Management of Chronic Pelvic Pain

Article

Abstract

Chronic pelvic pain is a complex condition that requires evaluation of the reproductive, gastrointestinal, urologic, musculoskeletal, psychological, and neurological systems. Usually, diagnosis and management entail identifying a network of disorders rather than a single cause of pain with a definitive cure. Only disorders that we commonly encounter in our practice will be discussed in this review.

Keywords

Chronic pelvic pain Management Irritable bowel syndrome Gastrointestinal dysfunction Diet Interstitial cystitis Endometriosis Ovarian remnant syndrome Uterine retroversion Adhesive disease Pelvic congestion syndrome Myofascial pain syndrome Pelvic floor tension myalgia Neurectomy Hysterectomy Trigger points Pelvic floor tension myalgia 

References

Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. 1.
    Howard FM. The role of laparoscopy in chronic pelvic pain: promise and pitfalls. Obstet Gynecol Surv. 1993;48(6):357–87.PubMedCrossRefGoogle Scholar
  2. 2.
    Mathias SD, Kuppermann M, Liberman RF, Lipschutz RC, Steege JF. Chronic pelvic pain: prevalence, health-related quality of life, and economic correlates. Obstet Gynecol. 1996;87(3):321–7.PubMedCrossRefGoogle Scholar
  3. 3.
    Chung MK, Chung RP, Gordon D. Interstitial cystitis and endometriosis in patients with chronic pelvic pain: The "Evil Twins" syndrome. JSLS. 2005;9(1):25–9.PubMedGoogle Scholar
  4. 4.
    Zondervan KT, Yudkin PL, Vessey MP, Jenkinson CP, Dawes MG, Barlow DH, et al. Chronic pelvic pain in the community–symptoms, investigations, and diagnoses. Am J Obstet Gynecol. 2001;184(6):1149–55.PubMedCrossRefGoogle Scholar
  5. 5.
    • Droz J, Howard FM. Use of the short-form McGill pain questionnaire as a diagnostic tool in women with chronic pelvic pain. J Minim Invasive Gynecol. 2011;18(2):211–7. Several of the McGill Pain Questionnaire descriptors had high negative predictive values but not high positive predictive values, which suggests that they have diagnostic usefulness in excluding but not predicting pelvic pain–related diagnoses. Overall, the McGill Pain Questionnaire descriptors were not as robust as diagnostic tools in the evaluation of women with chronic pelvic pain.PubMedCrossRefGoogle Scholar
  6. 6.
    • Chey WD, Nojkov B, Rubenstein JH, Dobhan RR, Greenson JK, Cash BD. The yield of colonoscopy in patients with non-constipated irritable bowel syndrome: results from a prospective, controlled US trial. Am J Gastroenterol. 2010;105(4):859–65. This study demonstrates that it is not necessary to perform routine colonoscopy to exclude serious pathology in all patients with irritable bowel syndrome. The procedure should be reserved for "alarm " signs that require further evaluation.PubMedCrossRefGoogle Scholar
  7. 7.
    Novick J, Miner P, Krause R, Glebas K, Bliesath H, Ligozio G, et al. A randomized, double-blind, placebo-controlled trial of tegaserod in female patients suffering from irritable bowel syndrome with constipation. Aliment Pharmacol Ther. 2002;16(11):1877–88.PubMedCrossRefGoogle Scholar
  8. 8.
    Muller-Lissner SA, Fumagalli I, Bardhan KD, Pace F, Pecher E, Nault B, et al. Tegaserod, a 5-HT(4) receptor partial agonist, relieves symptoms in irritable bowel syndrome patients with abdominal pain, bloating and constipation. Aliment Pharmacol Ther. 2001;15(10):1655–66.PubMedCrossRefGoogle Scholar
  9. 9.
    Choung RS, Herrick LM, Locke 3rd GR, Zinsmeister AR, Talley NJ. Irritable bowel syndrome and chronic pelvic pain: a population-based study. J Clin Gastroenterol. 2010;44(10):696–701.PubMedGoogle Scholar
  10. 10.
    Waxman JA, Sulak PJ, Kuehl TJ. Cystoscopic findings consistent with interstitial cystitis in normal women undergoing tubal ligation. J Urol. 1998;160(5):1663–7.PubMedCrossRefGoogle Scholar
  11. 11.
    Gillenwater JY, Wein AJ. Summary of the National Institute of Arthritis, Diabetes, Digestive and Kidney Diseases Workshop on Interstitial Cystitis, National Institutes of Health, Bethesda, Maryland, August 28–29, 1987. J Urol. 1988;140(1):203–6.PubMedGoogle Scholar
  12. 12.
    Hanno P. Is the potassium sensitivity test a valid and useful test for the diagnosis of interstitial cystitis? Against. Int Urogynecol J Pelvic Floor Dysfunct. 2005;16(6):428–9.PubMedCrossRefGoogle Scholar
  13. 13.
    Parsons CL, Zupkas P, Parsons JK. Intravesical potassium sensitivity in patients with interstitial cystitis and urethral syndrome. Urology. 2001;57(3):428–32. discussion 32–3.PubMedCrossRefGoogle Scholar
  14. 14.
    Taneja R. Intravesical lignocaine in the diagnosis of bladder pain syndrome. Int Urogynecol J Pelvic Floor Dysfunct. 2010;21(3):321–4.CrossRefGoogle Scholar
  15. 15.
    • Giamberardino MA, Costantini R, Affaitati G, Fabrizio A, Lapenna D, Tafuri E, et al. Viscero-visceral hyperalgesia: characterization in different clinical models. Pain. 2010;151(2):307–22. This paper highlights an important concept in understanding chronic pelvic pain: that pain symptoms may involve multiple organ systems through neural crosstalk.PubMedCrossRefGoogle Scholar
  16. 16.
    Berkley KJ. A life of pelvic pain. Physiol Behav. 2005;86(3):272–80.PubMedCrossRefGoogle Scholar
  17. 17.
    Dimitrakov J, Kroenke K, Steers WD, Berde C, Zurakowski D, Freeman MR, et al. Pharmacologic management of painful bladder syndrome/interstitial cystitis: a systematic review. Arch Intern Med. 2007;167(18):1922–9.PubMedCrossRefGoogle Scholar
  18. 18.
    van Ophoven A, Pokupic S, Heinecke A, Hertle L. A prospective, randomized, placebo controlled, double-blind study of amitriptyline for the treatment of interstitial cystitis. J Urol. 2004;172(2):533–6.PubMedCrossRefGoogle Scholar
  19. 19.
    Foster Jr HE, Hanno PM, Nickel JC, Payne CK, Mayer RD, Burks DA, et al. Effect of amitriptyline on symptoms in treatment naive patients with interstitial cystitis/painful bladder syndrome. J Urol. 2010;183(5):1853–8.PubMedCrossRefGoogle Scholar
  20. 20.
    Dawson TE, Jamison J. Intravesical treatments for painful bladder syndrome/ interstitial cystitis. Cochrane Database Syst Rev. 2007;4:CD006113.PubMedGoogle Scholar
  21. 21.
    Walter AJ, Hentz JG, Magtibay PM, Cornella JL, Magrina JF. Endometriosis: correlation between histologic and visual findings at laparoscopy. Am J Obstet Gynecol. 2001;184(7):1407–11. discussion 11–3.PubMedCrossRefGoogle Scholar
  22. 22.
    Muneyyirci-Delale O, Karacan M. Effect of norethindrone acetate in the treatment of symptomatic endometriosis. Int J Fertil Womens Med. 1998;43(1):24–7.PubMedGoogle Scholar
  23. 23.
    Schlaff WD, Carson SA, Luciano A, Ross D, Bergqvist A. Subcutaneous injection of depot medroxyprogesterone acetate compared with leuprolide acetate in the treatment of endometriosis-associated pain. Fertil Steril. 2006;85(2):314–25.PubMedCrossRefGoogle Scholar
  24. 24.
    Selak V, Farquhar C, Prentice A, Singla A. Danazol for pelvic pain associated with endometriosis. Cochrane Database Syst Rev. 2001(4):CD000068.Google Scholar
  25. 25.
    Petta CA, Ferriani RA, Abrao MS, Hassan D, Rosa ESJC, Podgaec S, et al. Randomized clinical trial of a levonorgestrel-releasing intrauterine system and a depot GnRH analogue for the treatment of chronic pelvic pain in women with endometriosis. Hum Reprod. 2005;20(7):1993–8.PubMedCrossRefGoogle Scholar
  26. 26.
    Jacobson TZ, Duffy JM, Barlow D, Koninckx PR, Garry R. Laparoscopic surgery for pelvic pain associated with endometriosis. Cochrane Database Syst Rev. 2009(4):CD001300.Google Scholar
  27. 27.
    Wright J, Lotfallah H, Jones K, Lovell D. A randomized trial of excision versus ablation for mild endometriosis. Fertil Steril. 2005;83(6):1830–6.PubMedCrossRefGoogle Scholar
  28. 28.
    • Healey M, Ang WC, Cheng C. Surgical treatment of endometriosis: a prospective randomized double-blinded trial comparing excision and ablation. Fertil Steril. 2010;94(7):2536–40. There is limited information on the efficacy of operative laparoscopic methods for the treatment of endometriosis. This is a small RCT that did not detect a difference in pain outcomes between ablation and excision treatments. Larger RCTs are necessary to determine the optimal surgical approach.PubMedCrossRefGoogle Scholar
  29. 29.
    Beretta P, Franchi M, Ghezzi F, Busacca M, Zupi E, Bolis P. Randomized clinical trial of two laparoscopic treatments of endometriomas: cystectomy versus drainage and coagulation. Fertil Steril. 1998;70(6):1176–80.PubMedCrossRefGoogle Scholar
  30. 30.
    Alborzi S, Momtahan M, Parsanezhad ME, Dehbashi S, Zolghadri J. A prospective, randomized study comparing laparoscopic ovarian cystectomy versus fenestration and coagulation in patients with endometriomas. Fertil Steril. 2004;82(6):1633–7.PubMedCrossRefGoogle Scholar
  31. 31.
    Latthe PM, Proctor ML, Farquhar CM, Johnson N, Khan KS. Surgical interruption of pelvic nerve pathways in dysmenorrhea: a systematic review of effectiveness. Acta Obstet Gynecol Scand. 2007;86(1):4–15.PubMedCrossRefGoogle Scholar
  32. 32.
    Zullo F, Palomba S, Zupi E, Russo T, Morelli M, Cappiello F, et al. Effectiveness of presacral neurectomy in women with severe dysmenorrhea caused by endometriosis who were treated with laparoscopic conservative surgery: a 1-year prospective randomized double-blind controlled trial. Am J Obstet Gynecol. 2003;189(1):5–10.PubMedCrossRefGoogle Scholar
  33. 33.
    Shakiba K, Bena JF, McGill KM, Minger J, Falcone T. Surgical treatment of endometriosis: a 7-year follow-up on the requirement for further surgery. Obstet Gynecol. 2008;111(6):1285–92.PubMedCrossRefGoogle Scholar
  34. 34.
    Namnoum AB, Hickman TN, Goodman SB, Gehlbach DL, Rock JA. Incidence of symptom recurrence after hysterectomy for endometriosis. Fertil Steril. 1995;64(5):898–902.PubMedGoogle Scholar
  35. 35.
    Yap C, Furness S, Farquhar C. Pre and post operative medical therapy for endometriosis surgery. Cochrane Database Syst Rev. 2004(3):CD003678.Google Scholar
  36. 36.
    Magtibay PM, Nyholm JL, Hernandez JL, Podratz KC. Ovarian remnant syndrome. Am J Obstet Gynecol. 2005;193(6):2062–6.PubMedCrossRefGoogle Scholar
  37. 37.
    Chao HA. Ovarian remnant syndrome at the port site. J Minim Invasive Gynecol. 2008;15(4):505–7.PubMedCrossRefGoogle Scholar
  38. 38.
    Nezhat F, Nezhat C. Operative laparoscopy for the treatment of ovarian remnant syndrome. Fertil Steril. 1992;57(5):1003–7.PubMedGoogle Scholar
  39. 39.
    Kho RM, Magrina JF, Magtibay PM. Pathologic findings and outcomes of a minimally invasive approach to ovarian remnant syndrome. Fertil Steril. 2007;87(5):1005–9.PubMedCrossRefGoogle Scholar
  40. 40.
    Ott J, Nouri K, Demmel M, Zafraani S, Greilberger U, Huber JC, et al. Fourteen-year experience with laparoscopic ventrosuspension in patients with retroverted and retroflected uterus and pelvic pain syndromes. J Minim Invasive Gynecol. 2010;17(6):749–53.PubMedCrossRefGoogle Scholar
  41. 41.
    Fauconnier A, Dubuisson JB, Foulot H, Deyrolles C, Sarrot F, Laveyssiere MN, et al. Mobile uterine retroversion is associated with dyspareunia and dysmenorrhea in an unselected population of women. Eur J Obstet Gynecol Reprod Biol. 2006;127(2):252–6.PubMedCrossRefGoogle Scholar
  42. 42.
    Ostrzenski A. Laparoscopic retroperitoneal hysteropexy. A randomized trial. J Reprod Med. 1998;43(4):361–6.PubMedGoogle Scholar
  43. 43.
    Weibel MA, Majno G. Peritoneal adhesions and their relation to abdominal surgery. A postmortem study. Am J Surg. 1973;126(3):345–53.PubMedCrossRefGoogle Scholar
  44. 44.
    Postoperative adhesion development after operative laparoscopy: evaluation at early second-look procedures. Operative Laparoscopy Study Group. Fertil Steril. 1991 Apr;55(4):700–4.Google Scholar
  45. 45.
    Howard FM, El-Minawi AM, Sanchez RA. Conscious pain mapping by laparoscopy in women with chronic pelvic pain. Obstet Gynecol. 2000;96(6):934–9.PubMedCrossRefGoogle Scholar
  46. 46.
    Demco L. Pain mapping of adhesions. J Am Assoc Gynecol Laparosc. 2004;11(2):181–3.PubMedCrossRefGoogle Scholar
  47. 47.
    Peters AA, Trimbos-Kemper GC, Admiraal C, Trimbos JB, Hermans J. A randomized clinical trial on the benefit of adhesiolysis in patients with intraperitoneal adhesions and chronic pelvic pain. Br J Obstet Gynaecol. 1992;99(1):59–62.PubMedCrossRefGoogle Scholar
  48. 48.
    Swank DJ, Swank-Bordewijk SC, Hop WC, van Erp WF, Janssen IM, Bonjer HJ, et al. Laparoscopic adhesiolysis in patients with chronic abdominal pain: a blinded randomised controlled multi-centre trial. Lancet. 2003;361(9365):1247–51.PubMedCrossRefGoogle Scholar
  49. 49.
    Beard RW, Highman JH, Pearce S, Reginald PW. Diagnosis of pelvic varicosities in women with chronic pelvic pain. Lancet. 1984;2(8409):946–9.PubMedCrossRefGoogle Scholar
  50. 50.
    Belenky A, Bartal G, Atar E, Cohen M, Bachar GN. Ovarian varices in healthy female kidney donors: incidence, morbidity, and clinical outcome. AJR Am J Roentgenol. 2002;179(3):625–7.PubMedGoogle Scholar
  51. 51.
    Tu FF, Hahn D, Steege JF. Pelvic congestion syndrome-associated pelvic pain: a systematic review of diagnosis and management. Obstet Gynecol Surv. 2010;65(5):332–40.PubMedCrossRefGoogle Scholar
  52. 52.
    Farquhar CM, Rogers V, Franks S, Pearce S, Wadsworth J, Beard RW. A randomized controlled trial of medroxyprogesterone acetate and psychotherapy for the treatment of pelvic congestion. Br J Obstet Gynaecol. 1989;96(10):1153–62.PubMedCrossRefGoogle Scholar
  53. 53.
    Kim HS, Malhotra AD, Rowe PC, Lee JM, Venbrux AC. Embolotherapy for pelvic congestion syndrome: long-term results. J Vasc Interv Radiol. 2006;17(2 Pt 1):289–97.PubMedCrossRefGoogle Scholar
  54. 54.
    Beard RW, Kennedy RG, Gangar KF, Stones RW, Rogers V, Reginald PW, et al. Bilateral oophorectomy and hysterectomy in the treatment of intractable pelvic pain associated with pelvic congestion. Br J Obstet Gynaecol. 1991;98(10):988–92.PubMedCrossRefGoogle Scholar
  55. 55.
    Chung MH, Huh CY. Comparison of treatments for pelvic congestion syndrome. Tohoku J Exp Med. 2003;201(3):131–8.PubMedCrossRefGoogle Scholar
  56. 56.
    Gargiulo T, Mais V, Brokaj L, Cossu E, Melis GB. Bilateral laparoscopic transperitoneal ligation of ovarian veins for treatment of pelvic congestion syndrome. J Am Assoc Gynecol Laparosc. 2003;10(4):501–4.PubMedCrossRefGoogle Scholar
  57. 57.
    Rundqvist E, Sandholm LE, Larsson G. Treatment of pelvic varicosities causing lower abdominal pain with extraperitoneal resection of the left ovarian vein. Ann Chir Gynaecol. 1984;73(6):339–41.PubMedGoogle Scholar
  58. 58.
    Slocumb JC. Neurological factors in chronic pelvic pain: trigger points and the abdominal pelvic pain syndrome. Am J Obstet Gynecol. 1984;149(5):536–43.PubMedGoogle Scholar
  59. 59.
    Weiss JM. Pelvic floor myofascial trigger points: manual therapy for interstitial cystitis and the urgency-frequency syndrome. J Urol. 2001;166(6):2226–31.PubMedCrossRefGoogle Scholar
  60. 60.
    Graboski CL, Gray DS, Burnham RS. Botulinum toxin A versus bupivacaine trigger point injections for the treatment of myofascial pain syndrome: a randomised double blind crossover study. Pain. 2005;118(1–2):170–5.PubMedCrossRefGoogle Scholar
  61. 61.
    Affaitati G, Fabrizio A, Savini A, Lerza R, Tafuri E, Costantini R, et al. A randomized, controlled study comparing a lidocaine patch, a placebo patch, and anesthetic injection for treatment of trigger points in patients with myofascial pain syndrome: evaluation of pain and somatic pain thresholds. Clin Ther. 2009;31(4):705–20.PubMedCrossRefGoogle Scholar
  62. 62.
    Cummings TM, White AR. Needling therapies in the management of myofascial trigger point pain: a systematic review. Arch Phys Med Rehabil. 2001;82(7):986–92.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2011

Authors and Affiliations

  1. 1.Department of Obstetrics & GynecologyUniversity of Rochester School of Medicine & DentistryRochesterUSA

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