Pelvic Adhesions (Scar Tissue): Causes, Symptoms & Complications

Medically Reviewed by Dr. Sony Sherpa, (MBBS)

Fact Checked by Dr. Rae Osborn, Ph.D.

Pelvic adhesions are a form of internal scarring that can develop following surgery, infection, inflammation, or trauma. While their formation is a normal part of the body’s healing response, excessive scar tissue can become problematic and lead to complications. The economic burden of pelvic adhesions is substantial. In the United States, direct healthcare costs exceed $2 billion annually, not accounting for indirect costs such as lost productivity. These costs stem from additional surgeries, extended hospital stays, treatment of chronic pain, and fertility interventions.

Adhesions are significant in operative gynecology because they complicate future surgeries, increasing the risk of injury, prolonging operative time, and sometimes necessitating conversion from minimally invasive laparoscopic approaches to open surgery. Similar concerns exist in general surgery, urology, and colorectal surgery, where adhesions can lead to bowel obstructions or surgical complications.

This article discusses how pelvic adhesions differ from normal scar tissue, causes, risk factors, diagnostic challenges, treatments, and more.

What Is Pelvic Scar Tissue?

Pelvic scar tissue, medically referred to as pelvic adhesions, consists of fibrous bands that abnormally connect pelvic organs or tissues that are normally separate.

Pelvic adhesions are highly prevalent, particularly after abdominal or pelvic surgery. Research indicates that 55–100% of patients undergoing pelvic surgery develop adhesions, with higher rates following repeated procedures. For example, the incidence increases with each cesarean section: 24–46% after a second cesarean and 43% to 75% after a third. Other populations at higher risk include women with a history of pelvic inflammatory disease, endometriosis, appendicitis, or abdominal trauma.

Normal Healing vs. Adhesions

During normal healing, the body repairs tissue damage by forming collagen to restore structural integrity. This process typically resolves without affecting organ mobility or causing complications. In contrast, adhesions occur when this healing process becomes excessive or misdirected, resulting in fibrous bands that tether organs together.

Why Pelvic Adhesions Are Problematic

Adhesions can be more than a minor inconvenience; they physically restrict the movement of organs, which may alter normal pelvic function. Their effects include:

• Pain: Chronic pelvic pain, back pain, or pain during intercourse.
• Reproductive Issues: Infertility, increased risk of ectopic pregnancy, menstrual irregularities.
• Digestive Problems: Constipation, diarrhea, bloating, or bowel obstruction.

Even when asymptomatic, adhesions can complicate future surgeries, increasing operative risk and recovery time. This combination of functional interference and potential complications makes pelvic scar tissue a significant health concern.

Causes and Risk Factors

Pelvic adhesions, also known as pelvic adhesive disease, are primarily caused by the body's healing response to injury or inflammation. The formation of scar tissue can occur in various situations, leading to the development of adhesions. The main causes and risk factors linked to pelvic adhesions include:

Surgical Interventions

• Gynecological Surgerie​s: Procedures such as cesarean sections, hysterectomies, myomectomies (removal of uterine fibroids), and ovarian surgeries are common contributors to adhesion formation. The risk increases with the number of surgeries, especially if they involve extensive tissue manipulation.
• Abdominal Surgeries: Surgeries involving the intestines or other abdominal organs can also lead to adhesions. The risk is higher with open surgeries (laparotomy) compared to minimally invasive laparoscopic procedures.

Infections and Inflammatory Conditions

• Pelvic Inflammatory Disease (PID): This infection of the female reproductive organs can cause inflammation and scarring, leading to adhesions.
• Tuberculosis: Genital tuberculosis can result in significant scarring and adhesions within the pelvic cavity.
• Inflammatory Bowel Diseases: Conditions, such as Crohn's disease and diverticulitis, can cause inflammation in the intestines, increasing the risk of adhesions.

Endometriosis

Endometriosis occurs when tissue resembling the uterine lining grows outside the uterus, triggering inflammation and scarring. As a result, adhesions may develop, binding the uterus, ovaries, fallopian tubes, and other pelvic organs together.

Previous Abdominal or Pelvic Trauma

Injuries to the pelvic region, such as those resulting from accidents or falls, can damage tissues and lead to the formation of adhesions during the healing process.

Radiation Therapy

Radiation treatment for pelvic cancers can cause tissue damage and scarring, increasing the likelihood of adhesion formation.

Body Mass Index (BMI)

Recent research suggests that people with a higher BMI may be at greater risk of developing intra-abdominal adhesions. Obesity can lead to increased intra-abdominal pressure and inflammation, both of which contribute to adhesion formation.

Gender Differences

Pelvic adhesions are more commonly observed in women, primarily due to gynecological surgeries and conditions such as endometriosis. The prevalence in men is lower, but when present, adhesions can still cause significant health issues.

Types, Symptoms, and Complications of Pelvic Adhesions

Broad Categorization of Adhesions

Pelvic adhesions can be classified based on their density and structure:

• Filmy adhesions – Thin, delicate, and often transparent; may cause minimal symptoms and are sometimes discovered incidentally.
• Dense adhesions – Thick, fibrous bands that can strongly bind organs together, often causing significant pain and functional impairment.
• Cohesive adhesions – Strong, fibrous connections that may involve multiple organs and are more likely to require surgical intervention.

Silent adhesions may exist without noticeable symptoms but can still impact fertility or complicate future surgeries. Common symptoms, when present, include chronic pelvic pain, back pain, pain during intercourse, digestive disturbances, and menstrual irregularities.

Specific Types of Pelvic Adhesions

Pelvic adhesions can form throughout the pelvic and lower abdominal cavity, most commonly involving the uterus, ovaries, fallopian tubes, bladder, and intestines.

Uterine Adhesions

• Scar tissue within or surrounding the uterus can lead to menstrual irregularities, pain during intercourse, and reduced uterine cavity flexibility.
• Intrauterine adhesions are a specific category often termed Asherman’s syndrome, which can cause symptoms such as reduced menstrual flow, amenorrhea, difficulty conceiving, and increased risk of miscarriage.

Ovarian Adhesions

• Scar tissue around the ovaries can restrict ovarian movement, causing chronic pelvic pain and potentially interfering with ovulation.
• May contribute to fertility issues by limiting egg release or capturing.

Tubal Adhesions

• Adhesions around the fallopian tubes can block or distort them.
• Major cause of infertility and ectopic pregnancy, as the egg may fail to travel to the uterus properly.

Bladder Adhesions

• Scar tissue attaching the bladder to surrounding organs or tissues can cause bladder dysfunction such as pain during urination, bladder spasms, or chronic pelvic discomfort.

Bowel Adhesions (Pelvic Side Wall Adhesions)

• Adhesions involving the intestines can result in digestive issues, including constipation, diarrhea, bloating, or even bowel obstruction in severe cases.
• Can also exacerbate pelvic and back pain.

Peritoneal Adhesions

• General adhesions within the peritoneal cavity may involve multiple organs.
• Can contribute to chronic abdominal or pelvic pain, and may complicate surgical procedures.

Complications Concerning Pregnancy

As discussed above, pelvic adhesions can significantly impact fertility and pregnancy outcomes. Potential complications include:

• Infertility – Tubal or uterine adhesions may prevent conception.
• Ectopic Pregnancy – Blocked or scarred fallopian tubes increase the risk of implantation outside the uterus.
• Miscarriage – Intrauterine adhesions can interfere with implantation or restrict uterine expansion.
• Placental Complications – Adhesions near the uterus may contribute to abnormal placental attachment.

Diagnosis of Pelvic Adhesions

Challenges in Diagnosing Scar Tissue

Pelvic adhesions are often hard to diagnose since their symptoms can be vague or mimic other health issues, such as pelvic congestion syndrome or irritable bowel syndrome (IBS). Pain may be intermittent, nonspecific, or absent, making physical examination alone often insufficient.

Diagnostic Tools

• Laparoscopy – The gold standard for diagnosing adhesions; allows direct visualization and sometimes simultaneous treatment.
• Hysteroscopy – Particularly useful for identifying intrauterine adhesions such as Asherman’s syndrome.
• MRI (Magnetic Resonance Imaging) – Non-invasive imaging that can detect dense adhesions in the pelvis, though less sensitive for filmy adhesions.
• HSG (Hysterosalpingography) – Uses contrast dye and X-rays to assess fallopian tube patency and uterine cavity structure.

Importance of Medical History and Symptom Tracking

Tracking symptoms over time and reviewing surgical, infection, or trauma history is critical for identifying potential adhesions. Patients with prior pelvic surgery or chronic pelvic pain are at higher risk.

Pelvic Adhesions vs. IBS or Pelvic Congestion

• IBS Misdiagnosis – Adhesions can mimic IBS digestive issues such as bloating, constipation, or diarrhea, leading to misdiagnosis. They can also aggravate existing IBS.
• Pelvic Congestion – Characterized by varicose veins in the pelvis causing dull, achy pain, often worsening during standing; differs from adhesion pain, which is more localized, sharp, or linked to organ movement.

Treatment Options for Pelvic Adhesions

Conservative / Non-Surgical Management

Natural Dissolution and Lifestyle Approaches

Some therapies aim to reduce symptoms or limit adhesion formation without surgery, including dietary adjustments, natural anti-inflammatory strategies, and specific physical therapy techniques.

Pain Management

• NSAIDs or other analgesics for chronic pelvic pain.
• Complementary approaches such as acupuncture or relaxation techniques may help.

Physical Therapy and Exercise

• Targeted pelvic stretches and mobilization exercises can help restore organ mobility and reduce pain.

Fertility Support

• IVF may bypass tubal adhesions or uterine scarring in women seeking pregnancy.

Shockwave Therapy

• Emerging technique aimed at reducing adhesion density and improving pelvic tissue mobility.

Surgical Management

Adhesiolysis

• Surgical removal or separation of adhesions via laparoscopy or laparotomy.
• Can immediately relieve organ tethering and improve fertility or pain symptoms.

Hysteroscopic Procedures

• Specifically for intrauterine adhesions (Asherman’s syndrome), restoring the uterine cavity.

CO2 Laser / NaProTECHNOLOGY Surgery

• Minimally invasive techniques that precisely remove adhesions while reducing collateral tissue damage.

Recovery and Recurrence

• Recovery time after pelvic adhesion surgery varies depending on the extent of adhesions and surgical method, generally 2 to 4 weeks for minimally invasive procedures, longer for open surgery.
• Recurrence is common, particularly in patients with multiple surgeries, severe endometriosis, or ongoing inflammatory conditions. Using adhesion barriers and minimally invasive techniques can help reduce recurrence risk.

Prevention and Management of Pelvic Adhesions

Preventing Adhesions After Surgery

Minimally Invasive Surgical Techniques

• Laparoscopic or robotic-assisted procedures reduce tissue trauma and limit adhesion formation compared to open surgeries.

Use of Adhesion Barriers

• Physical or chemical barriers applied during surgery can prevent tissues from sticking together as they heal.

Post-Surgery Physiotherapy

• Gentle pelvic stretches and mobilization exercises can improve tissue flexibility and prevent organs from adhering abnormally.

Healthy Lifestyle and Diet

• A balanced, anti-inflammatory diet supports tissue healing. Emphasize fruits, vegetables, lean proteins, and omega-3 fatty acids.
• Maintaining reproductive and overall pelvic health, including managing infections promptly and staying physically active, can reduce adhesion risk.

Living With Pelvic Scar Tissue

Coping with Chronic Pain

• Chronic pelvic pain from adhesions can be managed through medication, physical therapy, and mindfulness techniques.
• Pain management plans should be personalized, often combining medical, physical, and psychological approaches.

Fertility Considerations

• Adhesions affecting reproductive organs can interfere with natural conception. Assisted reproductive technologies, such as in vitro fertilization (IVF), may bypass tubal or uterine blockages.
• Early evaluation and treatment of adhesions, for instance, soft tissue therapy, are important for individuals planning pregnancy.

Support and Counseling

• Support groups, counseling, and cognitive behavioral therapy provide emotional assistance, coping strategies, and guidance for managing chronic pain, fertility challenges, and lifestyle adjustments.

Frequently Asked Questions (FAQ)

1. Can pelvic adhesions cause weight gain?

Adhesions themselves do not directly cause weight gain. However, chronic pain and reduced mobility from adhesions may contribute indirectly to weight changes.

2. Can pelvic adhesions cause nerve pain?

Yes. Adhesions can entrap nerves or pull on surrounding tissues, leading to referred pain, tingling, or radiating discomfort in the pelvis, lower back, or legs.

3. What happens if pelvic adhesions are left untreated?

If left untreated, pelvic adhesions may remain asymptomatic in some people but can also lead to chronic pelvic pain, digestive issues, painful intercourse, and fertility problems. In severe cases, untreated adhesions may cause bowel obstruction, ectopic pregnancy, or recurrent pregnancy loss, depending on the organs affected.

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