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Chronic Pelvic Pain in Women Treatment & Management

  • Author: Manish K Singh, MD; Chief Editor: Michel E Rivlin, MD  more...
 
Updated: Jan 13, 2015
 

Medical Care

Treatment of chronic pelvic pain (CPP) is complex in patients with multiple problems.[12, 13] 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.

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).[14] 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.[14]

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.

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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.[15]

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).

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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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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 Headache Society, American Association of Physicians of Indian Origin, American Medical Association, American Society of Regional Anesthesia and Pain Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Jashvant Patel, MBBS, MS, MD 

Jashvant Patel, MBBS, MS, 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, Medical Society of the State of New York

Disclosure: Nothing to disclose.

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 Institute of Ultrasound in Medicine, International Society for Clinical Densitometry, Society for Assisted Reproductive Technology, Society of Reproductive Surgeons, Society for Reproductive Endocrinology and Infertility, American College of Obstetricians and Gynecologists, American Society for Reproductive Medicine, Association of Professors of Gynecology and Obstetrics, Endocrine Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

A David Barnes, MD, MPH, PhD, FACOG Consulting Staff, Department of Obstetrics and Gynecology, Mammoth Hospital (Mammoth Lakes, CA), Pioneer Valley Hospital (Salt Lake City, UT), Warren General Hospital (Warren, PA), and Mountain West Hospital (Tooele, UT)

A David Barnes, MD, MPH, PhD, FACOG is a member of the following medical societies: American College of Forensic Examiners Institute, American College of Obstetricians and Gynecologists, Association of Military Surgeons of the US, American Medical Association, Utah Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Michel E Rivlin, MD Former Professor, 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, Royal College of Surgeons of Edinburgh, Royal College of Obstetricians and Gynaecologists

Disclosure: Nothing to disclose.

Additional Contributors

Suzanne R Trupin, MD, FACOG Clinical Professor, Department of Obstetrics and Gynecology, University of Illinois College of Medicine at Urbana-Champaign; CEO and Owner, Women's Health Practice; CEO and Owner, Hada Cosmetic Medicine and Midwest Surgical Center

Suzanne R Trupin, MD, FACOG is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Institute of Ultrasound in Medicine, International Society for Clinical Densitometry, AAGL, North American Menopause Society, American Medical Association, Association of Reproductive Health Professionals

Disclosure: Nothing to disclose.

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Transabdominal longitudinal view of the female pelvis.
Transabdominal transverse view of the female pelvis: The bladder is rectangular. The ovaries are seen bilaterally in the adnexa.
 
 
 
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