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. Gradually taper off treatments
      1. Pain lessens
      2. Vegetative symptoms decrease
   4. Regular follow-up regardless of symptoms
      1. Each visit focuses on a different aspect
   5. Avoid putting patient on defensive
      1. Do NOT have her prove the presence of pain
   6. Use multiple therapeutic regimens
      1. Analgesics
         1. Non-Narcotics are preferred (e.g. Acetaminophen, NSAIDs)
         2. Use at regularly scheduled doses
      2. Antidepressants
         1. Chronic Pain Management: Amitriptyline (Elavil), Gabapentin (Neurontin)
         2. Depression Management: SSRI (e.g. Fluoxetine)
      3. Anxiolytics
         1. Use sparingly (less then 2 weeks)
3. Management: Bowel or Bladder Symptom
   1. Constipation
      1. FiberLaxatives 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. 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
   2. General Posture
      1. Strengthening and flexibility
      2. Low back Exercise
   3. Piriformis Syndromes
      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 Dysmenorrhea management
   2. Oral Contraceptives for cyclic pain
      1. Polycystic Ovarian Disease
      2. Ovulation Suppression
         1. Mid-cycle, premenstrual, or menstrual pain
         2. Ovarian pathology
            1. Peri-ovarian adhesions
            2. Ovarian Cysts
   3. Other hormonal agents
      1. Mirena IUD
      2. Provera 50 mg orally daily (very high dose)
      3. Goserelin (GnRH agonist)
   4. Sacral ligament injection
      1. Preparation
         1. Lidocaine 3 cc
         2. Marcaine 2 cc
      2. Inject
         1. Cervical positions of 8 and 4 o'clock
         2. At fornix margin (Cervix-vaginal wall margin)
      3. Patient rates pain before and after procedure
   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
      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
   2. Ortiz (2008) Am Fam Physician 77:1535-42
   3. Zondervan (2001) Am J Obstet Gynecol 184:1149-55