Pelvic Pain Management

Since there are many different factors that can contribute to chronic pelvic pain (CPP), it is important to involve practitioners from relevant different disciplines. The goal of this multidisciplinary approach is for coordinated, team-based care. Other members of the team may include gynecologists, urologists, urogynecologist, gastroenterologist, radiologists, psychiatrists and psychologists, and the primary care practitioner.

At the Pain Management Center, you will be asked to fill out an evaluation prior to consultation in order to obtain a detailed history of the problem. This will be easier if you keep a daily diary of your pain, noting for example, how often it comes on, things that exacerbate or relieve it, and any associated symptoms.

A detailed physical examination is very important and can reveal many clues to the diagnosis. The physical examination includes a pelvic examination as well as examination of your abdomen.

Treatment with Medication

Various types of medication may be used to help relieve your pelvic pain, such as the following:

Opioids

Although opioid drugs such as codeine and morphine are not the mainstay of treatment, they can be useful to help with periods of worsening pain. They are very strong medications with many risks. They may make you feel sleepy and disoriented, and if they are used regularly, there is a risk of dependence. An overdose of these drugs can be extremely dangerous. Other conservative treatment options are usually tried first.

IV lidocaine infusion

This procedure is often done for chronic pain and neuropathic pain. The local anesthetic lidocaine has been shown to block abnormal firing of the nerves causing pain, without blocking normally conducting nerves. The procedure is usually lasts a few hours. While the lidocaine is being slowly infused, your vital signs are monitored. You will be asked often if you are experiencing any side effects such as dizziness, numbness (especially in the lips or tongue), slurred speech, visual changes, ringing in the ears or sleepiness. The length of pain relief varies and may last from a few hours to weeks. The length or amount of pain relief obtained will determine whether to repeat the procedure or consider oral anesthetics.

Neuropathic pain medications

These include tricycle antidepressants, serotonin-norepinephrine reuptake inhibitors (SNRIs) and anticonvulsants. Anticonvulsants are usually given to control seizures but are also used to decrease pain, as they make the nerves less sensitive to stimulation. Antidepressants are usually given to help decrease or prevent the symptoms of depression. They act by increasing certain chemicals in your body which may also help relieve pain. Chronic pain treatment often includes these medicines as a means to decrease pain, and you may be given them even if you are not depressed. Certain antidepressants have been shown to be very effective in certain pain conditions.

Nonsteroidal anti-inflammatory drugs (NSAIDS)

NSAIDs have been shown to be very effective for cyclic pain, and there is very little risk of becoming dependent on these drugs. However, there may be other side effects, including gastrointestinal upset, heartburn, ulcers and skin rashes.

Vaginal suppositories and cream

For women, these may be prescribed to be inserted into the vagina to help relieve symptoms.

Muscle relaxants

Pain from muscle spasm may be eased with medicine that causes relaxation of the muscles. In addition to oral medicines for spasms, botox injections may be used to treat spasticity.

Interventional Techniques

Interventional techniques involving nerve blocks target the specific nerves and pathways involved in pain transmission, with the aim of interrupting these nerve pathways. Nerve blocks may be performed for diagnosis, pain relief or both. They are performed under x-ray guidance in the clinic. Some common interventional procedures include:

Sympathetic nerve blocks

A hypogastric block interrupts innervation from parts of the GI tract, uterus, bladder and surrounding structures. A ganglion impar block is most effective for post-radiation pain involving the peritoneum and genitals. Positive results have been shown for pelvic pain from cancer of the cervix, bladder, rectum and endometrium, as well as for patients with coccydynia (pain originating from the coccyx).

Somatic nerve block

The pudendal nerve innervates most of the uterus, labia and vagina, perineum and skin over the pubic symphysis. This block is useful in vaginal pain secondary to nerve injury (endometriosis, entrapment, surgical injury, herpetic infection, multiple sclerosis, interstitial cystitis). There also are various other blocks performed depending on the nerves involved (for example, anterior cutaneous Nerve block, median cluneal nerve block, TAP block).

Trigger point injections

Abdominal trigger points are painful tissues often found in the muscular wall layer of the abdominal wall. They are tender to pressure and cause an aching or sharply painful sensation. The pain can radiate to the low back, groin and legs, and is made worse by pelvic organ sensations such as a full bladder, menses or ovulation. Numbing these points with a local anesthetic may reduce or even eliminate pain. Although the anesthetic will wear off, temporarily interrupting the pain signals appears to diminish the neuropathic pain some women experience.

The procedure is performed in the clinic. We carefully locate trigger points in your abdominal wall and inject the anesthetic with a regular needle. If trigger point injections are effective, the injection should reproduce the same pain you experience from your condition. Although the injection may be painful for a few minutes, the anesthetic should numb both the injection pain and your chronic pain within a few minutes. The amount of relief obtained from this procedure varies from person to person and may last anywhere from a few days to a few months. In some cases, a woman's pain may be completely resolved after a series of injections. Three to five injections may be necessary to reach all of the trigger points in a given area.

Transcutaneous electrical nerve stimulator (TENS)

A transcutaneous electrical nerve stimulator (TENS) unit is a small battery-powered device used for chronic pain. It attaches with wires to patches placed on the skin over the painful area. The patches deliver very mild electrical current to the skin. This acts to block pain from the nerves below and increases your body's own pain relievers. This may help decrease or control your pain when used over a painful body part. While not effective for all people, some may experience considerable pain relief.

Neuromodulation

Neuromodulation with nerve root or spinal cord stimulators involves a surgically placed device that provides a reversible treatment for chronic pain. It is gaining favor as first-line therapy for many conditions. There are no addictive issues and no systemic side effects. It blocks pain by sending electrical impulses to the sacral nerves in the lower spine, and it is very effective in the appropriate patient. You will undergo a screening process before it is deemed a suitable option for you. The first step is a reversible surgical procedure where a temporary, non-implanted (external) system is placed for about one week. If it is effective, then a surgical procedure is performed in the operating room to place the device. The device may be removed at a later stage once your pelvic pain has resolved completely.

Physical Therapy

Physical therapy has been shown to have an extremely important role in the successful management of chronic pelvic pain. Physical therapists treat injury or dysfunction with exercises or other physical treatments.

Their work focuses primarily on the muscles. They use massage and exercise techniques to strengthen muscles and reduce pain. They provide manual physical therapy of the pelvic floor muscles and pelvic floor muscle reeducation. They also provide trigger point release therapy on pelvic floor and abdominal muscles.

Another important tool that they provide is biofeedback, where they teach skills like diaphragmatic breathing and pelvic floor muscle relaxation. Biofeedback is a special way to control how your body reacts to things like stress or pain.

The first step in this training is to use electrodes to monitor your body responses. These electrodes are placed on different parts of your body, like the chest. The electrodes are attached to a monitor that gives a tracing of your heartbeat. You will be taught how to control body changes, such as slowing your heart rate, when you become upset. Several studies have been published which suggest that biofeedback is useful for women with vulvodynia and may also prove useful for treating CPP.

What to Expect from Treatment

Relief from CPP depends on the disease or problem that is causing the condition. All conditions causing the pain will need to be treated. In some cases, you may not be completely cured. However, our aim is to help you resume your usual daily activities, improve your personal relationships and enable you to go back to work so that your overall quality of life is improved.