Chronic Pelvic Pain Management

1. See Also
   1. Pelvic Congestion Syndrome
   2. Chronic Pain
   3. Chronic Pain Syndrome
2. Management: General Measures
   1. Discuss All contributing factors
   2. Treat all components and factors simultaneously
   3. Consider Pain Management Specialist referral
      1. Indicated in refractory Chronic Pelvic Pain
      2. Consider somatocognitive therapy (cognitive psychotherapy with physiotherapy)
   4. Gradually taper off treatments
      1. Pain lessens
      2. Vegetative symptoms decrease
   5. Regular follow-up regardless of symptoms
      1. Each visit focuses on a different aspect
   6. Avoid putting patient on defensive
      1. Do NOT have her prove the presence of pain
   7. 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. Tricyclic Antidepressants (e.g. Amitriptyline or Nortriptyline)
         2. Gabapentin (Neurontin) or Pregabalin (Lyrica)
         3. 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)
         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. Ear Acupuncture
      5. Anxiolytics
         1. Not generally recommended
         2. If used, use sparingly (less then 2 weeks)
3. Management: Bowel or Bladder Symptom
   1. Constipation
      1. Fiber Laxatives or high fiber diet
      2. Exercise
      3. Hydration
      4. Antispasmodic
   2. Bladder spasms and Urinary Frequency
      1. Antispasmodics (Oxybutynin, hyocyamine)
      2. Bladder drill
         1. Track voiding intervals
         2. Increase voiding intervals by urinating on schedule
      3. Coitus-associated Bladder symptoms
         1. Empty Bladder before and after coitus
         2. Consider daily Nitrofurantoin
4. Management: Musculoskeletal
   1. Physical Therapy
      1. Pelvic Floor Exercises
      2. Biofeedback
   2. Myofascial Pain or Trigger Point Pain
      1. Nonsteroidal Anti-inflammatory drugs (NSAIDs)
      2. 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
      3. 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)
5. 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)
   4. Sacral ligament injection
      1. Patient rates pain before and after procedure
      2. Preparation
         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. Injected into pelvic floor muscles
6. 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%
7. References
   1. Howard (2003) Obstet Gynecol 101:594-611 [PubMed]
   2. Ortiz (2008) Am Fam Physician 77:1535-42 [PubMed]
   3. Speer (2016) Am Fam Physician 93(5):380-7 [PubMed]
   4. Zondervan (2001) Am J Obstet Gynecol 184:1149-55 [PubMed]