chronic%20pelvic%20pain
CHRONIC PELVIC PAIN
Treatment Guideline Chart
Chronic pelvic pain (CPP) is a persistent, distressing, & severe pain of >6 month duration.
It occurs intermittently, cyclically, or situationally.
Localized to the pelvis, anterior abdominal wall at or below the umbilicus, the lumbosacral back, or the buttocks.
It is severe enough to cause functional disability or need medical care.
In women, CPP is not restricted to intercourse or menstruation & is not associated w/ pregnancy.
It is a symptom w/ a number of contributory factors & not a diagnosis; pathophysiology is complex & not well understood.
It is assumed that in the development of chronic pain, the nervous system is affected among others by inflammatory & chemical mediators & hormones.
A complex problem that is both multifactorial & multidimensional

Chronic%20pelvic%20pain Diagnosis

Chronic Primary Pelvic Pain Syndrome (CPPPS)

  • A subdivision of chronic pelvic pain (CPP), chronic pelvic pain syndrome (CPPPS) is pain localized to >1 organ site
  • It is the occurrence of CPP when there is no proven infection or without an obvious ongoing disease process that can account for the pain, often associated with negative behavioral, cognitive, emotional or sexual consequences in addition to symptoms that are suggestive of a bowel, lower urinary tract, gynecological, or sexual dysfunction
  • CPPPS is also suggested by the following: Pain persistence >6 months, incomplete pain reduction from prior therapies, pain is not consistent with tissue damage, loss of function and signs of depression are present, changes in the relationship and family dynamics
  • The term CPPPS may also be used when pelvic pain is poorly localized, specific pathology is unidentified, or if pain is localized to multiple organs within the pelvic area
  • CPPPS mechanisms include neuroplasticity and neuropathic pain mechanisms
  • CPPPS should be subdivided according to its corresponding phenotype based on the classification proposed by the European Association of Urology (EAU) if with adequate evidences
    • Based on the axis system recommended by the International Association for the Study of Pain (IASP)
  • CPPPS with cyclical exacerbations is pain without gynecological organ pain that occurs during cyclical exacerbations (eg irritable bowel syndrome, primary bladder pain syndrome) or pain similar to endometriosis/adenomyosis but without an identified pathology

Gastrointestinal Aspect

Irritable Bowel Syndrome (IBS)

  • Chronic or recurrent episodic pain in the bowel, has symptoms suggestive of a lower urinary tract or gynecological dysfunction, without proven infection or obvious local pathology, and is often associated with worry and pre-occupation about bowel function, and negative cognitive, behavioural, sexual or emotional consequences
  • Based on the Rome III Criteria, patient should have experienced 3 months of continuous or recurring symptoms of abdominal pain or irritation that may be relieved with bowel movement, may be coupled with a change infrequency, or may be related to a change in stool consistency
  • ≥2 of the following signs or symptoms are present at least 25% of the time: Change in stool frequency (>3 bowel movements per day or <3 per week), noticeable changes in stool form (hard, loose, watery or poorly formed stools), presence of mucus in stools, bloating or feeling of abdominal distension, altered stool passage (eg sensation of incomplete evacuation, straining, urgency)
  • Workup: Anorectal manometry with sensory testing
  • Treatment: Linaclotide may be considered for the relief of abdominal pain and bowel symptoms due to IBS with constipation
    • Neuromodulation techniques eg transcutaneous interferential electrical stimulation have been suggested
  • Please see Irritable Bowel Syndrome disease management chart for further information

Primary Chronic Anal Pain Syndrome (Chronic Proctalgia)

  • The following criteria should be met for the past 3 months with onset of symptoms at least 6 months before diagnosis: Chronic or recurrent rectal pain or aching, episodes lasting at least 20 minutes, other causes of rectal pain are excluded (eg coccygodynia, cryptitis, hemorrhoids, inflammatory bowel disease, intramuscular abscess and fissure, ischemia, prostatitis)
  • Also demonstrates severe tenderness on posterior traction of the puborectalis muscle
  • Primary intermittent chronic anal pain syndrome (proctalgia fugax) may be considered a subgroup of the chronic anal pain syndromes
    • Refers to severe, brief, episodic pain attributed to come from the rectum or anal canal which occurs at irregular intervals
    • The following diagnostic criteria should be met for the past 3 months with onset of symptoms at least 6 months before diagnosis: Recurring episodes of pain localized to the anus or lower rectum, episodes lasting from several seconds to minutes, absence of anorectal pain between episodes
    • Medical treatment and prevention is often ineffective due to the short duration of the episodes
  • Workup: Endoscopy, anorectal manometry, flexible rectosigmoidoscopy or colonoscopy, rectal balloon expulsion test, magnetic resonance imaging (MRI) defecography, pelvic floor muscle testing
  • Treatment: Biofeedback is the preferred treatment, Botulinum toxin A injection in women, electrogalvanic stimulation (less effective than biofeedback), percutaneous tibial nerve stimulation
    • May consider sacral neuromodulation; inhaled Salbutamol for intermittent anal pain syndrome

Gynecological Aspect

  • Pain that is predominantly cyclical is likely to have a gynecological cause
  • Pain associated with gastrointestinal and urinary symptoms must be assessed carefully
    • Symptoms suggestive of irritable bowel syndrome (IBS) or interstitial cystitis are frequently seen in women with CPP and these may be a primary cause or a component of CPP or a secondary effect brought about by the efferent neurological dysfunction of CPP
  • Workup: Complete gynecological examination, vaginal swab, endocervical swab, ultrasound, laparoscopy

Primary Vaginal and Vulvar Pain Syndrome

  • Pain persisting for >6 months in the vagina or the female external genitalia (vulva which includes the labia, clitoris, and vaginal entrance) with no proven infection or other local obvious pathology; also called vulvodynia
  • Causes of vulvodynia include history of chronic antibiotic use or sexual abuse, hormonal changes, injury or irritation to the nerve or muscle, hypersensitivity to yeast infections or allergies to chemicals or other substances, abnormal inflammatory response to trauma or infection
  • Treatment: Hormonal treatments (combined oral contraceptives, progestins, GnRH agonists, or Danazol) should be considered for pain that seems to be cyclical in nature
    • Laparoscopy for treatable causes
    • Other therapies include a multidisciplinary approach for persistent diseases and psychological treatment for refractory chronic vulvar pain
  • Primary generalized vulvar pain syndrome is constant or occasional pain occurs in different areas of the vulva at different times
  • Primary localized/focal vulvar pain syndrome is pain at the entrance of the vagina described as a burning sensation after touch or pressure

Primary Clitoral Pain Syndrome

  • Pain that can be localized by point-pressure mapping or is well-perceived in the area of the clitoris

Primary Vestibular Pain Syndrome

  • Pain that can be localized by point-pressure mapping or is well perceived in the area of the vestibule

Endometriosis-associated Pain Syndrome

  • Patients with laparoscopically-confirmed endometriosis with chronic or recurrent pain despite appropriate therapeutic strategies and associated with negative behavioral, cognitive, or emotional effects, or sexual, urological, gynecological or bowel dysfunction

Primary Dysmenorrhea

  • May be considered as a chronic primary pain syndrome if persistent during menstruation, not associated with well-defined pathology, and associated with negative behavioral, cognitive, emotional or sexual effects

Musculoskeletal Aspect

Primary Coccyx Pain Syndrome

  • Pain at the coccyx elicited by its manipulation that is due to pelvic floor hypertonicity and reduced coccyx mobility
  • Usually related to prolonged sitting or trauma and is worsened by arising, bending, sitting, defecation, or intercourse
  • Workup: Local anesthetic injection produces pain relief
  • Treatment: Anti-inflammatory drugs, physical therapy, massage, neuroablation
    • Consider local injection if coccyx is unstable

Primary Pelvic Floor Muscle Pain Syndrome

  • A dull pressure or ache that worsens with sitting or lying down and is frequently associated with incomplete evacuation
  • CPP can be a form of myalgia due to misuse of the pelvic floor muscles; pelvic floor overactivity and myofascial trigger points may also be involved
  • Workup: Test for pelvic floor function and myofascial trigger points, pelvic floor muscle electromyography (EMG) 
  • Treatment: First-line treatment is pelvic floor muscle therapy in patients with CPPS
    • Use biofeedback as adjuvant to muscle exercises
    • Treatment by pressure or needling is recommended for myofascial trigger points
    • May consider Botulinum A toxin injection for trigger points and pelvic floor muscle overactivity
    • Management of pain will involve a physiotherapist, a pain doctor, and a psychologist

Neurological Aspect 

Pudendal Neuralgia

  • Burning, crushing or electric pain perceived in the perineum from the anus to clitoris or penis
  • Related features include allodynia (pain on light touch), dysesthesia (unpleasant sensory perceptions usually but not necessarily due to provocation), hyperalgesia (heightened pain perception after a painful stimulus), and paresthesia (pins and needles)
  • Associated with history of pelvic surgery, prolonged sitting, and postmenopausal older women; rarely in trauma (eg birth trauma, fractures, falls), cancer, or cycling
  • Patient’s immobility and disability develop muscular aches and pain that lead to involvement of the musculoskeletal system
  • Workup: Imaging and neurophysiology may aid in the diagnosis, but investigations are often normal
    • Gold standard is an image and nerve locator-guided local anesthetic injection
  • Treatment: Refer to a specialist if a peripheral nerve problem is suspected
    • Treat as for any other nerve injury; utilize available standard regimens to neuropathic pain management
    • Injection of a local anesthetic with or without steroids may be considered in the presence of nerve injury
    • Pulsed radiofrequency stimulation and spinal cord stimulation have been suggested as a potential treatment option

Psychological Aspect

  • Majority of patients meet the diagnostic criteria for a persistent somatoform pain disorder in which pain is associated with psychosocial problems or emotional conflict
  • Evaluating the link between psychiatric diseases and CPP is difficult; while chronic pain can result in a psychopathology, an existing psychopathologic condition may also affect pain perception and encourage the development of chronic pain
  • Women with CPP often have comorbid conditions (eg anxiety, depression, substance abuse, or sexual problems)
    • Anxiety may be related to the patient’s fears of an undiagnosed pathology as the cause of pain, (eg cancer), and to uncertainties regarding treatment possibilities and the probable prognosis if treated or not
    • Depression may be attributed to pain or its impact
  • Workup: Assess patient’s psychological history and pain-related beliefs and behavior
    • Asking the patient’s perception about pain gives the chance for appropriate information and reassurance
  • Treatment: Offer psychological interventions in combination with other modalities (eg medical and surgical treatments)
    • Psychologically-informed physical therapy results in improved pain and function
    • Exercise and cognitive behavioral therapy combined with Medroxyprogesterone acetate reduces pelvic pain in majority of women

Sexual Aspect

  • Sexual dysfunction is prevalent in patients with pelvic pain syndrome, is multifactorial, and may be related to depression, use of antidepressants, relationship satisfaction, and many others
    • In men, the common complaints are erectile and ejaculatory dysfunctions
    • In women, dysfunctions that are most reported are sexual avoidance, dyspareunia, and vaginismus
  • Patients with symptoms suggesting CPPPS should be screened for sexual abuse
  • Workup: Inquire regarding psychiatric history and history of relationship, sexual functioning, and negative experiences eg abuse
  • May use the Female Sexual Function Index (FSFI) and the International Index of Erectile Function (IIEF) questionnaires
  • Treatment: Refer to a specialist for management of sexual dysfunction
    • Utilize a biopsychosocial approach in pain treatment
    • Offer partner treatment and behavioral strategies for coping with sexual dysfunction
    • Refer for pelvic floor muscle physical therapy

Urological Aspect

Primary Bladder Pain Syndrome

  • Persistent or recurrent pain, discomfort, or pressure perceived to be related to the bladder with at least daytime and/or nighttime increase in urinary frequency, aggravated by food or drink, relieved by voiding but returns soon, and other well-defined pathologies excluded
  • Reports showed female predominance estimated at 10:1 without any difference in race or ethnicity
  • Workup: Urinalysis, urine culture, uroflowmetry, general anesthetic rigid cystoscopy with hydrodistention, bladder biopsy, pelvic floor muscle testing, potassium chloride /KCl sensitivity test, micturition diary, Interstitial Cystitis Symptoms Index (ICSI) score list
  • Treatment: Hydroxyzine, Amitriptyline, Nortriptyline, Pentosan polysulfate, Cimetidine, Cyclosporin A, Methotrexate
    • Intravesical therapies: Pentosan polysulfate sodium (PPS), Dimethyl sulfoxide (DMSO), Botulinum toxin A plus hydrodistention, Hyaluronic acid, Chondroitin sulfate, Heparin, Lidocaine with Sodium bicarbonate
    • Other therapies include neuromodulation, bladder training, physical therapy, psychological therapy, sacral or pudendal nerve stimulation

Primary Epididymal Pain Syndrome

  • Persistent or recurrent episodic pain in the epididymis, has symptoms suggestive of a lower urinary tract or sexual dysfunction, and without proven infection or obvious local pathology

Primary Penile Pain Syndrome

  • Pain within the penis that is not primarily in the urethra, has symptoms suggestive of a lower urinary tract or sexual dysfunction, and without proven infection or obvious local pathology

Primary Prostate Pain Syndrome

  • Persistent or recurrent episodic pain perceived in the region of the prostate without lower urinary tract pathology for at least 3 months out of the past 6 months
  • Also called CPPPS of the male
  • Workup: Urine culture, uroflowmetry, transrectal ultrasound of the prostate, pelvic floor muscle testing, National Institutes of Health-Chronic Prostatitis Symptom Index (NIH-CPSI) scoring list
  • Treatment: Recommended are alpha blockers (Alfuzosin, Doxazosin, Silodosin, Terazosin) and single-use antibiotics (quinolones or tetracyclines) if duration is <1 year, and high-dose Pentosan polysulfate, may consider nonsteroidal anti-inflammatory drugs (NSAIDs)
    • Other therapies include phytotherapy, perineal extracorporeal shock wave therapy, electroacupuncture, percutaneous tibial nerve stimulation, psychological treatment focusing on pain

Primary Scrotal Pain Syndrome

  • Episodic pain that is persistent or recurrent within the scrotum, has symptoms suggestive of a urinary tract or sexual dysfunction, and without proven infection or obvious local pathology
    • Pain is not in the scrotal skin but perceived to be in its contents eg testes, epididymis, vas deferens, or the inguinal nerves
    • Usually associated with the nerves in the spermatic cord
    • Includes post vasectomy pain syndrome and pain after inguinal hernia repair
  • Post-vasectomy scrotal pain syndrome is categorized under primary scrotal pain syndrome that occurs after vasectomy
    • Associated with negative cognitive, behavioral, sexual or emotional consequences, and with symptoms suggestive of lower urinary tract and sexual dysfunction
    • Occurs in 2-20% of individuals who have undergone vasectomy
  • Workup: Semen culture, uroflowmetry, scrotal ultrasound, pelvic floor muscle testing
    • Scrotal ultrasound has limited value in diagnosing cause of pain
  • Treatment: Based on the principles of chronic pain syndrome therapy
    • Consider physiotherapy for an overactive pelvic floor
    • Surgical therapies include spermatic cord microsurgical denervation, epididymectomy if denervation was not beneficial, orchiectomy if all other therapies have failed
    • Vasovasostomy is an effective management strategy in post-vasectomy pain
    • There may be lower risk for pain with open inguinal hernia repair compared to laparoscopic repair

Primary Testicular Pain Syndrome

  • Persistent or recurrent episodic pain within the testes, has symptoms suggestive of a lower urinary tract or sexual dysfunction, and without proven infection or obvious local pathology

Primary Urethral Pain Syndrome

  • Episodic pain that is chronic or recurrent, perceived in the urethra suggestive of lower urinary tract, sexual, bowel or gynecological dysfunction, is without obvious local pathology, and may occur in both men and women
  • May be a part of bladder pain syndrome; urethral pain may be a neuropathic hypersensitivity after a urinary tract infection
  • Workup: Uroflowmetry, pelvic floor muscle testing, micturition diary
  • Treatment: There is no specific treatment for urethral pain syndrome; patients are recommended to be treated in a multidisciplinary and multimodal program
    • For distressed patients, may consider a pain-relevant psychological therapy

History

  • A complete and detailed history should include organ-specific inquiries on gastroenterologic, gynecologic, musculoskeletal, urologic and neurologic symptoms including a thorough review of systems of infectious, endocrine, psychiatric and sexual disorders
    • Ask for previous radiation or medical treatment, recent pregnancy, history of pelvic surgery or infections or use of intrauterine device (IUD), history of physical or sexual abuse, history of alcohol and drug abuse
      • A history of sexual abuse as a child may lead to the development of depression, anxiety or somatization which makes him or her vulnerable to developing chronic pelvic pain (CPP)
    • Rule out malignancy or other severe systemic diseases by noting “red flag” symptoms eg rectal bleeding, pelvic mass, weight loss, suicidal ideation, new bowel symptoms at >50 years of age, and in women postcoital bleeding, new pain after menopause, irregular vaginal bleeding >40 years of age
  • Characterize pain according to its quality, duration, location, intensity, timing, aggravating or alleviating factors, trigger situation, relation to movement and posture, association with menses, sexual activity, urination, defection, effect on quality of life
    • Visceral pain is dull, crampy, or poorly localized, somatic pain may be dull or sharp, and neuropathic pain may be burning, stabbing, electrical, or paresthesia-like
  • CPP often has more than one component and goal of assessment is to investigate contributing factors related to CPP including environmental, social (social isolation, family problems), cognitive (pain assessment, pain control perception), emotional (symptoms of anxiety or depression), behavioral (level of activity and medication use), and physical (tiredness, sexual dysfunction, sleep problems)
    • May make use of the history and physical examination forms from the International Pelvic Pain Society
    • Psychological comorbidities may also be detected using other validated symptom-based tools

Physical Examination

  • If pain is intermittent, patient is best examined while in pain in order to look for pathological conditions and to be able to reproduce the pain to identify physical contributors
  • Observe for general demeanor, mobility, and posture when patient walks into the clinic
  • Check the back for trigger points, pelvic asymmetry, sacroiliac tenderness
  • Abdominal exam includes checking for skin lesions, hypersensitivity around scars, or trigger points (areas where light localized pressure elicits a vigorous pain response)
    • A positive Carnett’s sign (examiner’s finger on the tender area of the patient’s abdomen while patient raises both legs off the table) with an increase in pain indicates a myofascial cause of the pain
    • Pain lessening on the head-raise test indicates an intraperitoneal cause of pain
  • Individual pelvic structures are then examined to differentiate sources of pain and localized areas of tenderness are identified to help guide specific therapy
    • Palpation of the back, outer pelvis, and pelvic floor may show trigger points indicating a myofascial component
      • Inspect also for enlargement, distortion, prolapse, discoloration, or infectious sequelae
      • Pelvic floor muscle function and dysfunction may be evaluated using the International Continence Society (ICS) classification
    • External genitalia exam, pelvic examinations with a single-digit one-hand exam followed by a bimanual exam in women, and a rectal exam to check for nodularity, masses, or point tenderness

Laboratory Tests

  • Initial workup includes a complete blood count (CBC), erythrocyte sedimentation rate (ESR), urinalysis with urine culture, beta-human chorionic gonadotropin (hCG), vaginal and endocervical swabs, semen and stool culture
    • Offer screening for sexually transmitted infections to sexually active patients with CPP
  • Cancer screening appropriate to patient’s age and related risk factors should be done
    • A serum CA-125 should be measured if the following symptoms occur >12 times per month: Early satiety, bloating, pelvic pain, urinary urgency or frequency
  • History and physical examination may point toward a specific diagnosis for which special testing may be indicated
    • Other special diagnostic tools or methods are reserved for specific questions but should not be included in the routine diagnostic workup

Imaging

  • Eg ultrasound, magnetic resonance imaging (MRI), computerized tomography (CT) scan, MRI with MR defecography, functional MRI (fMRI)
  • Should only be performed when clinically indicated
  • Transvaginal pelvic ultrasound in women is part of the initial diagnostic workup if history and physical exam are unrevealing of a specific diagnosis
    • Useful in evaluating pelvic masses
  • MRI and CT scan are not routinely done but can help evaluate ultrasound findings
    • MRI may be helpful if a clear cause for pain was not elicited on examination of patient
    • MRI may be used in assessing palpable nodules in the pelvis or rectovaginal disease
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