What could cause intermittent cold and burning sensations in the pelvic, back, and buttock regions?

Intermittent Cold and Burning Sensations in Pelvic, Back, and Buttock Regions

The most likely cause of intermittent cold and burning sensations in the pelvic, back, and buttock regions is neuropathic pain, which can arise from several conditions including pelvic floor myofascial dysfunction, pudendal or sacral nerve involvement, or chronic pelvic pain syndromes with central sensitization. 1

Primary Diagnostic Considerations

Neuropathic Pain Mechanisms

• Burning sensations combined with cold sensations are characteristic of neuropathic pain, where abnormal sensory processing occurs at the peripheral or central nervous system level 1, 2
• The combination of burning and cold sensations specifically suggests involvement of both A-delta cold-specific fibers and C-fiber nociceptors, with potential central gating dysfunction 2
• Dysesthesia (abnormal burning sensations) can persist even after resolution of underlying inflammatory conditions, representing neuronal sensitization that requires specific neuropathic pain management 1

Specific Conditions to Evaluate

Pelvic Floor Myofascial Pain:

• Can cause pain radiating to the back, buttocks, and throughout the pelvis 1
• Often presents with trigger points and areas of hypersensitivity that may produce burning or altered sensations 1
• Physical examination should specifically assess for pelvic floor muscle tenderness and trigger points 1

Interstitial Cystitis/Bladder Pain Syndrome (IC/BPS):

• Pain extends beyond the bladder to include the urethra, vulva, vagina, rectum, lower abdomen, and back 1
• Patients frequently use descriptors like "pressure" or "discomfort" rather than "pain" 1
• Symptoms lasting more than 6 weeks with sterile urine cultures support this diagnosis 1

Pelvic Congestion Syndrome:

• Causes chronic pelvic pain from venous reflux or obstruction affecting gonadal, gluteal, or periuterine veins 1, 3
• Can present with pain radiating to the buttocks and back 1
• Accounts for up to 30% of chronic pelvic pain cases but is frequently underdiagnosed 3

Pudendal Neuralgia or Sacral Nerve Involvement:

• Can cause burning pain in the perineum, buttocks, and pelvic region 1, 4
• May present with intermittent symptoms and altered sensations 1

Diagnostic Approach

Initial Evaluation

• Obtain detailed pain history including: exact location, quality (burning vs. cold), timing, aggravating/relieving factors, relationship to bladder filling/voiding, relationship to specific foods or activities 1
• Physical examination must include: pelvic floor muscle assessment for tenderness and trigger points, evaluation for vulvar/perineal abnormalities, assessment of sacral nerve distribution 1
• Urinalysis to exclude infection as a prerequisite for chronic pain syndrome diagnosis 1

Imaging When Indicated

• Transvaginal and transabdominal ultrasound with Doppler is the initial imaging modality for suspected pelvic pathology, including pelvic congestion syndrome 1
• Look for engorged periuterine/periovarian veins (>8mm), low-velocity flow, and retrograde ovarian vein flow on Doppler 1
• MRI may be appropriate for further characterization if ultrasound findings are equivocal or to evaluate for other structural abnormalities 1

Management Strategy

First-Line Approaches

Behavioral and Physical Interventions:

• Application of local heat or cold over affected areas (patients should determine which provides relief) 1
• Pelvic floor physical therapy with muscle relaxation techniques for myofascial components 1
• Stress management and manual therapy as part of multimodal pain management 1

Pharmacological Management for Neuropathic Pain

For Dysesthesia/Neuropathic Burning:

• Start with topical lidocaine 5% ointment applied to affected areas 1
• If topical therapy fails, initiate amitriptyline for neuronal sensitization 1
• Consider gabapentinoids (gabapentin or pregabalin) as part of multimodal regimen 5

For IC/BPS Component (if present):

• Second-line oral medications include amitriptyline, cimetidine, hydroxyzine, or pentosan polysulfate 1
• Intravesical treatments (dimethyl sulfoxide, heparin, or lidocaine) may be considered 1

Interventional Options

• For pelvic congestion syndrome: embolotherapy of refluxing ovarian veins and internal iliac vein branches has demonstrated efficacy in large case series 3
• Nerve blocks or ablative techniques should only be considered after other treatments have been attempted 1
• Trigger point injections may be beneficial for myofascial components 1

Critical Pitfalls to Avoid

• Do not dismiss symptoms as psychosomatic when physical examination appears normal; neuropathic pain and central sensitization are real physiological processes 1, 6
• Do not use topical corticosteroids for dysesthesia; this is neuropathic pain requiring specific neuropathic pain management 1
• Do not delay treatment waiting for definitive diagnosis; a "low threshold" approach is appropriate given the potential for progressive sensitization 1
• Recognize that multiple pain generators may coexist (chronic overlapping pain conditions); comprehensive evaluation is essential 6
• Avoid single-modality treatment; multimodal approaches combining behavioral, physical, and pharmacological interventions are most effective 1