chronic%20pelvic%20pain
CHRONIC PELVIC PAIN
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

Principles of Therapy

  • Patients should be offered pain control with appropriate analgesia even if therapeutic maneuvers have not yet been initiated
    • Attempts should be made to empirically treat the pain & develop a management plan even if pain cannot be explained initially
    • Aim to provide the least complicated treatment that can improve functional capacity
  • Consider involving trained physicians with expertise in chronic pain management at this stage
  • Listed below are general treatments that should be used in a management plan with a holistic approach including biological, psychological & social components
  • Combination therapy often gives a greater benefit than agents used alone allowing for usage of lower doses thus minimizing the side effects
    • Lowest effective dose should be used if benefit is limited by side effects
  • Simple analgesics are used initially then neuropathic agents if the former failed to provide adequate pain relief
    • If there is still no improvement, consider referral to a pain specialist

Pharmacotherapy

Analgesics

  • Analgesics for chronic pelvic pain (CPP) should not be used for a prolonged period of time

Paracetamol (Acetaminophen)

  • An antipyretic analgesic with a central mechanism of action
  • Has little evidence in the treatment of CPP but should be considered if not previously tried

Nonsteroidal Anti-inflammatory Drugs (NSAIDs)

  • Anti-inflammatory & antipyretic analgesics that inhibit the cyclooxygenase enzyme
  • Useful in painful conditions related to peripheral or inflammatory mechanisms
  • NSAIDs should be considered for mild to moderate pain
    • NSAIDs are mostly recommended as first-line empiric therapy
  • There is no good evidence to show that one NSAID is better than another for pelvic pain

Neuropathic Analgesics

  • Agents that modulate centrally mediated pain which are taken regularly than as required
  • Often used in combination, doses are titrated against benefit & side effects with the goal of improving patient’s quality of life
  • Side effects usually limit their use

Antidepressants

  • Used to treat concomitant depression
  • Treatment with antidepressants together with psychological support & other medical therapies may improve clinical outcomes

Tricyclic Antidepressants (TCA)

  • Amitriptyline is the most commonly used
    • Alternatives include Nortriptyline & Imipramine

Serotonin & Norepinephrine Reuptake Inhibitors (SNRI)

  • Eg Duloxetine, Venlafaxine
  • Venlafaxine has evidence of benefit for chronic pain; use with caution in patients with heart disease

Selective Serotonin Reuptake Inhibitors (SSRI)

  • Eg Paroxetine, Sertraline
  • Have fewer side effects but studies to show their benefit in pelvic pain are insufficient

Anticonvulsants

  • Eg Gabapentin, Pregabalin
  • Gabapentin inhibits excessive stimulation of the spinal cord’s secondary neurons & is commonly used in the treatment of neuropathic pain
  • A study suggests that Gabapentin provides significant pain relief when used alone or with Amitriptyline in women with CPP
  • Common side effects include drowsiness, dizziness, & peripheral edema but are often tolerated by patients

Other Agents

  • Considered after standard options have been tried & are best limited to specialists in pain management

Topical Capsaicin

  • More convenient than other medications due to its topical application though skin sensitivity may not be well tolerated

Antipsychotics

  • Have been previously used but a systematic review suggests further research on atypical antipsychotics

Opioids

  • Opioids act on the dorsal horns of the spinal cord causing central inhibition of pain; & is used to treat chronic non-malignant pain
  • Should only be used under the adequate supervision of a trained specialist
  • Due to its adverse effects & potential for abuse, opioids may be given as maintenance therapy for CPP only when previous non-narcotic therapies have failed & if persistent pain is the major limitation to improved function
    • Opioid-induced hyperalgesia may happen wherein patients on opioids become more sensitive to painful stimuli thus limiting its use
    • Opioid rotation may be done wherein a patient experiencing significant side effects & inadequate pain relief with an opioid is given another agent that may be better tolerated
  • Weak opioids are Codeine, Dihydrocodeine, & Tramadol; strong opioids are Morphine, Oxycodone, Fentanyl, & Hydromorphone
    • Morphine is the first-line opioid
    • Transdermal Fentanyl may be considered if oral preparations are restricted
    • Oxycodone may be better than Morphine in hyperalgesic states (eg visceral pain)
    • Tramadol has a dual mode of action with effects on opioid receptors & serotonin release

Local Anesthetic Injection

  • Trigger points of the abdominal wall, vagina & sacrum may be injected with a local anesthetic to provide relief of CPP
  • Has been reported to be effective for myofascial pelvic pain

Other Therapies 

Botulinum Toxin Type A

  • Inhibits release of acetylcholine at the neuromuscular junction & has a paralyzing effect on the striated muscles
  • Injections into the muscles of the pelvic floor have demonstrated benefit
    • As a muscle relaxant, it can reduce the resting pressure in the muscles of the pelvic floor
  • Has been successful in inactivation of trigger points because of its effect on muscle contraction
  • Data on optimum dosage, technique & effect duration are lacking

Antibiotics

  • Adjuvant therapy with antibiotics can be of supporting help in specific conditions

Non-Pharmacological Therapy

  • A treatment approach in patients without a specific diagnosis that addresses dietary, psychological, social & environmental factors in addition to medical therapy
  • A team of healthcare providers from different medical specialties (addictions, anesthesiology, gastroenterology, gynecology, physical medicine & rehabilitation, psychiatry, sleep medicine, urology) & allied health (clinical nutrition, kinesiology, nursing, occupational therapy, pharmacy, physiotherapy, psychology, social work) provides comprehensive assessment & integrated coordination of treatment interventions
  • Treatment strategies consist of medical, surgical, psychosocial & rehabilitative interventions
    • Have been shown to have improved outcomes over medical therapy alone
    • Current evidence shows that it is the most effective treatment for patients, especially women, with chronic pain syndrome

Exercise

  • Chronic pelvic pain (CPP) due to myofascial dysfunction may be managed with a home stretching & exercise program
    • Corrects muscle weakness, tightness, & spasms

Physical Therapy

  • Should be considered as a treatment option as different physical therapy modalities appear to help in the treatment of CPP (eg high-voltage galvanic stimulation, ultrasound, heat & ice)
  • Helps treat the myofascial component of pelvic pain syndrome by inactivation of trigger points
    • Beneficial in women with bladder pain syndrome
  • Also decreases referred pain

Psychotherapy

  • Eg Cognitive therapy, behavioral modification, operant conditioning
  • Addition of psychotherapy to the medical treatment of CPP appears to have an improved response over medical treatment alone
  • Psychotherapy should be integrated into the treatment plan at an early stage
  • Cognitive-behavioral therapies are effective for patients, particularly women, in developing strategies for coping with pain
    • Most widely used & has the most empiric support
    • Patients come to understand that their pain has physical, social & psychological causes & that it is possible to reduce pain through their efforts & with medical or surgical treatment

Biofeedback

  • Musculoskeletal sources of pain are responsive to biofeedback training
  • Biofeedback with physiological quieting & general relaxation are taught to patients with myofascial pelvic pain which control & decrease pain by decreasing muscle tension

Acupuncture, Acupressure, Transcutaneous Nerve Stimulation (TENS)

  • TENS help reduce somatic myofascial pain & has been demonstrated to be effective in decreasing pain in men with CPPS
  • Acupuncture may be helpful in patients with myofascial pelvic pain & visceral-peritoneal pain
    • Beneficial effect may be from gate control of pain pathways, increased release of endogenous opioid, & alteration of sympathetic tone
  • Acupressure had been approved for chronic pain relief in oncology patients

Neuromodulation

  • Eg Sacral nerve stimulation, percutaneous tibial nerve stimulation, pudendal nerve stimulation
  • A possible method for chronic pain relief, it should only be considered by specialists in pelvic pain management
  • May be considered for bladder pain syndrome, pudendal neuralgia, & chronic anal pain syndrome
  • Gabaminergic interneurons are electrically stimulated leading to an exaggerated sensory information with consecutive modulation in the CNS (eg spinal cord stimulation, sacral root stimulation, dorsal root ganglion stimulation, or peripheral nerve stimulation)
  • More detailed research is required
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