Chronic Pelvic Pain Management

See Also

Management
General Measures

Discuss All contributing factors
Treat all components and factors simultaneously
Re-evaluate with return visit every 4 to 8 weeks
1. Adjust management and consider referral if lack of improvement after 8 to 12 weeks
2. As symptoms improve, may gradually space clinic visits to every 6 to 12 months
Consider Pain Management Specialist referral
1. Indicated in refractory Chronic Pelvic Pain
2. Consider somatocognitive therapy (cognitive psychotherapy with physiotherapy)
Cognitive Behavioral Therapy
1. Core component of Chronic Pain Management
Gradually taper off treatments
1. Pain lessens
2. Vegetative symptoms decrease
Regular follow-up regardless of symptoms
1. Each visit focuses on a different aspect
Avoid putting patient on defensive
1. Do NOT have her prove the presence of pain
Use multiple therapeutic regimens
1. Analgesics
  1. Non-Opioids are preferred (e.g. Acetaminophen, NSAIDs)
  2. Use at regularly scheduled doses
2. Neuropathic pain
  1. Serotonin Norepinephrine Reuptake Inhibitors (e.g. Duloxetine 60 mg/day)
  2. Tricyclic Antidepressants (e.g. Amitriptyline or Nortriptyline)
  3. Gabapentin (Neurontin) or Pregabalin (Lyrica)
  4. If beneficial, may predict response to neuromodulation (Implanted stimulator)
3. Comorbid Depression Management
  1. Selective Serotonin Reuptake Inhibitor or SSRI (e.g. Fluoxetine, Sertraline, Escitalopram)
    1. Used in comorbid Major Depression, but not effective as monotherapy in Chronic Pelvic Pain
  2. Serotonin Norepinephrine Reuptake Inhibitor or SNRI (e.g. Venlafaxine, Duloxetine)
    1. May also be effective for neuropathic pain
4. Complimentary and Integrative Medicine
  1. Acupuncture
  2. Yoga
  3. Massage
  4. Tai Chi

Management
Bowel or Bladder Symptom

Constipation or Irritable Bowel Syndrome
1. Fiber Laxatives or high fiber diet
2. Exercise
3. Hydration
4. Antispasmodic
Bladder spasms and Urinary Frequency
1. See Interstitial Cystitis
2. See Pelvic Floor Exercise
3. Antispasmodics (Oxybutynin, hyocyamine)
4. Bladder drill
  1. Track voiding intervals
  2. Increase voiding intervals by urinating on schedule
5. Coitus-associated Bladder symptoms
  1. Empty Bladder before and after coitus
  2. Consider daily Nitrofurantoin

Management
Musculoskeletal

Physical Therapy
1. Pelvic Floor Exercises
2. Core Muscle Exercises (hips, low back, abdominal Muscle wall)
3. Stretching and strengthening Exercises
4. Biofeedback
Myofascial Pain or Trigger Point Pain
1. Nonsteroidal Anti-inflammatory drugs (NSAIDs)
2. Poor evidence for Muscle relaxants (e.g. Cyclobenzaprine, Methocarbamol)
  1. Flatow (2023) Curr Opin Obstet Gynecol 35(4): 311-5 [PubMed]
3. Local steroid injections
  1. Preparation
    1. Bupivacaine Hydrochloride (0.5%) 9 ml
    2. Consider adding Betamethasone (6 mg/ml) 1 ml
  2. Technique
    1. Inject 1-2 cc per focal lesion
    2. Inject weekly for up to 5 weeks
4. TENS Unit
  1. Indicated for Focal pain or incisional pain
General Posture
1. Strengthening and flexibility
2. Low back Exercise
Piriformis Syndrome
1. NSAIDs
2. Physical Therapy
  1. Stretching and Pelvic tilt Exercise
  2. Ultrasound or deep massage
  3. Electrical Stimulation (TENS unit)

Management
Gynecologic

Consider specific management strategies
1. See Dysmenorrhea
2. See Female Sexual Dysfunction
3. See Vaginismus
4. See Vulvodynia
5. See Atrophic Vaginitis
6. See Vaginal Dryness
Oral Contraceptives for cyclic pain
1. Polycystic Ovarian Disease
2. Ovulation Suppression
  1. Mid-cycle, premenstrual, or Menstrual Pain
  2. Ovarian pathology (peri-ovarian adhesions, Ovarian Cysts)
  3. Endometriosis related Dysmenorrhea
Other hormonal agents
1. Mirena Intrauterine Device (IUD)
2. Depo Provera 150 mg IM every 12 weeks
3. Gonadotropin-Releasing Hormone Agonist or GnRH Agonist (e.g. Goserelin/Zoladex)
  1. Used with Norethindrone 5 mg daily to reduce bone loss
Sacral ligament injection
1. Patient rates pain before and after procedure
2. Preparations
  1. Lidocaine 3 cc
  2. Marcaine 2 cc
3. Inject
  1. Cervical positions of 8 and 4 o'clock
  2. At fornix margin (Cervix-vaginal wall margin)
Botulinum Toxin Type A Injection
1. Transvaginal injection into pelvic floor Muscles

Management
Surgical

Surgical procedures (not effective unless pathology)
1. Diagnostic Laparoscopy
2. Laparoscopic Lysis of pelvic adhesions
  1. Pain Relief without Chronic Pain Syndrome: 75%
  2. Pain Relief with Chronic Pain Syndrome: 40%
3. Hysterectomy
  1. Treatment of last resort
  2. Improvement in 50% of patients, but persistent pain in 40% and worsening in 5%
4. Presacral neurectomy
5. Uterosacral nerve ablation
Surgery is not the cure (only a part of the plan)
Laparoscopy Results:
1. No apparent pathology: 33%
2. Endometriosis: 33%
3. Adhesions or Pelvic Inflammatory Disease changes: 25%
4. Miscellaneous: 9%

References

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