Chronic Pelvic Pain Management

Aka: Chronic Pelvic Pain Management

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II. Management: General Measures

  1. Discuss All contributing factors
  2. Treat all components and factors simultaneously
  3. 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
  4. Consider Pain Management Specialist referral
    1. Indicated in refractory Chronic Pelvic Pain
    2. Consider somatocognitive therapy (cognitive psychotherapy with physiotherapy)
  5. Cognitive Behavioral Therapy
    1. Core component of Chronic Pain Management
  6. Gradually taper off treatments
    1. Pain lessens
    2. Vegetative symptoms decrease
  7. Regular follow-up regardless of symptoms
    1. Each visit focuses on a different aspect
  8. Avoid putting patient on defensive
    1. Do NOT have her prove the presence of pain
  9. 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

III. Management: Bowel or Bladder Symptom

  1. Constipation or Irritable Bowel Syndrome
    1. Fiber Laxatives or high fiber diet
    2. Exercise
    3. Hydration
    4. Antispasmodic
  2. 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

IV. Management: Musculoskeletal

  1. Physical Therapy
    1. Pelvic Floor Exercises
    2. Core Muscle Exercises (hips, low back, abdominal Muscle wall)
    3. Stretching and strengthening Exercises
    4. Biofeedback
  2. 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
  3. General Posture
    1. Strengthening and flexibility
    2. Low back Exercise
  4. Piriformis Syndrome
    1. NSAIDs
    2. Physical Therapy
      1. Stretching and Pelvic tilt Exercise
      2. Ultrasound or deep massage
      3. Electrical Stimulation (TENS unit)

V. Management: Gynecologic

  1. 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
  2. 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
  3. 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
  4. 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)
  5. Botulinum Toxin Type A Injection
    1. Transvaginal injection into pelvic floor Muscles

VI. Management: Surgical

  1. 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
  2. Surgery is not the cure (only a part of the plan)
  3. Laparoscopy Results:
    1. No apparent pathology: 33%
    2. Endometriosis: 33%
    3. Adhesions or Pelvic Inflammatory Disease changes: 25%
    4. Miscellaneous: 9%

VII. References

  1. Howard (2003) Obstet Gynecol 101:594-611 [PubMed]
  2. Meisenheimer (2025) Am Fam Physician 111(3): 218-29 [PubMed]
  3. Ortiz (2008) Am Fam Physician 77:1535-42 [PubMed]
  4. Speer (2016) Am Fam Physician 93(5):380-7 [PubMed]
  5. Zondervan (2001) Am J Obstet Gynecol 184:1149-55 [PubMed]

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