Caring for patients with chronic pelvic pain

Chronic pelvic pain is defined as noncyclic pelvic pain with a duration of > 6 months, localized below the umbilicus to the anatomic pelvis, and resulting in decreased quality of life and the need for medical treatment.¹ Chronic pelvic pain affects approximately 15% of women in the United States every year. It is associated with significant costs to the healthcare system, estimated at nearly $2 billion per year.²

The multifactorial nature of chronic pelvic pain makes it difficult to evaluate and treat. In fact, 70% of cases of chronic pelvic pain are estimated to be from non-gynecologic etiologies.³ Despite the cause (and even following definitive treatment; eg, hysterectomy) chronic pain may result in central sensitization, maintaining chronic pain pathways between the periphery and the brain, altering the central processing of pain. This leading theory supports the use of multimodal therapy and centrally acting medications to treat chronic pain.⁴

Medications

Analgesics

Many patients with chronic pain have developed some level of centralized pain sensitization and will benefit most from medications that act on the central nervous system. However, traditional analgesics still have a role in management of chronic pelvic pain. Nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, and opioids can be used, alone or in combination, for patients with chronic pain who experience acute pain “flares” (Table 1).

NSAIDs work by non-selectively inhibiting the cyclooxygenase (COX) enzyme, which in turn inhibits formation of prostaglandins and thromboxane. The most commonly prescribed NSAIDs are aspirin, ibuprofen, and naproxen. Potential adverse effects of NSAIDs include gastrointestinal upset, ulcers, or bleeding, as well as renal failure, hypertension, heart attack, and stroke.

The exact mechanism of action of acetaminophen is unknown, but it is believed to work by inhibiting cyclooxygenase, specifically COX-2. Adverse effects include liver damage, skin reactions, and potential for overdose.

Many opioid medications, both synthetic and natural derivatives of the opium poppy, are used to treat chronic pain. Opioids work by binding to opioid receptors in the central and peripheral nervous system. They are highly effective for acute pain and chronic malignant pain but, their use in treatment of chronic noncancer pain remains controversial. Patients who require long-term opioid use are at risk of developing tolerance, physical dependence, and addiction.

In addition to common short-term adverse effects such as nausea and vomiting, itching, constipation, and drowsiness, many long-term negative health consequences are associated with opioid use (Table 2).⁵ Many patients are not familiar with the risks of long-term opioid use and have not been offered other alternatives for pain management.

Most patients with chronic pain do not want to be maintained on opioids and are agreeable to alternative therapies when given a choice. In general, we advise against routine use of opioids for management of chronic pelvic pain.

Antidepressants

Tricyclic antidepressants (TCAs) are a mainstay of treatment for chronic pain. While their effectiveness in pain management is well established, the anticholinergic adverse effect profile can limit use. Generally, the rule “start low and go slow” should be applied to centrally acting medications. This approach will reduce early discontinuation and improve compliance, as most centrally acting medications need to be given at a moderate dose for 6 to 8 weeks before they are declared ineffective.

Amitriptyline is the TCA for which there is the most evidence in literature on gynecologic pain, but it also may have the most adverse effects. In general, nortriptyline and desipramine may be better tolerated but they may have slightly decreased efficacy in pain management.

The selective neurotransmitter reuptake inhibitors (SNRIs) duloxetine and venlafaxine also increase norepinephrine. Pain relief from the SNRIs is most likely to be achieved at the higher doses. Currently, duloxetine is indicated for certain pain syndromes, including diabetic peripheral neuropathy, fibromyalgia, and chronic musculoskeletal pain such as chronic low back pain and osteoarthritis. Serotonin syndrome is a risk and if it occurs, a prolonged taper may be required.

Neuroleptics

Gabapentin and pregabalin can be effective centrally acting medications despite the expectation that they are only effective for neuropathic pain. These drugs are generally well tolerated and have few interactions with other medications, but consideration should be given to consulting a psychiatric provider if the patient has underlying mood disorders.

Anxiolytics

Despite the indicated use for anxiety, some anxiolytics provide an analgesic effect. Also, the management of anxiety and depression can decrease pain perception. Unfortunately, the risk of misuse is high due to the fast-acting euphoria associated with some anxiolytics. We recommend treating anxiety with antidepressants and using anxiolytics as short-term treatment for night pain and for temporary improvement in insomnia patterns.

Muscle relaxants

Cyclobenzaprine is effective for treatment of the myofascial pain seen in patients with fibromyalgia. The diazepam oral tablet or compounded suppository can be placed in the vagina to relieve pelvic floor muscle spasm. Both of these medications should be used as needed; we do not recommended scheduled use.⁶

Physical therapy

The role of the pelvic floor as a contributing factor in chronic pelvic pain has been well described.^7,8 In prospective evaluations, up to 73% of women with self-reported pelvic pain demonstrate pelvic floor muscle tenderness or hypertonicity.⁹

Despite this fact, many practitioners do not routinely include a thorough examination of the pelvic floor in their evaluation of patients with chronic pelvic pain (Table 3). In many patients with pelvic floor myofascial pain, it may be difficult to distinguish whether the pelvic floor is the primary cause of the pain or a reaction to another etiology.

Regardless of the initial etiology of pain, in women with chronic pelvic pain who demonstrate pelvic floor tenderness or hypertonicity, treatment with physical therapy of the pelvis has proven to be effective.

In one study examining the effectiveness of pelvic floor physical therapy in the treatment of pelvic pain, 63% of women reported significant improvement or resolution of pain, and pain scores improved in proportion to the number of physical therapy sessions completed.¹⁰ In addition to the improvements in pain provided by the therapy itself, there are other benefits to having patients work with a skilled pelvic floor physical therapist. It provides a great deal of education and individualized attention, and empowers them to become active participants in their care.

Other approaches

Lifestyle modifications

In addition to medical and therapeutic modalities for management of chronic pelvic pain, it is also important to address lifestyle modifications that can provide benefit to patients. These include diet modifications, exercise, sleep hygiene, and the use of complementary and alternative medicine techniques. No randomized, controlled trials have examined the effects of diet on chronic pelvic pain. However, we do know that chronic pain results in altered adrenal secretion of cortisol, which can make serum glucose levels unstable. Over time, that can lead to severe weight loss or gain, muscle wasting, fatigue, and poor mentation.¹¹ 

Although the effects of diet on pain may not be known, encouraging a healthy, balanced diet in patients with long-standing pain seems to make intuitive sense as a principal component of good health. Many patients who suffer from chronic pelvic pain may have food sensitivities. Having patients maintain a food journal and eliminate items that seem to correlate with pain flares may also be beneficial.¹² For patients with chronic pain who struggle to maintain a healthy diet, referral to a dietician may be helpful.

While it may seem counterintuitive to patients, exercise plays a very important role in management of chronic pelvic pain. A large body of evidence demonstrates benefit from regular exercise for numerous chronic pain conditions.¹³ Exercise has been shown to reduce the amount of pain medications required, reduce stress, improve symptoms of depression, improve muscle strength, increase energy, improve quality of sleep, and increase overall sense of well-being and ability to cope with pain.¹⁴

No specific exercise regimen has been proven beneficial over another, but it makes sense to recommend a routine that consists of aerobic and strength training exercises. We have found that yoga provides a good combination of aerobic and muscle-building activity, and is well tolerated by most women with chronic pelvic pain.

Patients with chronic pain conditions frequently suffer from poor sleep quality, and the prevalence of sleep disturbance in chronic pain patients is much higher than in the general population. Poor sleep quality has been reported in up to 80% of patients with chronic pelvic pain.¹⁵ These patients also often develop poor pain coping behaviors, such as spending excessive time in bed, frequent napping, opioid use, and overuse of caffeine, all of which further contribute to poor sleep quality.¹⁶

Lack of restful sleep can result in a host of behavioral and physical impairments, including changes in the nervous, metabolic, endocrine, and immune systems and decreased mood and cognitive capacity. Improving sleep habits can greatly improve the quality of life off patients living with chronic pain. Patients with chronic pain are also more likely to engage in spontaneous physical activity following a better night of sleep.¹⁷ The National Sleep Foundation has established a set of recommendations on good sleep hygiene that can be shared with patients (Table 4).¹⁸

Psychotherapy

Psychotherapy remains an important component in multimodal treatment of chronic pain. In addition to optimizing the treatment of baseline mental health abnormalities (anxiety, depression, etc.), introducing skills to cope with chronic pain can improve overall care. Coping techniques can be introduced through traditional pathways such as cognitive behavioral therapy or with mindfulness-based stress reduction. Both techniques have been shown to diminish emotional distress and reported pain intensity, and may contribute to an overall improvement in a patient’s perceived ability to recover.¹⁹

Identify local psychologists with a focus on pain management and pain coping to ensure that your patients receive exposure to these successful practices. They can also provide an opioid risk assessment for patients for whom you are considering long-term opioid therapy.

Complementary and alternative medicines

While limited evidence exists regarding complementary medicine practices and chronic pelvic pain, anecdotal experience is mainstream.²⁰ Dietary changes, supplement use, yoga, and acupuncture are popular pain management practices in patients with nonmalignant pain. However, clinical data are lacking. Referral to an academic-based integrative medicine program may not be covered by insurance but can provide guidance for patients interested in alternative practices for pain management.

Summary

Caring for patients with functional chronic pelvic pain without an obvious etiology can be very challenging. It is important to review realistic expectations with your patients in regard to tolerable daily pain levels and have an action plan to manage pain “flares” to reduce phone calls and emergency room visits. Regular scheduled visits to review the action plan can be effective.

Dr. Carey reports receiving honoraria from Teleflex.

Dr. Findley has no conflict of interest to resport with respect to the content of this article.

References

1. Chronic pelvic pain. ACOG Practice Bulletin No. 51. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2004;103:589–605.

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;87:321–327.

3. Howard FM. Chronic pelvic pain. Obstet Gynecol. 2003;101:594–611.

4. Rodriguez BAM, Afari N, Buchwald DS. Evidence of overlap between urological and nonurological unexplained clinical conditions.
J Urology. 2009;182:2123–2131.

5. Franklin GM. Opioids for chronic noncancer pain: a position paper of the American Academy of Neurology. Neurology. 2014;83(14):1277–1284.

6. Tofferi JK, Jackson JL, O’Malley PG. Treatment of fibromyalgia with cyclobenzaprine: A meta-analysis. Arthritis Rheum. 2004;Feb15:51(1):9–13.

7. Latthe P, Mignini L, Gray R, Hills R, Khan K. Factors predisposing women to chronic pelvic pain: systematic review. Br Med J. 2006;332:749–755.

8. Messelink B, Benson T, Berghmans B, et al. Standardization of terminology of pelvic floor muscle function and dysfunction: report from the pelvic floor clinical assessment group of the International Continence Society. Neurourol Urodyn. 2005;24:374–380.

9. Fitzgerald CM, et al. Pelvic floor muscle examination in female chronic pelvic pain. J Reprod Med. 2011;56(304):117–122.

10. Bedalwy MA, et al. Prevalence of myofascial chronic pelvic pain and the effectiveness of pelvic floor physical therapy. J Reprod Med. 2013;58(11–12):504–10.

11. Tennant F. The physiologic effects of pain on the endocrine system. Pain Ther. 2013; 2(2):75–86.

12. Friedlander J, et al. Diet and its role in interstitial cystitis/bladder pain syndrome (IC/BPS) and comorbid conditions. BJU International. 2012;109(11):1584–1591.

13. Sullivan AB. The role of exercise and types of exercise in the rehabilitation of chronic pain: specific or nonspecific benefits. Curr Pain Headache Rep. 2012;16(2):153–161.

14. Henningsen P, et al. Management of functional somatic syndromes. Lancet. 2007;369(9565):946–955.

15. Cosar E, et al. Sleep disturbance among women with chronic pelvic pain. Int J Gynaecol Obstet. 2014;126(3):232–234.

16. Emery PC, et al. Major depressive disorder and sleep disturbance in patients with chronic pain. Pain Res Manag. 2014;19(1):35–41.

17. Tang NK, et al. Better quality sleep promotes daytime physical activity in patients with chronic pain? A multilevel analysis of the within-person relationship. PLoS One. 2014;9(3):e92158.

18. National Sleep Foundation. Healthy sleep tips. http://sleepfoundation.org/sleep-tools-tips/healthy-sleep-tips. Accessed November 16, 2014.

19. Hatchard T, Lepage C, Hutton B, Skidmore B, Poulin PA. Comparative evaluation of group-based mindfulness-based stress reduction and cognitive behavioral therapy for the treatment and management of chronic pain disorders: protocol for a systematic review and meta-analysis with indirect comparisons. Syst Rev. 2014;3(1):134.

20. Udoji MA, Ness TJ. New directions in the treatment of pelvic pain. Pain Manag. 2013;3(5):387–394.