Pelvic Pain With No Clear Cause: What Could Be Missing?
Being told that your pain is stress, or that nothing can be found, is common with long-lasting pelvic pain, and it is exhausting. Pain is real whether or not a test shows it. This page explains what "no cause found" can mean, what has usually been checked, and which causes are worth asking about next.
Go to an emergency department now if pelvic pain comes with numbness around the genitals, anus or buttocks, not being able to pass urine, loss of bladder or bowel control, or new weakness in both legs. These can be signs of cauda equina syndrome, which needs urgent treatment.
Your pain is real, whatever the tests show
The International Association for the Study of Pain states that a person's report of an experience as pain should be respected. Pain is always a personal experience that is influenced to varying degrees by biological, psychological and social factors. That is true for every kind of pain, including pain with a clear physical cause.
What "no cause found" can mean
"No cause found" can mean different things.
- The tests looked for other conditions, such as infection or a tumor, and found none. That rules those out, but it does not rule out everything.
- The cause was not looked for. Scans and nerve tests can be normal in pudendal neuralgia, and no single imaging test confirms it. The diagnosis is clinical, based on the pattern of symptoms, an examination and often a diagnostic nerve block.
- The pain fits chronic primary pain: pain lasting longer than 3 months, with significant distress or disability, that is not better explained by another diagnosis. This is a recognized diagnosis and it is treated with a combined biological, psychological and social approach. It does not mean the pain is imagined.
When the pattern points to the pudendal nerve
Doctors use the Nantes criteria. The essential ones are pain in the territory of the pudendal nerve (from the anus to the penis or clitoris), pain that is mainly felt when sitting, pain that does not wake you at night, no objective sensory loss on examination, and pain relief after a diagnostic pudendal nerve block. If your pain fits this pattern, a specialist assessment of the nerve is a reasonable next step, even if your scans were normal. See pudendal neuralgia symptoms and why a normal MRI does not rule it out.
Other causes worth asking about
Pelvic pain that is called stress or "nothing" is often later linked to another condition, such as chronic prostatitis, bladder pain syndrome, pelvic floor dysfunction or vulvodynia. See pelvic pain misdiagnosis for how these conditions overlap with nerve pain.
Stress and pain can both be true
Stress and anxiety can make pain harder to live with, and long-lasting pain causes stress. Support for sleep, mood and coping is part of good pain care. It does not replace a physical assessment, and a physical assessment does not exclude psychological support.
Questions to ask at your next appointment
- Which conditions have been ruled out, and how?
- Has my pelvic floor been examined?
- Has a nerve cause been considered?
- What is the plan if the current treatment does not help?
Bring your test reports, a list of treatments you have tried and what each one did, and a short note on when the pain is worse (sitting, standing, during the day, at night).
Common questions
Can pelvic pain be caused by stress?
Stress can make pain worse and harder to cope with, but pain that lasts for months deserves a physical assessment as well. Both can be true at the same time.
What does "chronic primary pain" mean?
It means pain that lasts longer than 3 months, comes with significant emotional distress or functional disability, and is not better explained by another diagnosis.
Can pudendal neuralgia be present when my MRI and nerve tests are normal?
Yes. Scans and nerve tests can be normal, and there is no single imaging test that confirms the diagnosis on its own. Pudendal neuralgia is diagnosed from the symptom pattern, an examination and the response to a diagnostic nerve block.
Is "nothing found" the same as "nothing wrong"?
No. It means the tests that were done did not find a cause. Other causes, including nerve causes, may not have been looked for.
Speak with a pudendal nerve specialist.
Dr Renaud Bollens leads a specialist practice dedicated to chronic pelvic pain, with centers in Dubai and Belgium.