress is a major driver of pelvic floor hypertonicity; targeted yoga postures release hip and pelvic musculature.

India's Policy Direction: FOGSI, ICMR & EndoCare India

What India's Medical Authorities Are Now Saying

FOGSI Key Practice Points on Endometriosis explicitly recommend multidisciplinary management, naming pain physicians and pelvic physiotherapists as essential team members not optional referrals.

FOGSI Focus (November 2024) on Endometriosis and Adenomyosis endorses the IDEA TVS protocol, highlights that pain severity does not always correlate with disease stage, and calls for holistic team-based care.

FOGSI Expert Consensus (2026) on long-term endometriosis management underscores the need for sustained medical pain management — reducing the cycle of repeated surgery.

ICMR EndoCare India is India’s first national multidisciplinary framework for endometriosis and CPP within public tertiary hospitals. It mandates named teams including pain medicine; integrates telemedicine via e-Sanjeevani; and promotes Ayushman Bharat coding for pain procedures, physiotherapy, and mental health visits.

NDPS Act amendments progressively improve legitimate access to opioid analgesics for cancer-related pelvic pain — with full compliance at IBAP Clinics for intrathecal pump programmes and all controlled substance prescriptions.

The Significance: Both FOGSI and ICMR’s EndoCare India now formally recognise the interventional pain physician as an essential member of the pelvic pain team. This is a watershed moment for women’s pain care in India — and one we at IBAP Clinics have been advocating for years.

The IBAP Approach: Non-Surgical First, Team Always

At Indo British Advanced Pain Clinics, our approach rests on three non-negotiable principles:

Precision Diagnosis

We never accept “normal investigations” as the end of the road. Diagnostic nerve blocks, spinal assessment, and detailed pain mapping identify every contributor not just the most obvious one.

Non-Surgical First

Our clinical tilt is always toward safely avoiding surgery. We exhaust the full spectrum of evidence-based interventional options before surgery is considered. Where surgery is genuinely needed, we say so honestly.

Team-Centred Care

We coordinate with gynaecologists, urologists, physiotherapists, and psychologists around the patient not around our specialty. We are the pain hub; we are not the whole team.

"You deserve more than painkillers and patience. You deserve a team that finds every cause, treats every one — and does not rush to the operating theatre."

Happy Patients - Live Testimonials

Meenakshi, 75 years - Relived From Knew Pain

Mrs. Naga Sathyavathi relieved from Back Pain & Shoulder Pain

Mr. Bhaskar Reddy inspiring recovery from L1 Spine Issue.

Raghav Reddy recovered from Pain to Relief

Mr. Chakrapani recovered from Severe Joint and Neck Pain

Meenakshi, 75 years - Relived From Knew Pain

Mrs. Naga Sathyavathi relieved from Back &Shoulder Pain

Mr. Bhaskar Reddy inspiring recovery from L1 Spine Issue.

Raghav Reddy recovered from Pain to Relief

Mr. Chakrapani recovered from Severe Joint & Neck Pain

Our - Treatment Process

Appointment

Start your journey with a virtual consultation to discuss symptoms from home.

Medical History Review

We review your medical history and relevant reports for a clear understanding.

Personalized Consultation

Our doctors conduct a thorough assessment through detailed discussions.

Advanced Imaging

We confirm findings with state-of-the-art imaging like X-rays, CT scans, and MRIs.

Accurate Diagnosis

Our team identifies the root cause and key trigger points for treatment.

Effective Treatment Plans

We create a customized treatment plan, including necessary medications and procedures.

Holistic Rehabilitation

Our Pain Specialists support a complete recovery focused on total wellness.

Continued Care

We provide ongoing follow-ups tailored to each treatment plan, ensuring continuous care and long-term recovery support.

Call Us Now: + 91 9807 55 6789

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Some quick information

What are the most common causes of chronic pelvic pain in women ?

The most common causes include endometriosis, adenomyosis, interstitial cystitis/bladder pain syndrome, hypertonic pelvic floor dysfunction, pudendal neuralgia, pelvic congestion syndrome, IBS, and lumbar spinal problems at L4/L5/S1 that refer pain into the pelvis and groin. Multiple causes very frequently coexist in the same woman which is why a single-specialist approach is insufficient.

What is a superior hypogastric plexus block ?

A superior hypogastric plexus block is a minimally invasive, image-guided procedure targeting a network of sympathetic nerves at the L5–S1 spinal level. These nerves carry pain signals from the uterus, bladder, vagina, and colon. Blocking this plexus using local anaesthetic, steroid, or radiofrequency energy interrupts pain transmission without affecting motor function. It is used for endometriosis-related visceral pelvic pain, pelvic inflammatory disease, pelvic congestion syndrome, and cancer-related pelvic pain.

Can Spinal Cord stimulation really treat pelvic pain ?

Yes. Spinal cord stimulation (SCS) uses thin epidural leads placed at T10–T12 to deliver gentle electrical impulses that modify pain signals at the spinal cord before they reach the brain. A prospective multi-centre clinical trial of 10 kHz SCS for chronic pelvic pain demonstrated significant improvements in pain scores, quality of life, and analgesic use at 12-month follow-up. SCS is particularly effective for refractory endometriosis-related pain, complex CPP, and cancer-related pelvic pain.

Are kegel exercises always the right treatment for pelvic pain ?

No and this is a critically important distinction. Kegel exercises are strengthening exercises, appropriate only for weak (hypotonic) pelvic floor muscles. Most women with chronic pelvic pain have an overactive (hypertonic) pelvic floor that cannot relax properly. Performing Kegels on an already-tight floor increases muscle tension and worsens pain, dyspareunia, and urinary urgency. The correct treatment is pelvic floor relaxation diaphragmatic breathing, myofascial manual release, reverse Kegels, and biofeedback performed by a specialist pelvic physiotherapist.

How are FOGSI and the indian government improving pelvic pain care ?

FOGSI has published Key Practice Points on Endometriosis and a 2026 Expert Consensus recommending multidisciplinary teams including pain physicians and physiotherapists as essential members. ICMR’s EndoCare India framework provides India’s first national blueprint for multidisciplinary endometriosis and CPP care within public hospitals, integrating telemedicine, structured referral pathways, patient registries, and Ayushman Bharat coverage for pain procedures, physiotherapy, and mental health support.

Dr. Vijay Bhaskar Bandikatla

Founder IBAP Clinics, Pain Physician

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References & Evidence Base

Inzoli A et al. The Evil Twins of Chronic Pelvic Pain Syndrome: A Systematic Review and Meta-Analysis on IC/PBS and Endometriosis. Healthcare. 2024;12(23):2403. doi:10.3390/healthcare12232403.
Deuk Spine. L5–S1 Disc Herniation and Pelvic Pain: Pathophysiology Review 2024. deukspine.com.
Rawlins A. Can Botox Injections Help with Pelvic Floor Symptoms? The Origin Way. July 2024.
Gish B et al. Neuromodulation for the management of chronic pelvic pain syndromes: A systematic review. Pain Practice. 2024;24(2):321–340.
Kovacevic N et al. Peripheral nerve stimulation for pudendal neuralgia and other pelvic pain disorders. Front Urol. 2023. doi:10.3389/fruro.2023.1323444.
Deer TR et al. A Prospective Multi-Centre Clinical Trial of 10-kHz SCS for Chronic Pelvic Pain. Pain Practice. 2021. PMC7818476.
Spruijt MA et al. Botulinum Toxin A in Pelvic Floor Muscles for CPP: Double-Blinded RCT. BJOG. 2024. doi:10.1111/1471-0528.17991.
Yang S et al. Pudendal Nerve Blocks and Superior Hypogastric Plexus Blocks for Refractory IC/BPS. Cureus. 2023. PMC10191454.
FOGSI Focus on Endometriosis and Adenomyosis — Newer Updates. November 2024. fogsi.org.
FOGSI Expert Consensus on Elagolix for Endometriosis. Medical Dialogues. January 2026.
ICMR–NIRRCH. EndoCare India: Multidisciplinary Care Model for CPP. 2024–2025.
Song SY et al. Endometriosis-Related Chronic Pelvic Pain. Biomedicines. 2023;11(10):2868.
Harvard Health. Pelvic floor exercises: Help for incontinence and more. 2024. health.harvard.edu.

Founder IBAP Clinics, Pain Physician

MBBS, DA, FRCA (UK), FFPMRCA (Pain Medicine, RCOA, UK)
CCT (Anesthesiology And Pain Management)
Neuromodulation & Advanced Pain Research Fellowship (London), MBA (HM)

Founder IBAP Clinics, Pain Physician

MBBS, DA, FRCA (UK), FFPMRCA (Pain Medicine, RCOA, UK)
CCT (Anesthesiology And Pain Management)
Neuromodulation & Advanced Pain Research Fellowship (London), MBA (HM)