eMedicine Specialties > Obstetrics and Gynecology > General Gynecology

Chronic Pelvic Pain

Manish K Singh, MD, Assistant Professor, Department of Neurology, Teaching Faculty for Pain Management and Neurology Residency Program, Hahnemann University Hospital, Drexel College of Medicine; Medical Director, Neurology and Pain Management, Jersey Institute of Neuroscience
Elizabeth E Puscheck, MD, Professor, Department of Obstetrics and Gynecology, Wayne State University School of Medicine; In Vitro Fertilization Director, Gynecologic Ultrasound Director, Clinical Endocrine Laboratory Consultant, Department of Obstetrics and Gynecology, University Women's Care; Jashvant Patel, MD, Medical Director, Department of Pain Medicine and Comprehensive Rehabilitation, Medical College of Pennsylvania Hahnemann University

Updated: Dec 22, 2008

Introduction

Background

Chronic pelvic pain (CPP) is a common problem and presents a major challenge to health care providers because of its unclear etiology, complex natural history, and poor response to therapy.

CPP is poorly understood and, consequently, poorly managed. This condition is best managed using a multidisciplinary approach. Management requires good integration and knowledge of all pelvic organ systems and other systems including musculoskeletal, neurologic, and psychiatric systems.

A significant number of these patients may have various associated problems, including bladder or bowel dysfunction, sexual dysfunction, and other systemic or constitutional symptoms. Other associated problems, such as depression, anxiety, and drug addiction, also may coexist.

In the United States, estimated direct medical costs for outpatient visits for CPP (women aged 18-50 y) is approximately $881.5 million per year.¹

Pathophysiology

The pathophysiology of chronic pelvic pain is complex and multifactorial. It remains unclear.

Frequency

United States

Chronic pelvic pain is a common problem. It affects approximately 1 in 7 women.¹ In one study of reproductive-aged women in primary care practices, the reported prevalence rate of pelvic pain was 39%.² Of all referrals to gynecologists, 10% are for pelvic pain.³

International

A similar prevalence of chronic pelvic pain has been described in other countries.⁴

Mortality/Morbidity

As with other chronic pain, CPP may lead to prolonged suffering, marital and family problems, loss of employment or disability, and various adverse medical reactions from lifelong therapy.

Race

In one study, being African American was found to be a risk factor for pelvic pain.²

Sex

Chronic pelvic pain is most common among reproductive-aged women. Common causes of CPP in men include chronic (nonbacterial) prostatitis, chronic orchalgia, and prostatodynia.

Age

Chronic pelvic pain is most common among reproductive-aged women, especially those aged 26-30 years.²

Clinical

History

The proposed definition of chronic pelvic pain is nonmenstrual pain of 3 months duration or longer that localizes to the anatomic pelvis and is severe enough to cause functional disability and require medical or surgical treatment. Most authorities agree that patients should be diagnosed with CPP if they have pain primarily located in the pelvis for more than 3 or 6 months duration.

Patient history is important in cases of CPP. Because of the complex etiology and, often, the presence of associated disorders, a general approach with a thorough history that directs further evaluation and appropriate consultations is needed. Perform a detailed review of systems, including reproductive, gastrointestinal, musculoskeletal, urologic, and neuro-psychiatric. As needed, ask specific questions, especially if the patient has an associated disorder. A thorough past history also is important to avoid repeating invasive and expensive procedures.

• Focus history on characterizing the patient's pain, which can lead to appropriate diagnostic and therapeutic plans.
  • Location of pain: The location of pain is an important part of the history. Ask the patient to describe the pain location and type on a pain diagram (anteroposterior and lateral view of human picture).
  • Precipitating factors: Ask questions about factors that provoke or intensify pain. This may provide clues for possible etiologies or associated disorders. For example, in pelvic congestion syndrome, pain is related to posture and is worse at the end of day. In endometriosis, pain commonly is reported during or after intercourse.
  • Alleviating factors: Alleviating factors may exist. For example, rest may decrease pain of musculoskeletal or adnexal origin.
  • Quality of pain: Various terms can be used to describe the quality of pain. Such terms include throbbing, pounding, shooting, pricking, boring, stabbing, lancinating, sharp cutting, lacerating, pressing, cramping, crushing, pulling, pinching, stinging, burning, splitting, penetrating, piercing, squeezing, and dull aching.
  • Pain distribution: Spreading or radiation of pain also is important in the evaluation of neuropathic pain.
  • Severity or intensity of pain: Use some type of rating system to evaluate pain severity or intensity with a degree of objectivity and reproducibility. Different types of pain scales may be used. Numerical scales are more useful and reliable. The visual analog scale is one of the commonly used numerical scales.
• Obtain a history specific to different systems and disorders.
  • Gynecologic and obstetric: For example, excessive bleeding with menses suggests uterine leiomyomas or adenomyosis. History of previous surgery may suggest intra-abdominal or pelvic adhesions. Patients with cervical stenosis usually have a history of chronic cervical infection or treatment with cryosurgery/laser surgery/loop excision or endometrial resection. Having multiple sexual partners is a risk factor for pelvic inflammatory disease.
  • Urologic: A detailed history to evaluate the urological system is important. For example, as compared to patients with pelvic pain, patients with interstitial cystitis report urgency and increased frequency of urination as the most distressing features.
  • Gastrointestinal: For example, deflecting sigmoid adhesions are common in women with CPP and frequently are associated with gastrointestinal symptoms.
  • Musculoskeletal: History of vaginal delivery with prolonged second-stage episiotomies or tears may suggest pelvic floor relaxation disorder.
  • Neurologic: Constant burning pain is a common complaint in patients with pudendal neuralgia. Patients may report dysesthesia and vulvodynia but usually not dyspareunia.
  • Psychologic: A good psychosocial or psychosexual history is needed when organic diseases are excluded, or coexisting psychiatric disorders are suggested. Obtain sufficient history to evaluate depression, anxiety disorder, somatization, physical or sexual abuse, drug abuse or dependence, and family problems, marital problems, or sexual problems. Sexual abuse occurring before age 15 years is associated with later development of CPP.⁵ Somatization is a common associated psychologic disorder in women with CPP. Somatization scales can be used for evaluation.

Physical

Good rapport, tolerance, and an open-minded approach are important in the evaluation of any patient with chronic pain. A thorough systematic examination usually suggests an appropriate diagnosis and therapy.

• Obstetric-gynecologic and other system examinations could be long and stressful. Detailed examination of obstetric-gynecologic and other systems can be performed in different positions. Usually, this includes standing, sitting, supine, and lithotomy positions.
• Lithotomy examination usually includes the following:
  • Visual inspection of the external genitalia
  • Basic sensory testing and evaluation for trigger points
    • A cotton-tipped swab can be used for precise sensory and tender-point evaluation of the vestibule, vaginal cuff, cervical os, paracervical region, and cervical region.
    • Single-digit examinations of the vulva, pubic arch, levator ani coccyx, introitus, urethral, trigonal, cervix, paracervical areas, vaginal fornices, uterus, and adnexa are indicated.
  • Colposcopic evaluation of the vulva and vestibule
  • Sims retractor or single-blade speculum examination of the vagina and pelvic muscles
  • Bimanual pelvic examination
  • Rectovaginal examination
• Perform detailed examinations for other systems (eg, gastrointestinal, urologic, neurologic, musculoskeletal) as required. For example, gait and posture evaluation, spine examination, and sensory and motor examination often are useful.
  • Betty maneuver (for piriformis syndrome): When abduction of the thigh against resistance is requested, the patient will report pain.
  • Obturator sign (dysfunction of the obturator muscles or fascia)
  • Straight-leg raising test (possible herniated disc, radiculopathy)
  • Psoas sign: If pain is elicited during flexion of hip against resistance, this may suggest dysfunction of the psoas muscles or fascia.
  • Patrick or faber (flexion in abduction and external rotation) test for hip evaluation

Causes

Various reproductive, gastrointestinal, urologic, and neuromuscular disorders may cause or contribute to CPP. Sometimes, multiple contributing factors may exist in a single patient.

• Extrauterine reproductive disorders
  • Endometriosis
  • Adhesions
  • Adnexal cysts
  • Chronic ectopic pregnancy
  • Chlamydial endometritis or salpingitis
  • Endosalpingiosis
  • Ovarian retention syndrome (residual ovary syndrome)
  • Ovarian remnant syndrome
  • Ovarian dystrophy or ovulatory pain
  • Pelvic congestion syndrome
  • Postoperative peritoneal cysts
  • Residual accessory ovary
  • Subacute salpingo-oophoritis
  • Tuberculous salpingitis
• Uterine reproductive disorders
  • Adenomyosis
  • Chronic endometritis
  • Atypical dysmenorrhea or ovulatory pain
  • Cervical stenosis
  • Endometrial or cervical polyps
  • Leiomyomata
  • Symptomatic pelvic relaxation (genital prolapse)
  • Intrauterine contraceptive device
• Urologic disorders
  • Bladder neoplasm
  • Chronic urinary tract infection
  • Interstitial cystitis
  • Radiation cystitis
  • Recurrent cystitis
  • Recurrent urethritis
  • Urolithiasis
  • Uninhibited bladder contractions (detrusor-sphincter dyssynergia)
  • Urethral diverticulum
  • Chronic urethral syndrome
  • Urethral caruncle
• Musculoskeletal disorders
  • Abdominal wall myofascial pain (trigger points)
  • Compression fracture of lumbar vertebrae
  • Faulty or poor posture
  • Fibromyalgia
  • Mechanical low back pain
  • Chronic coccygeal pain
  • Muscular strains and sprains
  • Pelvic floor myalgia (levator ani spasm)
  • Piriformis syndrome
  • Rectus tendon strain
  • Hernias (eg, obturator, sciatic, inguinal, femoral, spigelian, perineal, umbilical)
• Gastrointestinal disorders
  • Carcinoma of the colon
  • Chronic intermittent bowel obstruction
  • Colitis
  • Chronic constipation
  • Diverticular disease
  • Inflammatory bowel disease
  • Irritable bowel syndrome
• Neurologic disorders
  • Neuralgia/cutaneous nerve entrapment (surgical scar in the lower part of the abdomen; usually iliohypogastric, ilioinguinal, genitofemoral, and lateral femoral cutaneous nerves)
  • Shingles (herpes zoster infection)
  • Degenerative joint disease
  • Disk herniation
  • Spondylosis
  • Abdominal epilepsy
  • Abdominal migraine
  • Neoplasia of spinal cord or sacral nerve
• Psychologic and other disorders
  • Personality disorders
  • Depression
  • Sleep disorders
  • Sexual and/or physical abuse
• Common causes of CPP in men
  • Chronic (nonbacterial) prostatitis
  • Chronic orchalgia
  • Prostatodynia

Differential Diagnoses

Other Problems to Be Considered

Reproductive system
Adenomyosis
Adhesions
Adnexal tumors
Cervical stenosis
Dyspareunia
Endocervical and endometrial polyps
Endometriosis and endosalpingiosis
Uterine leiomyomas
Ovarian retention syndrome
Ovarian remnant syndrome
Pelvic varicosities and pelvic congestion syndrome
Vulvodynia
Pelvic floor relaxation disorders
Accessory and supernumerary ovaries

Urinary system
Chronic and recurrent urinary tract infections
Urolithiasis
Pelvic floor dysfunction
Urethral diverticula
Chronic urethral syndrome

Gastrointestinal system
Chronic intermittent bowel obstruction
Colitis
Chronic constipation
Diverticular disease
Inflammatory bowel disease
Irritable bowel syndrome
Peritoneal abscess

Other diseases
Hernias (eg, obturator, sciatic, inguinal, femoral, perineal, spigelian, umbilical)
Neoplasia of the spinal cord or sacral nerves
Mononeuropathy and nerve entrapment
Abdominal epilepsy
Abdominal migraines
Pelvic floor pain syndrome
Rectus abdominis pain
Faulty posture
Bipolar affective disorder and depression
Chronic visceral pain syndrome
Chronic fatigue syndrome
Substance abuse
Spinal malformation
Spinal tumors

Workup

Laboratory Studies

• The decision to perform laboratory or imaging evaluations is based on the need for confirmation of the diagnosis and to help rule out other potentially life-threatening illnesses. Certain investigations sometimes are needed to provide appropriate and safe medical or surgical treatment.
• Complete blood cell count and sedimentation rate: These tests provide nonspecific findings, but the results can be sensitive indicators of inflammation or infection and, occasionally, malignancy.
• Serum drug screen: Perform this if any suggestion of prescription or street drug abuse is present.
• Urine test
  • Urinalysis and urine culture are relatively inexpensive and noninvasive and should be performed when necessary.
  • If hematuria is present, carefully evaluate the condition with a history, physical examination, urine culture, urine cytology, cystourethroscopy, and intravenous pyelography or CT scan.
  • If malignancy is suggested, perform urine cytology in addition to urinalysis and culture, especially if the patient smokes.
• Sexually transmitted disease testing
  • Testing for sexually transmitted diseases in women with chronic pelvic pain (CPP) includes cervical cultures or smears, syphilis serology (rapid plasma reagent, microhemagglutination-Treponema pallidum), hepatitis B screening, chlamydial polymerase chain reaction, and HIV testing.
  • Other tests used to help rule out specific infections may include vaginal cultures, vaginal wet preparations, vaginal pH, and urine analysis and culture.
• Hormone assays: Follicle-stimulating hormone level, estradiol level, and gonadotropin-releasing hormone agonist stimulation testing can be helpful in cases of ovarian remnant syndrome.
• Thyroid-stimulating hormone testing
  • This is used for evaluation of hypothyroidism, especially in a patient with depression.
  • Perform stool guaiac testing in patients with gastrointestinal symptoms and in patients older than 50 years. Testing stool specimens for ova and parasites also may be helpful in selected cases.

Imaging Studies

• Magnetic resonance imaging
  • MRI is a noninvasive tool that can provide excellent structural information without any radiation harm.
  • Intravenous contrast can be used when inflammation, infection, or malignancy is suggested.
• CT scan: This is useful in patients with pelvic masses and sometimes is helpful in differentiating an ovarian mass from a uterine mass, but it is more expensive than sonography.
• Ultrasonography
  • This is a noninvasive diagnostic tool and could be helpful in many patients with CPP.
  • It commonly is used to help identify pelvic masses or cysts and their origin, pelvic varicosities, and hernias (spigelian hernias).
• Plain film radiography
  • Obtaining chest and spine radiographs may be useful in fractures, infections, tumors, and other structural abnormalities.
  • Flat and upright abdominal radiographs may be obtained to help rule out intestinal obstruction and pelvic infection (eg, tuberculosis).
• Herniography (perineal hernia herniography)
• Bone scan
• Hysterosalpingography
  • Hysterosalpingography (HSG) is not a first-choice diagnostic tool for endometriosis; however, it may be useful in patients with infiltrative endometriosis of the uterosacral ligaments. Adolescents with endometriosis also can be evaluated for obstructive anomalies.
  • HSG may be useful in cases suggestive of endometrial polyps, Asherman syndrome, and adenomyosis.
• Barium enema radiography, colonoscopy, sigmoidoscopy, upper gastrointestinal series, and anorectal manometry
  • These can be used to evaluate a gastrointestinal etiology of chronic pain.
  • Anorectal balloon manometry can be used to assess colonic transit time.
• Vaginal sonography
  • This is useful in patients with possible pelvic congestion syndrome.
  • Transuterine venography commonly is recommended.
• Voiding cystourethrography: When interstitial cystitis is suggested, consider cystoscopy with hydrodistention.
• Double-balloon cystourethrography: This is a more sensitive diagnostic test than voiding cystourethrography for diagnosing urethral diverticula in women.⁶

Other Tests

• Endoscopic procedures used commonly in the evaluation and treatment of patients with CPP include laparoscopy, cystourethroscopy, hysteroscopy, sigmoidoscopy, and colonoscopy.
• Laparoscopy can be used as a diagnostic tool in patients with CPP, as follows:
  • More than 40% of laparoscopies are performed for the diagnosis of CPP.
  • More then 60% of women with CPP have at least one condition detectable by laparoscopy.
  • Most commonly, diagnoses made via laparoscopy include endometriosis, pelvic adhesions, and chronic pelvic inflammatory disease. Other diagnoses include ovarian cysts, hernias, pelvic congestion syndrome, ovarian remnant syndrome, ovarian retention syndrome, postoperative peritoneal cysts, and endosalpingiosis.
• Urodynamic testing can be performed if chronic urethral syndrome or interstitial cystitis is suggested in a patient with CPP.
• Nerve-conducting velocities and needle-electromyographic studies are used to help evaluate compression or entrapment neuropathy and pelvic floor function.
• Cancer antigen 125 (CA-125), used as a diagnostic test, has low sensitivity and specificity.
  • CA-125 may be elevated with diseases associated with pelvic pain, such as endometriosis or leiomyomata.
  • CA-125 levels also are elevated with malignancy (eg, ovarian, endometrial, colon, or breast cancer), pelvic inflammatory disease, pregnancy, and menses.⁷
  • Perform electroencephalography if the rare disorder of abdominal epilepsy is suggested.

Treatment

Medical Care

Treatment of pelvic pain is complex in patients with multiple problems. 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 (CPP) 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.
• 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.
• 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.

Surgical Care

• Various minimally invasive techniques may provide pain relief. These techniques include the following:
  • Trigger point injections: These injections are used mostly for localized trigger points (myofascial pain or neuroma).
  • 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.⁸
• Various surgical procedures may be considered to treat CPP. 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.

Medication

Pharmacotherapy consists of symptomatic abortive therapy to stop or reduce the severity of acute exacerbation of pain and long-term therapy for chronic pain.

Analgesics

Generally used in mild to moderate pain; however, also may be effective for severe pain.

Acetaminophen (Tylenol)

First choice for pain, especially during pregnancy and breastfeeding.

Dosing

Adult

650-1000 mg PO q6h prn

Pediatric

<3 years: Not established
3-6 years: 10 mg/kg/dose PO; not to exceed 720 mg/d
6-12 years: 10 mg/kg/dose PO; not to exceed 2.6 g/d
>12 years: Administer as in adults

Interactions

Rifampin can reduce analgesic effects; coadministration with barbiturates, carbamazepine, sulfinpyrazone, hydantoins, ethanol, and isoniazid may increase hepatotoxicity

Contraindications

Documented hypersensitivity; known G-6-P deficiency

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Hepatotoxicity possible in patients with chronic alcoholism following various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; APAP is contained in many OTC products, and combined use with these products may result in cumulative APAP doses exceeding recommended maximum dose

Ibuprofen (Advil, Motrin)

Inhibits inflammatory reactions and pain by decreasing activity of cyclooxygenase, which is responsible for prostaglandin synthesis.

Dosing

Adult

400-800 mg PO q8h while symptoms persist; not to exceed 3.2 g/d

Pediatric

Not established

Interactions

Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently

Contraindications

Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy

Naproxen (Aleve, Naprosyn, Naprelan)

For relief of mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing activity of cyclooxygenase, which results in a decrease of prostaglandin synthesis.

Dosing

Adult

275 mg PO tid or 550 mg PO bid

Pediatric

Not established

Interactions

Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; NSAIDs may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently

Contraindications

Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug

Opioids

Commonly used for many pain syndromes.

Fentanyl (Duragesic patch)

Potent narcotic analgesic with much shorter half-life than morphine sulfate. DOC for conscious sedation analgesia. Ideal for analgesic action of short duration during anesthesia and immediate postoperative period. Excellent choice for pain management and sedation; short duration (30-60 min) and easy to titrate.
Easily and quickly reversed by naloxone. When using transdermal dosage form, most patients are controlled with 72-h dosing intervals.
However, some patients require dosing intervals of 48 h.
Available in 12, 25, 50, 75, and 100 mcg doses.

Dosing

Adult

Apply 25-100 mcg/h system q48-72h

Pediatric

Not established

Interactions

Phenothiazines may antagonize analgesic effects of opiate agonists; TCAs may potentiate adverse effects of fentanyl when both drugs are used concurrently

Contraindications

Documented hypersensitivity; hypotension or potentially compromised airway when it would be difficult to establish rapid airway control

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in hypotension, respiratory depression, constipation, nausea, emesis, and urinary retention; idiosyncratic reaction, known as chest wall rigidity syndrome, may require neuromuscular blockade in order to increase ventilation

Anticonvulsants

Certain antiepileptic drugs (eg, the GABA analogue gabapentin and pregabulin [Lyrica]) have proven helpful in some cases of neuropathic pain. Other anticonvulsant agents (eg, clonazepam, topiramate, lamotrigine, zonisamide, tiagabine) also have been tried in CPP.

Gabapentin (Neurontin)

Has anticonvulsant properties and antineuralgic effects; however, exact mechanism of action is unknown.
Structurally related to GABA but does not interact with GABA receptors.

Dosing

Adult

100 mg PO hs to 1200 mg PO tid

Pediatric

<12 years: Not recommended
>12 years: Administer as in adults

Interactions

Antacids may significantly reduce bioavailability (administer at least 2 h following antacids); may significantly increase norethindrone levels

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in severe renal disease; abrupt withdrawal may precipitate seizures

Pregabalin (Lyrica)

Structural derivative of GABA. Mechanism of action unknown. Binds with high affinity to alpha₂ -delta site (a calcium channel subunit). In vitro, reduces calcium-dependent release of several neurotransmitters, possibly by modulating calcium channel function. FDA approved for neuropathic pain associated with diabetic peripheral neuropathy or postherpetic neuralgia and as adjunctive therapy in partial-onset seizures.

Dosing

Adult

50 mg PO bid initially; if needed, may increase to 75 mg tid within 1 wk

Pediatric

Not established

Interactions

May cause additive effects on cognitive and gross motor functioning when coadministered with drugs that cause dizziness or somnolence

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Discontinue gradually (over a minimum of 1 wk) to minimize increased seizure frequency in patients with seizure disorders; may cause insomnia, nausea, headache, or diarrhea with abrupt withdrawal; common adverse effects include dizziness, somnolence, blurred vision, weight gain, and peripheral edema; may elevate creatinine kinase level, decrease platelet count, and increase PR interval; doses >300 mg/d associated with higher rate of adverse effects and treatment discontinuation; decrease dose with renal impairment (ie, CrCl <60 mL/min); angioedema has been reported during postmarketing surveillance

Tricyclic antidepressants and SNRIs

Increase synaptic concentration of serotonin and/or norepinephrine in the CNS by inhibiting reuptake by the presynaptic neuronal membrane (eg, duloxetine [Cymbalta], venlafaxine [Effexor]).

Nortriptyline (Pamelor)

Demonstrated effectiveness in the treatment of chronic pain.

Dosing

Adult

25-100 mg PO hs; not to exceed 200 mg/d

Pediatric

Not established

Interactions

Cimetidine may increase levels when used concurrently; may increase PT time in patients stabilized with warfarin

Contraindications

Documented hypersensitivity; narrow-angle glaucoma; do not administer to patients who have taken MAOIs in past 14 d

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in cardiac conduction disturbances and history of hyperthyroidism, renal impairment, or hepatic impairment; because of pronounced effects in cardiovascular system, best to avoid in patients who are elderly

Amitriptyline (Elavil)

Analgesic for certain chronic and neuropathic pain.

Dosing

Adult

25-100 mg PO hs; not to exceed 150 mg/d

Pediatric

Children: 0.1 mg/kg PO hs; increase as tolerated over 2-3 wk to 0.5-2 mg/d PO hs
Adolescents: 25-50 mg/d PO initially; increase gradually to 100 mg/d in divided doses

Interactions

Phenobarbital may decrease effects; coadministration with CYP2D6 enzyme system inhibitors (eg, cimetidine, quinidine) may increase levels; inhibits hypotensive effects of guanethidine; may interact with thyroid medications, alcohol, CNS depressants, barbiturates, and disulfiram

Contraindications

Documented hypersensitivity; patient has taken MAOIs in past 14 d; history of seizures, cardiac arrhythmias, glaucoma, and urinary retention

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in cardiac conduction disturbances and history of hyperthyroidism, renal impairment, or hepatic impairment; avoid using in patients who are elderly

Selective serotonin reuptake inhibitors

Selectively inhibit presynaptic serotonin reuptake with minimal or no effect in the reuptake of norepinephrine or dopamine. SSRIs can be used in second-line or third-line treatment of painful diabetic neuropathy. Good for patients who already are depressed.

Fluoxetine (Prozac)

Considered an alternative to TCAs, with fewer adverse anticholinergic and cardiovascular effects.

Dosing

Adult

10 mg PO in am; increase q2wk up to 60 mg/d

Pediatric

Not established

Interactions

Increases toxicity of diazepam and trazodone by decreasing clearance; also increases toxicity of MAOIs and highly protein-bound drugs

Contraindications

Documented hypersensitivity; concurrently taking MAOIs or took them in the last 2 wk

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in hepatic impairment and history of seizures; discontinue MAOIs at least 14 d before initiating fluoxetine therapy; anxiety, insomnia, drowsiness, tremor, anorexia, and anorgasmia and other sexual dysfunctions have been reported; nausea, flulike symptoms, and agitation also are noted but resolve within a few weeks

Sertraline (Zoloft)

Considered an alternative to TCAs, with fewer adverse anticholinergic and cardiovascular effects.

Dosing

Adult

50 mg/d PO in am with 50-mg/d increments q2-3d to 100 mg/d, if tolerated; not to exceed 200 mg/d

Pediatric

Not established

Interactions

Increases toxicity of MAOIs, diazepam, tolbutamide, and warfarin

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in preexisting seizure disorders and in those who have experienced a recent MI, have unstable heart disease, or have hepatic or renal impairment; anxiety, insomnia, drowsiness, tremor, anorexia, and anorgasmia and other sexual dysfunctions have been reported; nausea, flulike symptoms, and agitation also are noted but resolve within a few weeks

Paroxetine (Paxil)

Considered an alternative to TCAs, with fewer adverse anticholinergic and cardiovascular effects.

Dosing

Adult

10 mg/d PO and titrate up to 50 mg/d

Pediatric

Not established

Interactions

Phenobarbital and phenytoin decrease effects; alcohol, cimetidine, sertraline, phenothiazines, and warfarin increase toxicity

Contraindications

Documented hypersensitivity; concurrent administration with MAOIs or administering within 14 d of discontinuing an MAOIs

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in history of seizures, mania, renal disease, and cardiac disease; anxiety, insomnia, drowsiness, tremor, anorexia, and anorgasmia and other sexual dysfunctions have been reported; nausea, flulike symptoms, and agitation also are noted but resolve within a few weeks

Follow-up

Further Inpatient Care

Hospitalization usually is not 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.

Further Outpatient Care

Patients with CPP generally are treated in an outpatient setting and require a variety of health care professionals to optimally manage their condition.

Complications

Like other chronic pain, CPP may lead to prolonged suffering, marital or family problems, loss of employment, disability, and various adverse medical reactions from lifelong therapy.

Patient Education

• The patient and the patient's family should have a good understanding about the multifactorial nature of chronic pain. They need multidisciplinary and comprehensive management plans.
• Instruct the patient to avoid uncomfortable stressful positions and bad posture. Also recommend regular exercise, good sleeping habits, and balanced meals.
• Try biofeedback and relaxation techniques.
• For excellent patient education resources, visit eMedicine's Bone Health Center, Muscle Disorders Center, Kidneys and Urinary System Center and Women's Health Center. Also, see eMedicine's patient education articles Chronic Pain, Bladder Control Problems, Female Sexual Problems, Endometriosis, and Pain During Intercourse.

Miscellaneous

Medicolegal Pitfalls

• Good rapport, tolerance, and an open-minded approach are important in the evaluation of any patient with chronic pain.
• Patients with chronic pelvic pain (CPP) may exhibit exaggerated pain behavior or sensations that seem to be hysterical or appear nonanatomic or nonphysiologic; however, these patients always must be taken seriously and appropriate conservative steps should be taken.
• Obtaining a thorough past history is important to avoid repeating invasive and expensive procedures.
• Consultation with a psychologist, urologist, neurologist, and gastrointestinal specialist or other appropriate specialists is very important, especially before considering invasive or aggressive management.

Special Concerns

• Appropriate caution must be taken during treatment of patients with the following characteristics:
  • Poor response to prior appropriate treatment
  • Unusual unexpected response to prior specific treatment
  • Avoidance of school, work, or other social responsibilities
  • Severe depression
  • Severe anxiety disorder
  • Excessive pain behavior
  • Frequent health care provider changes
  • Noncompliance with past treatment
  • Drug abuse or dependence
  • Family, marital, or sexual problems
  • History of physical or sexual abuse
• Pregnancy
  • The use of medication during pregnancy is not contraindicated, but it should be limited and carefully justified.
  • Initially, pain should be managed with nonpharmacologic measures such as reassurance, rest, hot or cold applications, positioning, stretching exercises, massage, ultrasound therapy, TENS, relaxation therapy, and biofeedback. If pain does not respond to a nonpharmacologic approach, symptomatic drugs may be used carefully.
  • Acetaminophen and codeine (alone or in combination) can be used during pregnancy.
  • Nonsteroidal anti-inflammatory drugs such as ibuprofen and aspirin may be considered during the first trimester of pregnancy, but they should be avoided especially during the last trimester. They may constrict or close the fetal ductus arteriosus and may cause maternal and fetal bleeding.
  • Limit benzodiazepine and barbiturate use. Do not use ergotamine, dihydroergotamine, and sumatriptan.
• CPP in men: Chronic (nonbacterial) prostatitis, chronic orchalgia, and prostatodynia are common causes of CPP in men of any age.

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Keywords

chronic pelvic pain, CPP, bladder dysfunction, bowel dysfunction, sexual dysfunction, depression, anxiety disorder, drug addiction, drug abuse, prostatitis, chronic orchalgia, prostatodynia, pelvic congestion syndrome, endometriosis, uterine leiomyomas, adenomyosis, pelvic inflammatory disease, PID, cervical stenosis, deflecting sigmoid adhesion, pelvic floor relaxation disorder, pudendal neuralgia, somatization, physical abuse, sexual abuse, sexually transmitted disease, STD, nonmenstrual pain, vulvodynia, dyspareunia, Betty maneuver, piriformis syndrome, obturator sign, psoas sign, Patrick test, faber test

adnexal cysts, chronic urinary tract infection, abdominal wall myofascial pain, carcinoma of the colon, chronic intermittent bowel obstruction, cutaneous nerve entrapment, shingles, sleep disorders, chronic ectopic pregnancy, chlamydial endometritis, chlamydial salpingitis, endosalpingiosis, ovarian retention syndrome, residual ovary syndrome, ovarian remnant syndrome, ovarian dystrophy, ovulatory pain, postoperative peritoneal cysts, residual accessory ovary, subacute salpingo-oophoritis, tuberculous salpingitis, atypical dysmenorrhea, endometrial polyps, cervical polyps, leiomyomata, genital prolapse

intrauterine contraceptive device, bladder neoplasm, interstitial cystitis, radiation cystitis, recurrent cystitis, recurrent urethritis, urolithiasis, detrusor-sphincter dyssynergia, urethral diverticulum, chronic urethral syndrome, urethral caruncle, compression fracture of lumbar vertebrae, fibromyalgia, faulty posture, mechanical low back pain, chronic coccygeal pain, muscular strains and sprains, pelvic floor myalgia, levator ani spasm, rectus tendon strain, femoral hernia, perineal hernia, umbilical hernia, spigelian hernia, sciatic hernia, obturator hernia, colitis, chronic constipation, diverticular disease, inflammatory bowel disease, irritable bowel syndrome, herpes zoster infection, degenerative joint disease, disk herniation, spondylosis, abdominal epilepsy, abdominal migraine, neoplasia of spinal cord

Contributor Information and Disclosures

Author

Manish K Singh, MD, Assistant Professor, Department of Neurology, Teaching Faculty for Pain Management and Neurology Residency Program, Hahnemann University Hospital, Drexel College of Medicine; Medical Director, Neurology and Pain Management, Jersey Institute of Neuroscience
Manish K Singh, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Pain Medicine, American Association of Physicians of Indian Origin, American Headache Society, American Medical Association, and American Society of Regional Anesthesia and Pain Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Elizabeth E Puscheck, MD, Professor, Department of Obstetrics and Gynecology, Wayne State University School of Medicine; In Vitro Fertilization Director, Gynecologic Ultrasound Director, Clinical Endocrine Laboratory Consultant, Department of Obstetrics and Gynecology, University Women's Care
Elizabeth E Puscheck, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Institute of Ultrasound in Medicine, American Society for Reproductive Medicine, Association of Professors of Gynecology and Obstetrics, Endocrine Society, International Society for Clinical Densitometry, Society for Assisted Reproductive Technologies, Society for Reproductive Endocrinology and Infertility, and Society of Reproductive Surgeons
Disclosure: Ferring Grant/research funds Other

Jashvant Patel, MD, Medical Director, Department of Pain Medicine and Comprehensive Rehabilitation, Medical College of Pennsylvania Hahnemann University
Jashvant Patel, MD is a member of the following medical societies: Alberta Medical Association, American Academy of Pain Medicine, American Academy of Physical Medicine and Rehabilitation, American Medical Association, American Society of Regional Anesthesia and Pain Medicine, and Medical Society of the State of New York
Disclosure: Nothing to disclose.

Medical Editor

Suzanne R Trupin, MD, Clinical Professor of Obstetrics and Gynecology, University of Illinois College of Medicine-Champaign; CEO and Owner, Women's Health Practice; CEO and Owner, Hada Cosmetic Medicine and Midwest Surgical Center
Suzanne R Trupin, MD is a member of the following medical societies: American Association of Gynecologic Laparoscopists, American College of Obstetricians and Gynecologists, American Institute of Ultrasound in Medicine, American Medical Association, Association of Reproductive Health Professionals, International Society for Clinical Densitometry, and North American Menopause Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

A David Barnes, MD, PhD, MPH, FACOG, Consulting Staff, Department of Obstetrics and Gynecology, Mammoth Hospital (Mammoth Lakes, California), Pioneer Valley Hospital (Salt Lake City, Utah), Warren General Hospital (Warren, Pennsylvania), and Mountain West Hospital (Tooele, Utah)
A David Barnes, MD, PhD, MPH, FACOG is a member of the following medical societies: American College of Forensic Examiners, American College of Obstetricians and Gynecologists, American Medical Association, Association of Military Surgeons of the US, and Utah Medical Association
Disclosure: Nothing to disclose.

CME Editor

Frederick B Gaupp, MD, Consulting Staff, Department of Family Practice, Hancock Medical Center
Frederick B Gaupp, MD is a member of the following medical societies: American Academy of Family Physicians
Disclosure: Nothing to disclose.

Chief Editor

Michel E Rivlin, MD, Professor, Coordinator of Quality Assurance/Quality Improvement, Department of Obstetrics and Gynecology, University of Mississippi School of Medicine
Michel E Rivlin, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, Mississippi State Medical Association, and Royal College of Surgeons of Edinburgh
Disclosure: Nothing to disclose.

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