Approach Considerations
Patients with chronic pelvic pain are generally treated in an outpatient setting and require a variety of health care professionals to optimally manage their condition.
Hospitalization is not usually required for patients with chronic pelvic pain (CPP); however, the need for hospitalization depends on the invasiveness of the treatment choice for pain control and on the severity of the case.
Medical Care
Treatment of chronic pelvic pain (CPP) is complex in patients with multiple problems. [16, 17] It usually requires specific treatment and simultaneous psychological and physical therapy. A good relationship should be established between the clinician and the patient. Treatment of chronic pelvic pain must be tailored for the individual patient.
The goals of treatment must be realistic. They should be focused toward restoration of normal function (minimal disability), better quality of life, and prevention of relapse of chronic symptoms.
Pharmacotherapy
Pharmacotherapy consists of symptomatic abortive therapy to stop or reduce the severity of the acute exacerbations and long-term therapy for chronic pain. Initially, pain may respond to simple over-the-counter (OTC) analgesics such as paracetamol, ibuprofen, aspirin, or naproxen. If treatment results are unsatisfactory, the addition of other modalities or the use of prescription drugs is recommended.
If possible, avoid use of barbiturate or opiate agonists. Also discourage long-term use and overuse of all symptomatic analgesics because of the risk of dependence and abuse.
Tizanidine may improve the inhibitory function in the central nervous system and can provide pain relief. Therapy with tizanidine is not considered the standard of care
Amitriptyline (Elavil) and nortriptyline (Pamelor) are the tricyclic antidepressants (TCAs) used most frequently for chronic pain.
The selective serotonin reuptake inhibitors (SSRIs) fluoxetine (Prozac), paroxetine (Paxil), and sertraline (Zoloft) also are commonly prescribed. Other antidepressants such as doxepin, desipramine protriptyline, and buspirone also can be used.
A randomized, controlled trial found that treatment with gabapentin did not result in significantly lower pain scores in women with chronic pelvic pain. Moreover, 7% of women in the gabapentin group had serious adverse events, compared with 2% in the placebo group, a statistically significant difference. Gabapentin was also associated with a higher rate of side effects, including dizziness, drowsiness, and visual disturbances. [18]
Physical therapy
Physical therapy techniques include hot or cold applications, positioning, stretching exercises, traction, massage, ultrasound therapy, transcutaneous electrical nerve stimulation (TENS), and manipulations. Heat, massage, and stretching can be used to alleviate excess muscle contraction and pain. Pelvic floor training also may be recommended.
In a Brazilian study of 58 women with pelvic pain of at least 6 months' duration and who received 6 months of multidisciplinary management, reduction of skin pain sensitivity with TENS was associated with an increase in pelvic pain threshold (P< 0.0001). [19] The investigators applied TENS to the anterior surface of the nondominant arm; in the group that experienced chronic pelvic pain reduction following 6 months of multidisciplinary treatment, the effect size of the electrical pain threshold was 0.86, whereas in the group that did not experience a reduction in pelvic pain, the size increase was 0.53. [19]
Psychophysiological therapy
Psychophysiological therapy includes reassurance, counseling, relaxation therapy, a stress management program, and biofeedback techniques. With these modalities of treatment, both frequency and severity of chronic pain may be reduced.
Biofeedback may be helpful in some patients when combined with medications.
Other treatment
A study by Teixeira et al that included 50 women with deeply infiltrating endometriosis evaluated the efficacy and safety of potentized estrogen compared to placebo in homeopathic treatment of endometriosis-associated pelvic pain. The study reported that potentized estrogen (12cH, 18cH and 24cH) at a dose of 3 drops twice daily for 24 weeks decreased the endometriosis-associated pelvic pain global score by 12.82 (P< 0.001) and that the group that used potentized estrogen also showed partial score (VAS: range 0 to 10) reduction in dysmenorrhea (3.28; P< 0.001), non-cyclic pelvic pain (2.71; P=0.009), and cyclic bowel pain (3.40; P< 0.001). [20]
Surgical Care
Various minimally invasive techniques may provide pain relief. These techniques include the following:
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Trigger point injections: These injections are used mostly for localized trigger points (myofascial pain or neuroma).
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Peripheral nerve blocks: Specific peripheral nerve block with local anesthetic and steroids may be helpful in selected cases.
Neuroablation of selected nerves can be performed by using different techniques, including thermocoagulation (radiofrequency ablation), cryoablation, or injection of chemical agents (alcohol, hypertonic saline, phenol). An intrathecal morphine pump may be used, but careful selection for appropriate patients is very important. Sacral nerve stimulation may be effective in the treatment of therapy-resistant pelvic pain syndromes linked to pelvic floor dysfunction. [21]
Various surgical procedures may be considered to treat chronic pelvic pain. Surgical procedures include presacral neurectomy (superior hypogastric plexus excision), paracervical denervation (laparoscopic uterine nerve ablation), and uterovaginal ganglion excision (inferior hypogastric plexus excision).
Consultations
Consultation with a psychologist, urologist, neurologist, and gastrointestinal specialist or other appropriate specialists is very important, especially before considering invasive or aggressive management.
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Transabdominal longitudinal view of the female pelvis.
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Transabdominal transverse view of the female pelvis: The bladder is rectangular. The ovaries are seen bilaterally in the adnexa.
