eMedicine Specialties > Obstetrics and Gynecology > General Gynecology
Chronic Pelvic Pain: Treatment & Medication
Updated: Dec 22, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
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.
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
Rifampin can reduce analgesic effects; coadministration with barbiturates, carbamazepine, sulfinpyrazone, hydantoins, ethanol, and isoniazid may increase hepatotoxicity
Documented hypersensitivity; known G-6-P deficiency
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.
Adult
400-800 mg PO q8h while symptoms persist; not to exceed 3.2 g/d
Pediatric
Not established
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
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding
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.
Adult
275 mg PO tid or 550 mg PO bid
Pediatric
Not established
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
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency
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.
Adult
Apply 25-100 mcg/h system q48-72h
Pediatric
Not established
Phenothiazines may antagonize analgesic effects of opiate agonists; TCAs may potentiate adverse effects of fentanyl when both drugs are used concurrently
Documented hypersensitivity; hypotension or potentially compromised airway when it would be difficult to establish rapid airway control
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.
Adult
100 mg PO hs to 1200 mg PO tid
Pediatric
<12 years: Not recommended
>12 years: Administer as in adults
Antacids may significantly reduce bioavailability (administer at least 2 h following antacids); may significantly increase norethindrone levels
Documented hypersensitivity
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.
Adult
50 mg PO bid initially; if needed, may increase to 75 mg tid within 1 wk
Pediatric
Not established
May cause additive effects on cognitive and gross motor functioning when coadministered with drugs that cause dizziness or somnolence
Documented hypersensitivity
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.
Adult
25-100 mg PO hs; not to exceed 200 mg/d
Pediatric
Not established
Cimetidine may increase levels when used concurrently; may increase PT time in patients stabilized with warfarin
Documented hypersensitivity; narrow-angle glaucoma; do not administer to patients who have taken MAOIs in past 14 d
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.
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
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
Documented hypersensitivity; patient has taken MAOIs in past 14 d; history of seizures, cardiac arrhythmias, glaucoma, and urinary retention
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.
Adult
10 mg PO in am; increase q2wk up to 60 mg/d
Pediatric
Not established
Increases toxicity of diazepam and trazodone by decreasing clearance; also increases toxicity of MAOIs and highly protein-bound drugs
Documented hypersensitivity; concurrently taking MAOIs or took them in the last 2 wk
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.
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
Increases toxicity of MAOIs, diazepam, tolbutamide, and warfarin
Documented hypersensitivity
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.
Adult
10 mg/d PO and titrate up to 50 mg/d
Pediatric
Not established
Phenobarbital and phenytoin decrease effects; alcohol, cimetidine, sertraline, phenothiazines, and warfarin increase toxicity
Documented hypersensitivity; concurrent administration with MAOIs or administering within 14 d of discontinuing an MAOIs
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
More on Chronic Pelvic Pain |
| Overview: Chronic Pelvic Pain |
| Differential Diagnoses & Workup: Chronic Pelvic Pain |
 Treatment & Medication: Chronic Pelvic Pain |
| Follow-up: Chronic Pelvic Pain |
| References |
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References
Mathias SD, Kuppermann M, Liberman RF, et al. Chronic pelvic pain: prevalence, health-related quality of life, and economic correlates. Obstet Gynecol. Mar 1996;87(3):321-7. [Medline].
Jamieson DJ, Steege JF. The prevalence of dysmenorrhea, dyspareunia, pelvic pain, and irritable bowel syndrome in primary care practices. Obstet Gynecol. Jan 1996;87(1):55-8. [Medline].
Reiter RC. A profile of women with chronic pelvic pain. Clin Obstet Gynecol. Mar 1990;33(1):130-6. [Medline].
Zondervan KT, Yudkin PL, Vessey MP, et al. Prevalence and incidence of chronic pelvic pain in primary care: evidence from a national general practice database. Br J Obstet Gynaecol. Nov 1999;106(11):1149-55. [Medline].
Lampe A, Solder E, Ennemoser A, et al. Chronic pelvic pain and previous sexual abuse. Obstet Gynecol. Dec 2000;96(6):929-33. [Medline].
Jacoby K, Rowbotham RK. Double balloon positive pressure urethrography is a more sensitive test than voiding cystourethrography for diagnosing urethral diverticulum in women. J Urol. Dec 1999;162(6):2066-9. [Medline].
Howard FM, Perry PC, Carter JE, eds. Pelvic Pain: Diagnosis and Management. Baltimore, Md: Lippincott Williams & Wilkins; 2000.
Everaert K, Devulder J, De Muynck M, et al. The pain cycle: implications for the diagnosis and treatment of pelvic pain syndromes. Int Urogynecol J Pelvic Floor Dysfunct. 2001;12(1):9-14. [Medline].
Baker PK. Musculoskeletal origins of chronic pelvic pain. Diagnosis and treatment. Obstet Gynecol Clin North Am. Dec 1993;20(4):719-42. [Medline].
Ben-David B, Friedman M. Gabapentin therapy for vulvodynia. Anesth Analg. Dec 1999;89(6):1459-60. [Medline].
Benes J, Nadvornik P, Dolezel J. Abdominoinguinal pain syndrome treated by centrocentral anastomosis. Acta Neurochir (Wien). 2000;142(8):887-91. [Medline].
Bergqvist A. Current drug therapy recommendations for the treatment of endometriosis. Drugs. Jul 1999;58(1):39-50. [Medline].
Bodden-Heidrich R, Küppers V, Beckmann MW, Rechenberger I, Bender HG. Chronic pelvic pain syndrome (CPPS) and chronic vulvar pain syndrome (CVPS): evaluation of psychosomatic aspects. J Psychosom Obstet Gynaecol. Sep 1999;20(3):145-51. [Medline].
Bost BW. Deflecting sigmoid adhesions: an anatomic cause of chronic pelvic pain and irritable bowel syndrome. Obstet Gynecol. Apr 2001;97(4 Suppl 1):S27.
Braverman PK. Sexually transmitted diseases in adolescents. Med Clin North Am. Jul 2000;84(4):869-89, vi-vii. [Medline].
Carter JE. A systematic history for the patient with chronic pelvic pain. JSLS. Oct-Dec 1999;3(4):245-52. [Medline].
Carter JE. Surgical treatment for chronic pelvic pain. J Soc Laparoendosc Surg. Apr-Jun 1998;2(2):129-39. [Medline].
Clemons JL, Arya LA, Myers DL. Diagnosing interstitial cystitis in women with chronic pelvic pain. Obstet Gynecol. Aug 2002;100(2):337-41. [Medline].
Cody RF Jr, Ascher SM. Diagnostic value of radiological tests in chronic pelvic pain. Baillieres Best Pract Res Clin Obstet Gynaecol. Jun 2000;14(3):433-66. [Medline].
Demco LA. Pain referral patterns in the pelvis. J Am Assoc Gynecol Laparosc. May 2000;7(2):181-3. [Medline].
Dwarakanath LS, Persad PS, Khan KS. Role of laparoscopy in the management of chronic pelvic pain. Hosp Med. Aug 1998;59(8):627-31. [Medline].
Economy KE, Laufer MR. Pelvic pain. Adolesc Med. Jun 1999;10(2):291-304. [Medline].
Ehlert U, Heim C, Hellhammer DH. Chronic pelvic pain as a somatoform disorder. Psychother Psychosom. Mar-Apr 1999;68(2):87-94. [Medline].
[Best Evidence] Finnerup NB, Otto M, McQuay HJ, et al. Algorithm for neuropathic pain treatment: an evidence based proposal. Pain. Dec 5 2005;118(3):289-305. [Medline].
Ghaly AF, Chien PF. Chronic pelvic pain: clinical dilemma or clinician's nightmare. Sex Transm Infect. Dec 2000;76(6):419-25. [Medline].
Grace VM. Pitfalls of the medical paradigm in chronic pelvic pain. Baillieres Best Pract Res Clin Obstet Gynaecol. Jun 2000;14(3):525-39. [Medline].
Gurel H, Atar Gurel S. Dyspareunia, back pain and chronic pelvic pain: the importance of this pain complex in gynecological practice and its relation with grand multiparity and pelvic relaxation. Gynecol Obstet Invest. 1999;48(2):119-22. [Medline].
Hewitt GD, Brown RT. Acute and chronic pelvic pain in female adolescents. Med Clin North Am. Jul 2000;84(4):1009-25. [Medline].
Holley RL, Richter HE, Wang L. Neurologic disease presenting as chronic pelvic pain. South Med J. Nov 1999;92(11):1105-7. [Medline].
Howard FM. Abuse history and chronic pain in women: I. Prevalences of sexual abuse and physical abuse. Obstet Gynecol. Jan 1995;85(1):158-9. [Medline].
Howard FM. An evidence-based medicine approach to the treatment of endometriosis- associated chronic pelvic pain: placebo-controlled studies. J Am Assoc Gynecol Laparosc. Nov 2000;7(4):477-88. [Medline].
Howard FM. Laparoscopic evaluation and treatment of women with chronic pelvic pain. J Am Assoc Gynecol Laparosc. Aug 1994;1(4 Pt 1):325-31. [Medline].
Howard FM. The role of laparoscopy as a diagnostic tool in chronic pelvic pain. Baillieres Best Pract Res Clin Obstet Gynaecol. Jun 2000;14(3):467-94. [Medline].
Howard FM. The role of laparoscopy in chronic pelvic pain: promise and pitfalls. Obstet Gynecol Surv. Jun 1993;48(6):357-87. [Medline].
Howard FM. The role of laparoscopy in the evaluation of chronic pelvic pain: pitfalls with a negative laparoscopy. J Am Assoc Gynecol Laparosc. Nov 1996;4(1):85-94. [Medline].
Howard FM, El-Minawi AM, Sanchez RA. Conscious pain mapping by laparoscopy in women with chronic pelvic pain. Obstet Gynecol. Dec 2000;96(6):934-9. [Medline].
Jarrell JF. The weight of chronic pelvic pain. J Obstet Gynaecol Can. May 2004;26(5):453-4. [Medline].
Justins DM. Management strategies for chronic pain. Ann Rheum Dis. Sep 1996;55(9):588-96. [Medline].
Kanazi GE, Perkins FM, Thakur R, Dotson E. New technique for superior hypogastric plexus block. Reg Anesth Pain Med. Sep-Oct 1999;24(5):473-6. [Medline].
Kontoravdis A, Hassan E, Hassiakos D, et al. Laparoscopic evaluation and management of chronic pelvic pain during adolescence. Clin Exp Obstet Gynecol. 1999;26(2):76-7. [Medline].
Large RG. Psychological aspects of pain. Ann Rheum Dis. Jun 1996;55(6):340-5. [Medline].
Luzzi G, O'Leary M. Chronic pelvic pain syndrome. BMJ. May 8 1999;318(7193):1227-8. [Medline].
Malik E, Berg C, Meyhofer-Malik A, et al. Subjective evaluation of the therapeutic value of laparoscopic adhesiolysis: a retrospective analysis. Surg Endosc. Jan 2000;14(1):79-81. [Medline].
McCrory P, Bell S. Nerve entrapment syndromes as a cause of pain in the hip, groin and buttock. Sports Med. Apr 1999;27(4):261-74. [Medline].
McDonald JS. Management of chronic pelvic pain. Obstet Gynecol Clin North Am. Dec 1993;20(4):817-38. [Medline].
Moore J, Kennedy S. Causes of chronic pelvic pain. Baillieres Best Pract Res Clin Obstet Gynaecol. Jun 2000;14(3):389-402. [Medline].
Morikawa JH. Laparoscopy for chronic pelvic pain. Hawaii Med J. Jan 1999;58(1):22-3. [Medline].
Negre E, Chaptal PA, Grolleau-Raoux D, Caporiccio A. [Systemic embolism after closure of an ostium secundum (author's transl)]. Ann Chir Thorac Cardiovasc. Jan 1975;14(1):21-4. [Medline].
Nezhat FR, Crystal RA, Nezhat CH, Nezhat CR. Laparoscopic adhesiolysis and relief of chronic pelvic pain. JSLS. Oct-Dec 2000;4(4):281-5. [Medline].
Olive DL, Schwartz LB. Endometriosis. N Engl J Med. Jun 17 1993;328(24):1759-69. [Medline].
Papathanasiou K, Papageorgiou C, Panidis D, Mantalenakis S. Our experience in laparoscopic diagnosis and management in women with chronic pelvic pain. Clin Exp Obstet Gynecol. 1999;26(3-4):190-2. [Medline].
Pashley DH. Dentin permeability and dentin sensitivity. Proc Finn Dent Soc. 1992;88 Suppl 1:31-7. [Medline].
Prentice A. Medical management of chronic pelvic pain. Baillieres Best Pract Res Clin Obstet Gynaecol. Jun 2000;14(3):495-9. [Medline].
Reiter RC. Evidence-based management of chronic pelvic pain. Clin Obstet Gynecol. Jun 1998;41(2):422-35. [Medline].
Richter HE, Holley RL, Chandraiah S, Varner RE. Laparoscopic and psychologic evaluation of women with chronic pelvic pain. Int J Psychiatry Med. 1998;28(2):243-53. [Medline].
Rickert VI, Kozlowski KJ. Pelvic pain. A SAFE approach. Obstet Gynecol Clin North Am. Mar 2000;27(1):181-93. [Medline].
Robert R, Prat-Pradal D, Labat JJ. Anatomic basis of chronic perineal pain: role of the pudendal nerve. Surg Radiol Anat. 1998;20(2):93-8. [Medline].
Sand PK. Chronic pain syndromes of gynecologic origin. J Reprod Med. Mar 2004;49(3 Suppl):230-4. [Medline].
Scialli AR. Evaluating chronic pelvic pain. A consensus recommendation. Pelvic Pain Expert Working Group. J Reprod Med. Nov 1999;44(11):945-52. [Medline].
Selfe SA, Matthews Z, Stones RW. Factors influencing outcome in consultations for chronic pelvic pain. J Womens Health. Oct 1998;7(8):1041-8. [Medline].
Selfe SA, Van Vugt M, Stones RW. Chronic gynaecological pain: an exploration of medical attitudes. Pain. Aug 1998;77(2):215-25. [Medline].
Steege JF. Office assessment of chronic pelvic pain. Clin Obstet Gynecol. Sep 1997;40(3):554-63. [Medline].
Stewart P, Slade P. Comparative study of pelvic and non-pelvic pain/the prevalence of chronic pelvic pain. Br J Obstet Gynaecol. Dec 1998;105(12):1338-9. [Medline].
Stone AR, Kim JH. Pelvic, perineal, and genital pain. In: Gershwin ME, Hamilton ME eds. The Pain Management Handbook: A Concise Guide to Diagnosis and Treatment. Totowa, NJ: Humana Press; 1998:147-63.
Stones RW, Mountfield J. Interventions for treating chronic pelvic pain in women. Cochrane Database Syst Rev. 2000;CD000387. [Medline].
Stones RW, Selfe SA, Fransman S, Horn SA. Psychosocial and economic impact of chronic pelvic pain. Baillieres Best Pract Res Clin Obstet Gynaecol. Jun 2000;14(3):415-31. [Medline].
Stovall DW. Transvaginal ultrasound findings in women with chronic pelvic pain. Obstet Gynecol. Apr 1 2000;95(4 Suppl 1):S57.
Summitt RL Jr. Urogynecologic causes of chronic pelvic pain. Obstet Gynecol Clin North Am. Dec 1993;20(4):685-98. [Medline].
Toozs-Hobson P, Bidmead J, Cardozo L. Chronic pelvic pain. Br J Obstet Gynaecol. Nov 1998;105(11):1238. [Medline].
Vercellini P, De Giorgi O, Pisacreta A, et al. Surgical management of endometriosis. Baillieres Best Pract Res Clin Obstet Gynaecol. Jun 2000;14(3):501-23. [Medline].
Walker JJ, Irvine G. How should we approach the management of pelvic pain?. Gynecol Obstet Invest. 1998;45 Suppl 1:6-10; discussion 10-1, 35. [Medline].
Winkel CA, Scialli AR. Safety of medical and surgical management of chronic pelvic pain and endometriosis. Obstet Gynecol. Apr 2001;97(4 Suppl 1):S28.
Wise TN, Arnold LM, Maletic V. Management of painful physical symptoms associated with depression and mood disorders. CNS Spectr. Dec 2005;10(12 Suppl 19):1-13. [Medline].
Zondervan K, Barlow DH. Epidemiology of chronic pelvic pain. Baillieres Best Pract Res Clin Obstet Gynaecol. Jun 2000;14(3):403-14. [Medline].
Further Reading
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
