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Chronic Pelvic Pain Management
Aka: Chronic Pelvic Pain Management
- See Also
- Pelvic Congestion Syndrome
- Chronic Pain
- Chronic Pain Syndrome
- Management: General Measures
- Discuss All contributing factors
- Treat all components and factors simultaneously
- Consider Pain Management Specialist referral
- Indicated in refractory Chronic Pelvic Pain
- Consider somatocognitive therapy (cognitive psychotherapy with physiotherapy)
- Gradually taper off treatments
- Pain lessens
- Vegetative symptoms decrease
- Regular follow-up regardless of symptoms
- Each visit focuses on a different aspect
- Avoid putting patient on defensive
- Do NOT have her prove the presence of pain
- Use multiple therapeutic regimens
- Analgesics
- Non-Opioids are preferred (e.g. Acetaminophen, NSAIDs)
- Use at regularly scheduled doses
- Neuropathic pain
- Tricyclic Antidepressants (e.g. Amitriptyline or Nortriptyline)
- Gabapentin (Neurontin) or Pregabalin (Lyrica)
- If beneficial, may predict response to neuromodulation (Implanted stimulator)
- Comorbid Depression Management
- Selective Serotonin Reuptake Inhibitor or SSRI (e.g. Fluoxetine, Sertraline, Escitalopram)
- Serotonin Norepinephrine Reuptake Inhibitor or SNRI (e.g. Venlafaxine, Duloxetine)
- May also be effective for neuropathic pain
- Complimentary and Integrative Medicine
- Ear Acupuncture
- Anxiolytics
- Not generally recommended
- If used, use sparingly (less then 2 weeks)
- Management: Bowel or Bladder Symptom
- Constipation
- Fiber Laxatives or high fiber diet
- Exercise
- Hydration
- Antispasmodic
- Bladder spasms and Urinary Frequency
- Antispasmodics (Oxybutynin, hyocyamine)
- Bladder drill
- Track voiding intervals
- Increase voiding intervals by urinating on schedule
- Coitus-associated Bladder symptoms
- Empty Bladder before and after coitus
- Consider daily Nitrofurantoin
- Management: Musculoskeletal
- Physical Therapy
- Pelvic Floor Exercises
- Biofeedback
- Myofascial Pain or Trigger Point Pain
- Nonsteroidal Anti-inflammatory drugs (NSAIDs)
- Local steroid injections
- Preparation
- Bupivacaine Hydrochloride (0.5%) 9 ml
- Consider adding Betamethasone (6 mg/ml) 1 ml
- Technique
- Inject 1-2 cc per focal lesion
- Inject weekly for up to 5 weeks
- TENS Unit
- Indicated for Focal pain or incisional pain
- General Posture
- Strengthening and flexibility
- Low back Exercise
- Piriformis Syndrome
- NSAIDs
- Physical Therapy
- Stretching and Pelvic tilt Exercise
- Ultrasound or deep massage
- Electrical Stimulation (TENS unit)
- Management: Gynecologic
- Consider specific management strategies
- See Dysmenorrhea
- See Female Sexual Dysfunction
- See Vaginismus
- See Vulvodynia
- See Atrophic Vaginitis
- See Vaginal Dryness
- Oral Contraceptives for cyclic pain
- Polycystic Ovarian Disease
- Ovulation Suppression
- Mid-cycle, premenstrual, or menstrual pain
- Ovarian pathology (peri-ovarian adhesions, Ovarian Cysts)
- Endometriosis related Dysmenorrhea
- Other hormonal agents
- Mirena Intrauterine Device (IUD)
- Depo Provera 150 mg IM every 12 weeks
- Gonadotropin-releasing Hormone Agonist or GnRH agonist (e.g. Goserelin/Zoladex)
- Sacral ligament injection
- Patient rates pain before and after procedure
- Preparation
- Lidocaine 3 cc
- Marcaine 2 cc
- Inject
- Cervical positions of 8 and 4 o'clock
- At fornix margin (Cervix-vaginal wall margin)
- Botulinum Toxin Type A Injection
- Injected into pelvic floor muscles
- Management: Surgical
- Surgical procedures (not effective unless pathology)
- Diagnostic Laparoscopy
- Laparoscopic Lysis of pelvic adhesions
- Pain Relief without Chronic Pain Syndrome: 75%
- Pain Relief with Chronic Pain Syndrome: 40%
- Hysterectomy
- Treatment of last resort
- Improvement in 50% of patients, but persistent pain in 40% and worsening in 5%
- Presacral neurectomy
- Uterosacral nerve ablation
- Surgery is not the cure (only a part of the plan)
- Laparoscopy Results:
- No apparent pathology: 33%
- Endometriosis: 33%
- Adhesions or Pelvic Inflammatory Disease changes: 25%
- Miscellaneous: 9%
- References
- Howard (2003) Obstet Gynecol 101:594-611 [PubMed]
- Ortiz (2008) Am Fam Physician 77:1535-42 [PubMed]
- Speer (2016) Am Fam Physician 93(5):380-7 [PubMed]
- Zondervan (2001) Am J Obstet Gynecol 184:1149-55 [PubMed]