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  • Nathan Riley, MD

Obgyno Wino Podcast Episode 48 - Chronic Pelvic Pain

"The mark of a wild heart is living out the paradox of love in our lives. It's the ability to be tough and tender, excited and scared, brave and afraid - all in the same moment. It's showing up in our vulnerability and our courage, being both fierce and kind." - Brené Brown

2017 Red Blend from Francis Coppola

PB#218 - Published March 2020


Five Pearls

1. Up to 33% of women with chronic pelvic pain will also meet criteria for diagnosis of major depression

2. An interdisciplinary approach is the way go to: gynecologist, physical therapist, and psychologist in the very least.

3. The physical exam should be approached very carefully and systematically

4. Yoga, acupuncture, and other complementary and integrative therapies should absolutely be considered.

5. Don't prescribe opioids for chronic pelvic pain. Go with neuropathic agents, SNRIs, and tricyclic antidepressants.


Consensus definition + epidemiology

- pain symptoms perceived to originate from pelvic organs/structures typically lasting more than 6 months. It is often associated with negative cognitive, behavioral, sexual and emotional consequences as well as with symptoms suggestive of lower urinary tract, sexual, bowel, pelvic floor, myofascial, or gynecological dysfunction

- this definition is inclusive of cyclical pain, but management of dysmenorrhea and Mittelschmerz (both cyclical) aren't included in this practice bulletin

- by the way, dysmenorrhea usually relates to "crampiness" of menstruation (reported immediately before, during, and after bleed); Mittelschmerz relates to ovarian remodeling related to ovulation (reported 2 weeks before bleed)

- chronic differs from acute, as the latter is usually the result of an inflammatory, infectious, or anoxic insult that resolves over time with treatment or repair

- some studies report prevalence as high as 25%, in the big studies, 70% of chronic pelvic pain is attributed to endometriosis, 60% to bladder pain syndrome (formerly interstitial cystitis), 50% to both

- hyperalgesia: exaggerated pain response to painful stimuli

- allodynia: painful response to non-painful stimuli


PEARL: UP TO 33% OF WOMEN WITH CHRONIC PELVIC PAIN WILL ALSO MEET CRITERIA FOR DIAGNOSIS OF MAJOR DEPRESSION


What is the root cause?

- unclear, but mounting evidence for central sensitization

- CNS may remain activated even after "treatment" is applied, which why we are often left stumped as to help women with pelvic pain like endometriosis






(yes...all of that...)



"The multifactorial nature of chronic pelvic pain lends itself to an interdisciplinary model of care that seeks to identify and treat an individual’s physical pain generators as well as co-morbid conditions, such as depression and anxiety, which together create the symptomatology and contribute to the overall burden of disease. For example, a chronic pelvic pain patient's pain may not improve until her endometriosis is treated, reactive pelvic floor myalgia is addressed, central sensitization is controlled with neuromodulator treatment, and depression is in remission."

Important considerations when exploring etiology

- visceral pain: reflect signaling from nociceptors often poorly described given varying input to the CNS, autonomic symptoms often accompany this type of pain (sweating, GI symptoms like diarrhea, and vital sign irregularities)

- neuromuscular disorders: may result from myofascial trigger points or neurovascular entrapment due to surgical injury or tendon/ligament inflammation; often can be isolated very precisely; these disorders often result from repeated microtrauma or poor posture

- psychosocial factors: "pelvic pain and dyspareunia are more prevalent in women with a history of abuse, mental illness, lack of support, social stressors, and relationship discord...psychosocial factors as separate but equally important pain contributors can increase the woman’s awareness of her conscious and unconscious perception of pain and facilitate her recovery."


Note: ACOG states that these factors don't alter the neuromuscular or visceral pain generators, but there is no counter evidence provided. I think we just don't really know...but is it too hard to imagine that physical changes can result from actions of the mind that produce emotions within the body? (Answer: no)


The work-up

- start with detailed medical, surgical, and gynecologic history

- self-assessment forms can be very helpful to guide this information gathering session (like those provided on the International Pelvic Pain Society website)

- physical exam is guided by the information gathered:

  1. Clothes on: watch her walk, touch toes, lunge, reach behind back, squat, get her to move!

  2. Clothes on: do a thorough assessment of spine and abdomen - any point tenderness? any rebounding/guarding? Do full neuro exam while seated. Ask her to contract her abdominal muscles (aka "Do a sit up"). Ask her to lift each leg to perpendicular to the floor.

  3. Undressed from waist down in stirrups or butterfly position, very slowly and deliberately check out a number of things. Get consent every step of the way. Move at her pace.

  4. Check for neurologic deficits like diminished sensation (cold/sharp) or decreased motor tone around vulva by gently probing the bulbocavernosus muscles and anal verge using the soft side of a cue tip (look for the reflexes!)

  5. Spread the labia majora with one hand and touch very places on the external genitalia with a cue tip using the other hand to identify any sites of pain. Can you reproduce her symptoms?

  6. Go a little deeper, remembering to move at her pace. Go to the vestibule and around the urethra. Do you see any lesions?

  7. Now insert a gloved finger into the vagina. Palpate the anterior, posterior, and lateral aspects of the vagina. Do it stepwise, hitting all four quadrants as you approach the cervix. Any cervical motion tenderness?

  8. Before you withdraw your finger, place your free hand suprapubically and perform a bimanual exam. This part can be very triggering for some women, so, again, be gentle and get consent and give direction (let her be your guide!). Palpate the bladder and adnexa. Are there any painful loci related to the uterus?

  9. As you withdraw your gloved hand, palpate the levator ani muscles. Does this elicit any pain?

  10. Finally, insert a lubricated speculum into the vagina, gently opening it reveal the vagina and cervix. Do you see any lesions? Do you see any mucopus? Is the cervix raw and inflamed?

  11. Have her get completely dressed and comfortable. Bring her a cup of water or tea. And discuss your findings.

Note: This exam can be a brief as 10 minutes in length depending on your experience level. On the other hand, for some patients, you may have to do this exam in stages, restarting at a later date if any part becomes overwhelming or too uncomfortable. It can put your patient at ease if they have a friend or partner present during this exam or if you have a chaperone (nursing, medical assistant, etc.) present for the exam.


What additional evaluations may be necessary?

- cystourethroscopy and urodynamic studies can be helpful in evaluating bladder wall and urethral sphincter muscle function (e.g. evaluate for bladder pain syndrome)

- referral to a gastroenterologist to evaluate for diverticulitis, irritable bowel syndrome, colon cancer, or inflammatory bowel disease may be helpful

- if a severe mood disorder may be contributing, a referral to psychology or psychiatry can be invaluable


Management

- pelvic floor PT

- cognitive behavioral therapy

- sex therapy

- neuropathic agents

- opioids

- trigger point injections

- Botox injections

- acupuncture

- yoga and tai chi

- massage and osteopathic manipulation

- cannabinoids


Pelvic floor physiotherapy

- broad category including:

  • internal tissue mobilization

  • myofascial release

  • manipulative therapies to mobilize visceral, urogenital, and joint structures

  • electrical stimulation

  • pelvic floor retraining

  • biofeedback

  • bladder and bowel retraining

  • pelvic floor muscle stretching

- found to be equally effective as trigger point injections in one study


Cognitive behavioral therapy

- through counseling, patients learn to modulate their thoughts and manipulate their environment to lessen their pain perception and improve coping skills

- most useful when provided as part of multi-disciplinary model (i.e. in combination with PT an/or sexy therapy and/or other therapies)


Note: please don't tell the patient that it's "all in your head". Unlikely to end well...


Neuropathic agents

- SNRIs and TCAs: anti-depressants that also work to diffuse neuropathic pain (outperformed placebos in a systematic review of 37 double-blind randomized trials for fibromyalgia and diabetic neuropathy but haven't been evaluated for chronic pelvic pain in women)

- Gabapentin, Pregabalin: inhibit action potential by blocking voltage-gated calcium channels (also good evidence for use in other neuropathies, but similarly poor evidence for these agents in treating chronic pelvic pain; however, low cost and well-tolerated, so why not?)


Opioids

- not appropriate

- 40% of opioid overdose deaths happened as a result of prescribed medications


Trigger point injections

- can be helpful if the etiology of chronic pelvic pain is myofascial in nature related to nerve entrapment that is refractory to PT and medication

- a variety of injectables including any combination of saline, opioids, anesthestic, or steroids have been proposed and used with successful, suggesting that perhaps the needle insertion itself can be therapeutic (who cares if it's the placebo effect in action)

- may require repeated injections for full benefit


Botulinum toxin injection

- no evidence of efficacy, but worth a shot if pain is refractory to PT and meds


Other procedures/surgeries

- meh (enemy of good is better)


Complementary and alternative therapies

- yoga has been found beneficial in chronic pain, though they have not been fully investigated as a means of mitigating chronic pelvic pain, so ACOG feels they are worth a shot (likewise for acupuncture)


"Yoga eventually influences all aspects of the person: vital, mental, emotional, intellectual and spiritual. It offers various levels and approaches to relax, energize, remodel and strengthen body and psyche. The asanas and pranayama harmonize the physiological system and initiate a “relaxation response” in the neuro endocrinal system. This consists of decreased metabolism, quieter breathing, stable blood pressure, reduced muscle tension, lower heart rate and slow brain wave pattern. As the neural discharge pattern gets modulated, hyper arousal of the nervous system and the static load on postural muscle come down...Meditation and pranayama, along with relaxing asanas, can help individuals deal with the emotional aspects of chronic pain, reduce anxiety and depression effectively and improve the quality of life perceived." - Vallath 2010
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