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P E LV I C PA I N M A NAG E M E N T

P E LV I C PA I N M A NAG E M E N T

EDITED BY

A S S I A T. VA L OV S K A ,   M D
Director, Pelvic Pain Center
Brigham and Women’s Hospital
Instructor in Anesthesia and Pain Management
Harvard Medical School
Boston, Massachusetts

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or under terms agreed with the appropriate reproduction rights organization. loss. Oxford University Press. No part of this publication may be reproduced. Valovska. WP 155] RD549 617. The authors and the publisher do not accept.to. Treatment for the conditions described in this material is highly dependent on the individual circumstances. Published in the United States of America by Oxford University Press 198 Madison Avenue.  2. . and expressly disclaim.5′5—dc23 2015036946 1 3 5 7 9 8 6 4 2 Printed by Webcom. It furthers the University’s objective of excellence in research. at the address above. the publisher and the authors make no representations or warranties as to the accuracy or efficacy of the drug dosages mentioned in the material. United States of America. p.  3.  Chronic Pain—therapy. The publisher and the authors make no representations or warranties to readers. while this material is designed to offer accurate information with respect to the subject matter covered and to be current as of the time it was written. 1 Oxford University Press is a department of the University of Oxford. Readers must therefore always check the product infor­mation and clinical procedures with the most up. stored in a retrieval system. express or implied. with new side effects recognized and accounted for regularly. Inquiries concerning reproduction outside the scope of the above should be sent to the Rights Department. without the prior permission in writing of Oxford University Press. or risk that may be claimed or incurred as a consequence of the use and/ or application of any of the contents of this material . © Oxford University Press 2016 All rights reserved. and education by publishing worldwide. paper) I. scholarship. as to the accuracy or complete­ness of this material.date published product information and data sheets pro­vided by the manufacturers and the most recent codes of conduct and safety regulation. And. You must not circulate this work in any other form and you must impose this same condition on any acquirer. any responsibility for any liability. and should not be considered. Canada This material is not intended to be. NY 10016.  Pelvic Pain—therapy. or transmitted. Library of Congress Cataloging-​in-​Publication Data Pelvic pain management / edited by Assia T. New York. ISBN 978–0–19–939303–9 (alk. in any form or by any means. [DNLM: 1. Includes bibliographical references and index. Without limiting the foregoing. research and knowledge about medical and health issues is constantly evolving and dose schedules for medications are being revised continually. or as expressly permitted by law. Oxford is a registered trade mark of Oxford University Press in the UK and certain other countries. by license. cm.  Valovska. Assia T.. a substitute for medical or other profes­sional advice. editor.  Physical Therapy Modalities.

Functional Abdominal Pain Syndrome  76 Acknowledgments  ix Jason Litt. Contributors  xi and Yury Khelemsky 10. and Emmanuel A. CONTENTS Preface  vii 9. Bobb. Pelvic Pain Management: Michael Hibner An Introduction  1 and Mario E. Valovska Syndrome  96 2. 11. Duke and Karen Wang 6. Musculoskeletal Causes of Chronic María del Pilar Pardo-​Bustamante Pelvic Pain  117 4. Chronic Pelvic Pain and Psychological Adeoti Oshinowo. Dessie and Eman Elkadry . Pain Treatment: A Physical Therapist’s and Assia T. Urman. Incapacitating Pelvic Congestion and Assia T. and 13. Anatomy of the Abdomen and Pelvis  6 Neeraj Rastogi. Richard D. Abrecht. 12. Karina Gritsenko. Valovska Perspective  28 14. and Yury Khelemsky Lila Bartkowski-​Abbate and Amy Stein 8. Castellanos Louis Saddic. Patel and Assia T. Pudendal Neuralgia  82 1. Pharmacological Management and Karina Gritsenko of Pelvic Pain  34 15. Yury Khelemsky. Pontari Ana Lucía Herrera-​Betancourt. Surgical Treatment of Pelvic Pain  134 Michele L. Lesley E. Pain Mechanisms in Chronic Pelvic Pain  13 Juan Diego Villegas-​Echeverri. Nii-​Kabu Kabutey. and Ducksoo Kim 3. Multidisciplinary Approaches to Pelvic Chris R. Mona K. Dyspareunia and Vulvodynia  44 16. Michel A. The Physical Therapy Approach to Pelvic Pain: Evaluation  149 Adham Zayed. Karina Gritsenko. Ghormoz Jorge Darío López-​Isanoa. Male Pelvic Pain  107 José Duván López-​Jaramillo. Matthews and Vesela Kovacheva Adam R. Disorders  143 Tanya E. Alin Ionescu. Endometriosis: Treatment and Pain Management  58 17. Valovska Gillian Lieberman. Anim. 5. Pelvic Cancer Pain  124 Stephanie Prendergast Jonathan Snitzer. and Georgine Lamvu Mohammed Issa and Raheel Bengali 7. Painful Bladder Syndrome and Interstitial Cystitis in Women  64 Sybil G.

Implantable Devices for the Treatment of Pelvic Pain  180 Index  207 Chris R. Valovska . The Physical Therapy Approach 20. Lim 19. Weisheipl. Sample Clinical Cases  190 to Pelvic Pain: Treatment  167 Bethany Skinner. Alison M. Nichole Amy Stein Mahnert. Abrecht. and Assia T.vi Contents 18. and Courtney S.

these people are subjected to inva- working as a pain physician. which develop a treatment plan with emphasis on mul- further worsen the pain. Valovska. abdomen and pelvis ensure that the clinical picture The emerging need for comprehensive educa- is confusing. Misunderstanding the complicated aspects and challenges of treating pelvic pain are the emerging Assia T. gastroenterology. and more. P R E FA C E This book was inspired by my patients and writ. professionally skills to diagnose the origins of pelvic pain. The goal is to provide the healthcare Pelvic pain touches every aspect of the patient’s practitioner with background knowledge as well life—​physically. even my teachers demand for opioids prompt a last-​resort referral were struggling to treat these patients. care coordination and management is a common dance of organs. this book. evaluation. I realized that I need sive procedures that do not provide pain relief. the patients are evaluated by phy- ten by leading experts in the field of pelvic pain. surgery. Boston. tidisciplinary management. Involvement of distant of pelvic pain causes. and to for low self-​ esteem. The lack of interdisciplinary Pelvic pain is a complex disease. emotionally. The abun. misleading. and muscles in the cause for failed treatment. MD reason for delayed or improper diagnosis. to and sexually. and organs as well as the musculo-​skeletal system fur. Massachusetts . knowledge that was not taught in medical school The procedural ineffectiveness and the increasing or during the pain fellowship. sicians across multiple specialties—​ gynecology. vessels. Not by the perplexity of their suffering. nerves. pathology. The exhausting experience is a cause perform a proper physical examination. to the pain clinic. depression. anxiety. treatment strategies is the driving force behind ther adds to the diagnostic dilemma. and often presented with tion across the specialties about the complexity poorly defined symptoms. Over the years uncommonly. socially. The demand to understand pelvic pain is driven urology. Usually.

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the rest is going to come on for your support and understanding. My deep appreciation for my colleagues from To my beautiful daughters and budding the Pain Management Center at Brigham and physicians: Thank you for growing smart and Women’s Hospital. its own! What would I do without the nursing team To mom and dad: Thank you for tirelessly “Tenderloin” on “Pearl Thursday”? Your tireless helping me achieve my dreams. I consider you my biggest friends and supporters. AC K N OW L E D G M E N T S I am eternally thankful to my patients for mak. Boston. Study hard. for that. I love you dearly give up the fight is fuelled by your resilience. Keep wearing those pearls! . ing me who I am. My determination to never lending a shoulder to lean on. MA—big thank you strong. work and deep compassion lighten my days. To my husband: You are always next to me. MD Thank you for putting up with my long hours. Valovska. Assia T.

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Massachusetts Adam R. C O N T R I BU TO R S Chris R. Massachusetts Brigham and Women’s Hospital Boston. MD Resident Division of Urogynecology Department of Anesthesiology. PRPC Clinical Instructor New Dimensions Physical Therapy. MS. Florida Chattanooga. MD Fellow Tanya E. Bobb. Duke. Chronic Pain Boston. Interventional Pain Management Mount Auburn Hospital Harvard Medical School Boston. Abrecht. DPT. MD OCS. New York Phoenix. Family & Mario E. Massachusetts Emmanuel A. Castellanos. WCS. Eman Elkadry. Tennessee Lila Bartkowski-​Abbate. MD Philadelphia. Brigham and Women’s Hospital Regional. Maryland Brigham and Women’s Hospital Boston. PT. Karina Gritsenko. Perioperative. MD and Pain Management Co-Director Resident Rotations: Acute Pain. Joseph’s Hospital and Medical Center College of Medicine Division of Gynecologic Surgery Bronx. New York Fellowship Director. MD Department of OB/​GYN Fellow. MD. Ghormoz Temple University School of Medicine Lesley E. PLLC Harvard Medical School Manhasset. and Physical Medicine and Creighton University School of Medicine Rehabilitation Assistant of Obstetrics and Gynecology Montefiore Medical Center/Albert Einstein St. Arizona . Perioperative. Female Pelvic Medicine and Reconstructive Surgery Raheel Bengali. Dessie. Anim. MD Sybil G. Massachusetts Co-Associate Regional Fellowship Director Assistant Professor of Anesthesiology. FACOG Social Medicine. Mid-​Atlantic Permanente Medical Group and Pain Medicine Upper Marlboro. Pennsylvania Resident Department of Anesthesiology. MD Department of Obstetrics and Gynecology Assistant Clinical Professor Division of Minimally Invasive Gynecologic Family Medicine Residency Program Surgery University of Florida University of Tennessee College of Medicine Gainesville.

PhD. MD. Florida Harvard Medical School Beth Israel Deaconess Medical Center Mohammed Issa. Veterans Administration (VA) Medical Center Alin Ionescu. MD Surgery Fellow. Lim. MD Ducksoo Kim. MD Boston VA HealthCare Kaiser Permanente Northern California Boston. MD Assistant Professor Jorge Darío López-​Isanoa. Massachusetts Harvard Medical School Clinical Instructor Courtney S. PhD Advanced Laparoscopy and Pelvic Pain Instructor in Anesthesia Unit—​Algia Harvard Medical School Clínica Comfamiliar Attending Anesthesiologist Pereira. MD. FACS Brigham and Women’s Hospital Creighton University School of Medicine Boston. Irvine Department of Anesthesiology UC Irvine Medical Center Division of Pain Medicine Irvine. MD. MD Advanced Laparoscopy and Pelvic Pain Professor of Radiology Unit—​Algia Boston University School of Medicine Clínica Comfamiliar Boston Medical Center Pereira. Pain Medicine Fellowship Advanced Laparoscopy and Pelvic Pain Department of Anesthesiology Unit—​Algia Division of Pain Medicine Clínica Comfamiliar Icahn School of Medicine at Mount Sinai Pereira. Joseph’s Hospital and Medical Center Georgine Lamvu. MD Florida Hospital Director of Radiologic Education Orlando. MD University of Central Florida Division of Advanced and Minimally Invasive Orlando. California . MD. New York Yury Khelemsky. New York José Duván López-​Jaramillo. MD Department of Vascular and Endovascular Jason Litt. California Icahn School of Medicine at Mount Sinai New York. FACOG. MD Program Director. MPH Division of Gynecologic Surgery Gynecologic Surgery and Pain Specialist Phoenix. Colombia New York. FACOG Vesela Kovacheva. Arizona Department of Surgery. MD Brigham and Women’s Hospital Departments Clinical Assistant Professor of Anesthesiology and Psychiatry Department of Obstetrics and Gynecology Boston. MD Boston. Pain Medicine University of California. Florida Gynecology Department of Graduate Medical Education Gillian Lieberman. Colombia Department of Anesthesiology. Perioperative and Pain Medicine Michael Hibner.xii Contributors Ana Lucía Herrera-​Betancourt. Massachusetts University of Michigan Ann Arbor. Michigan Nii-​Kabu Kabutey. Massachusetts Associate Physician Obstetrics and Gynecology Walnut Creek. Massachusetts Professor of Obstetrics and Gynecology St. Colombia Director of Cardiovascular and Interventional Radiology Nichole Mahnert.

New York Baylor Medical Center Garland. MD Associate Professor of Pharmacy Practice Fellow. MD. New York Boston. MPH Beyond Basics Physical Therapy. Pontari. Texas Richard D. Pain Medicine Massachusetts College of Pharmacy and Health Department of Anesthesiology Sciences University Division of Pain Medicine Advanced Pharmacist Practitioner in Pain Icahn School of Medicine at Mount Sinai Management New York. Perioperative and Pain Medicine Neeraj Rastogi. Colombia Perioperative Medicine Brigham and Women’s Hospital Karen Wang. MD Pelvic Health and Rehabilitation Center Instructor in Anesthesia and Pain Management Los Angeles. Massachusetts Amy Stein. Massachusetts University of Massachusetts Medical School Worcester. MD Department of Obstetrics and Gynecology University of Michigan Ann Arbor. IF Owner/​Founder Adeoti Oshinowo. Urman. Pain Medicine Louis Saddic. MD Associate Professor of Anesthesia María del Pilar Pardo-​Bustamante. Massachusetts Bethany Skinner. MD Fellow. CPE. BCACP Jonathan Snitzer. DPT. PhD Department of Anesthesiology Department of Anesthesiology Division of Pain Medicine Pain and Perioperative Medicine Icahn School of Medicine at Mount Sinai Brigham and Women’s Hospital New York. California Department of Anesthesiology. MD. MD Harvard Medical School Department of Vascular and Interventional Brigham and Women’s Hospital Radiology Boston. MD Harvard Medical School Advanced Laparoscopy and Pelvic Pain Brigham and Women’s Hospital Unit—​Algia Boston. MD Unit—​Algia Interventional Pain Fellow Clínica Comfamiliar Department of Anesthesiology. MD Fellowship Director Temple University School of Medicine Brigham and Women’s Hospital Philadelphia. Pennsylvania Boston. Colombia Juan Diego Villegas-​Echeverri. MD. Patel. Massachusetts Adham Zayed. Weisheipl. PharmD. FACOG Advanced Laparoscopy and Pelvic Pain Mona K. Contributors xiii Michele L. Michigan . MPT Alison M. Matthews. Massachusetts Instructor Associate Director MIGS Michel A. Massachusetts Stephanie Prendergast. BCB-​PMD. New York Brigham and Women’s Hospital Boston. MD Boston. MPT. LLC Gynecology Specialists of Garland New York. Massachusetts Clínica Comfamiliar Pereira. Pain and Pereira.

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38 A ences.34 and many reports bowel.”28 Although this statement is fairly gen. there is recurrent use syndromes”). Like many chronic pain disorders.23. the estimated global Association for the Study of Pain.14.28 demiology. including the of this challenge is due to variations in how duration of symptoms.6% of either men or woman that is often associated and one-​month prevalence of lower back pain with negative cognitive. have shown that up to 50% of women fail to tion. of symptoms and diagnosis. which has obstructed the diagnosis of chronic pelvic pain syndromes research efforts to accurately describe its epi.38 Further subdivisions have of medical resources and thus high healthcare also been described but are far beyond the scope costs. even after many years of follow-​ eralized. is a diagnosis of exclusion.34 Unfortunately.4. high prevalence rates are consistently widely cited definition that encompasses both cited. As mentioned above.6%.11. of the women diagnosed attempts to describe a fairly comprehensive in the primary care setting. sexual and at 20. patients.5.18. VA L OV S K A C hronic pelvic pain is a ubiquitous condi- tion that affects both men and women. which is surpris- pelvic pain.38 In the United States.34 Furthermore.38 . part variations in many components.7–​ 26. We simply highlight this distinction it has been estimated that chronic pelvic pain because of its prevalence in the literature and in woman costs the economy over $3 billion.3.18. this condition is defined.11. A N D A S S I A T.11.34 Even more so. R I C H A R D D . 1 Pelvic Pain Management An Introduction L O U I S S A D D I C . sexual. these issues lead malignancy) from cases without such association to absence from work. accurately ment. there is no uniform defi- because it may have significant implications for determining pathophysiology and management. which is compa- pain perceived in structures related to the pelvis rable to the prevalence of asthma at 4.3. many women with Sub-​categorizing chronic pelvic pain has also chronic pelvic pain also have coexisting symp- been a subject of widespread debate. pelvic floor or gynecological dysfunc. A common toms of depression and anxiety. Despite these differ- sion of cyclic pain.34. many strategy is to distinguish chronic pelvic pain patients also report a history of sexual and/​or associated with a known pathology (such as physical abuse. The inconsistency of its definition has describing the prevalence of chronic pelvic pain been described by many groups who cite large can be challenging.32.32. be diagnosed. location of pain.3–​8. it is well suited for this text. it is well known emotional consequences as well as with symp. exclu.23. that there can be significant delay between onset toms suggestive of lower urinary tract.1%. Despite its familiarity. It states that prevalence of chronic pelvic pain in woman “Chronic pelvic pain is chronic or persistent ranged between 5. and among the women (collectively referred to as “chronic pelvic pain who do receive treatment.34 For example. That being said.25. based on an updated men and woman comes from the International review published in 2014. Even more so. therapy in the successful management of these sion and exclusion criteria. and successful manage. and sadly.28.34 Frequently.11. pathology.1. for example.5.23. the conclusions ing given the concrete evidence that supports stated in research studies need to be carefully the essential role of multimodal and specialized analyzed in the context of their specific inclu. U R M A N.3–​26. which up. care must be taken to ensure that nition of this disease. and many more. behavioral. of this text.28. only 40% receive collection of conditions associated with chronic secondary or tertiary referral.

36 As we begin to learn states. patients in the environmental factors.20 in the central nervous system that leads to The mechanisms of chronic pelvic pain are hyperexcitability.28.2–​9.36 For exam- removed. Once sensitized. following noxious throughout the progression of chronic pelvic stimulation. there may increase our repertoire of treatment mech- is an abundant body of evidence to support the anisms designed to target the central nervous necessary role of the central nervous system in system.23. which probably contribute significantly to more about the central changes that take place the prevalence and severity of pain. there is com- nociceptors can lead to peripheral sensitiza. repeated stimulation of that occur at the site of insult. and plicated version of sensitization. a recent analysis of five com.2 Pelvic Pain Management Similarly in men.8. This Activated C fibers also produce substance P. we As with most chronic pain syndromes. and its studies have shown that chronic pelvic pain development in chronic pelvic pain is probably involves changes not only in the peripheral ner. more investigation lesions elsewhere.23. an insult in the bladder may lead to stances such as prostaglandins and histamine.33.33 process referred to as “neurogenic inflamma. For example.2. Evidence of central changes can be found tion.29. patients with a history of dysmenorrhea Animal and human studies have also who were not experiencing menstrual pain demonstrated important anatomical and devel.15 In a sense. therefore. hormones such throughout the literature. example. or nociceptors.9.31.25.29 In addition to the derangements of pain In the periphery. one group pain inhibitory mechanisms have recently reported that the percentage of woman with received a great deal of attention with regard hyperalgesia is higher in cohorts of women to their contribution to chronic pelvic pain. had increased activity of the entorhinal cor- opment changes that occur in the periphery tex compared to controls.30 Some studies have also reported pain.29. relief after surgical or medical ablation.37 ple.22.28. induces self-​ perpetuating latter category have pain that becomes more or changes in both the peripheral and central nervous less independent of peripheral stimulation.29 A popular model for the development nervous system itself. many of these studies have con- highly innervated areas compared to those with flicting outcomes.36 and others their own perivascular sympathetic and sensory have described alterations in the hypothalamic-​ innervation.21.29.26.10 These findings matched results pituitary-​adrenal (HPA) axis. In a rat model of endometriosis. has been used to demonstrate alterations in these neurons can at times develop the ability the activity in certain regions of the brain in to signal even after the initial stimulus has been women with chronic pelvic pain.2%. with deeply infiltrating endometriotic lesions in Unfortunately. For release of tissue-​derived local inflammatory sub.23. but in the central nervous system as ery and maladaptive changes within the central well.13 These results underscore the is required to fully understand their role in dynamic changes that occur in certain disease chronic pelvic pain. partly due to both responses from the periph- vous system. that due to some underlying genetic or others do not. visceral–​visceral crosstalk is likely to be a com- calcitonin gene-​ related peptide (CGRP). but also lead to increased vascular even globally from pelvic viscera to viscera in permeability and further inflammation via a other parts of the body.24.23.23. Nevertheless. monly a collection of sensory and functional tion.36 parable studies of male chronic pelvic pain “Central sensitization” is the process whereby syndrome/​ chronic prostatitis demonstrated a there is an enhanced response of neurons prevalence of 2. with a median of 8.”29 Even more commonly. ectopic gross changes in brain volume in patients suf- endometrial growths were shown to develop fering from chronic pelvic pain. the formation of chronic pelvic pain. such as inflam. irritable bowel syndrome or dysmenorrhea. The mechanisms of this complex and poorly understood.33 This may help explain of chronic pain syndromes describes an initial why some patients with endometriosis obtain functional insult in the periphery.28. phenomenon have been well studied.12. while mation.7%.12. which can also other factors that not only sensitize surrounding extend locally from viscera to somatic tissue.36 systems which translate into chronic pain.29 This process can be exacerbated by the disturbances that develop in nearby organs.17.36 Endogenous from human studies. .29. Neuroimaging with as estradiol have also been shown to contribute functional magnetic resonance imaging (fMRI) to sensitization in many types of chronic pelvic and positron emission tomography (PET) pain. especially endometriosis. in the development of chronic pelvic pain.

Routine use of computed these conditions in patients with chronic pelvic tomography (CT) and MRI is discouraged. Special attention should be tion to the physical complaints. can include a complete blood count.8. a thorough family history degree of pathology does not correlate with the should be obtained. Genome-​wide association stud.38 begin with the identification of its onset. a recent twin study pain mapping whereby tissues are probed under estimated the heritability of female chronic pel.38 Research has also shed light on and therapeutic potential. Chronic pelvic pain. and a detailed description of past and One of the most hotly debated forms of eval- current therapies used to treat chronic pelvic uation is the use of laparoscopy. but diagnostic as well.2. Sometimes tors. the presence and severity of pain. Disadvantages to laparoscopy include its cost.6.23.38 and prostate. including substance.25. and abdomen. In men. risk patients for the development of chronic pel. management. coping mechanisms. as the elements of chronic pain tend performed by physicians trained in non-​invasive to morph over time.7. physical. CA-​125.23. therapeutic. A  detailed social history pain management techniques. inflammatory markers. Other female patients. In addi. The history should also venography for pelvic congestion syndrome. past sur. severity. A  psychological assess. rectum. sive pelvic examination involving the external suring.7.7. history of sexual it is not surprising that the evaluation of patients abuse. and vic pain. which ultimately affects the quality of in the initial assessment of chronic pelvic pain.38 geries.35 Clinical suspicion for nerve the menstrual period.32. and coexisting psychological conditions.26. this includes an exten- The physician must remain compassionate. For example. urination. and these procedures should only be essential. more than one chronic pain condition.38 Advances in the important genetic components of chronic laparoscopic techniques. pelvic pain should be elicited. how- pain is well established.27 also be used to identify common genetic vari. as the high prevalence of pain is controversial. cystoscopy for interstitial cystitis. Benefits include both diagnostic the pelvis. reas. and sexual abuse The role of imaging in the evaluation of pelvic should be obtained.25. In women. tests. A  review of systems can be beneficial to pain is the primary indication for up to 40% of elicit coexisting chronic pain syndromes outside laparoscopies.26 with this disease can be time-​ consuming and Patience and sensitivity must be applied to maxi- challenging for the healthcare provider. including laparoscopic pelvic pain. Nerve blocks and intramuscular injections tion. quality. Developing a pain map entrapment or muscle spasm should guide inter- and having the patient keep a pain log are vention. specific imaging modalities can be used ment including mood.25.25. duration. this includes a thor- and social impairment and often are coupled with ough assessment of the penis.16. Special attention should be given to pain repeated blocks are necessary to observe a associated with sex. loca. any such as trigger-​point injections can be not only radiation. Laboratory testing is not routinely performed isfaction. such as prostate-​specific antigen (PSA) and tion of men with pelvic pain. disease does not exclude microscopic lesions. should be tailored to specific clinical The history of chronic pelvic pain should findings. defecation.32. severity of pain. ever. which Society provides a detailed template for the his. mize patient comfort.38 patient.26. these conditions given to the back. ants.7. and clinical effect. as these factors contribute to patient sat.19 Although this document is targeted for sexually transmitted infection screening. Therefore. urinaly- tory and physical assessment of patients with pel. pelvis and pelvic floor mus- are almost always associated with psychological cles. have been ies of common causes of chronic pelvic pain can successful for select patient populations. genetic sequencing studies complications of surgery.25.39 In the future. it can be adapted for the evalua. and to confirm suspected pathology. pregnancy test. pain sometimes persists despite Physical examination of patients with chronic ablation.36 The International Pelvic Pain Some clinicians do favor basic testing. and the lack of physical evidence of pelvic pain can be difficult for many reasons. including severity of pain. and the risk of neg- may play a large role in the screening of high-​ ative findings. testicles. With respect to endometriosis. . and any provoking or alleviating fac. or include other medical comorbidities. and open-​ minded when evaluating each genitalia and reproductive organs. such as pelvic the patient’s own theory about the cause of their ultrasound to identify an ovarian cyst. local anesthesia and patients are able to report vic pain to 46%. Pelvic Pain Management 3 Given the complexity of chronic pelvic pain. chronology. countless studies have demonstrated that the vic pain. sis.26.25.

Liberman RF. Long-​ uation of chronic pelvic pain: pitfalls with a neg.4(1):85–​94. noses and use of the health services. Gut. 17. Health Care Women comorbidity. Lamvu G. 2005. 8. 2003. Bohm-​ Starke N. 2007. et al.308(5728): 1. Am J 3. 2006. Iyer L. Johannesson U. Curtis KS. pain: A quantitative analysis. Fertil Steril. ANZJPH. Rapkin AJ. medical management can be tried prior to tests in chronic pelvic pain. Scialli care for the evaluation and treatment of patients AR. Proc Natl Acad Sci U S A. Vessey MP.8. Science. diag- and exposure to other medical specialties pro. As alluded to previously. such as with endometrio. Zondervan KT. Barlow DH. 15. Obstet Gynecol. 12. The role of laparoscopy in the and gastroenterologists dedicated to treating the chronic pelvic pain patient. 2000. Grace VM. sis. pain medicine physicians are best vation of endogenous inhibitory mechanisms in equipped to provide comprehensive care. 2004. term outcomes after surgical and nonsurgical ative laparoscopy. dence of chronic pelvic pain in primary care: evi. Kennedy SH. 13. and psychologists 2003. Swank DJ. diagno. Chronic pelvic pain: prev. The role of laparoscopy in the eval.25. irritable bowel syndrome patient subgroups and healthy controls. Consensus statement for the with chronic pelvic pain includes a multidisci. Brain functional mag- are limited and multiple specialists cannot be netic resonance imaging of rectal pain and acti- recruited.26. J Am Assoc Gynecol Laparosc. 1996. Peters sis and referral in women consulting for chronic AAW. Papka RE. many circumstances. and treatment experienced by women using 14. Swank-​Bordewijk SCG. 1587–​1589. Hop WCJ.27(7):585–​599. Papka RE.38 Res Clin Obstet Gynaecol. 2004. Zondervan K. 1999.53(11):1595–​1601. Nirkko A. et  al.195(2):591–​598. Interventional pain physicians abdominal pain:  a blinded randomised con- should play a central role in coordinating this trolled multi-​centre trial. trate a team of diverse consulting physicians. 2006. Chronic pelvic pain in the New Zealand health services for chronic pelvic women in New Zealand: comparative well-​being. Zondervan K. Greeven A. pain severity. Vessey MP. management of chronic pelvic pain and endome- triosis: proceedings of an expert-​panel consensus plinary approach.106(11):1149–​1155. laboratory and clinical research on chronic 11. Williams R.113(7):792–​796. 2006. Brodda Jansen G. Grace V. Steege JF. 18. Dawes MG. ter Kuile MM. 1999. Clin Obstet Gynecol. Berkley KJ. Barlow DH. Munro MG. ulodynia. assessment and management of both functional 10. Pain. 6. Reginald PW. Prevalence and inci. pain mapping for chronic pelvic pain: a prospective 4. Br J inhibitory controls (DNIC) elicited by cold nox- Obstet Gynaecol.14(13):433–​466.4 Pelvic Pain Management A  complete workup of chronic pelvic pain pelvic pain in UK primary care.87(3):321–​327. and impact on work and other activ- Int. Lipschutz RC. Kuppermann M.16(6):521–​535.101(30):11094–​11098. Patterns of diagno. Yudkin PL.106(11):1156–​1161. evaluation in a pelvic pain specialty clinic. These specialists are trained in the 1247–​1251. Howard FM. Zolnoun D. emotional and physical impairments associated Laparoscopic adhesiolysis in patients with chronic with the disease. Mittman BS. de Boussard CN. Zondervan K. functional sources of pain. the standard of 7.78(5):961–​972. 1995. model of endometriosis. Lancet. ventional pain procedures. Winkel CA. The pains REFERENCES of endometriosis. Health Care Women Int. management of chronic pelvic pain: one year after 1996. Howard FM. and economic ment and follow up of women undergoing conscious correlates. ities. Cody R. urologists. they are leaders in 2004.28(4):369–​375. Baillieres Best Pract surgery. 16. Grace VM. Clinical course of chronic . Diagnostic value of radiological sis. Mathias SD. Furthermore. 2. Gambone JC.361(9365): care team.46(4). 2002. Chronic pelvic pain pelvic pain. vides them with the unique ability to orches. Dekker FW. in situations where resources Redmond SM. they Innervation of ectopic endometrium in a rat are skilled in diagnostic and therapeutic inter. BJOG. Wilder-​ Smith CH. by physicians such as gynecologists. chronic pain and chronic pain syndromes. Problems of communication. Ascher S. and in Gynaecol. ious stimulation in patients with provoked vestib- 5. Yudkin PL. and their history of collaboration in New Zealand:  prevalence. cohort study. Swanton A. This consists of consultations process. Berkley KJ. Br J Obstet should be initiated prior to laparoscopy. health-​related quality of life. Obstet Gynecol. Kennedy SH. Evidence of diffuse noxious dence from a national practice database. Schindler D. Diagnosis. treat- alence. and physiotherapists specialized in treating the 9. Dmitrieva N. Weijenborg PTM.130(1–​2):31–​39. Dawes MG. Lovblad K.

Pelvic voked vulvodynia. Chronic stress in women with localized pro. N. Morotti M. Lee SWH. Abbiati A. 2014. Somigliana E. Becker etiology. Merskey H. Salivary cor. Warnaby C. 2014. Accessed October 19. Chronic pelvic pain and S117–​S123. Pain.155(12):2448–​2460. April 2008. Changes Antimicrob Agents. Best Pract Res 34. Kuchinad A. tisol concentrations. pain:  a pathway for care developed for both 2009. Number=1673. 30(1):73–​79. Chronic pelvic pain. tral changes in otherwise healthy women. Baranowski AP. Hermans L. pathogenesis and diagnostic approach. Classification of Chronic women. Chronic pelvic pain in 28. Available at:  http://​pelvicpain. WA: Williams FMK. Hammond CJ. Chronic pelvic pain in women: 36. Steege J. Roussel N.124(3):616–​629. Vercellini P. 2010. Brawn J. Dysmenorrhoea is associated with cen- form-​english.153(5):1006–​1014. Baranowski AP. 1994 (revised 2011). Powell G.17(2):141–​147. Zondervan KT. Definitions of Pain Terms.11(5):390–​397. Riley DE. Obstet Gynecol. Med J. As-​Sanie S. Zavos HMS. study. Hum Reprod Update. Pavy T. 24. lie chronic pain syndromes.31(Suppl 1):85–​90. Fedele L. 2009. ANZJOG. International Pelvic Pain Society: History and phys. Frawley H. Epidemiology of prostatitis. Increased gray matter density in M.. Accessed October 19. 2012. Jeon J. 2014. Garcia MC. 30. 35.25(3):149–​158. Spadari-​Bratfisch RC. Stratton P. Cheah PY. Pain. Hughes J. Prevalence of chronic pelvic pain Clin Gastroenterol. Stacy J. 2008. Ovarian hormones 27.20(5):737–​747. Lee J.85(999):24–​29. .152(9):1966–​1975. Berkley KJ. 2014. Pain. J Minim Invasive Gynecol. 2014. Kaya S. endometriosis:  translational evidence of the rela- 19. Central sensitization in urogynecological young women with chronic vulvar pain. Pain. Price C. Barbara G.aspx?Item. Pelvic Pain Management 5 pelvic pain in women. Siedhoff MT.17(3):327–​346. 2012. Chronic pelvic pain in women. Kornfeld D. Available at:  www. revised. Einstein G. 2009. chronic pelvic pain and endometriosis.16(4):291–​308. J Psychosom Obstet Gynecol. Practical guide to laparo- and chronic pain:  a comprehensive review. 2007. Central changes associated with Gynecol Endocrinol. 2013. men and women by the British Pain Society. Society. Stress. Lachance G.org/​PublicationsNews/​Content.23(4):593–​610.112(3):452–​459. Petta CA. Bogduk N. Pain. in regional gray matter volume in women with 21. Pain: Descriptions of Chronic Pain Syndromes and 39. Liong 2011. scopic pain mapping. 2nd ed. International Pelvic Pain 2011. 38. CM.aspx. 2014. Vincent K. 2014. Napadow V. Hassan S. Meeus Bushnell MC. Goucke R. 20. Bohm-​Starke 2014.52(6):502–​507. Postgrad Reprod Update. Steege J. Yunker A. Pukall CF. Harris RE. Pain Physician. tionship and implications. Seatle. Hum 26. Anaesth.132(Suppl 1): 29. Muere A. Willems T. Viganò P. et al. Pain Physician. Pain. Rylander E. stress and quality of life in 32. Grassi-​ chronic pelvic pain:  a voxel-​based morphometry Kassisse DM. ical examination form. Moore J. Vehof J. 1562–​1568. Shared genetic factors under- IASP Press.155(8): iasp-​pain. Br J 25. 2009.140(3):411–​419. ML. 23. among women: an updated review. 33.17(1):8–​11. chronic pelvic pain: a systematic literature review. Petrelluzzi KFS. Schweinhardt P. women with endometriosis and chronic pelvic Persistent pelvic pain:  rising to the challenge. Vincent K. Krieger JN. Tracey I. 22. Stagg CJ. Ehrstrom S. pain. Vincent K. Ahangari A. 2008. 37. Kennedy org/​docs/​resources/​forms/​history-​and-​physical-​ S. Int J 31. 2008.

(but not limited to) distribution of the pain. The unclear etiology presented and pubis fuse to form the acetabulum. and coccyx. with special attention to the female. The walls of the pelvis are covered by stri- Patients will frequently be uncomfortable with ated muscles that are invested in fascia. The pelvic rim defines the greater (above) of the pain. and perirectal fossa. that obliteration can manifest H I S T O RY A N D as back pain or pain along the sciatic distribu- PHYSICAL  EXAM tion. the pelvis contains the bladder and ple organ systems. constrictor function for the urethra. and lem. tion is weight bearing. Anteriorly. which a unique challenge for treatment of the pain. Inquiries should be made regarding and lesser (below) pelvis. vagina. and in the middle. aggravating factors. the umbilicus to mid-​ thigh and lasts for at Anatomy least six months. therefore. like sphincter posterolateral wall is composed of the piri- tone testing.1. which arises from the anterior talk the patients through the testing so they are and lateral surface of the sacrum and exits aware of the steps. The ilium.1). and musculoskele. genital organs (Figure 2. ischium cal component. which is a fibrocartilage cate. Muscles of the Pelvis associated bowel or bladder dysfunction. The pelvis is home to multi.3 be tested. 2 Anatomy of the Abdomen and Pelvis M O N A K . it is vital to obtain a detailed history joint. and since it is innervated by lumbar and sacral joints. this joint is relations. Over time. ischium. The joint is vic floor anatomy and physiological function in lined by a membrane that produces lubricating order to diagnose and appropriately treat pelvic fluid and is protected by a capsule. which is a synovial joint. The sacrum Recent clinical investigations have shed more meets the ilium posteriorly to form the sacroiliac light on the importance of understanding pel.2 The aim of this chapter is to permits little movement. posteriorly. The SI joint floor dysfunction. It comprises the ilium. The portions of the physical exam. Anteriorly. articulates with the femoral head. and serve the the nervous system and help localize the prob. PAT E L A N D A S S I A T. It is defined as pain that occurs below the anatomy of the pelvis to help with diagnosis of the origin of pain and appropriate treatment. pubis. Sensation and motor functions must both anal orifice. VA L OV S K A C hronic pelvic pain is a common prob- lem that has been poorly understood for decades. the uro- tal. and Muscles of the pelvic floor serve two major sexual function. The Bony Pelvis ories for the source of this pain had attributed The bony pelvis supports all the visceral organs and it to visceral organs or somatic structures in pelvic muscles. the pelvis in combination with a psychologi. Earlier the. and its primary func- review the pelvic anatomy and its clinical cor. the etiology of the pain can also be neuropathic or myofascial. the perivesicular fossa. the pubis symphysis.2. hence. it will be paramount to formis muscle. the rectum urogenital. A  broad physical examination purposes:  they form the floor upon which the can help determine any diffuse involvement of abdominal viscera are supported. tion of these organs. obliterated. sacrum. along with appropriate reflex testing. The sections below describe via the greater sciatic foramen and attaches to . the pubic bones meet to form The neuroanatomy of the pelvis is quite intri.3 In addition to pain arising from dysfunc. gastrointestinal. ner- vous system involvement. including the reproductive. (SI) joint.

also to function as an external hip a strong hip flexor and is innervated by L2–​L4. www. The superficial perineal surface of the anterior wall of the pelvis.3 (Figure 2. membrane and the inferior ramus of the pubis and the external anal sphincter. It mainly femur1.netterimages. ischiocav- arises from the medial aspect of the obturator ernosus. The pudendal and ischium and attaches to the lower part of nerve innervates these. All rights reserved. rotator.2). ischium and the obturator fibers join with the iliacus muscle. which fills membrane. Netter illustration used with permission of Elsevier.com. The psoas muscle is a fusi- functions as an external/​lateral hip rotator.1:  Topography of the female pelvic viscera: medial and paramedial sagittal views. The deep urogenital dia- the hip joint into the trochanteric fossa of the phragm layer. It layer consists of the bulbocavernosus. bral column and brim of the lesser pelvis. The form muscle located at lumbar region of verte- obturator internus muscle arises from the infe. the greater trochanter of the femur. its rior pubic ramus. also innervated by the pudendal . Anatomy of the Abdomen and Pelvis 7 Topography of the Female Pelvic Viscera: Medial and Paramedial Sagittal Views Median (sagittal) section Ureter Vesicouterine pouch Suspensory ligament of ovary Rectouterine pouch (of Douglas) Uterine (fallopian) tube Ovary Cervix of uterus Posterior part External iliac vessels of vaginal fornix Ligament of ovary Anterior part Body of uterus of vaginal fornix Round ligament of uterus (ligamentum teres) Rectum Fundus of uterus Levator ani Urinary bladder muscle Pubic symphysis External Urethra anal sphincter muscle Crus of clitoris Labium minus Anus Labium majus Vaginal orifice Paramedian (sagittal) dissection Rectouterine pouch Ureter (of Douglas) Uterine (fallopian) Vesicouterine pouch tube Ovary Rectum Ligament of ovary Ureter Round Vagina ligament of uterus Urinary bladder Ischiocavernosus muscle Pelvic diaphragm Body of clitoris (levator ani muscle) Labia Deep transverse minora perineal muscle (cut) Labium External anal majus sphincter muscle FIGURE 2. superficial transverse perineal muscles. It is foramen. as it exits through the lesser sciatic the iliac fossa to form the iliopsoas muscle.3 The obturator externus muscle is flat The pelvic floor is organized between super- and triangular in shape and covers the outer ficial and deep layers. Inc.

tively. puborectalis. The puborectalis makes up the phragm. upper vagina. and uterus. nerve. constantly to provide stability to the pelvic floor.3 All these muscles work together to keep The pelvic diaphragm is made up of levator the pelvic floor elevated and the urogenital hia- ani and coccygeus muscles. also known as the triangular ligament. medial fibers of the levator ani muscles that is a muscular membrane that occupies the area attach to the pubic bone and form a U-​shaped between the pubic symphysis and ischial tuber. comprises the ureterovaginal sphincter pubovaginalis. The urogenital dia. The pelvic diaphragm separates the internal and external anal sphincters.netterimages. Fibers from both sides come together to form The levator ani are made up of the pubococcy.3). as physiologically they are contracted are the arcus tendineus and the ischial spine. geus muscle is the most posterior and thinnest The levator ani muscles serve an important part of the levator ani muscles. tor plate. tus narrowed. www. The houses the urethra. rectum. . and iliococcygeus muscles. and puboana- and deep transverse perineal muscle. and to the anus between the the coccyx. The pelvic lis muscles. aiding in fecal continence.3 The puborectalis is a part of the anal sphincter com- pelvic diaphragm is primarily supplied by the plex. The iliococcy- ventral rami of sacral nerves 2 through 5. inner aspect of the pubic bone and to the lateral These muscles connect the pubic symphysis to walls of the vagina. the anococcygeal raphe. The urogenital hiatus is U-​shaped and tions to draw the junction toward the pubis. puboperinealis. and func- osities. and vagina. sling behind the anorectal junction. The anterior attachment is on the diaphragm forms the floor for the pelvic organs. All rights reserved. Netter illustration used with permission of Elsevier.com. Its attachments function.2:  Sacral and coccygeal plexuses. respec- pelvic cavity from the perineum (Figure 2. Inc. which provides support for the rec- The pubococcygeus muscle is divided into the tum.8 Pelvic Pain Management Schema Anterior division L4 Lumbosacral trunk Posterior division L5 Gray rami communicantes Superior gluteal nerve S1 S2 Pelvic splanchnic nerves (parasympathetic to Inferior gluteal nerve inferior hypogastric [pelvic] plexis) Nerve to piriformis S3 S4 Tibial nerve S5 Coccygeal nerve Sciatic nerve Common fibular Perineal branch of 4th sacral nerve (peroneal) nerve Nerve to levator ani and coccygeus (ischiococcygeus) muscles Pudendal nerve Nerve to quadratus femoris (and inferior gemellus) Perforating cutaneous nerve Nerve to obturator internus (and superior gemellus) Posterior femoral cutaneous nerve Lumbosacral trunk Sympathetic trunk Psoas major muscle Gray rami communicantes Superior gluteal artery and nerve L5 L4 Pelvic splanchnic nerves (cut) Obturator nerve (parasympathetic to inferior S1 Iliacus muscle hypogastric [pelvic] plexus) Inferior gluteal artery S2 Piriformis muscle Nerve to quadratus femoris S3 Internal pudendal artery S4 Nerve to obturator internus S5 Pudendal nerve Obturator internus muscle Co Superior pubic ramus Piriformis muscle Coccygeus (ischiococcygeus) muscle Sacral splanchnic nerves (cut) (sympathetic to inferior Nerve to levator ani muscle hypogastric [pelvic] plexus) Levator ani muscle Topography: medial and slightly anterior view of hemisected pelvis FIGURE 2. also known as the leva- geus.

parasympathetic. Reproduced from Harold Ellis. abdominal wall with his/​ her index finger. abdominis muscles. fol- ily via anterior and lateral cutaneous branches of lowed by asking patient to raise their head and the rami off T7–​T12. Clinical Anatomy: Applied Anatomy for Students and Junior Doctors. However. that can be spontaneous and elicited with pal- pation.3:  Structures in the anterior (urogenital) and the posterior (anal) perineum. Copyright Wiley. there can be entrapment the psoas muscle. or with posterior abdominal wall in the substance of muscle contraction. the ventral rami of spinal nerves T12–​L4 on the when the direction of the nerve changes. A  positive sign is elicited when the . 143. p. and sympathetic ring in the rectus sheath that allows the ante- components. and their relationships. 2010. Each of these nerves contains a fibrous somatic. Patients typically have a positive Carnett Somatic Nervous System sign. Anatomy of the Abdomen and Pelvis 9 FIGURE 2. Most of the sympathetically of these nerves—​ namely.4 This sign is produced when the examiner Thoracic Innervation localizes the area of maximal tenderness on the Sensory supply to the abdominal wall is primar. with permission. These sensory nerves run in torso with arms crossed over their chest. fi ­ gure 99. The lumbar plexus is formed from rior cutaneous nerves to travel freely. The nerve branches advance T H E N E RVO U S   S Y S T E M to the wall of the rectus sheath and supply the The contents of the pelvis are supplied by the skin. This superior hypogastric plexus and the parasympa- syndrome is characterized by abdominal pain thetic from the inferior hypogastric plexus. with a plane between internal oblique and transversus finger intact. anterior abdominis derived sensation and functions involve the cutaneous nerve entrapment (AACNE).

The iliohypogastric nerve runs along the It is formed by contributions from L4–​S4. Femoral nerves lie posterior to the psoas major muscle. L2). which terminates to supply the area of nus and gemellus superior (L5. perineum. has two branches. Special attention should be paid to the iliohypogastric (T12. and S1 come adjacent to the medial thigh. anterior thigh.3 As these nerves together to form the superior gluteal nerve. S2. 2 anterior). and on the location of pain. S1. The branches include medial leg. ultrasonography (US) can be used to this nerve gets trapped by staples or sutures. as it transverses through the greater sciatic psoas muscle and then posterior to the ureter. with the Sacral Plexus exception of the lateral femoral cutaneous nerve. S3 anterior) pro- nerve is commonly seen with inguinal hernia vides the cutaneous innervation to the buttock. to symptoms. nerve emerges posterior to the psoas muscle. Posterior femoral cutane- neuropathic groin pain. which supplies the quadratus femoris and gemellus inferior (L4. it lies inferior to the piriformis muscles As both the ilioinguinal and the genitofemoral and terminates to supply the gluteus maximus. and lower extremity after it exits infe- The lateral femoral cutaneous nerve ends riorly through the greater sciatic foramen. The femoral sor fascia latae.”2 The obturator nerve runs along with the of local anesthetic can be injected in the space vein and artery in the obturator canal to ter- under the rectus sheath to observe for relief of minate in anterior and posterior branches. lateral femoral cutane. and pierces more likely to be abdominal wall than visceral the abdominal wall close to the inguinal lig- in nature. these nerves during abdominal surgery so as to genitofemoral (L1. The plexus arises lateral to the sacral foramina have both a sensory and a motor component.2. L1). supply both sensation and motor innervation tic. The superior gluteal psoas muscle. anterior divisions). ilioinguinal (L1). they lie anterior to the gluteal nerves are anatomically named in relation quadratus lumborum muscles and lateral to the to the piriformis muscle. anterior) nerves. The inferior gluteal nerves also branch provides sensation to the anterior thigh. The ilioinguinal nerve They travel through the greater sciatic foramen supplies the innervation to the skin of the labia to provide innervation to the respective muscles. posterior divisions). Both in two branches (anterior and posterior) that anterior and posterior branches from L4. and femoral (L2. L5. provide sensation to the lateral thigh. If diagnosis. how- The nerve passes along the medial aspect of the ever. as the name alongside the gluteal vessels and travels superior implies. This and S1–​ S4 converge into a band to form the . and the anterior S1 anterior) and the nerve to the obturator inter- branch. repairs. obturator (L2. L3.1 foramen. majora and mons pubis. on the anterior aspect of the piriformis muscle. irritation to either one of these nerves called the nerve to the piriformis innervate the must be considered when treating patients with piriformis muscle itself. along with the skin The posterior divisions of L4. L3. L3. divisions. The genital branch to the piriformis to provide innervation to the passes through the inguinal canal and innervates gluteus medius and minimus. Entrapment of this ous nerve (S1. S1. S2 posterior).10 Pelvic Pain Management pain is persistent or increased with the maneu. All these nerves. knee. Small amounts ica. ver and suggests that the etiology of the pain is travels laterally to cross the iliacus. and then lateral to femo- Lumbar Plexus ral artery exit the pelvis laterally. skin just above the pubis.1. to continue to The branches of the lumbar plexus are the the anterior thigh and split into branches that somatic nerves that help with diagnoses based innervate the hip. The first branches are the nerve to the ting into the lateral branch. split. the thigh). with lateral abdominal wall between the transversus each nerve splitting into anterior and posterior abdominis and internal oblique muscle. L4. and repeat injections with local anesthetic to the medial thigh (the major adductors of and steroid can be therapeutic. it visualize the space between the internal oblique can result in neuropathic pain over the lateral and transversus abdominus muscles for diag. have similar origins (L5.1. S2 posterior. not compress the nerve beneath the psoas mus- ous (L2. The enter the pelvic canal.2 nerve innervate the skin adjacent to the medial Branches of the first and second sacral nerves thigh. a condition termed “meralgia paraesthet- nosis and therapeutic purposes. L4. L5. along with the ten- the labia majora and medial thigh.4 In addition to physical exam signs for ament to make its way to the lateral thigh. nerve exits through the greater sciatic foramen The genitofemoral nerve. thigh. Alleviation of symptoms is diagnos. 5 gluteal region (superolateral). cle or with laterally placed retractors.

nerves. The overlapping nature of vulvar and peri. the glans clitoris. nerve. the presynaptic neuron is long. as it synapses in a ganglion closer to the target organs.2 the psoas muscle and aorta on the left and The pudendal nerve is composed of anterior between the psoas muscle and inferior vena contributions from sacral nerves 2–​4. Fibers dal or Alcock’s canal with the internal pudendal from T5–​ T9 form the greater splanchnic artery and nerve. superior. where it functions purely as a uterus. also travels in plexus. As the inferior mes- vation to the posterior labia and vagina.1. pathetic fibers in the thoracic region. they . and ureters.2 The lumbar splanchnic nerves ter (both motor and sensory) and the area adja. converge anterior to the coccyx to form the men. It also enteric plexus travels caudally. skin between the anus and the tip of the coccyx. sympathetic counterpart at the celiac. parasympathetic functions). uterus and vagina patients. Coccygeal Plexus The coccygeal plexus is formed from anterior Parasympathetic Nervous System (PNS) division of S4. (uterovaginal plexus). The deep branch provides both sensory pathetic in nature). This descends from the white matter of the spi- nerve. One of the nerves that arise nerves. which supply the small intestine and vide cutaneous supply to the clitoris.3 The last major branch of and supply parts of the colon.2. The shorter. ian plexuses. ply the rectum and anal canal along with the The superficial branch provides cutaneous inner. ligament and reenters the pelvis via the lesser The splanchnic nerves arise from the sym- sciatic foramen. Fibers nerve travels in the pudendal canal and along from T10–​ T11 form the lesser splanchnic the ischiopubic ramus to terminate and pro. it becomes contributes to the mucous membranes of the the superior hypogastric plexus (purely sym- urethra. The plexus ter- neal region innervation makes it challenging to minates in multiple plexuses that supply the determine the true cause of pelvic pain in many bladder (vesical plexus). however. organ. There are commonly four between the piriformis and coccygeus muscles to abdominal sympathetic ganglia.1. uterosacral. get organ. which terminates at the target and terminates into the tibial and common pero. The two trunks leave the pelvis through the greater sciatic fora. and coccygeal nerves. The abdomi- Sympathetic Nervous System (SNS) nopelvic region is mainly supplied by the vagus The SNS consists of two neurons that trans. The nerve travels in the puden. Anatomy of the Abdomen and Pelvis 11 largest nerve in the body:  the sciatic nerve. which splits into left and and motor stimulation to the superficial and right divisions at the sacral promontory. Fibers from the vagus interact with their mit the signal from the spinal cord to the tar. and the rectum (middle rectal plexus). The second colon as well but via the superior mesenteric branch. The least splanchnic nerves arise from the pudendal canal with the respective vessels to T12 and send fibers to form renal and ovar- provide innervation to the external anal sphinc. receives contributions from the sacral splanch- vaginal areas share afferent fibers entering the nic nerves to form the inferior hypogastric dorsal horn of the spinal cord in close proxim. Cervical. The sympathetic chain runs between neal nerve close to the popliteal fossa. and vulvo.1.1. S5. The pudendal nerve terminates in plexus extends its fibers to the sigmoid colon. which synapse in the celiac plexus and proximally is the dorsal nerve to the clitoris. also exits via the greater nal cord from levels T1–​L2 to synapse with a sciatic foramen to the posterior thigh to inner. preganglionic neuron and inferior mesenteric plexuses. It travels cava on the right. In contrast to the sympathetic neurons. or pelvic plexus (combined sympathetic and ity. resulting Autonomic Nervous System in short postsynaptic neurons. This innervate the small intestine and colon. bral ganglion. which branches to the superior rectal plexus to sup- is divided into superficial and deep branches. terminate in the inferior mesenteric plexus cent to the sphincter. like the others. internal anal sphincter. The plexus nerves and contributions from the sacral spinal also supplies the sacrococcygeal joint and the nerves. The The PNS has a craniosacral outflow due to the muscles innervated by the plexus include the location of the fibers.2 This deep muscles. the inferior rectal nerve. It then travels laterally to the sacrospinous ganglion  impar. which arise from cranial levator ani and coccygeus muscle. longer postganglionic neuron at a paraverte- vate the major muscles in the posterior thigh. and also send the pudendal nerve is the perineal nerve. Each hypogastric nerve sensory nerve.

2011. Chronic to cause referred pain. as they have less con. Clin Anat. diagnosing and treating pelvic pain. glion to produce localized pain. Hoffman B. Schaffer J. et  al.2 REFERENCES PA I N PAT H WAY S 1. pelvic plexus. via the ventral roots that make them less likely 4.26:66–​76. These fibers enter the spinal cord 2012. peritoneal. abdominal wall pain and ultrasound-​guided tact with the somatic nerves entering at the abdominal cutaneous nerve infiltration:  a case same  level. Mohammadali M. pelvic Brashaw K. 2013. Clin Obstet Gynecol. 2nd ed. splanchnic nerves supply organs that are sub. 2005. Kanakarajan S. Cunningham F. kidneys. series. . are intraperitoneal. dromes. Pain Med. The parasympa. A  good thetic sacral fibers (S2–​S4 anterior) supply the understanding of the structures and the inner- digestive tract and the urogenital organs via the vation of these structures is therefore critical.1. Clinical neuroanatomy of the Somatic nerves are aggravated with noxious abdomen and pelvis:  implications for surgi- stimuli. nervous system (CNS) via the dorsal root gan. Williams Gynecology.48(3):627–​638. Mirza N. plex and explains in part the difficulty with colon. Halvosron L. and ureters. Visceral pain 2.12 Pelvic Pain Management synapse at enteric ganglia (Meissner’s plexus and The abdominopelvic anatomy is quite com- Auerbach’s plexus) to act on the small intestine.12:382–​386. and the signal is carried to the central cal treatment of prolapse. Roberts M. Naaraja R. High K. pathways are carried via sympathetic nerves Neuroanatomy of the female abdominopelvic that carry the signals to the spinal cord via region: a review with application to pelvic pain syn- the superior and inferior hypogastric plexuses. On the other hand. New  York:  McGraw Hill Profes­ sional. Sharma A. Schorge J. This is the primary pathway for structures that 3.

1 the healthcare system amount to nearly US$2. . irritable bowel nomic reactions such as nausea. chronic fatigue.000.5 therapies and treatment strategies. includ.000.​B U S TA M A N T E C hronic pelvic pain (CPP) is a severe. vomiting. skin.​B E TA N C O U R T. and fiber stretching.4 ual dysfunction. muscle. The impact on the quality of life of these patients. or adhesions). involved. interstitial cystitis/​ painful bladder diaphoresis. including heat. final treatment decision depends to a large In a large number of patients. vibration. families.​E C H E V E R R I . given that pain is rarely stimulus that warns the body regarding actual associated with a single underlying disorder or or impending harm. Direct costs for pain requires gaining greater knowledge of its pathophysiology and developing appropriate treatment strategies.000.8 billion per year. and other consequences associated Nociceptive Pain with chronic pain. CPP is associ.5 It includes somatic and contributing factor. pelvic inflammatory disease. pelvic con. Receptors respond to stimuli ing of pain processing and perception mech. it is estimated T Y P E S O F   PA I N that indirect costs associated with disability There are different neurophysiological mech- and absenteeism from work may amount to anisms involved in the production of pain. However. to the development of new pharmacological chemical insults. A N D M A R Í A D E L P I L A R PA R D O . 3 Pain Mechanisms in Chronic Pelvic Pain J UA N D I E G O V I L L E G A S . the origin of CPP is associ- ated not only with the presence of gynecological Somatic Pain disorders (such as endometriosis. or fibromyalgia. dis- abling condition that affects close to 15–​20% of women in childbearing age. or bones. Somatic pain is the result of injuries involving gestion syndrome. visceral pain. and the definitive diagnosis of the ceptive pain occurs in response to a noxious etiology is difficult.3 It usually worsens with physical activity and Over the past few decades. but very localized and circumscribed to the injured also with non-​gynecological diagnoses. and creates disability. Very frequently. area and is usually not accompanied by auto- ing myofascial pain disorders. ligaments. syndrome. It is remaining ovary syndrome. and sex. J O R G E D A R Í O L Ó P E Z -​I S A N O A . released by the injured cells as a result of differ- anisms has increased to a large extent. $15. (Figure 3.4. One way to describe these sources chological and social factors. joints. improves with rest.2. Management of chronic organs. A N A L U C Í A H E R R E R A . as well as multiple and mechanisms is to divide them into two comorbidities that have a significant negative groups:  nociceptive and neuropathic pain. degree on the type of pain and the mechanisms ated with depression. and healthcare practitioners Visceral pain results from lesions of internal involved in its care. or syndrome. cold.3 The causes of CPP are not Also called “normal” or “physiological.1 Moreover.” noci- well known.3 just as there are multiple sources of pain CPP is associated with several physical. physical limitations. CPP continues to pose a significant challenge to Visceral Pain patients.00. leading ent mechanisms. psy. the understand.1). J O S É D U V Á N L Ó P E Z -​J A R A M I L L O .

Skin nociceptors—​with three months after the occurrence of the insult. be continuous or paroxysmal. chemical. consequently. Ascending tracts in the spinal cord originate in visceral 4. These receptors generate painful sig- nals in response to harmful stimuli. or mixed or “pathological” pain. and it is defined as a painful response to stimuli that are usually • In physiological conditions. centers of the central nervous system (Figure 3. bleeding.6 c. cor- ceral pain include capsule distension. Nociceptors of nociceptive afferent fibers inside the 2. and it results from injury stimuli.7 • It is not always associated with a lesion and. It is considered a pathological mechanism per se. noxious not painful. High threshold to skin stimulation pain include deafferentation. probably due to the low concentration 1. thermal. they are divided into three tion in the peripheral or the central nervous sys. Dorsal horn neurons viscera. tingling. The pain is usually described as stimuli do not evoke painful responses in stinging. Neuropathic Pain There are different nociceptors that respond Neuropathic pain is also known as “abnormal” to mechanical.5 endings). or “needles. fundamental properties: The main mechanisms leading to neuropathic a. harmless stimuli and noxious stimuli (free nerve enteric inflammation or traction. pathway. direct pathological stimulus b.4 It may manifest days. has the ability to distinguish between lar abnormalities. Accurate encoding of the intensity of due to nerve fiber compression. distinct groups: tem. and characteristics. This type of somatosensory receptors.” It may all organs. it may be functional in nature. pathological func.2)5: • It tends to be diffuse or poorly localized. Absence of spontaneous activity . Supraspinal projections nociceptors. noxious stimuli) charges (ectopic foci). Nociceptors Among others.14 Pelvic Pain Management TYPES OF PAIN NOCICEPTIVE NON-NOCICEPTIVE SOMATIC VISCERAL NEUROPATHIC MIXED PAIN FIGURE 3. (they only activate with intense tional changes that give rise to spontaneous dis. weeks. ischemia due to vascu. Several characteristics describe visceral pain: Allodynia is pathognomonic. neoplasms. visceral responding to first-​order neurons in the pain muscle fiber distension. PA I N PAT H WAY S • It often results in referred somatic pain Four specific parts of the nervous system trans- due to the central convergence of somatic mit painful signals from the periphery to superior and visceral afferents.1:  Types of pain. or mes. and even 1. Depending on their function. the multiple generators of vis. burning. Only 2–​10% of the total afferents 3. and activation the stimulus mediated by the sympathetic nervous system. location and altered transmission of nociceptive informa.

Second-​Order Neurons eter. δ). they are known nals from the skin. Reproduced with permission from:  Das V. B. β. They are. There are three types of fibers. in general. Pain Mechanisms in Chronic Pelvic Pain 15 Cortex Perception Pain Descending pathway Ascending pathway Dorsal root ganglia (Spinothalamic tract) Modulation Ventral root Ventral horn Transmission Peripheral nociception Transduction Injury FIGURE 3. Given their ability to respond to sensory fibers. Visceral nociceptors fibers.9—​A There are two types of pain perception second-​ (with four subtypes. pain at a speed below 1. spinal ganglion and penetrates the spinal cord • C fibers (non-​myelinated) conduct slow through the posterior horn. Elsevier Inc. depending on their diam.5 meters per Peripheral fibers. muscle. the pregan- glionic fibers of the autonomic nervous The cell body of the nociceptors is located in the system and have a low conduction  speed. vessels. Muscle and joint nociceptors • B fibers are small in diameter myelinated 3. Volume 131 (2015). also known as peripheral second. and conduction speed2. and C: order neurons: • A δ (myelinated) nerve fibers are smaller • Specific nociceptive neurons (SNN) in diameter and conduct fast pain at • Wide dynamic range neurons (WDRN) a speed of 5–​30 meters per second. .3. Page 3.8. Sensation is experienced immediately after They both carry painful signals to the brain the injury and indicates its location. α. and as “polymodal nociceptors. 2. conduct painful and somatic sig.2:  Simplified schematic diagram of the pain pathway. and y.” joint capsules to the dorsal root ganglion. An introduction to pain pathways and pain “targets.” Progress in Molecular Biology and Translational Science. fascia. through different ascending spinal cord tracts. myelination. multiple noxious stimuli.

ending mainly in the nuclei. thalamus. action. and affective and auto- pathways through which nociceptive input trav.11 The spin- The raw input is made conscious at the thal. and to the thalamic midline and intralaminar nuclei posture. The accurate or fine localization of peripheral noxious nociceptive neurons contained in these areas stimuli. jections enable the interpretation of the sensory allel pathways and is transmitted by C fibers characteristics of pain such as location. while the to the upper periaqueductual gray colliculus other two tracts excite. cortex (PF). and to the thalamus as the cephalic. and they have limited at the ventral basal complex of the thalamus and receptor fields. spinoreticular. Traditionally. formation. and they also lamic nuclei and areas of the cortex comprising become sensitized to repeated stimuli. auditory reflexes. Most of the fast pain SNN axons converge in nothalamic tract. The axons of these neurons cross the spi- nal midline at the anterior white commissure Supraspinal Projections: Fast Pain and ascend to the thalamus as the lateral spi. drive. oreticular and paleospinothalamic tracts results The idea of tracts and fascicles as spinal in excitation.3). the thought Ascending Tracts was that the final integration of the sensory-​ discriminative and the affective components of Fast Pain pain occurred at a subcortical level. SNNs. and finally to the hypothalamus and the raphe vate descending fibers. which release pain signals to the brain. The paleospinothalamic tract projects sible for vision. Supraspinal Projections: Slow Pain encephalic tract. have characteristics similar to those of the spinal WDRNs respond to both harmless as well cord. the areas of presence of multiple connections capable of bi-​ the brain most frequently involved in the pain directional transmission (Figure 3. the WDRNs at the dorsal horn (DH). which explains why they lack sensation may be localized in the medial tha- the ability of accurate localization. also called intermediate nucleus. the prefrontal region (PF) and. ending at the interneurons. reflect. including emotions and primary motor cortex (M1). These areas control eye-​and head-​ pain pathways. to the reticular formation as The tracts that conduct slow pain (spinomesen- the spinoreticular tract. These pro- Slow pain travels along multiple ascending par. The spinomes- Slow painful signals ascend primarily encephalic tract conducts the painful signals through the paleospinothalamic tract. and locus ceruleus: cognitive and ments:  sensory-​discriminative and affective. they participate in the somatosensory cortex (S1 and S2 areas). and. For this reason. Activity in the spin- interpretation. receive multiple excitatory be classified as multi-​receptor WDR neurons. turning towards the noxious stimulus. which contains nervous centers respon. nomic responses to pain. avoidance. and paleospinothalamic) paleospinothalamic tract. afferent inputs from sensory.10 process include the: Supraspinal Projections • Anterior cingulate cortex (limbic system) Pain sensation is composed of two ele. The reasoning functions (feed-​forward. muscle. . anterior cingulate cortex (ACC). and acti. the supraorbital region. the prefrontal The cerebral cortex is responsible for supe. skin. which synapse with and quality. and rior thought processes. in particular. based on their properties. WDRN axons ascend to the midbrain as the spinomes. and also to the basal ganglia (BG). especially in Fast pain travels along the neospinothalamic the thalamus and the subthalamic diencephalic tract through A-​δ fibers. and and SN. also known as the lateral pain the posterolateral ventral nucleus (PLV) of the pathway.3 els in one direction has been abandoned to a As shown by PET (positron emission tomog- certain extent as a result of work suggesting the raphy) imaging studies (Figure 3. balance. The affective component of the painful visceral receptors. Third-​order neurons emerge from the PLV and project onto the primary (SI) and sec- Slow Pain ondary (SII) somatosensory cortex. end in different areas of the brain. oreticular tract ends in the brainstem reticular amus.16 Pelvic Pain Management SNNs respond exclusively to the activation of sensory-​discriminative dimension is integrated nociceptive afferent fibers.4). they may as harmful stimuli. intensity.

3:  Pathways for the neural response to pain. A beta fibres Local Ascending pathways Initial connections interconnections A beta fibres Neospinothalamic tract Spino-reticulo-diencephalic pathway Spinal cord Gate Control Perception of Pain In cerebral cortex Sensory and motor cortex areas First pain Second pain Premotor cortex (pain only nociceptors) (polimodal nociceptors) Pre Frontal cortex Other parts of the parietal cortex A delta fibres C fibres Cingulate cortex Insula Occipital cortex Descending modulation Peripheral receptors FIGURE 3. .

Chronic pain F R O M   C H R O N I C   PA I N ? patients always expect complete relief of their Acute pain and chronic pain are totally differ. it plays a useful biological role. teristics of pain chronic pain must be considered as a disease in • Primary premotor and motor cor. Zubieta JK.18 Pelvic Pain Management (a) (b) 1 2 3 2. 1. its own right. symptoms with treatment. is in itself a disorder. Therapy for acute pain aims to treat the ori- bus pallidus. Chronic pain does not serve any spe- memory of emotional responses cific biological purpose and has no recognizable ending point. Bushnell MC. diagnosis. assessment Acute pain is caused by a specific disease or • Somatosensory cortex (SI and injury. there is no evident tex: movement suppression or evocation triggering factor. and many believe ent entities in terms of their etiology as well as that their pain is attributable to an unrecognized . chronic pain • Prefrontal cortex: executive function. European Journal of Pain. In contrast. glo. and the input of single therapeutic modality.4:  Areas of the brain most frequently involved in the pain process. When associated with a disease in relation to current pain or tissue injury. and is SII): involved in interpreting the charac. ment of chronic pain often does not result in a completely pain-​ free condition.12 The role of the basal ganglia (striated. AMYG 3. On the other hand. Some individuals suffering working memory (decision to act. Although the treat- nociceptive information to superior motor areas. its resolution takes longer than • Thalamus (and amygdala): processing. self-​limiting in the majority of cases. plinary approach and involves more than a modulating nociceptive input. and progno- emotional stimuli with attention functions sis. Many times. Human brain mechanisms of pain perception and regulation in health and disease.11 empathy. 2005. mem. Therefore. substantia nigra) in nociception gin and to interrupt the transmission of noci- and pain suggests that they may be involved in ceptive signaling. and judgement) tions or of environmental effects may fall into • Inferior parietal cortex: related with cog. and integration of their course. from acute pain as a result of their own condi- ory. normal. treatment. the vicious cycle leading to chronic pain and nitive variables such as memory and input disability. and emotion). chronic determining the intensity of pain.9(4):463–​484. understanding WHY IS ACUTE the basis of chronic pain may lead to adequate PA I N D I F F E R E N T management and significant relief. Reproduced with permission from: Apkarian AV. they need to be considered and • Insular cortex (limbic system): processing managed as such. PCO HT PAG FIGURE 3. Treede RD. of converging information in order to While acute pain is a symptom of tissue create emotionally relevant context damage or an associated disease. discriminating pain therapy must be based on a multidisci- the affective and cognitive dimensions of pain.

leading to learning and memory. altered pain perception and altered emotional and the hippocampus. there is a corticolimbic pathway that cognitive and emotional processing inherent to goes from the primary and secondary somato. reduced activity can be based on realistic expectations.15. are at least three reasons to explain increased sistent pain. as is neuromodulators. depression. adrenalin levels in the body. we might say that dysfunctional pathway. ues beyond the resolution of any causal disease.20 increases the reflexive defensive response and Inherent to some mental disorders is altered pain perception. and with time. and defensive behavior. it is even impossible to identify be used as an example. cog.26 in the perception of the stimulus and may be Pain and negative emotions may influence beyond the awareness of the individual. either under-​or up-​regulated. its own signs and symptoms. and behavioral components. and schizophrenia. eat- healthcare providers and patients alike to under. sive disorders.24 cessing.27 and hypoalgesia because of the body’s need to It has been suggested that the underlying improve action. major depression could In many cases. mental disorders exercise different influences sensory cortex to parietal and insular structures.23. depressed individuals suffer cess involving closely related emotional. where there pain so that management plans and outcomes is a lower sensitivity to pain. together with other although without any apparent relationship. intensity. pain subjects is also related with increased pain perception results from a complex neural pro.14 pain sensitivity in this syndrome. Research on the interrelation between then to the amygdala. Price18 has chronic pain show a high prevalence of depres- proposed a dual pathway for affective pain pro. First. the main characteristic of depression is dysphoric E M OT I O NA L mood.19 each other. adrenalin acts as an important .16. on pain. and the absence elucidated.21. Theoretically. Apart from the direct spinothalamic Therefore. there the original etiological factor that triggered per. giving rise to by negative emotions selects this pathway and hyperalgesia. evoked by pleasant stimuli such as eating way. there is a associated with the emotional and cognitive weak relationship between abnormal physical processing of pain. Pain Mechanisms in Chronic Pelvic Pain 19 disorder. In this tem. This second pathway pain and emotion in general. Second. There are reports in the sense that Fendt and Fanselow propose a more import. amygdala and the ventral lateral prefrontal cor- it becomes nonexistent.18 unpleasant stimuli that produce anxiety. For this reason. chronic tex. perception in those patients.12. ing disorders.15 integrates the sensory characteristics of the pain It has been proposed that emotions involve with information coming from different sensory two motivational systems:  the appetitive sys- systems.25. including deactivation of the findings and the intensity of pain. the risk of developing musculoskeletal pain ant role for the cognitive impact of the nocicep.22.17 of control of experimental pain in healthy From the neurobiological perspective.25. and an avoidance system activated by long term to the affective processing of pain. related in the and sex. and finally converges on processing in mental disorders might be very the same structures that are activated directly useful in understanding the interaction between through the direct pathway. a cognitive aspect is added. and patients with nitive.13 has been reported in several regions of the brain In many chronic pain disorders. whereas unpredictable pain mechanism is that the avoidance system elicited causes anxiety and greater arousal. Finally. and the experimental induction of sad- S TAT E S A N D PA I N ness in healthy subjects leads to an increase in M O D U L AT I O N pain perception. the perirhinal cortex. with- Emotional modulation may occur very early on drawal or aggression. frequently from clinical pain. it is very important for the case in borderline personality disorder. and contin. the absence of con- The perception of painful stimuli is profoundly trol and the feeling of impotence and despair influenced by emotional variables whose are important factors in the development and neurobiological bases have not been clearly maintenance of depression. These findings point to the influence of cog- pain is an entity with a pathophysiology of its nitive and emotional processes on altered pain own. may be twice as high in people suffering from tive stimulus.15 stand the differences between acute and chronic In post-​traumatic stress disorder.28 Stressful situations increase perception of pain. Consequently. On the other side. Predictable pain may elicit fear depression as it is in healthy controls.

reducing defensive reflexes.32 range of conditions such as neuropathic pain. healthy adults as well as in adults with chronic It also participates in the evaluation of positive pain that catastrophizing remains stable during emotions and the activation of the appetitive sys. an important determinant of outcomes related ple. ened sensitivity to pain. including a petuate the symptoms. The exact mecha- nisms involved in the pathophysiology of pain Catastrophizing are not fully understood. although its exact mechanism is not well understood. Noradrenaline levels in N E RVO U S S Y S T E M the amygdala increase in response to stressful CHANGES situations.35 The amygdala is involved tional and cognitive changes that characterize in the evaluation of the emotional components it may alter endogenous inhibitory descending and the modulation of autonomic responses pain pathways. and chronic pelvic poral lobe and consists of interconnected nuclei. ception might have a clear effect on the devel- noradrenaline is of greater interest due to its opment of procedures for improving treatment hypoalgesic and analgesic effects and its action options in chronic pain. lumbar pain. Almost all adrenergic receptors are I N   C H R O N I C   PA I N located in the central amygdala. sequence of chronic pain. activation in the central amygdala in stress-​ which contribute to the persistence of pain and induced analgesia. but much more research is still els. unchanged after the resolution of acute pain and it appears to be involved in the enhancement the insult that provoked it. between catastrophizing and pain is not com- tion of autonomic and endocrine responses to pletely understood. it is believed The term catastrophizing was coined in 1979 that both the central as well as the peripheral to describe a maladaptive coping style used by nervous systems undergo acute and long-​ term patients with anxiety and depressive disorders. There is evidence in ative emotions is a component of pain therapy.37 processed.39 the hypothalamus. they are at a tems and the thalamus.29. where it has been shown that Of these. increased blood pressure. Consequently. modulation of these neg. weeks and months and it may even remain tem. ening situations. ence that affects many aspects of emotional life. The evidence available at the present time to short and long-​ term pain. and it causes suffering for millions of peo. In threat. pain is a multifaceted experi- algesia.34. basal nuclei. For this rea. catastrophizing is the cause or rather the con- lated by noradrenaline. and that it is also associated with (breathing. greater activity in the pain processing regions of and heart rate) associated with pain.32 on the amygdala. Catastrophizing has emerged as treat. son. the basal lateral amygdala. sweating. which is partly modu. moreover.20 Pelvic Pain Management modulator of pain perception at a spinal and tendency to amplify and focus on painful symp- supraspinal level.31 toms as well as on feelings of defenselessness Chronic pain continues to be difficult to and pessimism.” with projections to post-​operative syndromes. Chronic pain is associated with multiple changes dence of noradrenaline release and α2 receptor in the central and peripheral nervous systems. which patients with a high level of catastrophizing have can be described in simple terms as the “entry increased musculoskeletal sensitivity and height- point.” receives input from all the sensory sys. recent approaches to the treatment of pain Considering that the amygdala is a key compo- include cognitive-​ behavioral therapy as well as nent of the neural circuit where emotions are relaxation and the use of music for pain relief.38 make it difficult to manage. scleroderma. it appears to be involved in There is an ongoing debate on whether stress-​ related analgesia. and brainstem. It is proposed that the emo- affective stimuli. However. The exact mechanism for the association These connections are involved in the genera. the brain.40 (hyperalgesia) and reduction or inhibition (hypo. pain syndromes. analgesia) of painful signals. The amygdala is located in the medial tem. and it is con- sheds some light on pain transformation and sistently associated with heightened pain lev- modulation. This relationship is maintained in a wide required in order to complete the process. understanding its role in antinoci- Among the multiple pain neuromodulators.33 The central amygdala higher risk of developing persistent painful and is considered the “exit point. changes that alter the pathways of pain and end New approaches refer to a negative emotional up creating lasting abnormal responses that per- and cognitive response to pain. In summary.5 . There is evi.36.30.

and pudendal nerves to cell bodies peripheral innervation area). as harmless stimuli.45 Afferent activation of as adenosine triphosphate (ATP) and hydrogen a pelvic structure influences the efferent output ions are released from the cells. Tissue damage creates somatic fibers. in the spinal the medical management of chronic pain that cord (dorsal root reflexes).44.14 Repeated low-​frequency stimulation of C fibers produces a gradual increase in the discharge fre- Central Sensitization quency of second-​order neurons in the spinal “Central sensitization” (CS) refers to an increase cord until they arrive at a state of almost contin- in the excitability of the spinal and supraspi. hyperalgesia. and other pro-​ inflammatory substances. receptive field (with pain extending beyond the splanchnic. rectum.45 expansion of the and uterus is transmitted over the hypogastric. and unusually pro- in the thoracolumbar and lumbosacral dorsal longed pain after the painful stimulus has been root ganglions. and cen- nervous system.47 mal reflex pathways may occur locally in the Given the implications of sensitization. with allodynia. For this reason.42.46. The development of cross-​talk in pelvic disorder together with the individual’s altered organs requires cross afferent stimulus in the ability to deal with previous cognitive experiences pelvis. substance P. pain. ated in the skin. Therefore. Central “Cross-​talk” is the phenomenon wherein strong sensitization is a physiological phenomenon of electrical signals originating in poorly myelin. Peripheral sensitization is asso. or after persistent horn interneurons are largely influenced by nociceptive stimulation. In CS there is pain dissociation leading to duces an antidromic stimulus (from the center an expansion of hyperalgesia beyond the site of to the periphery) as well as co-​sensitization of injury. following tissue damage. the prodromic afferent eliminated. Pain Mechanisms in Chronic Pelvic Pain 21 Cross-​Talk activation of the peripheral receptors. are much more potent than those gener- sium ions. This states results in expan- nal neuronal circuits as a result of injury or sion of receptive fields. and dorsal forms of neuropathic pain. This theory the threshold. lowering mal activation of another pathway.49 as well as thermal stimuli regardless of whether they are harmless (allodynia) or noxious Spinal Cord Wind-​up (hyperalgesia).13. permanent biochemical . hyperexcitability leading to neuronal dysregula- ated (or non-​myelinated) nerve fibers produce tion and hypersensitivity to pathological as well de novo electrical signals in the adjacent affer. stimuli coming dramatic changes in the chemical milieu of to the dorsal spine from the muscle. the antidromic tral and peripheral pain elements must also be pathway may produce functional changes in managed. a burning sensation. The afferent information from the main and their impact on daily life.13. colon. releasing potas. ness. and cross-​hypersensitivity between sev- another “uninvolved” pelvic organ. prostaglan. is important to bear in mind when deciding zation of the afferent nerve fibers). often reported as visceral pain. In peripheral to another structure. bradykinin. uous depolarization.14 It appears that in CS there ent fibers that are not involved in the painful is a combination of a neurotransmitter-​mediated stimuli. in some dorsal root ganglion are visceral. These abnor.48 another pelvic organ with little or no organic pathology. patients report throbbing stimulus (from the periphery to the central ner. inflammatory mediators heighten injury in one pathway may influence the abnor- pain perception in response to stimuli. ple. Typically. Generally. some intracellular contents such the abdominal wall. eral somatic and visceral structures. Consequently. Only 2–​7% of all afferent nerve fibers in each tion may occur in inflammatory pain. or numb- vous system) from an affected pelvic organ pro. it periphery through collateral axons (dichotomi. Peripheral sensitiza.43. any disease or sensitization. especially in Additionally. This is why somatic pain is dins. may explain symptom or disorder overlaps in ciated with increased sensitivity to mechanical chronic pelvic pain.41.43 Visceral–​Somatic and Visceral–​Visceral Convergence Peripheral Sensitization There is convergence of the somatic as well as Both central and peripheral sensitization (PS) the visceral afferents on the same second-​order are the main causes of hypersensitivity to pain neuron in the dorsal horn of the spinal cord. tingling. for exam- peripheral nociceptor endings.44 CS is associated pelvic organs such as the bladder. and/​or in the central somatic symptoms must be controlled.

However. Aside from adverse physical effects. and neu- neurons. paracetamol scribing opioids. not only at a cortical second or third line of treatment for chronic level but also at a subcortical and spinal level. Consequently. the spinal cord. and rheumatoid arthritis concluded that was shown that the cortical areas where pain is there is a small functional improvement and represented displace medially. adverse sensory processing upregulation. Before starting the use of opioids. Their sales increased the inducible form and is produced in response nearly 176% between 1997 and 2006. One of the goals of interdisciplin. as is the case of ketamine. the increased An exception to the mechanism of opioids is activity of nociceptive stimuli may induce cen. 14% abandoned O F   C H R O N I C   PA I N the treatment. A  meta-​analysis of 41 random- It has been proposed that a barrage of painful ized controlled studies of the efficacy of opioids stimuli to the dorsal horn may lead to cortical in osteoarthritis. trigger or perpetuate chronic pain. antidepressants. the no neuropathic damage are still unclear. as well NSAIDs as other drugs that cannot be classified under a NSAIDs’ mechanism of action is to inhibit specific group. Other adverse effects include Pharmacological treatment is one part of the hyperalgesia and hypothalamic-​ pituitary axis interdisciplinary approach required in cases of (HPA) disorders. the cis- Neuroplasticity and Central terna magna. COX-​ 1 acts to Opioids are the most widely sold medications protect the gastrointestinal tract. pain. which reduces connectivity in the periphery and in the spinal pain in osteoarthritis. effects have to be considered. There is shown to be useful in neuropathic pain and .53. and. including nau- in itself. but.22 Pelvic Pain Management changes. physicians drugs are used in the management of chronic must be aware of their therapeutic and non-​ pain. maladaptive cortical reorganization may.56 the pro-​ inflammatory cyclo-​ oxygenase (COX) enzyme that produces prostaglandins and ara- Opioids chidonic acid thromboxanes. among others. reduction but less functional improvement when The mechanisms involved in cortical reor. Of patients followed PHARMACOLOGY for a period of 7–​24  months.54 painful phantom limb syndrome. with similar pain neighboring areas.evidence for determining the effectiveness of tical reorganization and chronic pain. It has International Association for the Study of Pain been suggested that in the complex regional pain and the European Federation of Neurological syndrome (CRPS). and as first-​line treatment in special cir- modifying the cortical representation regions of cumstances. lumbar reorganization in patients with chronic pain. dependence) when pre- inflammatory agents (NSAIDs).some improvement in terms of the severity of ing an expansion of that representation area to pain compared with placebo. drowsiness.tramadol (serotonin and noradrenalin reuptake tral sensitization and abnormalities in functional inhibitor and μ-​agonist opioid). and drug trafficking by patients order to achieve objective improvement.52 Many and practitioners alike.54.57 ganization in patients with chronic pain and On the basis of these findings.5. nonsteroidal anti-​ therapeutic use (abuse.5. and they to inflammation.55.50 effects. (acetaminophen). including opioids. Chronic tramadol when compared to other opioids. It pain. constipation. diabetic neuropathy. mortality. such as exacerbation of neuropathic the affected areas. pain may cause cortical reorganization. there is insufficient that there is always a relationship between cor. controversy regarding their efficacy. alter. and the afferent Reorganization nerve endings.51 sea. it is not possible to conclude ropathic pain. muscle relaxants. Their sites of analgesic action are the brain. lowering of the threshold. anticonvul- sants. and respiratory depression. chronic pain. leading to over- various strategies and applying pain scales in dose. opioids ary management is to improve function using entail the risk of abuse (45%). However. For example. adverse natively.5 are a first-​line treatment in acute management These types of medications have not been of moderate to severe cancer pain. constant pain may interfere Societies57 recommended opioids for use as the with sensory perception. possibly indicat. fibromyalgia. finally. and associated aberrant behaviors. in patients with pain. topical agents.compared with other analgesics. and COX-​2 is in the United States.

is one such agent. ulation of the γ-​ aminobutyric acid (GABA) cannabinoid receptors (CB2). Many studies have (SSRIs). The most common is gastropathy. GABA A  receptor inhibitory system. and serotonin. are effective in reducing neuropathic and mus- dence in relation to neuropathic pain. ing chronic pain through modulation of the cial effects. When compared with placebo. something that needs to be considered Muscle Relaxants when it comes to long-​term use. with stronger evi. and functional status. glutamate antagonism.63 . The best evidence supports mainly the use fibromyalgia.55. Pain Mechanisms in Chronic Pelvic Pain 23 have not been included in recent guidelines for these. upreg. pathic pain:  gabapentin. or sodium channels. and the tight margin between and other disorders in terms of improving pain. given that sedation is the because of the associated liver toxicity. medications. receptor potential ankyrin channel 1 (TRPA). it has been overdosing given its broad distribution. developed with the aim of reducing shown acute analgesic effects. and carba- and lumbar pain. and its cost is cle relaxants.59 culoskeletal pain. including osteoarthritis. derived from chili placebo in the treatment of chronic pain. safe and toxic dosing. Capsaicin. including the following groups:  transient calcium channels.60 are needed to examine its safety and toxicity with all routes of administration. calcium channels. including their action on localized pain. They are recommended as sort-​ Acetaminophen has weaker analgesic effect than term adjuvant therapy.54 Although the mechanism of muscle relaxants is not clear. they have been shown to cause Ketamine was introduced in the 1960s. Selective inhibitors of COX-​ 2 adverse effects include drowsiness. Studies have not shown NSAIDs. Long-​term Administration (FDA) issued a warning in 2010 therapy is challenging. Antidepressants Topical Agents Antidepressants have different effects that con. as they are delivered to the spe- noradrenaline.61 aline reuptake. and recent studies the adverse effects of the broad range of tricy. Other Medications arrhythmias). and weight gain.62 Anticonvulsants There is ongoing theoretical and experimen- Anticonvulsants’ mechanism of action is the tal work in the development of pain management modulation of voltage-​dependent sodium and drugs. So far. avoiding first-​passage metabolism and analysis suggested that they are better than drug interactions. in low-​quality studies. it acts by depleting moderate symptom reduction. been associated with an increased cardiovascu- lar risk. dizziness. pregabalin. blockade of increased NMDA receptor activity. or a combination of all of subtypes. Other Tricyclic antidepressants (amitriptyline and substances shown to be effective are topical cyclobenzaprine) block serotonin and noradren. and they have tolerabil. A  meta-​ cific site. One of their adverse reactions mazepine or oxcarbazepine. they have been shown to of three drugs for the management of neuro- be useful in osteoarthritis. over-​ shown to be better than placebo in fibromyalgia the-​counter sale. The main complication is unintended the most and. Topical agents are recommended in cases of tribute to analgesia. have shown long-​term effectiveness in improv- clic antidepressants.58 Efficacy has also substance P from the primary afferent neuron. Duloxetine is However. topical agents lumbar pain. and opioid systems. fibromyalgia. have fewer gastrointestinal effects. acetylcholine. They have the advantage of N-​methyl-​D-​aspartate (NMDA) receptors. and has been studied in the treatment of sev- Selective serotonin reuptake inhibitors eral chronic pain syndromes. but it is a good option for reducing significant differences among the various mus- gastrointestinal complications. rheumatoid arthritis. postural hypotension. and imidazoline receptors. on avoiding the adverse systemic effects of oral adenosine. They have adverse cardiovascu- lar effects (hypertension. most common adverse effect. it is thought to be associated with their Acetaminophen sedative effect. and headache.58 They have no effect on adrenalin. Cyclobenzaprine has been studied lower. with pepper. despite positive results. but they have fatigue. The US Food and Drug muscle spasm. have shown some benefi. diclofenac and lidocaine. it has falls in elderly patients. more studies used in fibromyalgia and neuropathic pain. an antagonistic effect on the NMDA receptor ity issues. been shown in neuropathic pain.

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Therefore. Pelvic girdle and pelvic floor muscle other sexual dysfunction. psychoso- Symptoms of pelvic pain syndromes can include cial. anxiety. or buttock pain. to the treatment plan (Figure 4. In the absence of organic pathology. Altered neurodynamics of peripheral patient may lie outside of the diagnosing pro. and pelvis gists. discussed in skeletal dysfunction. treat and rule out organic pathology. Through a history pudendal neuralgia. the first step of the algorithm is to actively involved in the management of pelvic evaluate. motor control.2 Currently. Connective tissue restrictions in the gynecologists. 4. fear-​ algorithm can be used to illustrate evidence-​ avoidance. a treatment 7. urinary urgency and frequency. disorders late an effective treatment plan by implementing 5. Central sensitization treatment protocols do not exist. Because 6. 4 Multidisciplinary Approaches to Pelvic Pain Treatment A Physical Therapist’s Perspective STEPHANIE PRENDERGAST P elvic pain is defined as a biopsychosocial syndrome that may include organic. Patients often do their myofascial trigger points.1). The second on physical therapy evaluation and treatment. burning or should include: itching. nerves—​tenderness and movement vider’s particular area of expertise. constipation. the diagnosing provider is well posi. and nonbacterial chronic and a physical examination. dyspareunia. Regardless of the discipline of the evaluat- and pelvic floor physical therapists have become ing provider. This exam genital. will examine the patient for physical. urologists. and/​or gastroenterolo. the treatment needs of the 3. Despite this disorders limitation. psychologists. peripheral and central neuropathic.) . Behavioral factors: catastrophizing. sleep based treatment options that can be used suc- cessfully in varying combinations. one therapeutic more detail in other chapters in this book. Joint dysfunction an interdisciplinary treatment approach. part of the chapter will discuss how to use clin- ical critical reasoning strategies to manage the patient who is not tolerating or not responding and psychosocial impairments. 85–​90% of The term “pelvic pain” encompasses a long people with pelvic pain present with musculo- list of symptoms and diagnoses. mus- culoskeletal. pain syndromes. and neuropathic impairments. established protocols do not exist Physical therapists treating pelvic pain for pelvic pain diagnoses such as vulvodynia.1. a physical therapist prostatitis or chronic pelvic pain syndrome. depression. In recent years. lower extremities. own online research and then attempt to get length and strength a diagnosis through primary care physicians. abdominal. dysuria. should have specialized experience in treating interstitial cystitis/​ painful bladder syndrome. Biomechanical and movement pattern tioned to help a person with pelvic pain formu. trunk. The first part of this chapter will discuss four (Please see c­hapters  17 and 18 for more detail conservative therapeutic domains. For this reason. high-​tone pelvic disorders. treatment domain is physical therapy. and anorgasmia and 1. a growing group of physicians. 2.

Multidisciplinary Treatment of Pelvic Pain 29

Abdominal, gluteal, pelvic, Urinary Dysfunction
genital, anal, perineal, CPP Bowel Dysfunction
vaginal, scrotal, and/or labia Sexual Dysfunction
pain

Pathology
(follow protocol)

Team Evaluations
• MFR And • CBT
• MTRrP Th Re-evaluations • PYSCHOANALYSIS
• CTM • SEX THERAPY
• NEURALMOB • HYPNOSIS
• STRUCTURE RX • BIOFEEDBACK
• ANS QUIETING
PT

Team
Plan

• DN and TPIs
• PERIPHERAL N. IPM PHARM
BLOCKS • SIMPLE
• PULSED RF ANALGESICS
• BTX/A • NEUROPATHIC
• NEURO- ANALGESICS
MODULATION • ANTICONVULSANT
Sacral • NMDA
Posterior Tib ANTAGONISTS
Pudendal • OPIOIDS

Not tolerate/
Respond
Not respond

Desired Therapeutic Outcome
Prendergast & Rummer 2010

FIGURE 4.1:  Treatment algorithm.
Adapted from Prendergast S, Rummer E. Interdisciplinary management of chronic pelvic pain. In: Chronic Pelvic Pain and Dysfunction.
Chaitow and Jones, eds. New York: Elsevier; 2012:171–​185.

Following the evaluation, a physical thera- and the patient’s history and etiological factors,
pist will develop a comprehensive assessment. and will help link the patient’s objective findings
An assessment takes into account all past med- to their symptoms. The therapist and patient
ical information, effective and failed treatments, develop short-​term goals, long-​term goals, and

30 Pelvic Pain Management

a treatment plan with an estimated frequency for patients. However, managing patient expec-
and duration. The treatment plan typically con- tations about the intended effects will increase
sists of patient education regarding pain physiol- their compliance and can be a useful supple-
ogy, and interdisciplinary treatment approaches, ment the treatment plan. Often, the medica-
manual therapy techniques, temporary lifestyle tions are intended to counteract or treat central
modifications, neuromuscular reeducation, and nervous system disorders and neuropathic pain,
a home exercise program. Generally, patients are and reduce anxiety and depression. It is use-
treated by a physical therapist once or twice a ful for the provider and the patient to discuss
week for 8–​12 weeks. The length of the treat- the expected effects of a medication and how
ment should be one hour. This often renders they are going to determine if the trial of the
the physical therapist one of the medical provid- medication is successful. Various combinations
ers with the highest amount of patient contact. of pharmacological topical ointments may also
Therefore, the physical therapist can be very be used that can include the above-​mentioned
useful in coordinating the treatment plan and medications, hormones, and anesthetic agents.
ensuring that the other providers have the infor- They can also serve to allow the patient to tol-
mation they need to carry out their role in the erate or become more responsive to treatments
treatment plan. in the other therapeutic domains (see Chapter 5,
When psychosocial impairments are identi- “Pharmacological Management of Pelvic Pain”).
fied, patients often benefit from services that fall Interventional pain management procedures
under a second therapeutic treatment domain, are a fourth therapeutic domain. Dry needling,
categorized as psychosocial behavioral health. acupuncture, myofascial trigger point injections,
Cognitive behavior therapy (CBT), psychoanal- peripheral nerve infiltrations, pulsed radio fre-
ysis, sex therapy, hypnosis, biofeedback, and quency or ablation, botulinum toxin injections,
autonomic nervous system quieting (ANSQ) are ketamine infusions, and neuromodulation are
examples of a few of these treatment strategies.3 a few examples of these types of treatments.8–​11
Patient goals and any psychosocial impairments Like the pharmacology options, these proce-
can help the provider determine if and when dures can be very useful when interdisciplinary
these services can aid the treatment plan. For critical reasoning is used to determine what may
example, a patient with dyspareunia who also provide the most benefit with the lowest risk for
reports a history of sexual trauma may benefit the patient.
more from these type of services than a woman
who developed dyspareunia as the result of a fall. T H E N O N -​R E S P O N D I N G
A  person with high levels of anxiety may bene- PAT I E N T
fit more from hypnosis than a person without People with polymorphic syndromes such as
anxiety. Having a comprehensive understanding pelvic pain rarely achieve complete pain resolu-
of the challenges facing the patient and of the tion with a single treatment in any of the treat-
particular services can help the team determine ment domains. Furthermore, they may not be
which services will be most useful for this par- able to tolerate a particular therapy, or certain
ticular individual. (See Chapter  16, “Chronic therapies may not be available to them. Critical
Pelvic Pain and Psychological Disorders,” for reasoning within the algorithm allows the team
more detailed information.) to use combinations that are available and rea-
In addition to physical therapy and psycho- sonable for their particular patient. Commonly,
logical services, certain patients can benefit from patients will report that individual therapies
pharmacological intervention to supplement “are not working.” The key is to figure out why,
their treatment plan. In an ideal scenario, one regardless of the treatment. This includes med-
pain-​management physician helps the team over- ications, injections, physical therapy, psychol-
see the patient’s medication. Simple analgesics, ogy, etc. Commonly, patients with pelvic pain
neuropathic agents, anticonvulsants, N-​Methyl-​ are misinformed or uninformed about why they
D-​ aspartate (NMDA) agonists, tricyclic anti- are doing a particular treatment and what the
depressants, and Serontonin Norepinepherine intended outcome is. For example, patients can
Receptor Inbibitors (SNRI) can be used in vary- be quick to dismiss a medication because their
ing combinations to treat pain, anxiety, and expectation is complete pain resolution. That
depression.4–​7 In isolation, these medications medication may not resolve their pain but may
rarely provide the desired symptom resolution allow them to tolerate physical therapy, which

Multidisciplinary Treatment of Pelvic Pain 31

may be a necessary part of their treatment plan. floor hypertonus and connective tissue
A  patient may not have access to physical ther- dysfunction in the territory of the nerve.
apy and may need pharmaceutical intervention Additionally, the vulvar connective
and other strategies to manage their pain. It is tissue restrictions are contributing
important for patients to understand that pain to the tenderness at the vestibule.
management is useful as they continue to treat The internal and external connective
the underlying causes. tissue restrictions can be causing her
This strategy can best be described in the intolerance to pants.
form of questions and answers using clinical 4. Treatment plan: The physical therapist
examples (Cases 4.1 and 4.2, below). and patient agree to a treatment plan
of one visit per week for eight weeks.
The plan includes manual therapy to
CASE 4.1 address the above-​mentioned issues, and
A 23-​year-​
old woman with unprovoked vag- a home exercise program to decrease
inal burning and dyspareunia:  Her pain gets the high tone, lengthen the pelvic floor,
worse when she sits, and she is unable to wear and improve connective tissue integrity.
pants because of her symptoms. She has a his- The goals for therapy are to be able to
tory of multiple yeast infections and is a former tolerate wearing pants, sitting for two
gymnast. hours without vaginal pain, and to
engage in intercourse without pelvic
pain symptoms.
5. Problem arises: After three sessions,
Treatment Considerations the patient is frustrated—​she reports
increased vaginal burning for several
1. Is there an active infection? No: start days following physical therapy. She
physical therapy. Yes: treat infection and is not sure if this treatment is the
then refer to physical therapy. right treatment. The physical therapist
2. Physical therapy evaluation reveals contacts the referring gynecologist to
myofascial causes of pelvic pain that discuss the situation and suggests that
include external connective tissue the patient speak with her doctor about
dysfunction in the trunk, bony pelvis, medication. They modify the physical
and lower extremities, piriformis and therapy treatment and stop internal
obturator internus myofascial trigger physical therapy, and they continue
points, (+) Tinel’s sign at Alcock’s with the external treatments for a few
canal bilaterally, hypertonic pelvic appointments until it can be better
floor muscles with poor motor control, tolerated.
positive Q-​tip test at the vestibule for 6. The patient returns to physical therapy,
pain, and vulvar connective tissue her doctor prescribes a tricyclic
restrictions. antidepressant and 2% lidocaine jelly
3. Physical therapy assessment: It is that can be used prior to internal
plausible that this patient had a physical therapy to minimize the pain
high-​tone pelvic floor because of her following physical therapy. Even with the
gymnastic background. Repetitive lidocaine, the patient still cannot tolerate
yeast infections can then sensitize the internal physical therapy.
vestibular tissue and the pudendal nerve, 7. The physical therapist reasons that the
leading to further muscle hypertonus. burning is not solely coming from the
The muscles, nerve, and tissue are vestibule, or the lidocaine would be
now impaired enough to generate her more effective. The patient presents
described symptoms, even though her with positive Tinel’s signs bilaterally
infections are resolved. The obturator on the pudendal nerve branches
internus hypertonus and myofascial at Alcock’s canal. This patient also
trigger point can contribute to pudendal presents with bilateral myofascial
nerve irritation, and the pudendal points in the obturator internus
nerve irritation can contribute to pelvic muscles. The physical therapist speaks

32 Pelvic Pain Management

with the patient’s physician to discuss physician discusses physical therapy,
considering a pudendal nerve block or but the patient declines, based on
botox injections to this muscle. They the nature of the treatment and her
agree that the myofascial trigger points anxiety. Her physician recommends
may be aggravating the pudendal nerve psychological services that are different
and therefore treating the trigger point from psychoanalysis, with the intention
may be a more useful choice. The of giving her tools to manage her pain
physician injects the obturator internus and anxiety and also treat her phobia of
with lidocaine first, which decreases medical providers. The patient is willing
the patient’s unprovoked vaginal to try hypnosis and cognitive behavioral
burning by 50%. This is satisfying to therapy with this new expectation.
the patient, and botox is then injected. 4. Following a successful course of hypnosis
The following week, the patient returns and cognitive behavioral therapy, the
to physical therapy and can tolerate young woman is ready to start physical
internal therapy. She is also now on therapy. The psychologist calls the
a therapeutic dose of the prescribed physical therapist prior to the first
medication. She continues with appointment and offers suggestions
physical therapy for 16 more sessions as to what will be most useful for
and achieves her goals of pain-​free this particular patient in terms of
intercourse and the ability to sit and communication and techniques that may
wear pants without vaginal  pain. reinforce the psychological improvements.
The physical therapist communicates with
the patient prior to the appointment that
this discussion has occurred and that
CASE 4.2 everyone will work together to coordinate
A 25-​year-​old woman with unprovoked vaginal an effective treatment plan.
pain and dyspareunia:  She has a history of sex-
ual abuse, anxiety and depression, and a phobia Cases 4.1 and 4.2 are examples of very dif-
of medical providers. ferent treatment plans for patients with similar
symptoms. They present with different under-
lying etiologies and physical and emotional
impairments. Using the algorithm to choose
Treatment Considerations individualized treatments based on a patient’s
specific assessment can help providers start a
1. Her gynecologist diagnoses this woman reasonable treatment plan. These plans often
with vulvodynia, and hypertonic need to change based on response to treatment,
pelvic floor muscles were identified. at which time a reevaluation should be used.
Additionally, the physician recognizes Because multiple therapeutic combinations exist,
that this patient also has unmanaged interdisciplinary provider and patient communi-
anxiety and will suffer emotionally if she cation can help troubleshoot challenges when
needs to attend weekly physical therapy patients do not respond or cannot tolerate a
appointments in her current frame treatment. Ongoing reevaluations and treatment
of mind. plan reorganization will lead to more successful
2. Physical therapy is not an appropriate outcomes and patient successes.
choice until someone in psychological
services treats her anxiety. The patient
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a slight improvement in her pain. The ments for vestibulodynia:  two-​and-​one-​half year

J nists in the treatment of chronic pain. Hough DM et  al.181(2):561–​567. Visser E. Presthus J. 2001. Oral gabapentin (neurontin) treat. Chartier-​ Kastler E. Sacral neuromodulation for 7. guided perineural injection technique. BJU Int. 2):S73–​S79. Botulinum toxin type 6. Utilization patterns of tricyclic vic pain. A for the treatment of provoked vestibulodynia. Reprod Med.51:467–​470.16(Suppl. antidepressants in a multidisciplinary pain clinic: 9. Dykstra KK. Clin J Pain. 2008.13:324–​329. Multidisciplinary Treatment of Pelvic Pain 33 follow-​up and predictors of outcome. 2006. by pudendal nerve entrapment: anatomy and CT-​ 5. Sasaki K et al. Clin J Pain.60(7): syndrome and non-​ obstructive urinary reten- 341–​348. Richeimer SH et al.26:59–​62. Obstet 8. tion: over 10 years of clinical experience. 2007. Langford C et al. 10. 2008. . Hewitt DJ.101(4):417–​423. 11. The role of ketamine in pain treating the symptoms of overactive bladder management. Biomed Pharmacother. The use of NMDA-​receptor antago. Chronic perineal pain caused a survey. Schug SA. 1997. AJR Am J ment of refractory genitourinary tract pain.7:47–​49. 2006. Tech Roentgenol 2003. Urol. Neurourol Urodyn. 2000. Levator ani trigger point injec- Gynecol.111(1):159–​166. tions: an underutilized treatment for chronic pel- 4.

g. hemostasis. including risk of hepatotoxicity should be considered and irritable bowel syndrome and interstitial cys- monitored. Celecoxib selectively inhibits the COX-​2 isoenzyme. includ. current drug therapy. however. Acetaminophen may be utilized PGs are implicated in the pathogenesis of var- as adjunctive symptomatic treatment. Nonselective NSAIDs such as naproxen regimen may be necessary over time. antipyretic.3. 5 Pharmacological Management of Pelvic Pain M I C H E L E L . It is often used as initial clude the use of alternative NSAIDs within dif- treatment for pelvic pain due to its availability ferent chemical classes. However. and encouragement throughout the treatment pro. ers of acetaminophen products have recom- dal anti-​inflammatory drugs (NSAIDs). resulting in PHARMACOLOGICAL analgesic.1). but it is believed to increase regard to the efficacy and safety of these med- the pain threshold by inhibiting prostaglandin ications.2 Therefore. underlying med. antidepressants. gastric mucosal integrity. and COX-​ 2 is inducible in many cess. or underlying conditions that may affect glutathione stores pathways involved in pain processing. and renal function. Additionally.. modifications to the treatment mation. and convenience. ical conditions. M AT T H E W S A N D V E S E L A K OVAC H E VA T he pharmacological approach to the man- agement of pelvic pain involves the use of pharmacotherapeutic agents that can target of alcohol use. much like NSAIDs. competitively inhibit both COX-​1 and COX-​ 2 by blocking arachidonate binding. and anti-​ inflammatory AGENTS effects. The effectiveness ofsible for various physiological responses. local mended that daily doses not exceed 3 grams per anesthetics. doses up to 4 grams per day may making with regard to selection of therapies continue to be recommended under clinician should include factors such as duration of pain. ferences in the chemical structures. NSAIDs can be beneficial as . thesis as well as the maintenance of normal cian should provide support. acetaminophen does not have significant anti-​ treatment failure with one NSAID may not pre- inflammatory effects. Decision-​ day. Goals of therapy for the manage. This is presumed to be related to dif- (PG) synthesis. The differences between NSAIDs Acetaminophen include not only COX isoenzyme selectivity The exact mechanism of action for acetamino. COX-​1 is responsible for PG syn- should be monitored regularly.1 Due to the likelihood that symptoms will cells in response to certain mediators of inflam- wax and wane. with NSAIDs have focused primarily on pain related studies focusing primarily on the treatment of to dysmenorrhea and endometriosis. the manufactur- ing anticonvulsants. but the ious pelvic pain-​ related diagnoses.but also significant inter-​patient variability with phen is unknown. and opioids (Table 5. especially in patients with a history titis. Acetaminophen is Food and Drug presumed mechanisms of pain. Nonsteroidal Anti-​Inflammatory ment of pelvic pain should focus on reducing Drugs (NSAIDs) acuity and severity of pain with emphasis on Cyclo-​oxygenase (COX) isoenzymes are respon- function and quality of life. (e. dysmenorrhea. Administration (FDA) pregnancy category B. concom- itant hepatotoxic medications. although Clinical trials evaluating the efficacy of evidence to support its use is lacking. and the clini. anorexia). supervision. as an over-​ the-​ counter medication. reassurance. therefore. cost. these medications along with any adverse effects Specifically. hepatic dysfunction. nonsteroi.4 However.

withdrawal symptoms Bowel movements with abrupt discontinuation. concomitant alcohol abuse. and immune behaviors modulation with long-​term use SCr/​BUN LFTs ECG (methadone) Morphine IR: 15 mg PO every 4 hours Hydromorphone IR: 2 mg PO every 4 hours Oxycodone IR: 5 mg PO every 4 hours Fentanyl Transdermal: initiate only in opioid-​tolerant patients taking ≥ 60 mg of morphine/​day or equivalent Methadone 2. or malnutrition Nonselective GI irritation. constipation. respiratory Oxygen depression (regardless of saturation formulation). maximum of 12 tablets per day Buprenorphine Transdermal: 5 mcg/​hour patch applied every 7 days (continued) . maximum daily dose = 1500 mg Indomethacin 25 mg PO 2–​3 times per day. cardiovascular events of GI bleeding SCr/​BUN LFTs Ibuprofen 400 mg PO every 6 hours. Vital signs Analgesics cognitive impairment. urinary Level of sedation retention.1  PHARMACOLOGICAL THERAPIES FOR CHRONIC PELVIC PAIN Drug/​Therapeutic Initial Adult Dosing Adverse Effects Monitoring Class Parameters Acetaminophen 500 mg PO every 4 hours Hepatotoxicity with doses LFTs >4 gm/​day. Aberrant abnormal pain sensitivity. renal Signs/​symptoms NSAIDs toxicity.5 mg PO every 8–​12 hours Oxymorphone IR: 5 mg PO every 4 hours Hydrocodone IR combination product containing acetaminophen: 5/​325 mg PO every 4–​6 hours. Urinary output seizures possible at high doses. hypotension. maximum daily dose = 200 mg Etodolac 200 mg PO every 8 hours. pruritus. drug-​related hormonal changes. Respiratory rate dysphoria. euphoria. GI bleeding. maximum daily dose = 1200 mg COX-​2 Selective NSAID Celecoxib 100 mg PO twice daily or 200 mg PO once daily Opioid Sedation. TABLE 5. maximum daily dose = 3200 mg Naproxen 250 mg PO twice daily. N/​V.

Weight Norepinephrine hypertension. sedation. sedation. maximum daily dose = 400 mg Tapentadol IR: 50 mg PO every 4 hours. maximum daily dose = 600 mg Tricyclic 25 mg PO at bedtime Dry mouth. constipation. xerostomia. seizures. TABLE 5. dependence Signs/​symptoms of serotonin syndrome Tramadol IR: 50 mg PO every 4 hours. Oxygen serotonin syndrome. weight ECG (TCAs) gain. constipation. headache. sexual Weight Inhibitors dysfunction. blurred vision. dry Vital signs Analgesics mouth. orthostatic hypotension.5 mg PO twice daily on days 2 and 3. mood changes. sedation. 12. dizziness. sedation. mood Vital signs antidepressants changes. 25 mg PO twice daily on days 4–​7 Venlafaxine IR: 25 mg PO three times daily Selective Serotonin Nausea. respiratory Respiratory rate depression.1 CONTINUED Drug/​Therapeutic Initial Adult Dosing Adverse Effects Monitoring Class Parameters Dual Mechanism N/​V. saturation blood pressure changes. Weight Amitriptyline urinary retention. bleeding Urinary output (SSRIs) LFTs Signs/​symptoms of bleeding Level of sedation ECG (citalopram) Citalopram 20 mg PO daily Sertraline 50 mg PO daily (continued) . Urinary output Nortriptyline arrhythmias LFTs Desipramine Signs/​symptoms of bleeding Level of sedation Serum nortrip- tyline levels (therapeutic range = 50–​150 ng/​mL) Serotonin Nausea. hepatotoxicity Urinary output Reuptake LFTs Inhibitors Signs/​symptoms (SNRIs) of bleeding Level of sedation Duloxetine 20 mg PO daily Milnacipran 12. Bowel movements tolerance. mood Reuptake changes.5 mg PO once on day 1.

Vital signs hypotonia. SCr/​BUN somnolence. rash. use of NSAIDs at high doses. may increase by 100 mg every 12 hours as needed up to a maximum of 1200 mg/​day Muscle Relaxants Drowsiness. renal. SCr = serum creatinine. and spectrum of adverse gastrointestinal (GI). may increase as tolerated to 450–​600 mg/​day in two divided doses Carbamazepine 100 mg PO twice daily on day 1. history of chronic debilitating comes with the increased potential for a broad conditions. GI = gastrointestinal.5 mg Abbreviations: PO = by mouth/​oral. peripheral edema. weight Weight gain. and selective COX-​2 inhibitors have also been . dry mouth LFTs Baclofen 5 mg PO 2–​3 times per day Cyclobenzaprine 5 mg PO three times daily Tizanidine 2 mg PO every 6–​8 hours Spasmolytics Nausea. blurred vision Bowel function Dicyclomine 20 mg PO four times daily Hyoscyamine 0. and hepatic effects. Pharmacological Management of Pelvic Pain 37 TABLE 5. LFTs = liver function tests. may increase as tolerated to 1800-​3600 mg/​day in three divided doses Pregabalin 50–​75 mg PO twice daily. ing risks (e. Risk fac. concurrent use of select medications with bleed- diovascular. CBC = complete blood count adjunctive therapy or for the management of history of prior complicated peptic ulcer disease acute pain exacerbations. antiplatelet therapy). IR = immediate-​release.g.1 CONTINUED Drug/​Therapeutic Initial Adult Dosing Adverse Effects Monitoring Class Parameters Anticonvulsants Dizziness. ECG = electrocardiogram. The use of NSAIDs or upper GI bleed. xerostomia. dizziness. somnolence. car. NSAIDs tors for adverse GI effects include older age. then 300 mg PO three times a day. weakness. dizziness.125–​0. Chemistry panel hepatotoxicity Skin exam LFTs SCR/​BUN CBC Serum carbamaz- epine levels (therapeutic range = 2–​7 mcg/​mL) Gabapentin 300 mg PO on days 1–​3. 300 mg PO twice daily on days 4–​6. N/​V = nausea/​vomiting.. blood pressure Level of sedation changes. BUN = blood urea nitrogen. maximum daily dose = 1.25 mg PO or SL every 4 hours or as needed.

a three-​ month course of a positive outcome and achievement of of treatment was found to be better than pla- therapeutic  goals. thereby exerting analgesic effects management of chronic pelvic pain from uro- through the activation of descending inhibitory logical causes suggested that the lack of evi- pain pathways. The doses for TCAs of falls.. however. periodic electrocardiograms. proton there were significant differences in pain scores pump inhibitors) for at-​risk patients. including TCAs. initiation of gastroprotective agents (e. arrhythmias. which accounts for the majority of important to ensure their adherence to treat- neurotransmitter activity following administra. cebo in a large. Nortriptyline is more likely in patients with cardiovascular disease or to inhibit the reuptake of norepinephrine than those that are on medications associated with serotonin.8 A prospective. amitriptyline is metabolized to of therapy and potential adverse effects is nortriptyline. and ment arms over time. six of the seven women who clinical presentation7. TCAs should be avoided tion of amitriptyline. are unknown. older adults due to the risk triptyline and nortriptyline. which may be a favor. Desipramine is associated with less QT interval prolongation due to the risk of anticholinergic activity in comparison to ami. and vascular death. include identification of risk factors. are severe pelvic pain from any cause. reported significant pain improvement.10 With vic pain syndrome may increase the likelihood regard to desipramine. use of antidepressants. ment. function tests. randomized controlled trial in patients with moderate to severe irritable bowel Tricyclic Antidepressants syndrome. tion in the urgency and frequency of urination. including GI. for the epinephrine. as this can cause a reduc. nortriptyline. After two months. such as myocardial infarc.6 It has been suggested that the of reduction in pain. such as diclofenac and ibuprofen. therefore. Amitriptyline possesses strong dence to support the use of these medications anticholinergic activity. in a prospective case series of 14 women with sive symptoms and the experience of chronic chronic pelvic pain with a primary end point pelvic pain. that four months of treatment with amitripty- line was more effective than placebo in decreas- Antidepressants ing pelvic pain and urgency in patients with Epidemiological studies of chronic pain have interstitial cystitis. Monitoring parameters for efficacy and are often lower than what is needed to exert safety of TCA therapy should include liver antidepressant effects. mechanisms. drug levels should be obtained for patients Studies evaluating the benefit of TCAs have on nortriptyline. selection of Baseline pain scores improved in all three treat- NSAIDs based on adverse-​effect potential. urological. and neurological diovascular events.5 Therapy considerations combination of gabapentin and amitriptyline. stroke. Patient education related to proper use Additionally. Serum the risk of sedation. TCAs are FDA pregnancy focused on pelvic pain related to various causes category  C. amitriptyline similar to those with COX-​2 inhibitors. a meta-​analysis studied TCA. Generally. randomized study found trimester.38 Pelvic Pain Management implicated in the development of major car. with the was compared to both gabapentin alone and the exception of naproxen. predominant disease and a history of abuse. and TCAs are often pre.13 and patients with a history of sei- that are used in the management of chronic pain zures. however.9 Nortriptyline was studied shown the strong association between depres. 50% of treatment of chronic pain can be improved if subjects discontinued treatment due to adverse depression is considered as part of the patient’s effects. . Amitriptyline has been the most-​ tion.11 triptyline. after 24 months.12 The long-​term able effect in select patients such as those with effects of TCAs for the treatment of pelvic pain interstitial cystitis. but with mixed results. and desipramine A systematic review of studies evaluating the decrease the reuptake of serotonin and nor. but category D in the third alone. especially in those with diarrhea-​ Tricyclic antidepressants (TCAs) such as ami. scribed to be taken once daily at bedtime due to and symptoms of serotonin syndrome. may be due to publication bias. The FDA in favor of gabapentin alone or gabapentin plus pregnancy category for NSAIDs is C for the amitriptyline in comparison to amitriptyline first two trimesters.g. the use of remained in treatment were either pain-​free or antidepressants in patients with chronic pel. In a small found that the risks associated with traditional study of women with a history of moderate to NSAIDs.

14 In a small random. the use of sertraline over or in combination with amitriptyline com- 13 weeks was not associated with significant pared to amitriptyline alone in women with improvements in prostatic symptom frequency chronic pelvic pain from any cause. blood such as phenytoin and carbamazepine. As previously mentioned. mechanism has been extrapolated to the man- ever. able evidence. For the treat. women with chronic pelvic pain found no dif. within the descending pain system. Pharmacological Management of Pelvic Pain 39 Selective Serotonin Reuptake implemented. reuptake inhibitors (SNRIs) increase levels of which is category X due to the risk of congeni- neurotransmitters within the central nervous tal cardiovascular malformations during the first system (CNS) to increase inhibitory activity trimester. patients ment of interstitial cystitis. therefore. voltage-​gated calcium channels within the CNS The SSRIs can be effective in patients with to reduce neuronal hyperactivity. ized. but with no significant improvement in nificant improvement in mood and pain. case series. Anticonvulsants are theorized to interact with cokinetics. sedation.17 Studies evaluating the cially in patients with vulvodynia. Unlike with other anticonvulsants.18 A small. gabapentin use was associated with spective case series of 14 patients with chronic improvement in genitourinary pain that per- pelvic pain who were treated with citalopram sisted six months after the end of treatment in showed no significant improvement in pain or 47% of patients. Expectations of therapy should be be separated from antacids due to the risk of discussed. with the exception of paroxetine. pelvic pain models.20 Based on the limited avail- causes are lacking. however. Close monitoring of mood is war- Inhibitors/​Serotonin Norepinephrine ranted with the use of all antidepressants due to Reuptake Inhibitors the risk of worsening depression and suicidality. as some of are unknown. including peripheral mean visual analog scale score.8 In a small or severity in comparison to placebo. Anticonvulsants are widely used for chronic ference in pain intensity in comparison to pain syndromes and have been studied in select placebo after six weeks. gabapentin was found to be more effective alone vic pain syndrome. espe- pain or urinary urgency. agement of chronic pain due to the occurrence agement of pain has been limited due to lack of of wind-​ up and central sensitization that are evidence. These drugs minimal hepatic metabolism. risk of drug interactions. how. nausea. safely in patients with hepatic dysfunction due nancy and lactation. and cost. pharma. selective serotonin reuptake inhib. A double-​ blind. commonly associated with neuropathic pain randomized crossover trial of sertraline among states. controlled trial of men with chronic pel. after eight role of SNRIs in chronic pelvic pain from other weeks of treatment. and cost. mon- pressure and heart rate monitoring should be itoring of serum drug levels is not necessary . however.16 of 22 women with chronic pelvic pain from any Duloxetine and other SNRIs have been cause found that pregabalin 75 mg twice daily studied and are frequently used in numerous was associated with significant reduction in the chronic pain syndromes. Gabapentin administration should syndrome. approximately 10% were evaluated after only one week of therapy. fit in patients with vulvodynia. long-​term effects of anticonvul- Therapy considerations for SSRIs and SNRIs sants in the management of chronic pelvic pain include their adverse-​effect profiles. preg. in noradrenergic activity. ing must be adjusted in the setting of renal nergic medications due to the risk of serotonin impairment.19 of patients rated improvement in overall well-​ An open-​label trial of lamotrigine showed sig- being. ness. with most bene- neuropathy and fibromyalgia. The differ- ences between SSRIs and SNRIs are related to Anticonvulsants their selectivity for neurotransmitters. prospective case series disability. Most commonly used SSRIs are FDA pregnancy itors (SSRIs) and serotonin norepinephrine category C. This proposed depression in the setting of chronic pain. weight gain. dos- should be avoided in patients on other seroto. Like TCAs. and periph- The use of SNRIs is associated with an increase eral edema. with emphasis on the importance of drug binding resulting in reduced gabapentin taking the medication consistently and on the efficacy. the role of these medications in the man. these agents can cause weight gain and sexual Gabapentin and pregabalin can be used dysfunction. Common adverse effects include dizzi- risk of withdrawal with abrupt discontinuation.15 A pro. placebo-​ controlled.

and tapentadol exert weak mu receptor agonist iliopsoas spasm or pelvic floor dysfunction). pregnancy category C. Dicyclomine thoughts. soprodol. from the periphery to the spinal cord. however.21 Patients should be educated on the Common adverse effects include sedation. Close These agents should be avoided in patients with monitoring of mood and affect is indicated.. to be at low risk for misuse and abuse. serotonin and norepinephrine. Carisoprodol use should be short-​term use of opioids for chronic pain for avoided in patients at high risk for medication improvement specifically in pain and quality of misuse and abuse.24 There is fair evidence to support the be monitored.g. (meprobamate). resulting in a is unavailable. and adverse-​effect profile. and alter limbic gamma-​ aminobutyric acid (GABA). Both gabapentin and pregabalin are is pregnancy category B. is used system activity. and activation of its effects through agonist activity at alpha-​ 2 subtypes of these receptors can lead to analge- adrenoreceptors. activity as well as inhibition of the reuptake of these agents can be very effective. It should also be irritable bowel syndrome. of chronic pain include morphine. is a pharmacologically long-​acting opioid with ants for the management of chronic pelvic pain highly variable pharmacokinetics. Adverse effects common opioids for chronic pain are lacking. metaxalone. which is metabolized to a barbiturate oxymorphone. interstitial cystitis. high-​quality studies evaluating effect profile. Receptors activated sclerosis and spinal cord injuries. and xerostomia. and kappa receptors. methadone. Nonetheless. resulting in muscle relax. if a patient is identified long half-​life and drug accumulation. like activity due to its structural similarities to Opioids differ based on their chemical structure. mu-​2). Opioids also modify the sensory extensively for spasticity related to multiple and affective aspects of pain. or noted that reports of gabapentin abuse are on in the presence of dysmenorrheal component. Methadone Evidence to support the use of muscle relax. particularly cari. pregabalin is a Schedule V through anticholinergic mechanisms and can be medication in the United States due to trial data useful for chronic pelvic pain in the setting of suggestive of abuse potential.. with the exception of had failed other therapies and were considered cyclobenzaprine which is category B. Muscle Relaxants Opioids The mechanisms of action for most muscle Opioids bind to opioid receptors in the CNS relaxants are believed to be related to central to inhibit the transmission of nociceptive input inhibition of neurons.. descending inhibitory pathways that modulate tural analog of the inhibitory neurotransmitter transmission in the spinal cord. the use of opioids for chronic non-​cancer pain ziness.22 Tizanidine is opioid receptors have been identified. tapentadol. Cyclobenzaprine has TCA-​ sia (e. as cardiovascular disease. amitriptyline.40 Pelvic Pain Management for gabapentin and pregabalin. by opioids are abundant within the CNS and baclofen possesses analgesic effects through throughout peripheral tissues. hydromorphone. apy is often based on patient tolerance.23 the rise. and methocarbamol Commonly used opioids in the management may work more like sedatives. Various types of antagonism of substance P. obstruc- these agents may increase the risk of suicidal tive uropathies. delta. and cost. Tramadol to have a significant muscular component (e. Choice of ther. mu-​1) or adverse effects (e. The opioid-​related adverse effects has risen in a lin- same considerations for the use of TCAs should ear fashion relative to increased prescribing. oxycodone. diz. cyamine induce smooth-​ muscle relaxation trolled substance. urinary retention. patients included in these studies pregnancy category C. All muscle relaxants are FDA life. however. activate ation and reduced spasticity. Baclofen. GI dysmotility. con- importance of adherence to therapy to increase stipation. The primary Spasmolytics differences between these two anticonvulsants Spasmolytics such as dicyclomine and hyos- are related to potency and scheduling as a con. CNS depression is addi. to all muscle relaxants include drowsiness. and fentanyl. and blood pressure should and abuse. Tizanidine can at high doses. and the incidence of tive with other centrally acting medications. Additionally. tramadol.25 . while hyoscyamine is FDA pregnancy category C. use be applied to cyclobenzaprine. has increased dramatically.g. and older adults. and as a consequence of misuse cause hypotension. efficacy and minimize risk of withdrawal. Other muscle relaxants such as receptor activity. carisoprodol. including structurally related to clonidine and exerts mu.g. a struc. and GI effects. adverse-​ Long-​term.

or those compounded therapy. and cost. failure to comply with pudendal neuralgia. and alpha-​2 agonists can be useful for prescribers or pharmacies. Therapy should be assessed on a regu.31 These include medications that should provide informed consent and sign a may improve sleep. opioids) while use of combination opioid formulations (e. and pres. arrhythmias. hydroxyzine). morphine should be avoided in patients with Risks include overdose. validated tools such as the Screener and Opioid Assessment in Pain Patients–​Revised (SOAPP-​ Miscellaneous R)26 is highly encouraged. function due to the risk of accumulation. Pharmacological Management of Pelvic Pain 41 Frequently. maintaining or increasing analgesic efficacy.29. Examples of aberrant ladonna and tramadol as a vaginal suppository drug-​ seeking behavior include multiple “lost” for neuropathic pain due to Tarlof cysts and or “stolen” prescriptions. respiratory pain history and assessment of patient factors depression. management involves the use of one or more available formulations. and adverse effect profiles. age. drug mechanisms of action. constant versus intermittent). Benefits of opioid therapy include sia. and hyperalge- evaluation. and baseline and periodic electro- ral to the pain specialist. and pruritus. opioid use is associated with immunosuppres- along with a comprehensive benefit-​ to-​harm sion. especially at high doses and for function).. and possible be implemented in the setting of hepatic dys- misuse. Short-​ acting drugs to minimize adverse effects. there is limited available evidence from clinical ment should be performed through the use of trials. vulvodynia and postherpetic neuralgia. Patients be considered. constipation.. selling. although available evidence suggest no significant difference in efficacy or S U M M A RY adverse effects in comparison to short-​ acting The management of chronic pelvic pain can formulations. phar- long-​term use. nausea. such as diazepam sup- lar basis and should include evaluation of pain. anticonvulsants. Most ment of opioid misuse risk through the use of opioids are pregnancy category B  or  C.27 due to lack of evidence in chronic pelvic pain.g. Intravenous lidocaine may also be consid- periodic urine drug testing and tools such as the ered. examples include the combination use of bel- ence of aberrant behavior. development of phys. along with urine drug Adjunctive therapies that target symptoms and/​ testing and the review of data obtained from or complications of chronic pelvic pain should a prescription monitoring program.g. A  few or long-​ acting opioid formulations results in small studies have demonstrated benefit with consistent plasma drug concentrations..25 Adverse effects common to all be challenging and complex. can assist with selection of therapy. the of high-​risk medications (e. important consid- due to the risks associated with the non-​opioid erations include patient factors (e. into vaginal preparations. mood.. or forging. and dose adjustments should ical dependence and tolerance. increase opioid formulations may be beneficial for adherence. as well as The concept of rational polypharmacy in pain drug-​specific factors including adverse effects. R AT I O N A L current drug therapy. endocrine dysfunction. Beyond .30 Opioids with active metabolites such as analgesia and improvement in daily function. organ component. A  thorough history cardiograms should be monitored. although or stealing prescriptions. although the role of this therapy is limited Current Opioid Misuse Measure (COMM). and cost. abuse.g. and the use of rational polypharmacy for the man- these are recommended for patients with con. such as sedating antihista- treatment agreement prior to the initiation of mines (e. stant chronic pain. or addiction. however. Methadone use is associated with cardiac ness of opioid therapy is the reason for refer. assessment for the appropriate. oxycodone/​ acetaminophen) should be limited When combining therapies. multiple prescriptions from different NSAIDs. drugs. Compounded topical prod- monitoring. A  comprehensive opioids include CNS depression. positories for pelvic floor dysfunction. The use of extended-​ release macokinetics. agement of chronic pelvic pain.g.g..28 Long-​term and physical assessment should be performed. current use of alcohol or illicit ucts containing antidepressants. adverse effects. apy should be based on patient-​ specific fac- tors such as underlying medical conditions.32 Other function. If opioids are considered. Ongoing risk manage. and pattern of pain P O LY P H A R M A C Y (e. adverse drug effects. choice of ther. renal impairment. Baseline assess. and reduce the need for higher doses patients with intermittent pain.

Citalopram Nonsteroidal anti-​ inflammatory drugs for dys- in the treatment of women with chronic pel- menorrhoea. et  al. Syst Rev. J Psychosom Res. 3. 1999 Jan. Int J Psychiatry Med.(1):CD001751. Committee on Practice Soc. noradrenaline reuptake inhibitor duloxetine for Nonsteroidal anti-​inflammatory drugs for pain in the treatment of interstitial cystitis:  results of an women with endometriosis. American Geriatrics Society. doi:  10. Hertle 23. Savidge CJ. Proctor M. Anand KS. J Urol. Chuang Y. ACOG Practice Bulletin 14. Katon W. chronic pain in the United States:  promises and 10. 1997. 51. 14651858. et  al. a multidisciplinary desipramine versus placebo for moderate to severe approach should be implemented to address all functional bowel disorders.119:95–​110.1002/​ 14651858. inflammatory drugs in the management of pain 15. Pokupic S. Nonsteroidal anti-​ vic pain. Sengun IS. Engel Jr. Hertle L. Prasad A. J Am Geriatr Gynecologists (ACOG). framework. American College of Obstetricians and ate medication use in older adults. Gregory D. double-​blind cross- Mar. Psychological aspects of chronic 2009.81(2):147–​149. J Urol. 2001. Rinaldi ipant data from randomised trials. 797031.36(3):275–​282. Sharma S. lacking. Kress NW.53(3):191–​195. Cochrane Database Syst Rev.(2):CD004753. Skapinakis P. Trinkley KE. American Society of 11.7:47–​49.1002/​ 18. Whitehead W. K.. pelvic pain. A randomized. Evidence to support most analge. Derks RS. 2005. Chronic pelvic pain treated with gab- dorsal horn assessed by receptor internaliza- apentin and amitriptyline:  a randomized con- tion:  NMDA receptors counteract a tonic inhi- trolled pilot study. for the treatment of interstitial cystitis. Pain. Sator-​ Katzenschlager SM. Chronic pelvic pain. bition by GABA(B) receptors. 2014 depression in chronic pain:  a diathesis-​ stress Jun. Treatment of irrita- L. ventional Pain Physicians. Engel AL. et  al.172:533–​536.28(6):491–​496. Eur J Neurosci. Marvizon JC.30(2):265–​269. Wiener klinische Wochenschrift. Lancet. doi: 10. Bhala N. Farquhar C. 24. 2007. Emberson J. 2013 Dec. Epub 2010 Feb 14. Cochrane Database observational study. Papandreou C. Obstet Gynecol. Hopewell S. Allen C. J Clin Pharm Ther. 2009 Apr 15. Adv Urol. 2009. Scharbert G. 13. Mavreas V.CD004753. over trial of sertraline in women with chronic pel- 2.117:761–​768. doi:  10. Wilson JD.6(1):3–​11. Zolnoun D.pub3 Chancellor M. N. Lee RA. Prentice A. An perils. Sasaki K. Psychol Bull. Vascular and upper gastrointes- 19. Jan 20. Meltzer-​ Brody S. Walker E. J Reprod Med. Bullis J.44(2):203–​207. Smith C. No. Jemelka R.154(Suppl 1):S94–​S100. 2013. 1998. Giannakis D. Grady EF.42(5):433–​444. Bulletins—​Gynecology. 22. Marjoribanks J. Toner B. 2010 vic pain:  an open-​ label trial. The response to ser- and inflammation: a basis for drug selection. drugs:  meta-​ analyses of individual partic- 20. Opioid therapy for 2004. Ther. Schifano F. Interventional Pain Physicians (ASIPP) guide­lines Cognitive-​behavioral therapy versus education and . Tech Coxib and traditional NSAID Trialists’ (CNT) Urol.11:417–​426. Drossman D. J Psychosom Res. Sofikitis pelvic pain. placebo con- ble bowel syndrome. Nahata MC. Merhi A. van Ophoven A. Wan J. Roy-​Byrne P.177(2):552–​555. Banks SM. J Neurol Sci [Turkish]. Howe CQ. Oral gabapentin (neurontin) treat- 5. Pregabalin in chronic pelvic tinal effects of non-​steroidal anti-​inflammatory pain. Sullivan MD. CD001751. Franks AS.382(9894):769–​779. Lee J. Walker EA.103(3):589–​605. however. there is robust anecdotal expe. Gastroenterology.42 Pelvic Pain Management pharmacological treatment. Misuse and abuse of pregabalin and 7. Am J traline in men with chronic pelvic pain syndrome. Bunnett 8. 1991. 2011 trolled. Antidepressant drugs for chronic sics in the management of chronic pelvic pain is urological pelvic pain:  an evidence-​based review. Leserman J. van Ophoven A. 6. American Geriatrics Society REFERENCES updated Beers Criteria for potentially inappropri- 1. J Reprod Med. West RM. randomized. focusing on efficacy in vulvodynia. Sengun HI. 1996. Mayer EA. open trial of nortriptyline in women with chronic 25. double-​ blind study of amitriptyline Jun. Substance P release in the HG. Steege J. Manchikanti L et  al. 1999. CC. aspects of care. 16.54:171–​178. 9. including those focusing on the 2003. psychological and emotional impact of chronic 12. and the ment of refractory genitourinary tract pain. 2005.125:19–​31.2009:797031. The dual serotonin and 4.21:245–​252. Heinecke A. 21.1155/​2009/​ rience to support these therapies. STIs. Open-​ label trial of lamotrigine 2013. 2008. Kim J.60(4):616–​631. Stefani E. A prospective.pub2 17. 2012 Apr. Explaining high rates of gabapentin:  cause for concern? CNS Drugs. American Society of Inter­ pelvic pain. Ling FW. Brown CS. Collaboration. 2012 Beers Criteria Update Expert Panel. Kerns RD. Slade P.. 2004 Armstrong A.

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” a particular partner. in the English language only. . Clinical Key. National Guidelines Clearinghouse and the fifth edition of the Diagnostic and Statistical Manual of Mental ships. dys- METHODOLOGY pareunia and vulvodynia are two separate enti- Relevant research about dyspareunia was identi. limited to specific situations. Dyspareunia is present either just before. or limited to include articles published or available partner. course that has been present since initial including the Agency for Healthcare Research intercourse.1 Despite the reported high prevalence of these disorders. or during Literature (CINAHL). the search terms remained broad. Research shows that sexual pain is often Disorders (DSM-​5). movements such as sitting.4 The dyspareunia and vulvodynia as chronic pain term “dyspareunia” comes from the Greek word syndromes and to provide the reader with a “dyspareunos. Bibliographies of all relevant described by medical providers as dyspareunia reviews and primary studies were hand-​searched or vulvodynia. Although related. during. system. positions. and pelvis. clinical ting together. tampon insertion. activities such as intercourse. Ovid. A L I N I O N E S C U. tom of an underlying condition rather than ter will also review the basic framework for how a diagnosis in and of itself. position. ences databases.3 Dyspareunia is recurrent or persistent genital The focus of this chapter will be to discuss pain associated with sexual intercourse. A  comprehensive • Primary Dyspareunia: Pain with inter- search was made of internet and print resources.” • Situational: Pain with intercourse that is plus secondary terms in MeSH/​ keyword/​title. or “physical examination. AND GEORGINE  LAMVU S exual pain is a common symptom that can have devastating effects on a woman’s qual- ity of life and her social and sexual relation- and Quality (ARHQ). In order to ensure that relevant studies were not Expert authors have used the following terms missed. only one in five women seek DEFINITIONS help for their pain. A N I M . This chap. and both conditions are associ. and related pathology.” meaning “bed partners not fit- basic understanding of the definition. or provoked by primarily from PubMed. Cumulative Index to Nursing and Allied Health when the vulva is touched by clothing.2.” and “cervical pain. ties. fied by searching the biomedical and social sci. and the Cochrane Library. TA N YA E . to identify articles not captured by electronic ated with significant burden on the healthcare searches. 6 Dyspareunia and Vulvodynia A D E O T I O S H I N OWO .” and truncated language such as • General Dyspareunia: Pain that is not “diagnosis” and “pain.”5 Usually dyspareunia is a symp- presentation. It may be present patients with these conditions should be evalu. “speculum.” “bimanual. These to describe types of dyspareunia6: were Medical Subject Headings (MeSH) term/​ keywords “dyspareunia. or immediately following intercourse.” Material included was limited to a specific situation. a variety of medical problems that affect the vulva. with key articles obtained be present without provocation. Seven research databases were This differentiates it from other pelvic pain syn- searched for publications from 2005 through to dromes such as vulvodynia in which pain may the present (2014).” “external. as a part of a constellation of symptoms from ated and treated. vagina.

that vulvodynia be classified as generalized to • Secondary Dyspareunia: Pain with the entire vulva or localized to the vestibule intercourse that occurs after a period (Figure 6.e. For the purposes of this chapter.1) as “provoked vulvodynia” (i. of pain-​free intercourse. Continuous pain without any identifiable atrophic vaginitis. rawness.8 OF VULVODYNIA AND DYSPAREUNIA Unlike dyspareunia.5 This is associated with indicative of PVD. vulvodynia is a chronic lower gen..1:  Anatomy of vulvodynia.1). and the pain is often enced with deep penetration of the vagina. These two categories can be further subcate- gorized (Table 6. • Mixed tious. “unprovoked cussion to two types of dyspareunia—​superficial vulvodynia” (occurring spontaneously). and cervicitis. Typically.14–​16 Throughout this chapter. provoking stimuli is classical for generalized • Deep Dyspareunia (DD): Pain experi- unprovoked vulvodynia.7.12. provoked vulvodynia • Superficial Dyspareunia (SD): Pain (PVD) will refer to both localized and general- limited to the vulvar vestibule or ized forms. fibroids. we will limit dis- with tampon use or sexual activity). Dyspareunia and Vulvodynia 45 Mons Pubis Urethral Opening Vulva Area of Vestibulitis (Vestibule) Hart’s line Anus FIGURE 6. which may have multi.9–​11 • Localized • Deep Patients may present with complaints of vul. Vulvodynia Dyspareunia ple causes. Pain described as “burning” is highly vaginal introitus. burning. • Unprovoked tion. or neurological cause.1 CLASSIFICATION adhesions. • Provoked var stinging. and and deep. this pain has been associated with conditions such as endometriosis. TABLE 6. and vulvovaginitis. and/​ or irrita.5.17 conditions such as vaginal dermatoses. • Generalized • Superficial ital pain syndrome of unknown etiology that • Provoked manifests as pain and occasional erythema of • Unprovoked the vulva without obvious evidence of infec. dermatological.13 The International Society for the Study • Mixed of Vulvovaginal Disease (ISSVD) recommends . “mixed” (both provoked and unprovoked).

the rate of dys. 2.21 One study involv.21 The World Health Organization (WHO) more common in specific subsets of women. the prevalence of dyspareunia was aged women35 and deep dyspareunia is more 8–​21. interstitial cystitis (4.3%.1% in Sweden.16. For instance. only sexually active portion of women report improvement in symp- women were queried regarding dyspareunia. States.patients and to society associated with vulvo- tion studied identified themselves as Hispanic). since women who were not surveyed women who do not improve with estrogen ther- may have not been sexually active due to the apy. Additionally. in this high rates of psychological distress such as study. For sponsored a meta-​analysis of subtypes of chronic example. or (6%) direct non-​ healthcare costs. In the smaller percentage of reporting. The prevalence of dyspa. it was found that the weighted prevalence related quality of life.be due to vaginal atrophy.16 Interestingly.Vulvodynia is essentially a diagnosis made upon reunia in men ranges from 1–​5%. toms when they are treated with vaginal topical This may lead to selection bias and under-​ estrogen therapy. prevalence of dyspareunia. Dyspareunia is also issues in acquiring accurate data regarding the especially common in post-​menopausal women. the researchers found an increased or irritable bowel syndrome. ies did not distinguish subtypes of dyspareunia such as vaginal dryness and soreness.16 The effects of prevalence of vulvodynia among Hispanic women vulvodynia extend past the patient.36 . women. with only to be 45% in the US studies.”16 economic burden of vulvodynia in the United Due to varying definitions of dyspareunia. the pain is thought to lems they point out are that in many dyspareu.20 In the United the exclusion of other causes of vulvar pain.32 the national in interpretation of “pain” or “discomfort. and her friends. although the prevalence among one or more other idiopathic chronic pain con- African American women was also substantial ditions such as fibromyalgia.1% worldwide. and a substantial pro- nia studies they reviewed.269 of whom completed the sur. however. temporomandibular joint disorder (TMJ). The economic impact to it should be noted that only 2. Dyspareunia may be of 20%.23 leading EPIDEMIOLOGY to additional selection or response bias.3% Caucasian).2% African American vs.24–​31 Vulvodynia patients than Caucasian women to screen positive for are also two to three times more likely to have vulvodynia. some information survey-​ based study among 2. it is important to consider other causes of pain they experienced when previously sexually dyspareunia. sexual dysfunction. In this meta-​ analysis it was found in women with endometriosis than in controls.542 Michigan is available about vulvodynia.8% of the popula. superficial dyspa- pareunia was 1. and of vulvodynia was 8.1 12–​21% among adult women. 9.6%) compared to Caucasian women (however. and $553 may reflect a true difference in prevalence. based on 54 studies with a total of 35.22 a few case reports of vulvar or hymeneal endo- Kao et  al. while it was found reunia is rarely seen in endometriosis.043 (68%) direct healthcare the prevalence among racial and ethnic groups costs. on the other hand. The rates of dyspareunia also commonly associated with endometriosis than is differed by country. further delineated many of the metriosis noted in literature.34 that.2).superficial dyspareunia.vulvodynia is associated with very poor health-​ vey. $6. ily. (IC).33 quantifying the incidence and prevalence of the condition is often difficult. Based on may reflect differences in symptom reporting or an annual prevalence of 3–​7%. sitting and sleeping. The authors also found that many stud- wearing clothing. The prevalence of vulvodynia is estimated at 3–​ The impact of dyspareunia on women’s lives 16% among American women. her fam- (15. States ranges from $31 to $72 billion annually.265 (26%) indirect costs.862 per patient The authors postulated that these differences in per 6  months. the prevalence of dyspareunia ranges from for which no obvious etiology can be found. dyspareunia is four times more frequent pelvic pain.19.973 Endometriosis affects up to 10% of reproductive-​ participants.18 In a recent is poorly studied. Not surprisingly. dynia has been estimated at $8. and sources may cite ETIOLOGY widely ranging figures. is a symptom ing 251 sexually active adolescent females (ages that may be associated with many other medi- 12–​19  years old) also demonstrated a prevalence cal conditions (Table 6. Some of the prob.46 Pelvic Pain Management described as severe enough to interfere with active.In this group of women. In fact.Dyspareunia. walking. African American women were less likely depression and anxiety. $2.

25. ovarian cavity cysts23. progressive. and dysuria (33%) Pelvic Inflammatory Polymicrobial infection of the upper genital Deep dyspareunia37. involving keratinized and mucosal dyspareunia. most commonly C. also accompanied by pelvic pain Irritable Bowel Chronic disorder characterized by Deep dyspareunia Syndrome abdominal pain or discomfort associated either with constipation. diarrhea. and deep dyspareunia46 urgency. with anogenital region edema and resorption of the labia minora. Atrophy (VVA) and results in thinness of the vaginal superficial and deep dyspareunia4 mucosa and/​or vulvar epithelium. and C. vaginal bleeding. vulvovaginal swelling C. malignancy.26 Lichen Planus Inflammatory autoimmune disorder Itching. Interstitial Cystitis Clinical diagnosis with unclear etiology Urinary urgency and frequency. characterized by urinary frequency and pelvic pain. pruritus (50%). If the tissues also become inflamed it is termed atrophic vaginitis Fibroids Benign uterine tumors that consist of Superficial dyspareunia. with Deep dyspareunia37 or without vaginal penetration Pelvic Floor Situation in which the pelvic floor muscles Superficial and deep dyspareunia45 Myalgia do no not relax or may even contract when relaxation is functionally needed Adnexal Masses Endometrioma. inflammatory skin Intense vulvar itching. functional Deep dyspareunia ovarian cysts.2  CONDITIONS ASSOCIATED WITH VULVODYNIA Condition Definition Associated Signs and Symptoms Endometriosis Occurs when endometrial glandular and/​or Infertility/​subfertility. superficial dyspareunia.38 Disease tract.29 Vaginismus Involuntary vaginal muscle spasm Superficial (insertional) dyspareunia30–​32 interfering with sexual intercourse Vulvovaginal Occurs as a result of decreased estrogen Dryness. Vulvovaginal Candidiasis yeast species.34 Vulvovaginal Vaginal infection caused by one of the Superficial dyspareunia. typically associated with gonorrhea and/​or chlamydia infections Postpartum State May be a result of morphological and Deep or superficial dyspareunia39. postcoital bleeding. burning. and excoriated. or sequel from vaginal laceration or episiotomy Pelvic Floor Long-​term complications such as pelvic Superficial and deep dyspareunia41–​44 Surgery pain and dyspareunia may be as high as 25% Sexual Abuse May include rape or molestation.40 hormonal changes of the pelvic floor during pregnancy or following delivery. TABLE 6. thickened. or alternating symptoms of constipation and diarrhea . etc. tropicalis (24%). dysuria. irritation. deep uterine smooth muscle dyspareunia33. dysmenorrhea. Skin may appear condition found most often in the white. stromal cells grow outside of the uterine abdominal or pelvic pain. glabrata. albicans.27 surfaces and pain Lichen Sclerosis Chronic. superficial dyspareunia28. which becomes pale and dry.

inter- only 45% of the cases. initiates the conversation regard.39 The sexual history is best taken when the • Gather relevant information about the patient is clothed and has spent some time inter- patient and their symptoms acting with the healthcare provider. Pazmany and col- tidimensional pain scales such as the McGill leagues41 confirmed that partners can also add . Therefore.15 A  brief refer- neutrality about sexual practices or preference. it became apparent that a fourth • Provoked or unprovoked (sexual. could be assessed via three questions: during or after) • Location—​superficial (entry). Presently. 73% complained of dys.2. Of the 437 women enrolled in this study who irritation. the healthcare the quality and intensity of their pain as well as provider should assume an active role. healthcare providers should inquire spe- duces sexual distress. but the complaint was “bothersome” in (specific partner. then obtaining a partner-​ related problems. vaginismus. quality-​of-​life questionnaires.48 Pelvic Pain Management C L I N I C A L P R E S E N TAT I O N Pain Questionnaire may be more helpful than A N D E VA L UAT I O N unidimensional pain scales (such as the Visual Analogue Scale) because they allow patients to Patient History provide clinicians with a better description of In order to identify sexual pain. the patient. Are any of your sexual problems bothersome? (yes/​no) Presence of sexual pain should be viewed in the context of sexual difficulty and dysfunction. rather than questions in evaluating the characteristics of the the physician.5 Since dys- Sexual Dysfunction (FSD). or both) tress.37 Roos et al. nonsex- question. Once spousal and sexual abuse has be contributing to the symptoms been ruled out. the impact the pain has on their lives. Are you sexually active? (yes/​no) • Intensity 2. intermittent 3. to address the issue of personal dis. pareunia and sexual dysfunction are closely tion is necessary only if the sexual problem pro. according to the International Among women who have sexual dysfunction. menstrual cycle. as psychosex- and associated conditions is crucial. Do you have any problems with sex? • Quality—​women with dyspareunia often (yes/​no) use terms other than “pain” to describe their discomfort: itching. should be introduced in the questionnaire: • Precipitating or ameliorating factors • Previous treatments 4.3 proposed a simple screening general • Onset—​lifetime or episode “health questionnaire. or deep 1. anorgasmia. and lives. if sexual pain is identified.1 had a sexual complaint. Consensus Development Conference on Female approximately 26% experience pain.” in which sexual function • Timing—​relative to intercourse (before. Subsequent • Validate that the patients’ symptoms visits may be required to ensure patient com- are real fort.40 showed that partners of patients A detailed pain history should be taken to with PVD may be negatively impacted with assess the degree of symptoms. • Association with other circumstances pareunia. ence for the normal sexual cycle is provided in The goals of the interview are to1: Figure 6. a clinical interven. Identification of psy- thorough and extensive history of the symptoms chosexual morbidity is important. ual counseling may be necessary to complement mental approach should be used. burning. and complete assessment of • Exclude other clinical diagnoses that may the history. it is generally helpful to invite • Educate and reassure the partner to be present during the evaluation. arousal. maintaining the medical treatment of pain. however. linked. Thus. ual. pain include17: ing sexual issues. stinging. stabbing and/​or rawness. Is sex painful? (yes/​no) • Duration—​continuous. cifically about the presence of desire. The use of pain regard to some sexual and physical aspects of diaries. Smith et  al. full disclosure. ade- Considering the devastating effects on patients’ quate lubrication.15. and mul. upon analysis of the course position) collected data. A  nonjudge.38 Useful about 80% of the time. their relationship.

6. entry pain involving the entire vul. it is essen- Sexual Arousal tial to ask the patient regarding her previous experiences with this type of exam. if pain is elicited and if the pain experienced tory.3). trichomonas. candida Inflammatory Lichen. General Physical Exam External Musculoskeletal Exam The physical examination should begin with a A systematic pelvic and low back exam should global assessment of the patient’s mood and affect.3. usually feels. Dyspareunia and Vulvodynia 49 before proceeding to a full musculoskeletal and Intimacy-Based Model of Female Sexual Response Cycle vaginal exam (Figure 6. IBDb Functional Menstrual history. these questions may help identify additional eti. atrophic vaginitis. while the pain concentrated only • Use of a topical anesthetic. incontinence and prolapse procedures Anatomical Imperforated hymen. or vulvodynia. spine or pelvis conditions a Interstitial cystitis b Irritable bowel disorder . anorgasmia) Traumatic/​Surgical Fissures. For example. be performed seeking evidence of any pelvic TABLE 6. ICa. While performing the pelvic examination. As in any patient who presents with painful • Patient should be made aware of her symptoms. measures can be taken to facilitate a successful examination42: Reprinted with permission from Basson R. lack of lubrication. vulvar dermatoses. traumatic. The answers to any point. herpes. vaginismus. Obstet Gynecol. anatomical. if desired. done before the exam.17 A  few FIGURE 6. exclude other diagnoses. Before the examination. sexual dysfunction (arousal. irritant/​contact dermatitis. 2001. uterine fibroids. determine the type and location of the pathology. • Use of a narrow speculum or no var area may suggest vulvitis. mesh erosions. The goals of physical exam are to localize and possibly recreate some Emotional Intimacy of the pain or discomfort. • Patient should be given as much control as possible over the process. adnexal masses Musculoskeletal Joint or muscle pain. during the examination is similar to what she culoskeletal causes. speculum. insight into the evaluation. gonorrhea.3  CAUSES OF DYSPAREUNIA AND VULVODYNIA CHARACTERIZED BY COMPONENTS OF THE PATIENT’S HISTORY History Conditions Infectious Chlamydia. site of examination. the vaginitis.1.6 Sexual Drive Pelvic examinations can be anxiety-​ Arousal and producing and painful for a significant number Sexual Desire of patients. or vulvo. syphilis. or mus. the interview of women with dyspa. thus supporting the • Patient should be told what is going to be involvement of partners in the treatment process. limited mobility. Healthcare providers may choose to physician should instruct the patient to report characterize the pain by infectious. and reassure her if no Spontaneous Sexual Stimuli pathology is uncovered. functional. as listed in Table 6. ability to control the pace of the examina- reunia should include a full review of the past tion and to terminate the examination at medical and surgical history.2:  The stages of the normal sexual cycle. vaginal septum. Emotional and educate the patient regarding the normal anat- Physical Satisfaction omy and sexual function. inflamma.98(2):350–​353. • Patient should have visual access to the ological factors and guide the diagnostic process. Aug. at the vaginal opening might be due to vestibu- litis.

while she is touched with the cotton portion of the thin. bacterial vaginosis.. characterized as pain in response “to a stimulus reunia.e. to light pressure. Clinicians Using a similar cotton-​tipped applicator tech- can distinguish between mechanical allody. or irritants). hyper- number of possible causes for pain. patient on the cotton-​tip examination such that candidiasis. or dermatitis (i. perianal areas of the groin. pathology that might be contributing to dyspa.44 In this case Vulvar Examination the patient would report “pain” instead of just a Visual inspection of the external genitalia. the baseline is established as “cotton ball” when chronicus or vulvar eczema. or “dynamic” if it occurs in and loss of range of motion in the pelvic joints response to light brushing.6. Because pain is a subjective dermatoses. perineum vulva. the musculoskeletal evalua.17 Diffuse or focal erythema and experience. “pin prick” when touched with the wooden por- perineum. including sensitivity.1). Careful visualization can reveal a participant has allodynia. S2/​S3. hypertonicity. . Conversely. it is recommended that the sensory thickening can occur with subclinical human examination should begin by first educating the papilloma virus infection. With this type of sensory the pubic mons is the first step of the vulvar examination. hyperalgesia.50 Pelvic Pain Management General Physical Exam General Physical Exam External Non pelvic Musculoskeletal Exam musculoskeletal Exam Inspection INSPECTION vulva. lichen simplex.” when it occurs in response the spine curvature. and a normal anal infection. inflammation. and tion of the applicator. and S1 with a cotton swab. sation. a brief neurosensory exam of with the wooden portion.17 Next. or “pin prick” when she is touched sclerosis. nique. trauma.43 algesia is characterized as increased sensitivity to a painful or noxious stimulus. fissures. Patients should also the vulva and perineum can be done by gently be instructed that. That is. Patients with chronic vulvar or vaginal touched with the cotton portion of the appli- pain often lean to one side in an attempt to avoid cator. This exam visual analogue scale (0–​ 10). a patient would gait and posture in the sitting and standing report “pain” instead of “cotton ball” when position.9. the pain should be quantified using a S4/​S5. hyper- and muscles. vagina. Mechanical allodynia is further differ- the painful side. perineum Single Digit Exam and Q tip TEST Bimanual Exam Optional Speculum SINGLE DIGIT Exam Exam BIMANUAL Exam Optional SPECULUM Exam FIGURE 6. normal sensation.3:  Components of the dyspareunia and vulvodynia physical examination. that does not normally provoke pain. dry tissue can suggest atrophy or lichen applicator. L1. the examiner can then proceed to sensory nia and hyperalgesia. where 10 is the is easily done with the cotton and the wooden worst imaginable pain. the provider can determine if the examination.”44 such tion should involve observation of the patient’s as the cotton swab. vagina.44 Mechanical allodynia is examination of the vulvar vestibule (Figure 6. if they feel a painful sen- touching the sensory dermatomes T12. and reflex (“anal wink”). Specifically.44 portion of a cotton-​tipped applicator. This often leads to changes in entiated as “static. asymmetry.

who in turn had Single Digit Internal more dysfunction in these areas than non-​affected Musculoskeletal and Bi-​Manual women. heightened contractile responses due to pain. and adnexa. The index finger can be used to palpate and rule out pelvic pathology (masses. vaginal evaluation with index finger insertion like vestibulodynia. pathic from inflammatory processes can have sig.1 On the other a tense pelvic floor resting tone.4:  Cotton-​tip sensory evaluation of the vestibule. any involuntary spasm of the muscles of If tolerated by the patient. and decreased extensibility of the tissues at the nificant implications for treatment selection and vaginal opening. present with pelvic floor muscle dysfunction.1. and pelvic floor mus- cles. the urethra. In addition.4).. Image courtesy of Ronnie J. or involving the bladder. vagina helps assess the tone of the pelvic floor tion on the midline. ..e. Six anatomical sites on the vestibule are deter. cles. Fowler II.47 reliable method for evaluating pelvic muscle At the end of the single-​digit examination. acterized by increased pelvic floor muscle tone including the perineum and labia majora. a speculum examina- the introitus. and any scars from tion should be done.43 hand. hypertonicity) and activity (i. interstitial cystitis. and posterior walls of the that may give rise to deep dyspareunia.46 Reproducible pain on single-​digit palpa- Examination tion of the anterior vaginal wall may provide clues The next step in examination should involve a to an inflammatory process involving the vestibule. hyperactivity) addition to having visible inflammatory changes at rest. poor relaxation capacity following contrac- of the skin. women with conditions affecting the general There is evidence that women with PVD can anogenital region (infections.” with 12 o’clock and 6 o’clock positions cor. or contact as possible.43. neuro. abdominal hand can be added to further assess the piriformis. dermatoses. one study found that thus is an important part of the examination in women with vaginismus exhibited significantly women with dyspareunia or vulvodynia.43 Patients with pelvic floor dysfunction will sia and allodynia characterized as exquisite pain often demonstrate poor contractile function and located specifically in the vestibule.e. tion.38 and her ability to contract and relax the mus- Women with PVD usually report hyperalge. chronic urethritis. warm. checking for any specific areas of tender. This is regarded as the most urethral diverticulum. Having the mined with reference to the conventional “clock patient contract the muscles of the pelvic floor face. cul-​de-​sac. Speculum Exam ness.1 vagina. using a small-​size. with as little vestibular trigonitis.17 in (i. like just past the introitus. Dyspareunia and Vulvodynia 51 12 o’clock 6 o’clock FIGURE 6. levator sling. In addition. and internal obturator. adhesions) the lateral.6. an tenderness in muscles such as the levator ani. previous surgery or episiotomy.45 condition of the uterus. while the examiner has the index finger in the responding to the anterior and posterior posi. respectively (Figure 6. more hypertonicity and poorer muscle strength in comparison to women with PVD. anterior. differentiating neuro. char- pathic process) may report a more diffuse pain.

slow. intercourse leading to more pain. Medical and more obtained in order to rule out specific infectious conservative therapy is almost always preferable causes of dyspareunia. there are both hor- apy for cervical dysplasia. cervical allodynia. Large numbers of although the above pathologies are associated white blood cells (WBCs) suggest candidiasis. like urodynamic testing (incon. the cervix can be lightly touched with a Doing so will increase the likelihood of patient cotton-​tip applicator to determine if there is any compliance with the treatment plan. most types of Often. ogies will be covered in subsequent chapters endometriosis). along with vag. and psychoso. Resuming intercourse with pain will only pro- abnormal pap smear. and until she feels comfortable doing so. and therefore will only be mentioned T R E AT M E N T briefly here. and an individualized multidisci. and cervical cultures. or presence of high-​risk mote more pain and reinforce a cycle of fearful human papilloma virus [HPV] strains). as with all symptomatology. with deep dyspareunia and can result from cer. and testing for sexually transmitted vic floor myalgia. adnexal pathology. sized. All efforts should be cognitive and behavioral therapy ideally should made to insert the speculum through the hyme. anti- cultures should be obtained from the patients fungal and antimicrobial therapies for infections with vaginal discharge. and surgical interventions for infections (STIs: gonorrhea. Education.17 Experts in gynecology. Small vul. adhesions.” and giving recommended. to allow the pelvic floor muscles to accom. “all in her head. Therefore. a condition that is associated Dyspareunia. more rarely seen. trichomonas. uterine fibroids. Urine cultures.e.6. will help align her expectations. the var biopsies can be helpful in identifying vulvar patient must refrain from intercourse until the dermatoses that result in lichenification. Lastly.49 pudendal neuralgia. post-​excisional ther.1. topical corticoste- Diagnostic Tests roid treatments for dermatoses.6. pain management. infection. During treatment for dyspareunia. treated first. pain has resolved (or significantly improved) Other tests. pelvic vascular conges- tion). vaginal causing vulvovaginitis. colposcopy (biopsy of visible lesions. the provider can visualize the internal and treatment timeline cannot be overempha- vaginal tissues for the presence of fissures. are indicated on an individual (i.1 It is important to and mental health professionals specializing in reeducate the patient and her partner in sexual . plinary approach to treatment of dyspareunia is acknowledging that her pain is “real. can all contrib. and Goal Setting ute to dyspareunia.50 Treatment copy (suspected interstitial cystititis). that the problem is approached from many dif- inal secretions wet-​mount should be obtained. Informing the patient from the beginning inal atrophy. It is rare that dyspareunia is caused by one factor alone. as noted above. work in concert in an effort to treat all possible neal ring without touching the urethra or vulvar factors associated with the patient’s experience vestibule. tinence). sexual therapy.52 Pelvic Pain Management well-​lubricated instrument. to surgery in patients who have a chronic pain A normal vaginal pH excludes atrophy and diagnosis. ferent angles. phys. physical therapy for pel- wet preps. trichomoniasis. During this portion of patient’s agreement about treatment selection the exam. that treating her pain will be a long process. and vaginal depth. herpes and syphilis) should be and pelvic organ prolapse. For example. painful bladder syndrome. the patient experiencing dyspareunia or long-​standing dyspareunia will have overlapping vulvodynia has at some point wondered if it was treatments. or desquamative vaginitis. monal and non-​hormonal treatments for vaginal atrophy and vaginal dryness. gonorrheal or chlamydial diagnoses have dyspareunia. vag. endometriosis. Validation. a pap smear. to herself and her partner. It is important to acknowledge that. basis. ultrasound for deep dyspareunia caused by organic etiol- or other pelvic imaging (fibroids. with dyspareunia. Organic. bacterial vaginosis (BV). chlamydia. candida. cystos. pharmacological A vaginal pH and a sample for Gram stain and and surgical treatments for endometriosis.17 At this time. The importance the provider’s and the modate the speculum. musculoskeletal. ovarian cysts. is a symptom whose underlying cause must be vicitis or. it a name will help legitimize the patient’s pain ical therapy.. not all women who have these lichen.48 Insertion of the speculum should be of dyspareunia. cial etiologies.” Validation of the patient’s pain.

by estrogen deficiency. Dyspareunia and Vulvodynia 53 attitudes and practices. can cause significant dyspareunia.6 Education on vulvar care measures is taining pills and ointments. lubrication prior to and during intercourse should be advised. Venlafaxine. Mirena • Estrogens (Topical. progestin-​only pills. Klonopin GnRH Agonists (Injectable) DD due to Leuprolide endometriosis a Superficial dyspareunia b Provoked dyspareunia c Deep dyspareunia d Vulvovaginal atrophy . giving the patient previously. Dehydroepiandrosterone (DHEA). have been shown to significantly allevi- have sufficient evidence supporting their use for ate pain with intercourse. Letrozole Antidepressants (Topical. phys. Superficial with water and pat-​drying (and after cleansing).4  COMMON PHARMACOLOGICAL THERAPIES FOR DYSPAREUNIA AND VULVODYNIA Drug Class (Route) Indication Type Analgesics (Topical. cells are increased. Estrogen ther- clothing during the day and none at night. DD. Very few of these treatments have reunia. some knowledge and therefore control of her Hormonal medications. but not limited to. Oral) DDc intrauterine device.38 modulate estrogenic effects by indirectly stimu- When the patient resumes intercourse. Nortriptyline. gently cleaning the vulva ens and revascularizes the epithelium. PVD a b Lidocaine. Injectable) SD . Flexeril. Cymbalta Anticonvulsants (Topical. PVD Premarin.54. scented tampons.53 Topical analgesics.1. Fluoxetine. and symptoms of atrophy and using a preservative-​free emollient to hold are alleviated. topical analgesics can be compounded with any sus amongst vulvar pain specialists about which other topical therapy to provide enhanced effects. such as lidocaine been vetted with randomized controlled trials or ointment. Estrace.4). and thick- cotton menstrual pads. Marcaine Hormones SD. douches. avoidance and newer selective estrogen receptor modulators of irritants such as perfumed soaps. and behavior. medical treatments are beneficial. however.55 Both emollients and vulvodynia. Pregabalin Neuromuscular Blockers (Injectable) SD.51 SERMS and intravaginal DHEA in moisture and provide a barrier to irritation. DHEA • Progestins (Oral.38 Antidepressants and Hormones and Hormone Anticonvulsants/​Neuroleptics Modulators Use of compounded tricyclic antidepres- Vulvovaginal atrophy (VVA) is a common sants (TCAs) in a water-​ based ointment has symptom in the postmenopausal state. thus. Norethindrone. detergents. PVD Botox A Muscle Relaxants SD. use of lating estrogen receptors in the body. (SERMs) such as ospemifene and intravaginal dyes. Desipramine. thus specifically treating dyspa- (Table 6.52. as mentioned iology. such as estrogen con- situation. PVD Amitriptyline. sexual anatomy. using apy restores normal vaginal pH levels. can be used to wearing cotton underwear and loose-​ fitting treat dyspareunia caused by VVA. there is a growing consen. advised: including. Caused been shown to provide moderate to excellent TABLE 6. PVD Valium. Oral) SD. Oral) DD Gabapentin. Implantable) • DHEA (Vaginal) SERMs (Oral) PVS due to VVAd Osphena. vaginal sprays. DD. Vaginal. Emollients and Topical Analgesics Non-​ hormonal topical emollients can also be Medical Therapy used as vaginal moisturizers targeted to increase Many pharmacological treatments have been lubrication during sexual intercourse and pro- tried to ameliorate dyspareunia and vulvodynia vide a barrier. VVA.

7. Patients with dyspareunia treated with vulvar surgery:  for example.67 dyspareunia caused by pelvic floor myalgia and contracture. in patients who levator ani myalgia.60 therefore making intercourse less painful. especially as it relates to superficial dys- endometriosis has been shown to be relieved pareunia caused by vaginismus. which may help them viate deep dyspareunia in a patient. or lysis of adhesions.65 A  well-​trained ical treatment for vulvodynia that is thought to pelvic floor physical therapist uses techniques be due to neuropathy. Although Kegel it is important to note that the surgery in and exercises are often recommended in patients of itself can be a catalyst for pelvic pain and with poor pelvic support. Currently. including dyspareunia. anxiety.15 If patients cannot tolerate or Physical Therapy are not responding to use of TCAs. has been shown to alleviate best-​studied tricyclic. it is be helpful in mitigating symptoms. con- after colporrhaphy for pelvic organ prolapse. adding placebo able to decrease their catastrophization of pain. and TENS (transcutane- extended release gabapentin for the treatment of ous electrical nerve stimulation) units to help PVD-​related symptoms. those who chose progestin-​therapy for treatment S U M M A RY over repeat surgery had significantly more relief The symptom of dyspareunia is multifactorial of their pain. attention to detail. and fear of pain. to release stenosis for postoperative stricture and assistance in coordinating care. Gabapentin is becoming important and necessary adjunct to almost all increasingly popular as both an oral and a top. a mental health professional who . massage. anticonvul.57 Injection of well as sexual and cognitive correlates to PVD. the side-​ effect dyspareunia. surgery can pareunia or vulvodynia. a randomized like biofeedback with surface electromyogra- control trial is being conducted on the use of phy. treatment for dyspareunia. exci.63.62 and requires a multidisciplinary approach to Superficial dyspareunia can be occasionally achieve optimal care. As noted above. dilators. and vulvodynia are a very sensitive population sion of the hymeneal remnant.49 Amitriptyline is the to cover the defect. could significantly alle. a vestibulectomy. a pelvic floor physi- PVD. their pelvic floor muscles.64 profile might influence the patient’s compliance with treatment. In fact. With regard to the pelvic floor. in those exercises will allow them to learn to control with obvious pathology.56 relax the pelvic floor muscles and retrain pain receptors that cause both deep and superficial Injectables dyspareunia.6.61 hysterectomy. However. Ideally. comitant involvement of a gynecologist who In select patients with vulvovestibulitis causing specializes in pelvic pain.38. PFPT was also found to be helpful in preventing cles has been shown in some studies to decrease persistent dyspareunia after vestibulectomy. when there There is no one preventative measure for dys- is an underlying organic etiology. to surgical treatment. or perineoplasty who require attentiveness. with relaxing the pelvic floor. fibroids or adnexal pathology.69 Surgical Therapy PREVENTION Especially with deep dyspareunia. removal of about vulvar care. Pelvic floor physical therapy (PFPT) is an sants can also be used. a study dyspareunia in patients with dyspareunia due to by Vercellini et  al. pelvic organ pro. however. teaching patients how to properly do pelvic floor lapse procedures. Kegels can exacerbate even dyspareunia in patients.59 Cognitive and Behavioral Therapy Cognitive behavioral therapy (CBT) has been Other Drugs shown to be effective in conjunction with other Deep dyspareunia believed to be caused by therapies.66 botulinum toxin A  in to the pelvic floor mus. in which the vestibule cal therapist. Excision important for the patient to be knowledgeable of endometriosis.65 PFPT has also been shown to be Pudendal nerve blockade has been used to treat effective in treating PVD-​related dyspareunia as vulvodynia caused by neuralgia.54 Pelvic Pain Management improvement of dyspareunia symptoms in is excised and the vaginal mucosa is advanced patients with vulvodynia.68 When patients significantly more when adding gonadotropin-​ are able to find a way to curtail their pain-​ releasing hormone (GnRH) agonist to surgical hypervigilance. showed that.70 had already had one surgery for endometriosis.58. they are treatment of endometriosis vs.

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subsequently present at birth. 7 Endometriosis Treatment and Pain Management A D H A M Z AY E D . This results in the production of tissues through the fallopian tubes to the ovaries. with a peak of 25–​35  years of age. and decreased pro. and ory delineating how endometrial tissue becomes cytokines. which causes further This can spread to the peritoneum. the resulting cells continues to shape our understanding of this are in their extrauterine location. cycle. a similar fashion to these hormonal changes. When the tissue is shed corresponding to Ongoing research into old and new interventions a drop in progesterone levels.3 esis is not clearly understood and is probably The result of all four theories is the pres- multifactorial. pain from the active bleeding or from localized inflammation of these ectopic sites. It is associated with dysmenorrhea and before subsequent proliferation and shedding. an estrogen/​progesterone receptor profile similar Consequently. and peritoneal walls. There can be chronic. K A R I N A G R I T S E N K O . none are definitive.2 reactive oxygen species. tization and subsequent pain. Superficial . The tissue trauma resulting from these endometrial tissue via misdirected Mullerian inflammatory processes can lead to nerve sensi- ducts. that in the United its response to estrogen and progesterone. bladder. be developed and differentiated in the peritoneum toms. there is tissue proliferation during including both medical and surgical interven. dependent and predominantly affects menstruat. Extrauterine cells undergo change resulting in ing women. the estrogen-​dependent stage of the menstrual tions. chemokines. vagina. of depth of implantation of extrauterine endo- The Müllerian remnant theory hypothesizes metrial tissue. Breakdown of menstruation. The associated morbidity results ence of extrauterine stromal tissue. Ectopic tissue can be categorized by its sive to hormone changes in puberty. Accordingly.1 thus it responds like native intrauterine cells. there is retrograde flow of stromal deposition. PAT H O P H Y S I O L O G Y The presence of endometrial stromal tissue It is possible that endometriosis is composed of in the peritoneum has been found to stimulate multiple disease processes. The loca- in increased healthcare costs. its prevalence is probably around enough to endometrial tissue that it responds in 10% of reproductive-​age women. and States are estimated in the billions of dollars. There are many potential treatment options. mediated inflammatory response4 resulting in The most prevalent theory is that of retrograde angiogenesis and lesion growth. tion of this extrauterine tissue does not limit ductivity due to work absence. unfortunately. chronic pelvic pain. although. tation. During menses when the uterine red blood cells results in intraperitoneal iron lining is shed. and respon. ators. and debilitating disease. location to help guide management. during organogenesis. there is spread of disease. There is a subsequent macrophage-​ ectopic. painful. including the localized tissue trauma resulting in progression bowel. The pathogen. including prostaglandins. There are four main an increased production of inflammatory medi- theories of the pathophysiology—​with each the. which further exacerbates the that. Inflammation of the resulting ectopic tissue The endometrial stem cell implantation theory proposes that endometrial precursor cells migrate into the peritoneum. A N D Y U RY K H E L E M S K Y E “ ndometriosis” is defined as the presence of endometrial tissue outside the uterus. resulting in extrauterine stromal implan. causing endometrial tissue to results in a spectrum of presenting pain symp. The disorder is estrogen-​ The last theory is metaplastic change.

and is also important to evaluate any DIAGNO SIS risk of sexually transmitted infections or preg- nancy. including gyneco- tissue can also be in the ovary. Its causal relationship is is largely suggestive of dysmenorrhea possibly not clearly defined in early endometriosis. colon. or “chocolate cysts. Imaging quent diagnoses made incidentally. Although the timing of There is a high correlation between endome. respectively. There has been some correlation between tions associated with endometriosis. Endometriosis is often associated cascade causing a hostile environment to egg with heavy or prolonged menses. urological. osis. narrow the list of differential diagnoses. and the ses and comorbid diseases. dia. They can also be asymptomatic. exam should be performed as suggested by the copy. scope. dysuria. possibly due to nerve irritation. pelvic pain. pain symptoms occurring only during menses triosis and infertility. logical. an operating room. Tissue Biopsy The gold standard for diagnosis is visualization Physical Examination of cell histology under microscope. Laboratory Studies or necessary intervention for most patients. This creates a uterosacral ligament and fallopian tubes. infertil. pain and the severity of its sequelae. studies have arising secondary to chronic inflammation. ureters. many diagnoses of endometriosis are of endometriosis. Women elevated Ca-​125 levels and advanced endometri- most commonly present with dysmenorrhea. and/​or sperm. personnel. bladder. linked Endometriosis has also been associated with to multiple genetic foci. However. Social history is also hyperalgesia. female. both intrauterine and ectopic. it is not pathognomonic of is thought to be secondary to the inflammatory endometriosis. Labs should be completed as indicated to but can also present with dyspareunia. shown a 51% hereditary component. menstrual history and chronologically correlate phragm. but from ectopic lesions. lung. It is also important to obtain a detailed fam- ity can occur as a result of anatomical changes ily history. A  positive diagnosis is made when endo. In late endometriosis. important. It is important to obtain a detailed toneum and retroperitoneum in the liver. and a rectal metrial cells are seen in an extrauterine biopsy. cysts. the physical should include taken intraoperatively and sent to the pathology assessment of vital signs. An iron-​deficient History (microcytic) anemia is largely suggestive of heavy It is critical to obtain a detailed history due to menses in an otherwise healthy menstruating the varied presentations and comorbid condi. and a detailed gynecological exam. and intermenstrual pelvic pain. with subse. . known as endo. nal exam. Endometrial women who have been diagnosed with chronic tissue has also been described outside the peri. which requires general anesthesia with an patient’s history to assess for differential diagno- endotracheal tube. including bimanual palpation. As There are no laboratory studies that are diagnostic a result. results can help narrow the differential diagnosis by ruling out other pathologies. gastrointestinal. Additional components of the physical The biopsy is performed via diagnostic laparos. dysche. and can be made. cost-​worthy. There is Imaging studies are also not solely diagnostic. This is not a practical. Endometriosis 59 peritoneal implants include ectopic tissue on the and presenting pain symptoms. some lab detailed history and physical examination. and umbilicus. it with pain symptoms. time. Although the genetic penetrance and (adhesions. which must be ruled include endometrial tissue that can be found in before a presumptive diagnosis of endometriosis the vaginal fornix. and mus- metriomas. Endometriosis is present in 87% of pouch of Douglas. as endometriosis has been separately and a spectrum of social stresses and psychiatric linked in patients with increased alcohol con- illnesses secondary to complications of chronic sumption and low exercise levels. where it is visualized under the micro. a detailed abdomi- laboratory. Ectopic broad differential diagnosis. or rectal wall. A  sexual history can reveal evidence of dyspa- reunia. A  biopsy is At minimum. some correlation between location of lesions although they can be used as aids in diagnosis. sterile equipment and costs asso- ciated with it. exam. in conjunction with presumptive or empirical diagnoses based on a a detailed history and physical exam. pleura. zia.” Deep nodules culoskeletal pathologies. mechanical obstructions) expressivity are not yet defined.

add-​ MEDICAL back therapy can be considered in successful MANAGEMENT cases of GnRH analogues resolving pain symp- If diagnostic laparoscopy is not chosen. Uninterrupted courses Gonadotropin-​releasing hormone (GnRH) is of oral contraceptive agents are theoretically normally secreted by the hypothalamus. ranging tins plus bisphosphonates. Calcium supple- from suppression of ovulation to inhibition of mentation is recommended for all patients on the inflammatory cascade. cations to minimize some of the adverse effects ment regimen can be started. The treatment regimens discussed There are known adverse effects to the induced herein will focus on the treatment for pain asso. This ultimately endometriosis. toms. In comparing com- regimens can be long. motor instability. progestins. as lution of symptoms and tolerance of side effects. Magnetic resonance imaging progesterone. respectively. Maintenance of fertility remains toms when compared to placebo or no treat- the most important factor. as this can restrict ment. or proges- parts of the known pathophysiology. Directed hormone (LH) in response to this stimulation. and osteoporosis. the utilization of surgical interventions and There was a benefit in reduction of symptoms medical therapies available. There is tovaginal or bladder lesions. Exogenous GnRH is recommended only as a second-​line test after analogues bind to GnRH receptors with greater a non-​diagnostic ultrasound for suspected rec. but it can be used to diagnose gland. repeating courses of bined estrogen and progesterone pills to pro- patient-​driven trial and error. although the evidence was of low quality. which controls the release of estrogen and perirectal region. or progesterone only) work the expected to return if a successful medication same way for treatment of endometriosis as course is terminated. No medical therapy add-​back therapy to promote bone stability. the latter may be preferred. Subsequently. gesterone only. affinity than does endogenous GnRH. resolution of Contraceptive Agents symptoms on a treatment regimen is not diag. A  recent retrospective systematic review agement of endometriosis is largely driven by reported a benefit in the suppression of symp- patient factors. As the gold stan. treatment they do for contraception. minimizing exogenous estrogen intake theoret- ically minimizes its downstream proliferation GnRH Analogues of endometrial tissue. Therefore. with superior to interrupted courses (21  days or . currently available is curative beyond its active treatment course. genital atrophy. use of transvaginal ultrasound can be used to FSH and LH have subsequent receptors in the visualize endometriosis in the perivaginal or ovary. they ciated with endometriosis. tion. a histologically confirmed diagnosis is not required to begin Add-​Back Therapy treatment. Oral contraceptive agents (estrogen and pro- nostic of endometriosis. Pain symptoms are gesterone. treatment is a mix inhibits the trigger for the subsequent inflamma- of medical therapies and surgical interventions tory cascade.60 Pelvic Pain Management Abdominal ultrasound is not definitive for receptors located on the anterior pituitary endometriosis. osteopenia. a balance of reso.5 It consists of “adding back” some medi- bined diagnostic-​ therapeutic medical manage. mood changes. Subsequently. medical treatments are directed against different It can include estrogen.5 for many women. when compared to danazol. The anterior pituitary secretes follicle-​ endometriomas and other gynecological masses stimulating hormone (FSH) and luteinizing that can cause similar pain symptoms. difference when compared to the levonorgestrel tion (diagnostic laparoscopy). a com. The man. it is not compatible with concep- recting the underlying pathology. As this treatment results in ovarian aimed at both minimizing symptoms and cor. Furthermore. suppression. In large part. it is not optimal intrauterine device. a subsequent downstream downregulation of receptors resulting in ovarian suppression and a T R E AT M E N T hypoestrogenic environment for the intra-​and There is no absolutely curative treatment for extrauterine endometrial stroma. Currently available of bone resorption caused by GnRH analogues. state of hypoestrogenism. and no observed dard for diagnosis requires a surgical interven. Accordingly. and not with the mimic physiological changes associated with broader management of infertility associated menopause or premature ovarian failure:  vaso- with endometriosis.

) have inconclusive regarding their efficacy specifically been frequently used for pain control for both for endometriosis pain.Depending on the location of the lesions. For superficial perito- ranges from 200–​800 mg daily. management. mizing endometrial shedding. surgical removal of lesions can be per- and regularity of menstruations in most women. tematic review showed benefit of this IUD for Lesion removal can be done via excision. or vagina can warrant deeper excision although the evidence was weak. Drugs (NSAIDs) metriosis. The dose more extensive surgery. It was the first FDA-​approved Severe cases of endometriosis can warrant drug for treatment of endometriosis. Deep Nodule Management and change in voice. Androgenic side effects are are norethisterone acetate and dienogest. However. the data are still NSAIDs (e. The most promising add-​back therapy. a derivative of 19-​ Hysterectomy nortestosterone. the latter the pituitary. Levonorgestrel is a second-​ generation progestin. and can some- are other forms of progestin-​only contraceptive times be managed by dose de-​escalation. A  recent systemic ret. including acne. vaginal insertions) that are used for Non-​Steroidal Anti-​Inflammatory contraception and have been studied for endo.5 mediators in endometriosis. which results in some unde- sired side effects. The IUD lifespan is If diagnostic laparoscopy for tissue biopsy is up to five years. However. Like with GnRH analogues. formed in conjunction. It decreases the release of gonadotropins from If there are no lesions on the ovary. A  recent sys. There found to be dose-​dependent.laparoscopy with removal of lesions versus diag- triosis therapy per se. sur- rospective review found some benefit in reduc. agents (subcutaneous implants. For patients with deep lesions. and it reduces the frequency desired. bladder. Although promising. albeit danazol functions to increase circulating levels less with bilateral oophorectomy. After manual placement of SURGICAL MANAGEMENT the IUD. hypoestrogenic side effects can occur. ibuprofen.5 recurrence is common with fertility-​sparing sur- gery where the anatomy is left relatively intact. ovary-​sparing hysterectomy with salpingectomy. A  recent systematic ret. performed. ureters. intramuscular injections. naproxen. Even when fertility environment and endometrial tissue atrophy.endometriosis. These med- rospective review also showed no difference ications inhibit the release of prostaglandins. or shaving. of testosterone.5 contraception. and it is often neal implants.g. as there is constant inhibition the been replaced by GnRH analogues for treating trigger of the inflammatory cascade by mini. is sacrificed and this more extensive surgery is both intra-​and extrauterine. Additionally. It results in a hypoestrogenic effects of hypoestrogenism. Danazol Danazol is an oral androgen. thus blunting the luteinizing technique may be preferred to prevent the side hormone surge. to its undesired side-​effect profile. in efficacy between oral contraceptives and a which have been implicated as inflammatory GnRH analogue.gical removal of lesions on the colon.5 However due of this tissue. coag- reduction of pain symptoms versus expectant ulation. this can be total hysterectomy recommended not to be continued beyond six with bilateral salpingo-​ oophorectomy. or an months.can be treated by concurrent administration of ied for endometriosis pain.with removal of lesions can be a definitive treat- tive treatment for endometriosis. Diagnostic laparoscopy minimizes menstruation is a potentially effec. endometriosis can still recur. There is some evidence Although it is not yet approved by the US Food to support decrease of symptoms after diagnostic and Drug Administration (FDA) for endome. laser vaporization. tion of symptoms for danazol versus placebo. a recent The levonorgestrel-​ releasing intrauterine retrospective failed to show a reduction in device (IUD) is also an effective device for symptoms when compared to placebo.endometriosis and dysmenorrhea.. any agent that nostic laparoscopy alone. it has largely there appear to be improved pain outcomes with . levonorgestrel is released directly into the uterus at a constant rate to have an effect like Diagnostic Laparoscopy other exogenous progestins.ment with complete resolution of symptoms.6 Danazol has multiple effects in vivo. which Progestin-​only agents have also been stud. Endometriosis 61 otherwise). hirsutism. in theory. etc.

tions from the more extensive surgery. to ovarian torsion. the decision to reoperate must be proliferation. Surgical management is typically incision vivo angiogenesis for normal tissue growth. nation with and compared to GnRH agonists. tion. In cases of recurrent endometriomas inhibitors is thought to decrease endometrial after surgery. causing tissue prolifera- increased risk of ovarian dysfunction or infertil. trials before recommendations can be made on ment regimens. there are still limited medical inter- ventions to manage the intraabdominal fibrosis Adhesion Management and adhesions caused by the chronic inflamma- The chronic inflammatory milieu secondary to tion in late endometriosis. with promising results. it is hypoth- tomatic patients to prevent their progression esized. There is some evidence that sup. medical management versus further encouraging results. Similar in mechanism of action to other non- sions with every surgical access to the peri. which has been impli- associated with an increased risk of complica. Additionally.8 Pentoxifylline has also the risk for future adhesions.9 preventing the recurrence of endometriosis. excision warrant their use at this time. the limited trichostatin A  have all been studied but require results limit their potential recommendation to further testing in larger randomized controlled patients with refractory disease to initial treat. ine endometrial tissue. Recent studies of intraperitoneal admin- With potential recurrence after surgical inter. and tial medical therapies. tor agonism elsewhere in the body. These newer agents all target the their use in endometriosis. albeit with the unwanted side effect of limiting in tility. surgically managed in symptomatic or asymp. They and drainage or complete excision. as there has been immune response causing the inflammatory cas- no benefit for any agent shown in the literature. However. Anti-​Inflammatory Agents there is an increased risk of fibrosis and adhe. valproic acid. Statins. carries an increased risk of infertility or ovarian dysfunction. Selective Estrogen Response Modulators PRO SPECTIVE FUTURE These agents have endometrial estrogen receptor THERAPIES antagonism while maintaining estrogen recep- Randomized controlled trials have been per. there are no set guidelines for post-​ human trials. steroidal anti-​inflammatory agents.10 Post-​Surgical Medical Immunomodulators Management Immunomodulators such as anti-​tumor necro- Although post-​ surgical drugs are prescribed sis factor agents have been studied in limited frequently. Due to an have not been thoroughly tested in humans to endometrioma’s proximity to the ovary. Further formed to evaluate the efficacy of other poten. istration and direct injection both have had vention. cated in the pathology of early endometriosis. continued pelvic pain without any guarantee of with some promising results.7 However. It has a higher expression rate in extrauter- ity in repeated surgeries for recurrent endome. including diagnostic laparoscopy. they can minimize proliferation of lesions. surgical intervention must be considered on a case-​by-​case basis. Overall. They are thought to inhibit the surgical medical management. and infer. there is an in endometrial tissue. which may lead to been studied in randomized controlled trials. studies are required. ovarian rupture. cade. as each surgical procedure can increase ing symptom control. although they are also inflammatory cascade. cyclooxygenase-​ 2 (COX-​ 2) inhibitors like Management at this point becomes more com.3 ongoing endometriosis exposes the peritoneum to tissue fibrosis and adhesions. Targeted use of aromatase triomas. By interfering with cell proliferation. Antiangiogenics Endometrioma Management Antiangiogenics such as rapamycin have been It is recommended that endometriomas be tested in animal models. . They have been studied in combi- made on a case-​by-​case basis. Aromatase Inhibitors ports decreased recurrence of endometriomas Aromatase stimulates the expression of estrogen with excisional surgery. however. specific toneum.62 Pelvic Pain Management more extensive removal. rofecoxib have shown promising results regard- plicated.

the high morbidity and high recurrence rate of 11. 4. nerve in the uterosacral ligament near its con. Surgical interruption of pel- out alternative therapies. Uterine nerve ablation involves ablation of the 3. Endome­ Uterine nerve ablation and presacral nerve abla. Hummelshoj L. et al. it is premature to categorically rule KS. There may be a role for presacral nerve 5. further research is required before conclu- related pain symptoms: a systematic review. Maouris P. Surgical Interruption REFERENCES of Nerve Pathways 1.274:203–​205. Endometriosis: an overview ablation. between Chinese herbal medicine and danazol. Johnson NP. J Med.15:62–​66. Cobellis L. pain. Reprod sive recommendations can be made. pared to traditional lesion excision is unclear. Hum Reprod Update. Vigano P. Giudice LC. Fedele L. Hart RJ. 2004. Since danazol is not the gold standard of treat- Use of aromatase inhibitors to treat endometriosis-​ ment. 2014. Clinical practice. Endometriosis 63 OT H E R S U R G I C A L therapies. Presacral nerve ablation Rev Endocrinol. Endometriosis. Endometriosis: pathogenesis and treatment. Hickey M. Hum Reprod. triosis:  cost estimates and methodological per- tion have both been performed. Cochrane Database Syst Rev. Am J Pathol. Nature nection to the uterus. Latthe PM. 2010. Eur J Obstet Gynecol Reprod Biol. Over one CONCLUSION thousand patients with early stage endometrio- Considering the prevalence. although more studies are needed. Monno A. Somigliana E. as well as augmenting the develop- I N T E RV E N T I O N S ment of novel therapies. Capobianco A.5 10. Morey R. 2011. Proctor ML. Hummelshoj L. Cochrane Database Syst Rev. McQueen J. helium is directed at the lesions in a manner Excisional surgery versus ablative surgery for ovar- to vaporize this ectopic tissue. Farquhar CM. Remorgida V. are urgently required. 2014. Arch Gynecol Obstet. dysmenorrhoea. involves transection of the sacral nerve plexus Macrophages are alternatively activated in patients at the level of the superior hypogastric plexus. 2007. Ferrero S.28:1552–​1568.12 A  beam of 7. osis. Simoens S. with varying spective. N Engl ciated with endometriosis and dysmenorrhea.3:Cd009590. and more studies are recommended.175:547–​556. Johnson NP. Cochrane Database Syst Rev. Razzi S. Pentoxifylline after con- when compared to Chinese herbal medicines. Considering Biol Endocrinol. results for treatment of chronic pelvic pain asso. J Minim Invasive Gynecol.116: A recent retrospective review showed weak evi. D’Hooghe T. Bacci M. 2005:Cd001896. servative surgery for endometriosis:  a random- with a different study showing no difference ized. 2008. et  al. (HELICA):  safety aspects. with endometriosis and required for growth and The limited studies of uterine nerve ablation vascularization of lesions in a mouse model of dis- show no benefit in treatment of endometriosis ease. dence that auricular acupuncture was beneficial 9. Khan the disease. 100–​102.10:261–​275. . Buckett W. Kamencic H. ian endometriomata. Brown J. 12. Helium plasma coagulation is another method 2013. Thiel JA. as there is a lack of vic nerve pathways for primary and secondary conclusive evidence regarding many of the allo. and sis treated with the Helica Thermal Coagulator healthcare costs associated with endometri. controlled trial.9:89. 2009. 2. 2008:Cd004992. The treat- ment with a COX-​2 specific inhibitor is effective A LT E R N AT I V E in the management of pain related to endometri- MEDICINES osis. Gillott DJ. to remove lesions via laparoscopy. Laparoscopic Helium 6. De Simone S. trials exploring effectiveness of existing 2006. Vercellini P. et  al. pathic interventions currently being used. Its efficacy com. Farquhar C.13:395–​404. Consensus on cur- Plasma Coagulation rent management of endometriosis. Hill N. 8.362:2389–​2398. morbidity.11 of Cochrane Reviews. Venturini PL.

also known as interstitial cystitis and bladder pain syndrome (BPS). Among studies that surveyed patients Society as “the complaint of suprapubic pain about PBS symptoms. 2011). The Society of Urodynamics and Female Urology uses a sim- ilar definition. pressure. 2000). or diagnosed incor. 1997. source of pathology and pain and. This complexity can lead to (Rover.7–​ 6. This disorder can have sig- frequency” (Van De Merwe. D E S S I E A N D E M A N E L K A D RY P ainful bladder syndrome (PBS) is a chronic disorder affecting millions of women (Konkle. 2008). and major financial implications as More recently. In this model. the American Urological well as decreased productivity (Nickel. however. the syndrome and treatment of PBS and concluded that there is not well understood and is often diagnosed is insufficient literature to provide an evidence-​ late in a patient’s course.000 (Johnson. 2012). 8 Painful Bladder Syndrome and Interstitial Cystitis in Women S Y B I L G . The definition and terminology used to describe PBS will probably continue to evolve D E F I N I N G PA I N F U L over time as better understanding of the patho- BLADDER SYNDROME physiology evolves. rectly. 2. there is limited However. 2010. people (Simon. as well as disorders that may present similarly (Hanno. exclusion due to its poorly understood etiology ical presentations. . infection or other obvious pathology” (Abrams. titis” implies that there is inflammation within given the variable definitions. few effective treatments. ity of life. Association released guidelines for the diagnosis Robinson. In addition. in the absence of proven urinary (Parsons. but symptoms must be present for nificant negative impact on patients’ qual. symptoms such as increased daytime and night. or discomfort tionally been split between two theories. population sam- the bladder. It is difficult to estimate the prevalence of PBS. based diagnosis of PBS in clinical practice. PBS is far more common in women than in men time frequency. Despite ongoing research.5% of American related to bladder filling. The perceived to be related to the urinary bladder first theory focuses on the bladder as the main accompanied by at least one other urinary symp. has P R E VA L E N C E evolved over time. tom such as persistent urge to void or urinary treatment focuses on the bladder. Payne. accordingly. on the basis of clinical principles. 2011). 2010). Estimation of prevalence in the misdiagnosis and often to delayed treatment literature ranges from 10–​865 cases per 100. this is true in only about pling. The definition of PBS. The European Society of the Study of ETIOLOGY Bladder Pain Syndrome/​Interstitial Cystitis uses The cause of PBS is not well understood. 2007). they understanding of the pathogenesis of chronic recommend diagnosis of PBS by excluding other pelvic and bladder pain syndromes. The term “interstitial cys. 2007) in self-​report PBS is defined by the International Continence studies. at least six weeks (Hanno. Unfortunately. 2006). the term “bladder pain syndrome. PBS is often a disease of array of symptoms with multiple possible clin.” describing it Research on the disease’s etiology has tradi- as a “chronic pelvic pain. 2002). There is a wide literature. accompanied by other women have symptoms consistent with PBS. and survey methods used in the current one-​third of patients with PBS.

and perceived stress PBS and irritative urinary symptoms (Peters. history of sexual abuse and symp- pelvis. women with PBS pres- along with other end organs. The GAG layer protects the cause and which is the effect. 2007). there are changes in with filling or emptying). feelings of bloating or vaginal pressure. women with interstitial cystitis (IC) have noted Stress is also often cited as an exacerbating fac- hypertonicity of the pelvic floor muscles (Weiss. often with urgency. and hot peppers (Shorter. 2001. There also seems to be a higher incidence of Symptoms often wax and wane over days to PBS with other inflammatory and autoimmune months. 2010). artifi- including the pelvic floor. 2001). it is unclear which is the primary glycan (GAG) layer. leading to tissue that PBS represents a process with the bladder inflammation and epithelial injury. stimulates inflammation and aids in the 2009). Potential bladder insults. or chronic pelvic pain syndromes. As pain in the ent with symptoms of bladder pain (especially bladder becomes chronic. 2002. Tissue injury as the end organ of various inciting events that might also activate c-​fibers (which carry nerve lead to local bladder inflammation. including a temic factors in the pathogenesis of urological distension injury. or con- 2007. and twin studies have also tissue injury and pain as well as treatments to shown a possible genetic link (Wright. tor (Rothrock. Previous studies of cial sweeteners. 1997). including (Koziol. including abnor- pelvic floor dysfunction with resulting inflam. can damage the GAG layer. It is possible leak into the bladder lining. physical Regardless of the primary insult and resultant activity. anxiety. and frequency in the central nervous system. painful stimuli (such as bladder filling) (Nazif. nosis and treatment may be useful. Some women also have dyspareunia. 2007. Wright. The foods pain pathways. peripheral signals to the central nervous system). This can: and central neural upregulation. This suggests that a genomic approach to diag- Engelhardt. and drinks most likely to make symptoms flare physiology does involve all the pelvic structures. This allows activity and abnormalities in the sympathetic solutes from the urine (such as potassium) to nervous system (Mayson. bowel syndrome. Patients should . stipation. Alagiri. 2004). release (which can trigger pain) There is evidence to suggest that genetic risk • trigger an immune or allergic response factors contribute to chronic bladder and pel- vic pain syndromes (Dimitrakov. These myofascial abnormalities. Patients can sometimes identify things complaints. Talati. (Whitmore. However. Studies have shown familial clustering preventing or managing the factors that lead to (Dimitrikov. include coffee. Lilius. and fibromyalgia. tea. 2010). alterations in the HPA axis. heal the GAG layer (Hurst. mal hypothalamic-​pituitary-​adrenal (HPA) axis mation. such as irritable tract infections or recurrent vaginal infections. sometimes without testing or culture. bacterial bladder infection. In this line of thought. 1994. the bladder lining known as the glycosamino. how painful stimuli are processed neurologically and dysuria. 2009). 1973. Women that women with PBS have a higher incidence may report being treated for recurrent urinary of other painful conditions. treatment focuses on 2008). citrus fruits. bladder epithelium from irritation by urine and An emerging body of research implicates sys- bacteria. as well as chronic fatigue syndrome that trigger or exacerbate their pain. are thought to contribute to the pain of toms of PTSD. Oyama. 2011). 2001). 2009). Lilius. for vulvodynia and other non-​urological pelvic • activate mast cells leading to histamine pain syndromes (Aloisi. The other school of thought centers around generalized pelvic neurogenic inflammation S Y M P TO M S causing the bladder to be secondarily affected In clinical practice. Walters. 1973). menses. certain foods or drinks. there is evidence that the patho. 2007. sexual activity. or prolonged sitting. vulvar pain. 2009. found Women with PBS also have higher rates of on palpation of muscle and other tissue in the depression. Weiss. Painful Bladder Syndrome and Interstitial Cystitis 65 a bladder insult disrupts the protective layer of 2007. bladder pressure. Similar pathways may also be responsible transmission of pain). This can lead to (defined as voiding eight or more times per a lowered pain threshold and pain from non-​ 24 hours). Vulvodynia or other end organ pain This theory is consistent with the finding symptoms are often present as well. alcohol. and changes in central perception • lead to the release of substance P (which and processing of nociceptive stimuli (Mayson. 2011).

these agree that questionnaires should not be used tests can be painful and can delay the initia- alone to diagnose PBS (Kushner. Similarly. palpating the pelvic Nevertheless. Frequency Symptom Scale and to define the benefits. there is other. and urgency. or surrounding muscles.66 Pelvic Pain Management be screened for these disorders during their To examine the pelvic floor. can be performed if the diagnosis is in doubt tify how much and what type of beverages the and can provide information on other lower uri- woman is drinking and give an estimate of her nary tract disease (Hanno. these tests were The physical examination should include a recommended to confirm the physical findings complete gynecological and urological assess. or a pelvic mass. both in confirm. 1997). The history should focus on the start of Cystoscopy and urine cytology should be symptoms. is no longer required for diagnosis. possible diagnoses. whether there are factors that exacer. place one or two evaluation. is not required to monitoring symptom severity over time. possible occurrence of an inciting performed if indicated. cystoscopy can usually be visual analog scale). Index questionnaires (O’Leary. and urethral studies reveal that healthy women with no diverticula. and guishing PBS from other urinary complaints or potassium sensitivity testing. thought to be pathognomonic of PBS. Women with PBS often exhibit tion. especially if there is concern niques that are useful in reducing her frequency about underlying pathology. behavioral tech. In addi- be performed. which was found to have a high ically and in research settings for diagnosing sensitivity and specificity for identifying women and monitoring PBS. bladder capacity. including the health bladder glomerulations. tion of treatment. Urgency. the The diagnosis of PBS is based on the presence woman should note a feeling of pressure during of characteristic symptoms and the exclusion of this examination. If dietary triggers are suspected. it is reasonable to perform a pelvic ultra- be used to educate the woman about bladder sound or examination under anesthesia (often retraining and fluid titration. particu- the bimanual exam usually elicits pain. The diary should include the In some women. such as ment of pelvic structures. In addition. a There is interest in finding a urinary bio- food and drink diary can help to narrow down marker that could be useful in the diagnosis the list of possible triggers. experts diagnose PBS (Hanno. In the past. further study is needed Pain. 2006). whether symptoms are chronic or inter. thigh muscles. factor (APF). bladder base. urodynamics A 24-​hour voiding diary can help to quan. larly cystoscopy with hydrodistension. Although . 1998). and in women with PBS (Denson. based upon physical event. Examples include the with PBS. assessment for bladder volume under anesthesia. similar disorders. Normally. as well as a rectal exam. copy with hydrodistension. In addition. urethra. and decreased of external and vaginal tissues. pelvic masses. including cystos- these questionnaires might be useful for distin. also performed as needed. of PBS. One such biomarker is antiproliferative Standardized questionnaires are used clin. fingers inside the vagina and apply pressure to the posterior and lateral vaginal walls while gen- DIAGNO SIS tly pulling towards the introitus. In this volume for all fluid intake. performed in the office. However. vaginal discharge. costs. low back. such as urinary tract cancer Laboratory tests should include a urinalysis and or stones. 2000). In addition. Vaginal and cervical cultures are retention. overactive bladder. 2011). In women with PBS. infection. However. these findings are not consistently present tenderness of abdominal. urinary urine culture. and urethra during recommend and perform these tests. A  medical history and often moderate to severe pain with palpation of physical exam are important. ulcers. Although cystoscopy mittent. This information can case. it is import- bate or alleviate symptoms. rectum. bladder biopsy. While Further diagnostic testing. 2011). symptoms of painful bladder symptom can also a complete musculoskeletal assessment should have these findings (Waxman. hip. This pain may refer to the blad- ing the diagnosis of PBS and in ruling out other der. and the symptom ant to eliminate other bladder pathology and severity (using a 0–​ 10 Likert-​style scale or a sources of irritation. it is not possible to com- time and volume of each void and the time and plete an internal pelvic exam due to pain. 2008). the pelvic floor. and limits to this the O’Leary-​Sant Symptom Index and Problem approach (Forrest. many physicians continue to floor muscles. findings and risk factors. with cystoscopy).

an elimination diet. beverages. the required motivation to follow this program. As the evidence for Activity restrictions are recommended only many of these therapies is lacking. 1993). symptom flare. If nocturia is a problem. 2011). subjective bladder filling. we recommend that women drink cal therapy should be performed by a therapist four to six ounces per hour throughout the day. 2001). 2005). the patient becomes more comfortable. we recommend that women identify period of weeks. a also be used to reduce exacerbations of symp- woman will need to try several therapies to find toms (Rothrock. This type of regimen can be used as a general T R E AT M E N T guideline for patients even if they cannot strictly Treatment for PBS aims to decrease pain and adhere to the schedule. urinary symptoms. procedure. treatment to modify the dysfunctional pelvic An important adjunct to bladder retraining floor musculature that contributes to bladder is fluid titration. might provide some symptom relief (Clemens. 2001). Dubin. Obstacles to adherence general anesthesia or sedation. 2008). their disor. 2010). 2009). imagery techniques can improve symptoms der. we recommend about 50% of women (Ottem. This technique moderates the and pelvic pain (Weiss. Although randomized trials are still rience. Stress-​management techniques can of treatments for all women. Women who are able to follow this regimen often have Physical Therapy an improvement in urgency and frequency Physical therapy (PT) for PBS is an important (Chalken. Exacerbating foods can be identified with (3–​5 hours) and decrease urgency. and avoid items that are a trigger to their symp- ing is to restore a normal voiding interval toms. 2011). as well as patient lacking. most commonly prescribed class of medications Ice or heat applied to painful areas such as the for this disorder (Anger. recognition and avoidance of pain triggers. the procedure is usually performed under hours before bedtime. We do not recommend eliminat- niques are used to delay urges until the appro. Clinical frequently to avoid the pain associated with studies are limited to retrospective. Fitzgerald. 2011). ularly scheduled intervals during the day and 2006. Pelvic floor physi- are few data. and treatment options (Hanno. will also give patients a sense of control over cial support. 2011. The goal of bladder retrain. exercise seems to improve chronic pain preference. in patients (Fuentes. There (Carrico. while foods with alkalinizing agents Bladder retraining involves voiding at reg. milk on cereal. Intervals are slowly increased as registered dietitian (Friedlander. Distraction tech. Making changes in voiding and reports (Shorter. Initial void. 2012). treatment for patients with PBS is education There are also some data to suggest that guided-​ regarding normal bladder function. increasing the include patients’ work or activity schedule and costs and risks. Bologna. Painful Bladder Syndrome and Interstitial Cystitis 67 some women have relief of symptoms after this This includes all fluids (e.g. This medications. The treatment should include Other behavior modifications include the a combination of pelvic floor physical therapy. treatment is if an activity is a trigger of pain or worsening often guided by physician preference and expe. woman’s fluid intake so that she drinks small It is considered a second-​line treatment by the amounts throughout the day rather than larger American Urological Association after behavioral amounts at infrequent intervals. and psychoso. or supplements can trig- Many women with PBS empty their bladder ger or exacerbate symptoms of PBS. the one(s) that works best. behavior changes. anecdotal evidence. Although the evidence slowly increasing the voiding interval over a is limited. Unfortunately. 2007). der pain.. or avoiding it only during a current voiding frequency. The first-​line bladder or perineum can sometimes be helpful. Studies suggest that drinking behaviors can help relieve symptoms of foods high in citric acid can exacerbate blad- urinary urgency and frequency. narcotics are the their disease. This might mean avoiding ing intervals are chosen based on a woman’s the item completely. There is widespread belief that particu- Behavior Modification lar foods. Although there modifications (Hanno. In addi. Stress is a common trigger for is no single “best” treatment or combination PBS flares. In many cases. 2001. who is experienced with myofascial and other . it is short-​lived and only occurs in soup). which can help empower them. ing entire food groups without guidance from a priate interval. symptoms. that the woman stop drinking three to four tion.

Treatment is done in a private room with side effects such as drowsiness. SNRIs are a chemical neuromodulators. 2008). were found to relieve pain in some people with ment. 2012). connective tissue restric. PT was small (Dimitrakov. especially women who can- symptoms are severe enough to preclude wait. medication approved by the US Food and Drug tic modalities. In our practice. than 50 mg per day (Foster. 2008). . (SNRIs) were developed to treat depression but ations such as insurance coverage. urgency. and frequency. The standard dose is anecdotal evidence that the activation of mast 100 mg three times per day on an empty stom. to begin therapy can impede treatment. anticholinergics. Starting at the lowest possible dose sions with home exercises and stretches. Treatment with PPS is support the efficacy of hydroxyzine (Sant. it is not clear if other antidepressants pines. macromolecule that is believed to repair injured often in combination with PPS. Myofascial physical recommended for six months before deciding if therapy has been shown to be more efficacious the drug is effective. The therapist works on the abdomen. The therapy should In clinical studies. are approved to treat pain. and the patient in the dorsal lithotomy position. especially when taken at doses greater pelvic floor muscles (transvaginally or transrec. would provide a similar benefit. while milnacip- Oral medications used to treat PBS include pen. duloxetine is approved to treat physical Medications pain associated with depression. Depending upon the duration Antidepressants and severity of symptoms. although some providers recommend. we include medications when have chronic pain. Clinical trials have failed to 200 mg twice per day. This is based on areas of the GAG layer. alone (Davis. sometimes in combination with oral PPS be used as the primary treatment modality for (Davis. trigger points. time commit. changes. and to desensitize hypersensitive areas. tosan polysulfate sodium (PPS). However. and long wait times chronic pain. Logistical consider. We often recommend medications Starting with a low dose and increasing slowly in conjunction with both PT and behavioral can help minimize side effects. Clinical studies 2001). show that amitriptyline can provide modest pain hips. to take effect. 2014). Two of the drugs in this category. Dosing for intravesical PPS Pelvic floor physical therapy is usually done is discussed below (see “Intravesical Therapies”). in one-​hour sessions once or twice per week for at least 10 weeks. However. symptoms of PBS. 2007). as many women with severe PBS Administration (FDA) for the treatment of PBS will need a combination of treatments to achieve (Rourke. other anticholinergic side effects can be limiting Therapists will often supplement treatment ses. cells (as with seasonal allergies) can exacerbate ach. duloxetine and milnacipran. depending on symptom severity and patient preference. geographic distance. thighs. it is reasonable to discontinue. placebo in relieving symptoms of pain. tricyclic antidepressant for PBS. It is the only oral is best used in conjunction with other therapeu. one year or more of Amitriptyline is the most commonly prescribed weekly treatment may be required (Kotarinos. benzodiaze. groin. PPS was more effective than aim to release tight. perceived intrusive nature of PT and occasional Serotonin-​norepinephrine reuptake inhibitors pain flares with therapy. tally). the margin of benefit tions. tender pelvic floor muscles. Side effects ing for the benefits of PT or behavioral changes of SNRIs can include nausea and drowsiness. reasonable option for women with PBS who In our practice. Patient and increasing slowly will help some women acceptance is high (Fitzgerald. not tolerate other treatment options. lower back. dizziness. PT can also 2013). 2003). frequently used treatment for PBS. the best response. If no improvement is seen than global massage for the treatment of women at six months. and internal relief. Antihistamines and H-​2 Receptor Antagonists Pentosan Polysulfate Sodium (PPS) Medications such as cimetidine or hydroxyzine Pentosan polysulfate sodium is a heparin-​ like are widely prescribed for treatment of PBS. scarring. at this dose. However. 2010). ran is approved to treat the pain of fibromyalgia. A  combination of oral and intra- women who do not wish to take medications or vesical PPS appears more effective than oral PPS try more invasive approaches. 2009)  despite the adjust to these side effects. with PBS (FitzGerald. and antidepressants. skeletal muscle relaxants.68 Pelvic Pain Management manual-​ release techniques. PT is the most PPS can also be given intravesically (Offiah.

as tolerated. and difficulty thinking. once-​daily dose (usually at bedtime) and lorazepam can be useful for pain management slowly titrated up to three times per day over among PBS patients. This allows the medication to be given by as a preventive treatment. sometimes in combination with heparin cations are recommended in combination with or PPS. It is important to discuss the addic. medications targeted specifically for patients constipation. etal muscle relaxants (Leite. blurred vision. The most com- symptoms. at least temporar- Neuromodulators ily (Nickel. In addition. Painful Bladder Syndrome and Interstitial Cystitis 69 therefore we do not recommend it. patients should term benefit. this does not preclude trying the other. Benzodiazepines Gabapentin or pregabalin should be started at Medications such as diazepam. darafenacin. Thilagarajah. and a low. 2010). anism of action for relieving pain is unclear. 1994. such anxiety. In women with chronic pain. 2009). given the mini- Anticholinergic Medications mal efficacy of current oral treatments. 2003. dosing frequency. In clinical . More research is needed on the efficacy of other with the most common including dry mouth. Recent literature examining injections solafenicin. Lee. These medications are simi. may effective. 2001. of Adalimumab compared to placebo among and fesoterodine. there are inadequate data to support can help obviate the need for narcotics or other long-​term use of either benzodiazepines or skel. changes in cognition. Intravesical Treatments In women with PBS with urinary urge incon. However. If one drug is not ants. Their mech- studies have examined the benefit of cimetidine. We reserve the use of a single provider in a controlled fashion to avoid these medications for severe cases to ease pain potential abuse. 2014). skeletal muscle relax. clonazepam. 2009). caine. daily pain. Similarly. potentially addictive mediations. as in a flare. but vary in cost. and found to be significantly better at reducing quency. vesical treatments reveal that they are effective in reducing pain and urgency. Intravesical treatments for PBS are instilled by tinence or significant urgency or frequency catheter directly into the bladder. Increased sleep has shown to help lessen PBS symptoms Upcoming Medications (Nickel. New medications are being examined to see if they can help patients with PBS. and change between the two groups (Bosch. trospium. and nocturia. Finding an effective neuromodulating medication However. the muscle relaxant properties of benzo. Parsons. instructed to hold the solution in the bladder for tin and pregabalin are anticonvulsants that are as long as possible (at least 30 minutes). 2014). anticholinergic medications are a monly used treatment includes alkalinized lido- reasonable option to consider. not clinic. Pregabalin can also cause periph- muscle spasms. tolterodine. The patient is Neuromodulating medications such as gabapen. women with PBS demonstrated no significant lar in efficacy. data regarding their use with PBS are limited 2001). Examples of commonly pain at up to three months of treatment (Chen. and an H-​2 antagonist (Seshadri. Clinical studies of lidocaine-​based intra- anticholinergic treatment. such as cyclobenzaprine and baclofen. heartburn. have a limited role in the treatment of PBS. 2005). as drowsiness. prescribed anticholinergics include oxybutynin. The studies found that cimetidine reduced (Sasaki. anecdotal experience supports their use. In our practice. Side effects can be significant. espe- cially in women with chronic. Several small also used to treat neuropathic pain. narcotic pain tive nature of these medications with patients medications are recommended on a limited to ensure that they are willing to follow dosing basis due to their addictive nature and short-​ instructions closely. eral edema and weight gain. and with PBS. Side effects. Phatak. Sildenafil Anticholinergic medications are often used was compared to placebo in 48 women with PBS to address symptoms of urinary urgency. symptoms among refractory patients. Treatment is started at a low dose once or Narcotics twice per day. side effects. dizziness. Behavior modifi. symptoms and to allow better sleep. 2009. fre. we refer patients be prescribed these medications only when who require narcotics to a pain-​ management severe symptoms are present. There are no data on the effect of this class of medication on PBS/​IC. diazepines can provide relief of pain related to can be limiting. While traditionally used for three to four weeks.

return to the office if there are pain flares. 2010). Although there were varied methods. including resiniferatoxin. with BTX-​ A injections. nary tract infection. who benefit can be taught to perform this treat. risks as well. ment lasted from 5–​12  months in most patients caine. therefore decreasing However. large-​scale studies sup. studies have yet to support the ben- muscle contractility at the injection site. clinical experience reveals that it can pain. BTX-​ efit of PTNS for women with PBS (Zhao. spasticity.000 units of heparin. A to the bladder trigone were shown to have arin. 2009). there does appear to be a trend towards benefit One combination of a lidocaine-​ based of treatment over placebo. hematuria. urgency can be reduced for hours to days. and quality-​ of-​ life indicators. Adverse effects of BTX-​A are usually tem- vesical heparin treatment before improvement is porary and can include dysuria. This is thought to decrease the BTX-​A in the pelvic floor and levator muscles sensitivity of the bladder to irritating substances rather than into the bladder with good success in the urine. 2009). ing a pacemaker-​like device into the hip. and is given at a dose of. In a prospective trial of women sodium bicarbonate (to reach a total volume of suffering from PBS. and the Other intravesical treatments have been need for intermittent self-​catheterization (ISC). benefit in strengthening the bladder surface Recent studies have also looked at the use of mucin barrier. Patients should be warned about these fore. popula- ment at home one to three times per week. this potential improvement. patients with refrac- Intravesical heparin is given for its proposed tory PBS/​IC may benefit from BTX-​A injections.70 Pelvic Pain Management practice. However. The needle is (Hanno. 2008). We are currently conducting a porting the benefit of heparin are lacking. therefore. In randomized controlled trial of BTX-​A for pelvic addition. Patients voided volume. multiple injections of BTX-​ 15 mL). The treatment involves implant- (Smith. and effects on the afferent pathways in the bladder urge incontinence. 40. Reported improve- intravesical treatment includes. 2013). and outcome measures in these studies. take months to greater than one year of intra. and 8. including PBS. Botulinum toxin A (BTX-​A) acts as a neurotoxin PTNS was initially designed to treat over- that inhibits the release of acetylcholine at the active bladder and urinary urge incontinence. including respiratory dence to support its use and can cause pain distress and even death. BCG is associated Percutaneous posterior tibial nerve stimulation with no significant efficacy compared to pla. 200 mg (two improved pain symptoms from baseline with 100 mg capsules) mixed with 30 mL buffered minimal complications (Pinto. Oxybutynin instillations have been shown to improve bladder capacity Percutaneous Posterior Tibial and the number of urgency episodes and may Nerve Stimulation be helpful (Offiah. 2013). (Adelewo. It has Sacral neurostimulation is an FDA-​approved treat- been suggested that BTX-​A has anti-​nociceptive ment for symptoms of frequency. Currently it is has been approved by the FDA for the treatment of overactive Sacral Neurostimulation bladder but not for any pain syndrome.  2011). urgency. voiding difficulty. neuromuscular junction. Resiniferatoxin have been reports of rare systemic reactions is a capsaicin analogue that has equivocal evi. PPS is sometimes substituted for hep. there treatments. 2004 A is injected cystoscopically into the bladder at and. which . mostly in children with during instillation (Dawson. There Guérin (BCG). and oxybutynin. not all women benefit from intravesical In a majority of studies of BTX-​ A. it should not be used the skin near the medial malleolus. there. which has not been shown to be more effective than pla. 2013).  2008). with a tions. connected to an electric stimulator to stimulate the posterior tibial nerve during a 30-​minute ses- Botulinum Toxin A sion that is repeated once weekly for 12 weeks. In women who do benefit. pain and were noted improvements in frequency. uri- noted (Moldwin. used to treat PBS. PROCEDURES cebo (Dawson. multiple sites. Based on saline (Davis. 200 mg lido. 2004). 2007). Patients must understand the risk of urinary dimethyl sulfoxide (DMSO). there are limited data on DMSO.4% of (Anger. (PTNS) is a procedure that involves placing a cebo and can have potentially life-​threatening needle (typically an acupuncture needle) through complications. Bacillus Calmette-​ retention and be willing to perform ISC. Similarly. we do not recommend its use. pain.

sev- eral clinical studies have noted that women with • National Institute of Diabetes and PBS have a higher incidence of depression and Digestive and Kidney Diseases (http://​ . Psychosocial support is available from a ing afferent nerve pathways at S3 site (Wyndaele. As noted. minimally invasive basis. L-​arginine. (Whitmore. Cystoprotek. Because of the dearth of evi. refrac. 1987) options (Walters. 2007). If anxiety or depression is suspected. (such as quercetin). the following websites: tory of physical or sexual abuse. ing websites: bination of factors leaves many women feeling frustrated. It is thought to work by stimulat. appeals to many women with PBS due to its tory symptoms. The patient can control the device with a handheld Peters. • Exercise and yoga (Ripoll. assess the potential benefit of treatment on a Examples of CAM used for PBS include the temporary. CAM reasonable option in women with severe. device problems. support groups and social workers or psycho- stimulation include pain. number of resources. Painful Bladder Syndrome and Interstitial Cystitis 71 sends mild electrical impulses to the sacral nerves. For this rea. and unable to find • Interstitial Cystitis Network (www. This includes online support their symptoms. evidence supporting the benefit of As with BTX-​A. PAT I E N T R E S O U R C E S Women with PBS often see multiple healthcare There are a number of resources available for providers in an attempt to find the source of women with PBS. and Cysta-​Q and do not guarantee pain relief.com) questions or a validated questionnaire (such as the Beck’s Depression Inventory II). (Moldwin. 2004). ileocystoplasty. therapists. past sexual or physical abuse (Goldstein. either with informal ichelp. 2002) and urinary diversion. However. ation and treatment. These treatment options • Proprietary herbal blends include carry high morbidity given their invasive nature. sacral neurostimulation is a most CAM treatment is lacking. These mucopolysaccharides. be screened for depression. when conservative management fails. transure. network. and the device can be removed. Psychosocial Support The value of psychosocial support for women with chronic pain should not be underestimated. programmer. safe. The data regarding the efficacy of this Complementary and Alternative treatment modality for PBS are limited but some. 2008. including local and online 2000).ic-​ relief from their pain. such as Several surgical options exist as a last resort calcium glycerophosphate. 2007). Potential adverse effects of sacral neuro. Karper. The use of test stimulation prior perception as being natural. Medicine (CAM) Treatment what promising. of PBS. clinical dence supporting best practices in the treatment studies. and under the to permanent implantation allows patients to woman’s control. many physicians are unsure how to Online support is available from the follow- identify and manage these women. infection. and information. The treat. and Chinese herbs thral resection of the bladder. Women Reliable sources of information is available from should also be questioned about any past his. 2002. 2011). The battery must be replaced approximately every five years. As with some traditional patients with PBS (Marcelissen. local support groups. following: Surgical Procedures • Herbs and nutraceuticals.com) All women being evaluated for PBS should • Interstitial Cystitis Association (www. treatments. skin irritation. all other conservative options should be • Guided imagery (Carrico. This com. the woman should be referred for further evalu- ment is reversible. Larger prospective trials are There are a wide variety of complementary and needed before definitive conclusions can be made alternative medicine (CAM) treatments adver- regarding the use of sacral neuromodulation for tised to treat PBS. Algonot. 2007) son. and lead movement. bioflavonoids include ablation of Hunner’s lesions. and books. 2008) exhausted prior to proceeding with one of these • Acupuncture (Rapkin. misunderstood.

The standardisation of terminology of ings in patients with suspected interstitial cystitis. (www. Standardisation Sub-​committee of the International Dimitrakov J. • A Headache in the Pelvis: A New duration. Abrams P. The effi- • The Interstitial Cystitis Survival cacy of calcium glycerophosphate in the preven- Guide: Your Guide to the Latest Treatment tion of food-​related flares in interstitial cystitis. of depression. Cardozo L. Kosloff L. and develop coping skills. Griebling TL. J Urol.36(7):1032–​1039. 2008 Jan–​Feb. J Urol.gov/​ intravesical botulinum toxin for idiopathic over- active bladder symptoms:  a systematic review of Books about PBS: the literature.84:51–​56. Predictors of symptom severity in patients with ized based on the patient’s symptoms and response chronic prostatitis and interstitial cystitis.57:119–​120. double-​blind. Aloisi AM.164:1908. Guthrie D.149(6):1445. treatment options.175:963–​966. Standardization Denson MA. for women with interstitial cystitis: results of a pro- yet remains under diagnosed and undertreated. Outcomes of • http://​clinicaltrials. J Urol. A  high index of suspicion should be for the treatment of refractory interstitial cystitis. Blaivas ST. J maintained when seeing women with persistent Urol. 2010. Multidisciplinary care is often needed randomized double-​ blind clinical trial.49(5A Suppl):52–​57. and cost in patients with interstitial cysti- Understanding and Treatment for tis and painful bladder syndrome. Syndromes. identified and treated or avoided as necessary. A randomized. Carrico DJ. with medications. poten. Triggers should be titis:  results of a randomized. Painful bladder syndrome is a debilitating. J Altern Research into the etiology and pathophysiol. Calhoun EA. Chen W. Brown SO.niddk. Blaivas JG. Peters KM. spective. 1993 Jun. et al. Hanno interstitialcystitis/​) PM. Cochrane REFERENCES Database Syst Rev. J Urol. ogy of PBS may help better determine treatment Chaiken DC. but they often need to be combined Clemens JQ. such as Davis EL. Fall M. Slade D. Prostatitis and Chronic Pelvic Pain 2011. Clemens JQ. 1997 May. 2007 Oct 17. Anger JT. Genetics and phenotyping of Continence Society. Behavioral therapy approaches. Suttorp MJ. Talbott EO.179(1):177–​185. randomized controlled pilot study. Diokno AC. Dawson TE.183:2258.(4):CD006113. Additional testing will Chen H. Int Urogynecol J. Interstitial cystitis:  unexplained associations • National Association for Continence with other chronic disease and pain syndromes. to intervention as well as her comfort level with 2006. Intravesical treatments for pain- ful bladder syndrome/​interstitial cystitis. physical therapy and behavioral cystitis/​painful bladder syndrome with low dose modification is the first line of treatment used by sildenafil. may be reserved for efficacy of the use of intravesical and oral pen- refractory patients that fail initial management tosan polysulfate sodium for interstitial cystitis: a approaches.22:395–​400.191:77–​82. 2000. 2014. Weinberg A. Neurourol Urodyn. et  al.72 Pelvic Pain Management kidney. 2011 Aug. 2009. Merlo L.nafc. Options and Coping Strategies by Robert Urology. Efficacy of daily low-​ dose sildenafil for treating interstitial cys- exclude underlying pathology. Chottiner S. J Urol. double-​ blind. placebo-​controlled trial—​treatment of interstitial Currently. et al. Moldwin Bosch PC. urgency. Gomelsky A. lower urinary tract function:  report from the J Urol. or pain. M. Cohen MB. Guided imagery tially chronic condition that affects many women. Anger JT. 167–​178. Chronic pain For information about participating in a clinical therapy and hypothalamic-​pituitary-​adrenal axis trial: impairment.nih.14(1):53–​60. El Khoudary SL. Complement Med. Lukban JC. et  al. frequency. Jamison J.21(2): urological chronic pelvic pain syndrome. placebo con- trolled trial of adalimumab for interstitial cystitis/​ S U M M A RY bladder pain syndrome. Wang F. Treatment must be individual. Buonocore M. Sub-​ committee of the International Continence Comparison of cystoscopic and histological find- Society. . 2011.gov/​kudiseases/​pubs/​ Alagiri M. et al. Urology. Newer modalities. Zabihi N. provide treatment 2008. Kreder KJ. et al. Ratner V. Treatment choice.org) Urology.181:1550. Psychoneuroendocrinology. David Wise Bologna RA. Safety and Botox and neuromodulation. 2014. 2002. our practice. to address all patient symptoms.

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Differences will be pointed out where relevant. To diagnose FAP in adults. this chapter will refer to three months. or noc- used tool for diagnosis of any of the multiple turnal pain causing sleep disturbance. food allergies or intolerances. While a thorough history and pain complaints that are worked up by the phy. K A R I N A G R I T S E N K O . As in any condition. for simplicity. once other hood functional abdominal pain (CFAP) and organic conditions have been ruled out. than six months prior to diagnosis: tional abdominal pain syndromes. • Continuous or nearly continuous abdominal pain DIAGNO SIS • No relationship or only occasional rela- There is a multitude of conditions that present tionship of pain with physiological events with the chief complaint of abdominal pain. functional gastrointestinal disorders (FGID) in Historically. As an example. inal pain (FAP) is a functional gastrointestinal Thus. physical exam are always indicated. The term “functional dis.g. the childhood functional abdominal pain syndrome diagnosis of FAP is made using the Rome III (CFAPS). laboratory with Crohn’s disease who will have abdominal studies. the dis.5 functional gastrointestinal (GI) disorders. or menses) . but otherwise has ities. diagnosis of exclusion. and imaging studies. or an abdominal wall agement of FAP take place in the pediatric pop. other medical conditions. pain even when they are in clinical remission. many physi- sician often yield inconclusive or normal results. care should be taken to perform a thorough his- Technically speaking. many abdominal abdominal pain.2 Unfortunately. some patients who have been previously in adults and children. 9 Functional Abdominal Pain Syndrome J A S O N L I T T. chapter will focus primarily on childhood FAP. (FAPS) in adults and differentiate between child. eating.. cians will choose to forgo more invasive tests like leaving the patient and parents frustrated.1 The colonoscopies and endoscopies in the absence of Rome III Diagnostic Criteria for Functional alarming symptoms like rapid and unintentional Gastrointestinal Disorders is the most widely weight loss. of both Crohn’s disease and FAP. with symptom onset being greater FAP as a blanket diagnosis for any of the func. chronic abdominal wall pain. A N D Y U RY K H E L E M S K Y A bdominal pain is one of the most com- mon complaints in both adult and pedi- atric patients.4 On the other While the Rome III criteria describe FAP hand. this with other comorbidities. In both adults and children. FAP has been thought of as a adults and children. in up to 65% of children with entrapment syndrome that is causing their pain. Functional abdom. there is a subset of patients unremarkable physical exam findings. As the research for the causes and criteria. it is also possi- order” is used to describe conditions in which ble to have FAP with other abdominal comorbid- the patient is symptomatic.3 Accordingly. pain syndrome such as anterior cutaneous nerve ulation. the majority of current diagnosed with FAP later find out they have research and evidence on the causes and man. and drug reactions are just a few of many median prevalence rate of 12% in children aged diagnoses that are in the differential diagnosis for 2–​18  years. celiac disease. however. FAP can occur as an isolated disorder or order continues into adulthood. defecation. Clearly. all of the management for all these diagnoses is largely following criteria must be present for the last the same. (e. Moreover. bloody bowel movements.1 Chronic abdominal pain has a Inflammatory bowel disease. the Rome III criteria tory and physical to elucidate if FAP is the most identify functional abdominal pain syndrome likely cause of abdominal pain. they are considered to carry diagnoses disorder that can occur in adults and children.

also social stigma of obesity. when look- ing at studies comparing children with FAP to To diagnose CFAP. lesbian. there are notable psychophys- present at least once per week for at least two iological differences in the response to stressful months prior to diagnosis: stimuli. as there is no evidence of somatic more common in children who undergo abdomi. and the vast majority of patients will associated with psychophysiological alterations make changes to their eating habits based on . For example. the sympathetic and parasympathetic functions ment of FAP. both parents and patients per- surgery and FAP is incompletely understood. it is not surprising that.11 nal surgeries in infancy.7 Also. reviewed journal articles about children between metabolic.8 orders than normal-​weight children do. Nevertheless. Determining how auto- is experienced by the child. some weight children were found to have at least one studies have shown that surgeries without bowel FGID. In a systematic literature review of peer-​ • No evidence of an inflammatory.10. that system dysregulation. research. almost half of the obese and over- tion and resulting visceral hypersensitivity. or bisexual have been opment or progression of FAP will take further found to have a higher prevalence of FAP. Of note. hyper­sensitivity.9 ceive that diet plays a significant role in FAP It is has been shown that chronic stress is symptoms. heart rate variability (HRV) as a reflection of and social factors that contribute to the develop. have been shown to be is visceral. Some studies looked at or difficulty sleeping. like an umbilical hernia repair. and other unknown biophysiological suggests that the physical stress of surgery.6 children with chronic abdominal pain had a significant lag time in pupillary reaction. chronic abdominal pain. other. the condition is referred the pupillary reflex as a reflection of the para- to as childhood functional abdominal pain syn. This indicates that there is probably a degree of autonomic dysregulation and hyper- • Episodic or continuous abdominal pain sensitivity in children with FAP in response to • Insufficient criteria for other FGIDs stress. similar. For instance. In many of is severe enough to interfere with daily function. The research points to stress from the manipulation. it does appear that Looking at the biopsychosocial factors thought there is an association between chronic abdom- to impact the development of FAP. studies looking at Studies have examined psychological. infants who Obese and overweight children have a higher undergo abdominal surgery for pyloric stenosis prevalence of FAP and other functional GI dis- are four times as likely to have FAP in childhood. there is often a inal pain (as in FAP) and autonomic nervous degree of stress. either emotional or physical. anatomical. While it is likely that some or all have found mixed results as to the likelihood of of these factors exert different degrees of influ. Functional Abdominal Pain Syndrome 77 • Some loss of daily functioning in the autonomic nervous system and endo- • Malingering is not present crine system. in C AU S E S addition to an unstable pupillary recovery pat- The cause of FAP is undoubtedly multifactorial. might contribute causes. the observed hypersensitivity FGIDs. including FAP. sympathetic nervous system and found that drome (CFAPS). youths nomic dysregulation contributes to the devel- who identify as gay. and/​or is associated with noted between healthy children and those with somatic symptoms such as headache. there were significant differences ing 25% of the time. of 4 and 18. the studies. a heightened inflamma- increase the likelihood of FAP. the bulk of existing research focuses on While many of these studies are pilot studies and the psychological nature of this pain disorder.12 to FAP. the correlation seen between Interestingly. While some have hypothesized that this increased in one study of 450 children between the ages risk of FAP is secondary to bowel manipula. not without their limitations. limb pain. autonomic dysregulation in children with FAP. ence. biological. these criteria must all be healthy children. This observation tory state. and the factors present in heavy children as possible inflammatory state that ensues. Since children with FAP and other • Insufficient symptoms to meet criteria for FGIDs experience chronic stress secondary to other FGID their pain. In fact. However. there the symptoms were many studies that looked at the autonomic nervous system in children with chronic abdom- When CFAP occurs and the abdominal pain inal pain versus healthy children. tern. or neoplastic process that explains the ages of 4 and 18 with abdominal pain.

21 ment in FAP. Randomized controlled trials have primarily the risks and benefits of adding an antidepres- looked at two psychological therapies in regard sant to the therapeutic strategy for treating FAP to FAP:  cognitive behavioral therapy (CBT) and should be weighed based on the patient’s symp- hypnosis. gluten. there is still work that needs difference in therapeutic response. to that. In many of these instances.17 deficiencies like scurvy.1. in one retrospective study that looked Accordingly. placebo-​controlled. namely amitriptyline. have been used in treating patients with FAP. extreme care be helpful in reducing symptoms by as much as must be taken to ensure healthy eating habits. patient education While it is not a common occurrence. and dietary alterations in line with supported by the latter study. In fact. specifically patient pain. after four weeks of placebo or amitripty- Clearly. should be continued throughout the course of even when a food allergy or intolerance exists.16 Due to the appar. Furthermore. nutritional counseling by a pediatrician. Thus. are known FAP is not only a condition seen in the to have antinociceptive properties below the United States.13 In severe cases. it is clear that a common culprits that people with FAP will try key component to management of FAP is coun. shown that reported food allergies and intoler- it is imperative that psychological intervention ances are much higher than their actual preva- be started as soon as FAP is suspected. other modes of counseling Medicinal and Dietary by a trained professional have been shown to be Interventions equally advantageous. While CBT is successful at treat- ing symptoms of FAP. CBT is an effective intervention considered to assess for a prolonged QT interval that is also the most heavily researched treat. in multiple studies it has been notable improvement in patient symptoms. Milk products. relationship is instrumental in the treatment a screening electrocardiogram (ECG) should be approach to FAP. Nevertheless. double-​ blind.18 In an association between antibiotic use and FAP a multicenter. but has also been shown to be therapeutic range for depression.14 tricyclic antidepressants. Avoiding specific foods. and hypovita- Additionally. to eliminate from their diet to improve their seling. while there are many theories about line. hypnosis has been shown to minosis A have developed. it was found that the food of FAP. when depressants have been utilized for the treatment investigated further. there are limited well-​ researched at 98 pediatric patients with FAP who took a treatment options. While anxiety and depression occur fre- item(s) in question was/​ were not causing the quently with FAP.78 Pelvic Pain Management food associations they perceive as precipitating In addition to psychological counseling. or with a pediatrician. Whether or not the counseling is with a symptoms. and it lence when the patients are tested. anti- their pain.22 Thus.19 Contrary to be done to elucidate the underlying causes. illness for optimal improvement. While many patients will report an psychological professional trained in either CBT improvement of symptoms after these so-​called or hypnosis. some and counseling by an experienced pediatrician patients have symptoms that are exacerbated was shown to be equally efficacious at reducing by eating and will avoid activities that might symptoms in FAP. After one year of treatment.16 toms and degree of debilitation.13 ing factor of the former study is that TCAs often do not show therapeutic benefit until well after Psychological Interventions one month of initiating treatment. it was found that there was no significant what causes FAP.6% of the patients (n  =  77) responded combination of psychological interventions. antidepressants. 60% of patients show significant improvement vomiting after meals. to treatment after an average of 11  months.13 the tricyclic antidepressants (TCAs). removing the culprit food will not always . which usually consist of a TCA.15 randomized trial looking at children with FGID in which abdominal pain was a major compo- MANAGEMENT nent. there is a elimination diets. and fructose are ent success of these treatments. and skipping meals have or recovery after receiving either CBT or regular all been reported. half in children with FAP. Of note. pellagra. trigger a pain attack.20 As medications. For this reason. 78. prevalent with similar rates in other countries. Prior to initiat- A consistent healthcare provider–​ patient ing therapy with the pro-​arrhythmogenic TCAs. in children has never been demonstrated. or other major conduction abnormalities. one potential limit- the biopsychosocial model of care. contrary to what some clinicians believe.

and its efficacy.23 supplement for many GI conditions. but for the fam- Peppermint oil acts as an antispasmodic ily. but the act of eating that triggers the pain weeks and then remain in follow-​up for an addi- attack through the dysfunctional autonomic ner. not just for the patient. Age at diagnosis. increased maternal anxiety is associated with permint oil in children is limited. constipation and gas buildup that can lead to abdominal pain. maintaining quality of life and optimizing func- pared with placebo. On the other hand. Thus it Like peppermint oil. One of the studies likely to have a degree of visceral hypersensi. In regard to When counseling patients on their eat. Risks with but associated somatic and depressive symptoms using peppermint oil are limited. The LGG group had a signif- vous system regulation and resulting visceral icant reduction of frequency and severity of pain hypersensitivity. The will need to be done to determine the true effi- foods that are considered to be potentially help. dition. sug- On the other hand. The parents of children with FAP have a higher domized controlled trials have demonstrated prevalence of anxiety disorders and FGIDs. there is and medication management in order to miti- some evidence that low fiber intake is a risk fac. FAP. as the pain experienced is pain severity do not predict FGID later in life. probiotics are not FDA-​ appears that food allergies and intolerances can regulated. and abdominal to children with FAP.27 . Functional Abdominal Pain Syndrome 79 improve the symptoms. gate the comorbidities associated with FAP and tor for FAP. and probiotics in particular have been a multimodal treatment strategy that includes shown to be promising functional foods for FAP. G OA L S O F   C A R E tation for treating FAP show variable results. patients with FAP are in children aged 5–​16  years. and while some an accurate composition of their bacterial con- patients will report improved symptoms with tents. Despite this. in one two-​ worse outcomes. While the evidence for using pep. Peppermint oil can also population of children with FAP. but studies on fiber supplemen. While the data are controversial. examined 141 children with IBS or FAP over tivity.13 tionality. pepper. in addition to causing bronchospasm in was present in approximately half of the study infants and children.26 More studies to be beneficial for some patients with FAP. the patients had improved symptoms. and is already more school days and have more physician visits widely used for treating symptoms of irrita. it is not the to receive either a placebo or LGG for eight food.13. AND PROGNO SIS One recent double-​blind study of 8–​16-​year-​old While FAP is a frustrating and debilitating con- patients with FAP found that partially hydro. but in excess it are significant predictors. GG (LGG) significantly reduced abdominal pain and as previously noted. and only 10% of probiotic labels give occur in conjunction with FAP. there is evidence from two randomized con- ing habits.13 referred to as “functional foods.11 week double-​ blinded randomized controlled Pediatric patients with FAP have a higher trial. the majority of esophageal reflux disease (GERD). sex. the addition of certain gesting that the benefits of LGG persist beyond supplements or foods to the diet has been shown cessation of its administration. Children with FAP will often miss by relaxing GI smooth muscle. which is thought to play a role in symp. probiotics are becoming elimination diets. the goals of care need to be focused on lyzed guar gum reduced clinical symptoms com. and when reduce esophageal pressure and worsen gastro- placed on a low-​fructose diet. In treating FAP. Perhaps. in these cases. ble bowel syndrome (IBS) after many ran. 16 weeks. Fiber softens the stool and relieves improve the patient’s quality of life.13 both after eight weeks and then at 16 weeks. than children with inflammatory bowel disease. cacy of different strains of bacteria and the effect ful by reducing symptoms in FAP have been each has on a variety of GI symptoms. tional eight weeks. it is important to keep in mind that trolled trials that Lactobacillus rhamnosus strain mastication and digesting stimulate the bowels. psychological intervention. dietary modification.25. 76% of 8–​ 17-​ year-​ old patients with IBS likelihood of FGID and miscellaneous chronic reported improvements in pain severity. the clinician should focus on mint oil.” Fiber. the foods are typically not the widely accepted by physicians and patients as a sole cause of the pain. as well. considered to be of similar etiology.24 Many pain and distress in adolescence and young authors feel that these findings are generalizable adulthood. in can lead to intestinal nephritis and acute renal one study it was found that fructose intolerance failure.11. The children were randomly assigned tomatology.

Wypij D. Child and parent perceived food-​ or depression are more likely to develop FAP.153:1798–​1806. needs to be to a strong healthcare provider–​patient relation- educated. and there is no proven treatment with a dietary or situational triggers is occasionally 100% success rate. 2. Smith Comorbid psychiatric disorders are prevalent CA. Goyal A. relaxation. 2012. Weimer K. Moayyedi P. guided imagery. ages of 8 and 18. yoga. Morgan DG. Inflamm Bowel Dis. dietary modifica. Rosario M. along with his/​her family. Walker LS. Schwille-​Kiuntke J. and an overall lower nia repair increases the rate of functional gas- quality of life.26:738–​744. has been shown to e54702. J Acad Nutr Dietet. de Jager-​Kievit JW. Porcaro F. J Pediatr. FAP is a condition that can last a life. frequency in children with FAP between the 7. Frequent abdom- the treatments should be multimodal. Scheltinga MR. Bruehl S. 2013. and young adulthood. helpful. Shulman RJ. REFERENCES COMORBIDITIES 1. 2013. and as such. and medication. Enck P. perhaps by its known impact on the functional pain in U. 2014. youths with anxiety Chumpitazi BP. these are associated with a worse nal disorders with chronic pain and psychiatric outcome. Carlson MJ.19: medications. through adulthood. Current Issues in the orders is highest if FAP persists into young Management of Pediatric Functional Abdominal Pain. The T H E   F U T U R E   O F   FA P overlap of functional abdominal pain in pediat- Small trials have looked at novel treatments with ric Crohn’s disease. 826–​831. cent patients and will often afflict many of them 2011. population without FAP. FAP is a condition that has a pyloric stenosis have a higher risk of developing profound impact on many children and adoles- chronic abdominal pain in childhood. Sexual orientation and ation. diagnosis of existing comorbidities. depressant and a treatment for chronic pain. Garber J. Bercik P. Of paramount importance in car. Lightdale JR. Aliment are effective at reducing symptom intensity and Pharmacol Ther. Chronic abdominal wall pain mis- a dietary supplement that has efficacy as an anti. Roberts AL. higher risk of anxiety disorders in adolescence Pain. Zimmerman LA. Functional abdominal pain patient subtypes in people with functional pain disorders and. One 5. even if the pain resolves 3. Saps M.32 8. ship. Characteristics of func- doses of SAM-​ e between 200 mg/​ d and 1400 tional bowel disorder patients:  a cross-​sectional mg/​d. Saps M. early psychological intervention and counseling.39:312–​321. Reviews on Recent Clinical Trials. Schlarb AA. possible referral to an experienced psychologist and reassurance. and acupuncture for patients with FAP. Adams PN. but it is still higher than the general 13–​20. While adding medications and addressing time. Gulewitsch MD. 10. study found that patients reported improvement 6. The risk for anxiety dis. Roumen RM. reasonable quality of life. 2014. Romano C. ing for these patients is an understanding that 2013.114:403–​413.2014:524383. In most instances. and the parent education and reassurance is the first step patient. tion. in childhood.16 Childhood FAP is associated with a comorbidities in adolescence and adulthood. Muller J. Early life events:  infants with In summary. including inal pain in childhood and youth:  a systematic psychological intervention. 2014. Austin SB. Ford AC.31 Guided imagery and relax.80 Pelvic Pain Management Expectations need to be managed. decrease pain in FAP. Through effective education. patient/​ Gastroenterol Res Pract. study looked at S-​adenosylmethionine (SAM-​e). Moore CE. RESEARCH AND 4. anxiety. van Assen T. JABFM. young adults: the medi- ating role of childhood abuse. in childhood predict functional gastrointesti- when present.(9)1: adulthood. J Pediatr. trointestinal disorders in children.30 Other studies have found yoga exercises survey using the Rome III criteria. 2014.163:1065–​1068. Sherman AL.159:551–​554 e1. Tsai CM.S. PloS One. Rosen JM. Corliss HL. Bonilla S. Accordingly.28 Additionally. Srinath AI. most people with FAP can have or psychiatrist have been shown to be the most adequate symptom management to maintain a beneficial for reliable long-​term pain relief. Pintos-​ in pain scores over the two months they took Sanchez MI. review of psychophysiological characteristics. diagnosed as functional abdominal pain. FAP is different for every patient. These patients have a higher 9. et  al. Bolino C.29 induced gastrointestinal symptoms and quality of life in children with functional gastrointestinal CURRENT disorders. .8: autonomic nervous system. the cause is often multifactorial. The 2013. Umbilical her- risk of depression.

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by British obste- trician Dr.6 The pudendal nerve is burning perineal pain who all had a history of formed by the ventral rami of the second. aching and P U D E N D A L N E RV E A N D itching at the perineal area. vagina/​ scrotum. vaginismus. or release of the entrapped pudendal nerve may alleviate symptoms. CASTELLANOS P udendal neuralgia is defined as pain in the dermatomal distribution of the puden- dal nerve. Neuralgia Association (tipna. EPIDEMIOLOGY perineum and/​ or rectum. sensory. third. 10 Pudendal Neuralgia MICHAEL HIBNER AND MARIO E. and of assafœtida and valerian combined with the sympathetic fibers. such as vulvodynia. Pudendal neuralgia is one of the main causes of levator ani syndrome. symp. Classically. In this chapter. bladder. All and Disease. but from our personal observations this impingement of the nerve that may be observed condition seems to be much more common. French physiatrist Gerard Amarenco maintaining continence via control of the rectal noticed a group of patients who presented with and urethral sphincters.” carries motor. neuropathic pelvic pain. It then runs on the ventral surface and described pudendal nerve entrapment as a of the piriformis muscle dorsal to the ischiococ- possible cause. Symptoms include pain. It standing. pathic origin is poorly understood and there- Thus.5 Pelvic pain of neuro- therefore has a broad spectrum of presentations. The during surgery. extensive cycling and named it the “cyclist syn. and fourth sacral spinal nerves that join at the drome. The Pudendal “pudendal neuralgia” strictly as a symptom.4 burning in the clitoris/​ penis. The exact prevalence of drome. Roger Robert established level of the cephalad border of the sacrotuber- the diagnostic criteria for pudendal neuralgia3 ous ligament. and it multiple organ systems.000 people have pudendal neu- entrapment.” of the genitals and rectum and is important for In 1987. and sexual function. He described it as A N AT O M Y O F   T H E “very distressing sensations of heat. tingling.000 patients have pudendal neuralgia and The term “pudendal neuralgia” was first used in that approximately 4% of patients with chronic 1882 in the book The Change of Life in Health pelvic pain suffer from this condition.”2 In 2008. may account for up to 15% of all patients and ated with other pelvic pain conditions that affect has a vast differential diagnosis that crosses into the bowel. He also established that surgical cygeus muscle and exits the pelvis through the .” He further reported P E LV I C   F L O O R that this sensation is “worsened by walking and The pudendal nerve.1 Pudendal neuralgia is often associ. prostatodynia.  Edward John Tilt.net) estimates that 1–​5/​ H I S T O RY 10. Evaluation of patients with chronic pelvic pain toms are aggravated with sitting and relieved by is a common practice in gynecological offices. Prof.org) website esti- This definition is in contrast to “pudendal nerve mates that 1/​100. It is responsible for sensation external application of opiates and belladonna. Women at the Decline of Life. derived from the Latin over-​exertion and relieved by internal exhibition word for “shameful. it is frequently confused with diseases fore not commonly recognized by practitioners.” which is defined as compression or ralgia. A  Clinical Treatise of the Diseases these numbers are estimates and have not been of the Ganglionic Nervous System Incidental to described in any properly designed study. we will use the term pudendal neuralgia is unknown. European website Portal for Rare Diseases and Orphan Drugs (orpha. and painful bladder syn.

The inferior rectal nerve then continues within the interligamentous space—​ the space through the ischiorectal fossa to the rectum. divides into its two terminal branches—​ dorsal ament and reenters the pelvis through the lesser clitoral/​penile and perineal nerves (Figure 10. Vasoactive changes leading to erection anywhere along its course. The main trunk of the nerve of the nerve to the dorsal surface of the sacro- enters Alcock’s canal.1). In some patients. The pudendal nerve forms fascia of urogenital diaphragm.1:  Pudendal nerve between sacrospinous a—​ischial tuberosity and sacrotuberous ligaments.8 first branch of the pudendal nerve. joining the nerve just dorsal clitoral nerve accompanies the ischiocav- cephalad to the sacrospinous ligament. From ernosus muscle and runs anteriorly and medially there. it runs Perineal nerves course medially and accompany in the fat of the ischiorectal fossa (Figure 10. the are controlled by parasympathetic cavernous branches may arise separately from the ventral nerves of the clitoris and are not related to the rami. In general. The nerve then wraps the inferior edge of the ischiopubic ramus and around the dorsal surface of the sacrospinous lig. acute nerve canal (Alcock’s canal). Cadaveric dissection of b—​pudendal nerve exiting pudendal (Alcock’s) canal right gluteal region: c—​superficial transverse perineal muscle a—​cut edges of the sacrotuberous ligament d—​bulbospongiosus muscle b—​sacrospinous ligament e—​ischiocavernosus muscle c—​piriformis muscle f—​inferior pubic ramus d—​gluteus muscle g—​perineal branch of the pudendal nerve e—​pudendal nerve h—​dorsal clitoral branch of the pudendal nerve . sciatic foramen. The exit ment. Branching of the continues to the glans providing sensation to the pudendal nerve is highly variable and may occur clitoris. The the internal iliac vessels.2). which is a 3–​ 4  cm pas. the inferior rectal nerve is the pudendal nerve. The first and it even pierces through the sacrospinous liga. nerve may occur in several locations along rospinous ligament.2:  Pudendal nerve exiting the pudendal Medial nerve (Alcock’s) canal. spinous ligament or by the falciform process on sage between the aponeurosis of the obturator the ventral surface of the sacrotuberous liga- internus muscle and the muscle itself. and for a short distance. and within narrow canals. crura of the clitoris on the dorsomedial side and ineal. Pudendal Neuralgia 83 greater sciatic foramen.7 In some cases. per. flexion. the vessels accompany all the branches of between the superior and inferior layers of the the pudendal nerve. Entrapment may occur with the fixation around the anus. It between the sacrospinous and sacrotuberous lig- innervates the external anal sphincter and skin aments. and inferior rectal/​anal. to within the pudendal its course. Cadaveric dissection of the right perineal region: FIGURE 10. entrapment of Alcock’s canal is located in the medial surface of the ischial tuberosity. the superficial transverse perineal muscle to The internal pudendal vein and artery branch off innervate the perineum and labia/​scrotum. The nerve then follows f e a h d c g b e c b d a Cephalad a FIGURE  10. especially in areas of fixation. most common area of the nerve entrapment is ment. entrapment of the pudendal may occur anywhere from cephalad to the sac. It then enters the three branches:  the dorsal clitoral/​ penile. Branching In general.9 When adhesions are absent.

14 Still. or athletic activity.10 The second potential area of of the pudendal nerve at the interligamentous compression is within Alcock’s canal. causing compres. 2. 3. curved retractors. may lead to CAUSES OF PUDENDAL NEURALGIA direct compression of the pudendal nerves and its branches as they travel through Alcock’s canal and muscle fibers. muscle spasms. childbirth. surgery is the most common cause from compression of the nerve within a nar.  Anal intercourse/​use of anal devices the nerve. Pudendal rectal nerve. (3)  direct injury to the nerve the pathway of the trocar from posterior com- from scar tissue. pression of the nerve at the sacrospinous lig- ineal and/​or dorsal nerve and spare the inferior ament by long. vulvar. Through Classically. described mechanisms of pudendal nerve entrap- gence. 5. intercourse. or surgical mate. ment. or caused by some other remains unclear whether traumatic or operative pain condition in the pelvis. since muscle spasms often 4. It is almost always caused by pelvic 8.  Pelvic surgery. and (2)  com- latter area of compression would affect the per.1  of the obturator internus muscle.  Bicycle riding accompany neuropathic pain. Although initially difficult to narrowed by spasms of the obturator internus rationalize. it to pelvic floor injury. Extreme flexion of the hip or sitting lapse. related injuries occur after vaginal deliveries. has been implicated as a cause of puden- can further narrow the space. and/​ or rectal pain that is worse with sitting. dal nerve entrapment.1).2 The narrow seat of the bicycle places vic viscera refer pain to somatic structures via pressure on the perineum. especially for pelvic organ pro- ligaments. scarring sion of the nerve.11 During a vaginal delivery. of pudendal nerve entrapment (Box 10.13 infection. Adhesions space is often found during pudendal decom- may form within the canal. and (4)  biochemical injury from disease or direct injury. One of the most vaginal deliveries predispose patients to devel- common diseases in women that cause pelvic oping pudendal nerve entrapment. The nerve via the pudendal artery. Other areas of potential compression the nerve may be:  (1)  secondary to retroperito- that are (infrequently) encountered are at the neal bleeding during ligation of uterine artery level of the pyriformis muscle and medial to the that extends along the course of the pudendal ischial tuberosity at the ischiopubic ramus. nerve may be stretched or compressed at the sentation very similar to that of pudendal neu. the pudendal Pelvic floor muscle spasms often have a pre.  Pelvic trauma Certainly. nerve entrapment may also occur after mesh kit placement for repair of vaginal compartment ETIOLOGY defects (see below “Special Considerations”). There are four main mechanisms that may give In this case. psychological. row canal formed by the close proximity of the Hysterectomy.  Excessive masturbation trauma from events such as surgery. level of the ischial spines by the infant’s head. Constipation from mechanical injury or compression of 7. ligaments. the nerve may be pierced or com- rise to pudendal neuralgia: (1) pelvic floor mus. This compression may 1. .84 Pelvic Pain Management may be caused by stretching of the nerve from sitting. the (2)  pelvic floor muscle spasms causing nerve inferior rectal nerve runs in close proximity to compression. In addition. In these patients.12 These muscle Pudendal nerve latency tests have shown that spasms may be idiopathic. especially spasms BOX 10. pressed by the mesh exiting on the posterior cle spasms without true pudendal neuropathy. cycling is one of the better-​ phenomena called “visceral-​ somatic conver. In our acute flexion at the sacrospinous ligament or experience. partment repair mesh kits and is susceptible to rial. These painful muscles lead to vaginal. floor muscle spasms is endometriosis. especially with use of mesh lead to pain from physical activity and sitting. side of sacrospinous ligament. Childbirth gia from neuralgia.1. it is very difficult to distinguish myal. ralgia from nerve compression. the likely mechanisms of scarring of muscle.” endometriosis implants located on pel.  Prolonged sitting Pudendal nerve entrapment (PNE) occurs 6. or the canal may be pression surgery. leading to repetitive afferent nerves converging at the dorsal horns. In addition.

leading to discomfort from and restricted. Pain is usually least in the morning stimuli. swelling. obturator. neuropathic pain in the distribution of the as the cause of their symptoms. patients begin to experience pain ment of the underlying disease. Other causes of pudendal nerve Depending on which branches of the nerve entrapment are instrumentation of the vagina or are involved patients can have pain with urina- rectum from use of vibrators or masturbation. better with lying down. Pain can be bilateral or uni. Patients touch or clothing. Neuralgia sensitization.17 Bowel movements. It is probably the result of direct nerve injury or orgasm. Other associated symptoms often develop allodynia that extends outside the . may be difficult to identify pudendal neuralgia ing. HIV). There is often improve. Legs. muscle spasm. abdomen. Similarly. or the time it takes to (herpes zoster. Patients may sensitization. The pain does not wake pudendal neuralgia often develop symptoms up the patient at night. persistent sexual arousal that becomes painful. painful joint movement. or it may affect a combination of these neurons respond to both noxious and innocuous locations. as Symptoms of CRPS include severe burning. it The hallmark of pudendal neuralgia is burn. This difficulty is pudendal nerve that is worse when sitting. may develop of the sciatic. and due to central sensitization. may lead to pelvic floor muscle spasms early enough and activity stops. stabbing nal cord. Another. This pain is secondary to Persistent neural activation leads to increased activation of the nervi nevorum of the pudendal intracellular calcium that in turn and enhances nerve within the interligamentous space. two. which is activation of peripheral also point to their right or left lower quadrant nerves from inflammation or impingement. of complex regional pain syndrome (CRPS). and worse in the evening. joint tenderness. or stimulation of severe muscles spams causing frequency. abdomen or buttocks. When S Y M P TO M S patients present with global pain symptoms. Also. rare group are patients who devel. Allodynia and hyperes. athletic activity may lead pain are often mistaken for interstitial cystitis/​ to hypertrophy of the obturator internus muscle. S E N S I T I Z AT I O N A N D erbated by sitting.15 Treatment of these patients involves treat. time.18 This is usually preceded by peripheral pain deep in the vagina or rectum. lower back. Patients with pudendal nerve entrapment PA I N S Y N D R O M E or direct injuries are more likely to have unilat. Nevertheless. skin tenderness and color. especially while consti- in the Alcock’s canal. feel uncomfortable with sitting. nerve. intercourse. Central sensitization develops from increased eral pain. most patients CENTRAL experience symptoms continuously that is exac. While some patients only have pain when sitting. Alcock’s canal. decreases over rosis. This mechanism branches of the pudendal nerve. receptors. oped pudendal neuralgia due to viral infection Comfortable sitting time. leading to hyperalgesia and allodynia. This results in scarring of the include allotriesthesia. thus or clitoris. diabetes. neuron response in the dorsal horn of the spi- amentous space. outside the area of innervation of the pudendal their symptoms may persist even after treatment. If symptoms are noted pated. full bladder. Some symptoms may reverse without any additional patients report pain with sexual arousal. painful bladder syndrome or overactive blad- causing direct compression of the pudendal nerve der. changes in sacrospinous ligaments. Bladder symptoms such as urgency. tion. ment of pain with sitting on a toilet seat. perineum/​vagina. indicating myalgia of Patients with more severe or prolonged the pelvic floor muscles. COMPLEX REGIONAL lateral. they may have sharp. or all three apses on dorsal horn neurons. the patient’s and temporary worsening of symptoms. and dysuria in the setting of pelvic entrapment. therefore. this alleviates pressure from the perineum and edema. bowel movements. If impingement is within the interlig. thesia are common. pain is conducted by N-​methyl-​D-​aspartate (NMDA) may be isolated to the rectum. or have treatment. or multiple scle.16 synaptic inputs by increasing the number of syn- Pain can involve one. Pudendal Neuralgia 85 micro-​ trauma. Symptoms tend to worsen over time. Neuronal excitability follows. which is the sensation of nerve medial to the ischial tuberosities and within a foreign body in the vagina or rectum. and buttocks probably secondary to peripheral and central are common areas of associated pain. and/​ or posterior femoral cutaneous nerves.

patients present with pain located in the area of innervation of pudendal nerve that is unilateral or bilateral. Patients with trauma. DIAGNO SIS careful inspection of the genitals and rectum should be performed for lesions and dermato- History logical changes. Patients often report that they feel minimal to no pain when they wake up in the morning and worsening pain with daily activities. Attention scope of this chapter.20 tion can be performed. pudendal neuralgia rarely causes majority of patients develop symptoms after a sensory deficits. Establishing the onset and/​ or anus. or sexual activity such pudendal neuralgia almost always have spasm as vigorous intercourse or the use of vibrators of the pelvic floor muscles. The urinary symptoms FIGURE 10.3:  Innervation of the perineum: may range from urgency and frequency to severe a—​pudendal nerve dysuria. Injury during surgery may elicited with palpation of the obturator internus occur with hysterectomy. They may also avoid sexual activity or arousal or have symptoms of persistent sexual arousal. Nevertheless. Because of autonomic Onset may be immediate or delayed. vaginal delivery. Patient often describe feeling a like a ball is lodged in their rectum or vagina. since compression after persistent pelvic infections. d—​genitofemoral nerve . but careful sensory examina- traumatic event. Ketamine. To summarize. Quality of life is poor. sport of skin over the affected area. Tenderness should be present Pudendal neuralgia is mostly diagnosed based with palpation of the perineum. and affects their personal c—​obturator nerve relationships with their family. Palpation placement. and of the pudendal nerve occurs.3). on three things:  (1)  confirmation of pain in the Central sensitization and CRPS can be very distribution of the pudendal nerve. It is important to review medical over the sacrospinous ligament medial to the records and operative reports if pain starts after ischial spine may reproduce symptoms or cause surgery. Common dysfunction. vulva. Almost all patients with pudendal neuralgia have pain with inter- course and postcoital dyspareunia. This response is urethritis. Examination for pudendal neuralgia is focused tion in NMDA receptors. They also report less pain when sit- ting on the toilet.86 Pelvic Pain Management dermatome of the affected nerve. The other nerves. positioning.” Tinel’s sign ondary to peripheral sensitization. Detailed dal neuralgia (see “Differential Diagnosis”)20 description of use of ketamine in treatment of (Figure 10. commonly known as “Tinel’s sign. Pudendal neuralgia may also develop a severe. the pres- shown its significant benefit in the treatment of ence of any anterior abdominal wall myalgias. such as injury to the pelvis.19 and allodynia/​hyperalgesia from abdominal and pelvic nerves. chronic pain syndromes. on the patient’s history. Tenderness is often (anal or vaginal). This development is likely to be sec. prostatitis. clitoris. but several studies have should be placed on abdominal scars. there may be identifiable dryness traumatic injuries are pelvic surgery. stabbing. an anesthetic used tion of the pelvic floor muscles. A thorough abdominal and pelvic chronic pelvic neuropathic pain is beyond the examination should be performed. is used other painful conditions that may mimic puden- in the treatment of those conditions. Pain is neuro- pathic and always worse with sitting. (2)  evalua- difficult to reverse. some patients report a gradual onset without any identifiable instigating event. and (3) ruling out in pediatric and veterinary medicine. Unlike patients with injuries to and initial setting of pain is very important. or the sensation of a hot poker. sharp pain. It affects their work b—​inferior cluneal nerve since they cannot sit. or mesh muscle and ischiococcygeus muscle. During the pelvic examination. Type II CRPS Examination begins with nerve injury and causes upregula.

(Figure 10. Therefore.23 prove more useful than the functional scans Electromyography (EMG) is another electro. also called measures the impulse at the anal sphincter or “MR neurography. This time. Thus. For instance. to diagnose nerve injury in other nerves in the Mark’s electrode that is attached to the exam. measured prior to the test. In addition. nerve. with the small diam- prolonged latency does not correlate well with eters for the pudendal nerve (3–​ 5  mm for the nerve injury. and the vibration test.24 These tests rely on asymmet- Pudendal Nerve Motor Terminal Latency rical presentation where the unaffected side can Pudendal nerve motor terminal latency is be compared to the affected side. firm a neuropathy. Quantitative sensory testing can be used to con- neath the inferior ramus of the pubic bone. Quantitative sensory testing has been used latency.25 activity and thus may not be relevant in patients Pudendal nerve magnetic resonance neurogra- with neuropathic pain without motor defi. be inferred by measuring the pudendal veins. the has not been proven in properly designed studies. form MRN of the pudendal nerve. In needles that are moved away from each other theory.” is measured in milliseconds. dal vein and artery. therefore. Intra-​observer and There are only a handful of providers who per- inter-​observer variability in obtaining and inter. The base of the index Magnetic resonance testing can be divided into finger contains a registering electrode that anatomical scans and functional MRI.22 In our experience. Unfortunately. phy uses chemical to biochemical properties of the cits. called the two-​point discrimination test uses two blunt the “latency.21 resonance imaging may turn out to be the best Practitioners have questioned the validity of test to assess for compression of the pudendal the pudendal nerve motor latency test. They can detect compression of physiological test to assess pudendal nerve qual. the current technology is still not accu- the test remains controversial for the diagnosis rate enough to show nerve scarring/​compression of pudendal neuralgia. most nerves are highly organized and run in a parallel patients with pudendal neuralgia have normal direction. Specific tests that have been used are the warmth detection threshold test Electrophysiological Testing (WDT). the scar tissue less than 1–​2 mm. and temperature is increased slowly. patients with focal compression of the until the patient can discriminate the sensa- nerve have slow conduction and a prolonged tions. Similarly. and the fact that other nerves may innervate Since the pudendal nerve runs with the puden- pelvic floor muscles makes this test less useful. this depends on its length. Impingement may validity of that test has never been confirmed. The muscles assessed are the levator muscles vantage is that the resolution of 1. the latency of the nerve main trunk and 1–​2  mm for the branches). the nerve by visualizing scar tissue. compression of the nerve . The disad- ity. neuralgia do not rely on this test to diagnose Anatomical scans of the pudendal nerve may pudendal nerve entrapment. which for the most part are inner. Pudendal Neuralgia 87 may also be present when percussing the dorsal Quantitative Sensory Testing clitoral/​penile branch as it emerges from under. Unfortunately. the two-​point discrimination test. and this length cannot be difference in the signal may not be easily seen. Measurements are obtained with a St. In the WDT a well-​known test to assess for injury to the test. body. it is possible that disorganized. independent studies to confirm these findings or most physicians treating patients for pudendal correlation with observations during surgery. nerve to its target muscle. The test is a motor nerve conduc. During the test.” Even though the magnetic bulbospongiosus muscle. but its usefulness in pudendal neuralgia iner’s gloved index finger. The value at tion study that measures the time it takes for which the patient notes a change in temperature an impulse to travel along the length of the is compared with the unaffected side. There are no preting measurements is also high. while signals from adhesions are very pudendal nerve latency. MRIs are not powerful enough to visualize fine vated by pudendal nerves.5 and 3 Tesla of the pelvis. motor latency is significantly nerve fibers to enhance its signal and distinguish prolonged in many asymptomatic women who it from the surrounding scar tissue. a heated probe is applied to the affected area nerve. Signals from delivered vaginally. tip of the finger that contains a stimulating electrode is placed vaginally or rectally on the Magnetic Resonance Imaging sacrospinous ligament.4). The test measures motor with high enough certainty and reproducibility.

or in response to visceral b pain by visceral somatic convergence. Nevertheless. Pudendal neuralgia shares many similarities pudendal nerve entrapment.2). tears in pelvic floor fasciae or tendons. Additionally. physical activity. This correlation was validated in a neuropathic. Additionally. labia.4:  MRI image of pudendal nerve: occur. Vulvodynia or provoked vestibulodynia surgical decompression of the pudendal nerve. pelvic floors (see “Treatment” section). c psychological. entrapment were developed by Roger Robert in the etiology of PBS/​IC is unknown. and Nantes. They include urgency. Clearly.17 Pain in patients with painful or labrum tears. pelvic floor tension myalgia must be ruled out in in would lead to compression of the vein. dysuria. and lower back. This pudendal neuralgia patients with spastic can form a varicosity that is visible on the MRI. Painful bladder syndrome/​interstitial tomical MRI have never been shown to correlate cystitis has several symptoms that are with surgical observations. Thus. Interestingly. the findings of ana. out other conditions such as Tarlov’s cyst. identifiable cause.3 Professor it has been postulated that a neurogenic Robert is one of the pioneers of treatment and inflammatory process may play a role in diagnosis of pudendal neuralgia and is the first the onset of the disease.27 Vulvar pain tify patients who are candidates for pudendal in vulvodynia is considered to be neurolysis. 1. intercourse. directed at avoiding stimuli and use of antidepressants. vagina. but it is also often Nantes Criteria present in the urethra. neuropathic DIFFERENTIAL pain of the vulva could be secondary to DIAGNO SIS pudendal nerve sensitization. Similar to functional MRI. Postcoital pain that last for hours to days may also FIGURE 10.88 Pelvic Pain Management Al region. and pain with full masses. The differential diagnosis of genital pain is patients with vulvodynia may be broad. and treatments are randomized study3 (Box 10. with other painful diseases affecting the genital vulvodynia may be secondary to injury . and common conditions should be ruled suffering from pudendal neuralgia or out. Many patients with pudendal a—​sacrotuberous ligament neuralgia share these symptoms since b—​sacrospinous ligament neuralgia may lead to pelvic floor c—​pudendal nerve muscle spasms. Symptoms consists of pain with sitting. 2.12 Urinary hesitancy is a a hallmark symptom of pelvic floor dysfunction since patients cannot relax the pelvic floor to urinate. the identical to some of those in pudendal anatomical MRI may still be important to rule neuralgia. and orgasm.26 bladder syndrome/​interstitial cystitis is located suprapubically. Nantes criteria for diagnosing pudendal nerve perineum. are a popular diagnosis of exclusion Nantes criteria were developed to help predict for patients with vulvar pain without pudendal nerve entrapment and therefore iden. those painful diseases are mostly diagnoses of exclusion and therefore may actually represent a subset of pudendal neural- gia in some cases. and published in 2008. France. pelvic frequency. therefore. Pelvic floor tension myalgia (also called levator syndrome or vaginismus) is caused by spastic tender muscles of R L the pelvic floor that may be idiopathic.20 person to describe the transgluteal approach to 3. bladder.

gymnastics.2  NANTES CRITERIA INCLUSION CRITERIA Pain in the area innervated by the pudendal nerve Pain does not awaken patients from sleep Pain with no objective sensory impairment Pain relieved by diagnostic pudendal block EXCLUSION CRITERIA Pain located exclusively in the coccygeal. numbing Allodynia or hyperesthesia Allotriesthesia (sensation of foreign body) Pain progressively worse throughout the day Pain predominantly unilateral Pain triggered by defecation Significant tenderness around ischial spine Abnormal neurophysiology testing Pudendal Nerve Motor Terminal Latency (PNMTL) A S S O C I AT E D S I G N S Buttock pain (around ischial tuberosity) Referred sciatic pain Pain referred to the medial side of the thigh Suprapubic pain Urinary frequency with full bladder Pain after orgasm/​ejaculation Dyspareunia or pain after intercourse Erectile dysfunction Normal PNMTL of the genitofemoral or posterior femoral Repetitive trauma to the pudendal nerve may cutaneous nerves. developed pudendal neuralgia from trauma . Avoidance of symptoms is extremely effective when pudendal neuralgia T R E AT M E N T is associated with an activities such as cycling. athletics. this Avoidance of painful activities is the single most strategy cannot be applied to patients who important treatment of pudendal neuralgia. or hypogastric area (without pain in the area of distribution of pudendal nerve) Pruritus Pain exclusively paroxysmal Abnormality on imaging (MRI. and dancing. as they each have increase scarring. pelvic floor muscle spasms and may lead to central sensitization. Pudendal Neuralgia 89 BOX 10.28 Non-​invasive Treatment Patients who stop these activities may improve Avoidance of Symptoms without further treatment. CT) that can account for pain C O M P L E M E N TA RY C R I T E R I A Pain characteristics: burning. while persistent pain increases sensory innervation to the area. shooting. gluteal. pubic. Nevertheless. climbing.

lying down. and scopol. nerve blocks use ultrasound. Alternatively. vagina. Therapy is improvement of pain in two weeks.30 Botulinum toxin causes the release pain. Some patients improve after one trical stimulation. but the majority need repetitive injections ment of muscle spasms may be able to sit longer every three months when the effects of the toxin and perform more physical activities. Diazepam 5. and most patients report tive tissues. focusing are performed transvaginally into the levator ani on posture. and education. For . vaginal delivery.90 Pelvic Pain Management such as a fall. Patients who have improve. and a steroid and may be performed unguided and they have been used for treatment of pelvic or with the assistance of imaging technology. these patients. All patients with pudendal neuralgia will of any kind of neuropathic pain and are effec. atropine. In synapses. but sedation is preferred to limit prov- tion. restrictive connec. whether a pudendal nerve entrapment is pres- Gabapentin binds to α2δ subunit of voltage-​ ent. Pudendal Nerve Blocks ication is a vaginal suppository with diazepam Pudendal nerve blocks are used to help estab- and baclofen.9% sterile saline and and lengthen the muscle include myofascial injected in 1 ml increments. Guided pudendal Opium mostly contains morphine and codeine. and reduc.16 From our experience. Interventional Procedures oral muscle relaxants do not have much effect on pelvic floor muscles. Botulinum Toxin Injections Physical Therapy Botulinum toxin injections into the pelvic floor Physical therapy is a very important treatment muscles may benefit patients who have persistent in patients with pudendal neuralgia since mus. therefore decreasing neuropathic pain. Belladonna are injections consisting of a local anesthetic and opium rectal suppositories are also effective. muscle spasms despite adequate pelvic floor phys- cle spasms are a significant component of their ical therapy. pain since the nineteenth century. In patients in whom no relief is obtained. and trigger-​point release. stretch. ful procedure. Manual be focused on areas of spasms. and the most effective med. Doses may be include using “zero-​gravity” chairs and kneeling increased to a maximum of 600 mg/​day in two chairs. or Second-​ line medications are antiepileptic computer tomography (CT) to visualize land- GABA analogues such as gabapentin and pre. 900 mg/​day in three divided doses. perineum. range of motion. lifestyle modifications can help The usual starting dose for neurontin is 300–​ manage symptoms. Other modifications ally started at 75 mg twice a day. fluoroscopy.1 Therapists address muscle contraction. dependent calcium channels in the central ner. experience a transient relief of pain regardless of tive in some patients with pudendal neuralgia. Other modalities ocation of further muscle spasms from the pain- include biofeedback. exercises. soft and connective tissue mobiliza. or surgery. This can be done in release. thereby inhibiting ation of pelvic floor muscles. First-​line medical therapy for pudendal neural- gia is muscle relaxants.mg of baclofen into a suppository and may provide long-​term pain relief. seen in about five days. Effects from the Botox are spasm.mg is compounded lish the diagnosis of pudendal neuralgia and with 4. and elec. dose. to three divided doses. Injections administered as “hands-​on” techniques. muscle group and obturator internus muscles ing. Lyrica is usu- the perineum with sitting. titrated up ions with a cut-​out center to alleviate pressure at to a maximum of 3600 mg/​day. It prevents the formation of new nically successful block can be confirmed. the office. ing physical activity. or buttock by palpating 1  cm amine and is a potent smooth muscle relaxant. marks and confirm injection of solution at the gabaline. ultrasonography. Belladonna is Unguided blocks are performed through the a mixture of hyoscamine. standing at work.29 They are widely used in treatment site. Most of these patients have bilaterally in patients with global pelvic floor significant muscle spasm and subsequent muscle tension myalgia. medial to the ischial spine. The main role of physical therapy is relax. Botox is diluted techniques that help release the muscle spasms to 10 units per 1 ml of 0. pudendal neuralgia may be ruled out if a tech- vous system. Nerve blocks inserted vaginally up to twice a day. muscle imbalances. and other dysfunctions. Approximately 60–​70% of patients have significant improvement of pain after the botuli- Medications num toxin injection. Most patients sit on cush. wear off. of acetylcholine in synapses. injections may shortening throughout the pelvic girdle.

but this num. Transgluteal pudendal neurolysis is the most com- ber seemed too high in clinical practice. long-​ term pain relief was seen when patients were followed for 12–​18 months. Approximately 1600 pulses are applied.32 In mon and successful approach to surgical decom- our experience. It was true pudendal nerve entrapment and therefore first described by French neurosurgeon Roger less likely to respond to steroids.35 Surgery b Surgical decompression of the pudendal nerve d is reserved for patients with a high suspicion of pudendal nerve entrapment or for patients who a b c FIGURE 10. Some patients also experience long-​ term Different approaches to access and release the relief from the steroid injected.6). This energy is delivered in short 20-​millisecond bursts of energy fol- lowed by 480 milliseconds of cooling period.5:  CT guided pudendal nerve block.20. help pelvic stability. CT-​ guided blocks may be more have failed to respond to conservative treat- desirable because one can review images and be ments. decrease adhesion formation. and improve which both thermal and nonthermal energy is postsurgical pain. reduce inflammation and ectopic nerve activ- ity. Robert in 1989 and has since been modified by the authors of this chapter to improve visualiza- Pulsed Radiofrequency Ablation tion. surgery strongly depends on patient selection.20 approach allows complete access to the pudendal This observation may be secondary to a large nerve trunk and visualization of the most com- portion of patient in our practice who have a mon areas of compression (Figure 10. but it appears that strong electromagnetic fields may cause upregulation of c-​Fos protein expression and inhibition of C-​ fibers. Pudendal Neuralgia 91 this reason.34 In a 2013 prospective study. Since a true pudendal nerve entrapment certain that the injection was done in the proper can only be confirmed with surgery.36 delivered to the nerve. The mechanism of pain relief is not known.6:  View during transgluteal pudendal neu- rolysis (right): a—​sacrotuberous ligament b—​sacrospinous ligament FIGURE 10. Steroids help pudendal nerve have been described. One study showed that 92% of patients Transgluteal Pudendal Neurolysis have some relief after the block. Patient c—​pudendal neurovascular bundle in the intraligamen- prone: tous space a—​needle d—​ pudendal neurovascular bundle in the pudendal b—​contrast in the right intraligamentous space nerve (Alcock’s) canal c—​right obturator internus muscle . promote nerve Pulse radiofrequency ablation is a technique in regeneration. This surgical patients have long-​term relief from the block. it appears that about 30–​40% of pression of the pudendal nerve.5).33 There are several c case reports describing good pain relief after a this procedure. success of location31 (Figure 10.

this continuous nerve block sacrospinous ligaments. This inci. and one-​third have no improve. Also. and the pudendal .37 the perineum in men. the non-​surgery group. secondary to broadly The pudendal nerve can be approached through varying individual experience of symptoms the abdominal cavity either during laparotomy. It is most suitable for may help reverse the central sensitization that patients with isolated clitoral or perineal pain. The ligament Transischiorectal Pudendal Neurolysis is identified and a Z-​type incision is made to Transischiorectal pudendal neurolysis was open up the interligamentous space. one-​third of After the retroperitoneal space is opened and patients have no pain. or robotic-​ assisted laparoscopy.38 Based on stud. sphincter. rather provides excellent postoperative pain control.4% of through the lesser sciatic foramen. the patient is placed in the develop. described by French gynecologist Eric Bautrand sion helps improve visualization while allowing in 2003 as an alternative to the transgluteal the surgeon to repair the ligament without using approach. it can be ment of pain. When an incision that is painful and difficult to heal. Studies from laparoscopy. the nerve is free. This liga- patients in the surgery group had improvement ment can then be transected. The biggest drawback to the piriformis muscle to the distal Alcock’s canal. the sacrospinous ligament is A  study from France showed pain resolution in transected and the nerve is transposed anteri. Measuring objective outcomes of transgluteal Endoscopic Transperitoneal pudendal neurolysis or any other treatment for Pudendal Neurolysis chronic pain is difficult. and measuring muscle activity at the external anal duration of symptoms. compared to 13. The nerve is then freed fore may decrease the risk of instability of the from its surrounding tissue from the level of the sacroiliac joint.3% of patients in jackknife position. and these veins are typically of the nerve.41 France showed that after surgery. lateral to the labia majora in women or the scro- ies. it is believed that Epidermal Growth Factor tum in men.39 This procedure is preformed trans- a graft. One of the advantages of The pudendal nerve is identified using the Nerve this procedure is that it does not require tran- Integrity Monitoring System (NIMS) wand and section of the sacrotuberous ligament and there- surgical microscope. vaginally in women and through an incision in ament is important to maintain pelvic stability. procedure seems to be the limited visualization At this point. orly. A  transgluteal incision over the sac- rotuberous ligament is performed. nerve integrity. repair of the lig. Platelet-​rich plasma (PRP) is then used lithotomy position and an incision is performed to coat the nerve after surgery. 71. The nerve integrity monitor. than the main trunk between sacrotuberous and More importantly. In anterior to the artery as it leaves the pelvis a sequential randomized control trial. Sacrospinous ligament is then found at risk of getting worse after this procedure. ischiopubic ramus. one-​third have improve. A pain pump is then Transperineal pudendal neurolysis is a proce- placed next to the nerve. however.40 many patients with pudendal nerve compression In this procedure. it requires transected to reduce nerve compression. varicosities of the pudendal vein of the nerve and poor access to the entire length may be observed. decreasing the risk of nerve compression this high rate of success was not confirmed by and allowing it to run a straighter course. and skin closed.4 Results may depend on ing system is used to help identify the nerve by the degree of entrapment. which is responsible for proper nerve usually entraps the nerve to the surface of the function and healing. Outcomes of this procedure ment is then repaired and subcutaneous tissue are not clear. This pump allows for dure developed for patients who have entrap- continuous two-​ week block of the nerve and ment of terminal branches of the nerve.92 Pelvic Pain Management The surgery begins with patients in a prone. The any other practitioner.18 The sacrotuberous liga. Although controversial. followed until the internal pudendal artery is ment. 83% of patients after this procedure. of Schwan cells and therefore the production of The nerve is then freed from scar tissue that myelin. nerve is then wrapped in any of the commer- cially available nerve wraps to decrease the risk Transperineal Pudendal Neurolysis of re-​scarring of the nerve. the internal iliac artery is identified. and its impact on quality of life. at 12  months. The nerve is identified at the distal (EGF) present in the PRP promotes the growth Alcock’s canal medial to the ischial tuberosity. Approximately one percent of patients are found. in male patients.

ful treatment. Occasionally. car. the pudendal nerve may be entrapped by ies. Conservative therapies such as avoid- through or anchored to the obturator internus ance. such as psy- ries an increased risk of nerve injury from dense chiatric disorders and endocrine disorders. pudendal neuralgia should removed. or reinjury pudendal nerve entrapment. Pudendal neuralgia is a debilitating and pain- tinence and pelvic organ prolapse. Outcomes are mixed and numbers are too small Persistent Genital Arousal Disorder to assess the outcomes.42 Failure of initial surgery may This arousal is not related to any feelings of have been secondary to poor visualization of sexual desire. first dal neuralgia is still not well understood. leading to compression and irritation of for patients for whom medical management has the pudendal nerve. such as riding in a the nerve at the time of surgery. In some cases. falls. therefore. In these patients. Botox injections to further research is needed to describe patient pelvic floor. especially if it is attached 1–​ 2  cm nerve block can be performed to confirm the from the ischial spine. One of the most vexing symptoms in patients with pudendal nerve entrapment is persistent Redo Pudendal Neurolysis genital arousal disorder (PGAD). or for patients who have a sion. and this carries potential com. the portion of the interligamentous space and limits visual. Surgical decompression is reserved floor. We reported our by congestion of the veins around the clitoris results from this procedure in nine patients.43 Patients Reoperation using a transgluteal approach may have the constant sensation of being on the be performed for patients who have failed verge of orgasm and may have to mastur- pudendal nerve decompression surgery by bate several times an hour to relieve that ten- other approaches. mesh traveling diagnosis. S U M M A RY vaginal mesh used in the treatment of incon. the outcomes in reliev- ing symptoms of PGAD may not be as good at Post–​Vaginal Mesh Pudendal Neuralgia relieving pain. Nevertheless. Pudendal Neuralgia 93 neurovascular bundle is identified posterior to removal of mesh is beneficial in patients with the ligament. A  pudendal ligaments. standing or sitting on a toilet seat. of the mesh that is posterior the sacrospinous ization to other possible areas of entrapment. Several surgeons to remove part of the mesh may be necessary. causing this condition. and men can experience ejaculation. but there may be from a fall or trauma. a transgluteal pudendal neurolysis plications and additional pain. puden- cate conservative treatment of pelvic floor. be gradual or immediately following a traumatic dal neuralgia from two possible mechanisms. Chronic ful neuropathic condition in the area of inner- pelvic pain after mesh placement is one of vation of pudendal nerve. perform transperitoneal pudendal neurolysis. or penis. patients will need to have the mesh ment. not using pre. The repeat surgery car. In patients in whom the may be needed. and including physical therapy. and nerve blocks. Treatment of PGAD is difficult and eight of whom had global improvement and two should be targeted toward the specific etiology of whom had complete resolution of pain. Hallmark symptoms the most serious complications. In 2011 Food and Drug Administration released a warning of potential complications of trans. failed.13 Second. and vaginal deliver- One. Published literature shows that the be suspected in patients complaining of genital . event such as surgery. surgi- cal decompression of the pudendal nerve may Special Considerations be necessary. however. However. we advo. resulting in include pain with sitting and relief of pain with decreased productivity and poor quality of life. If conservative phenotypes and to establish diagnosis and treat- therapy fails. Vibrations. and medications are muscle may cause severe spasms of the pelvic preferred. Despite advances in medicine. some other causative conditions. In ligament cannot be removed through a vaginal addition. transection of the levator ani muscle or abdominal approach. This technique allows for access post–​vaginal mesh pain. orgasms. lifestyle modifications. This fibrosis. The Nantes criteria offer a reproducible way the mesh that is anchored to the sacrospinous to diagnose pudendal neuralgia. may provoke it. pain persists. patients have spontaneous recurrence of symptoms after initially success. the surgical microscope and syndrome may be also potentially be caused NIMS monitor are invaluable. PGAD may be caused by ventive measures against adhesions. Onset may Many of these patients have pain from puden.

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general surgeons. treatment modalities of unresolved incapacitating ogy. magnetic resonance imag. pain specialists/​anesthesiologists. including primary care pain. uterine prolapse/​mal- ogies that can cause pelvic pain. or vaginal veins. but can all contribute to pelvic pain pathology.2. Selective ovarian venography1. obtained to rule out more common pelvic pathol. such as endometriosis.1. vein incompetence from non-​obstructive causes. vide treatment options.15 Therefore.12. The primary and secondary PCS. or—​female varicocele or pelvic vascular congestion (PVC)—​because it defines the etio-​pathology asso.8.7.11 The presence of varices of the pelvic veins that is causing the problem. PCS coil embolization as a safe and effective treatment as a clinical entity was first described in 1949 by modality in the management of PCS.9. and describe the endovascular dilated ovarian. Referred pain from the abdominal multi-​parous women.2. AND DUCKSOO  KIM P   ain secondary to pelvic venous congestion syndrome (PCS) or pelvic venous incompe- tence (PVI) is defined as non-​cyclical pelvic pain is usually performed in females with PCS that does not respond to medical treatment. Testing should position.2 Fifteen percent of women viscera and neurogenic and psychogenic factors experience PCS between the ages of 20 and 50. NII-K ​ A B U K A B U T E Y. PAT H O P H Y S I O L O G Y ciated with pelvic congestion and venous engorge. periuterine. It usually occurs in premenopausal and to discern. G I L L I A N L I E B E R M A N. as Nutcracker syndrome (NCS).4. most patients with PCS. Pain not all experience symptoms. and interventional radiologists. primary ing (MRI) and pelvic venous duplex ultrasound PCS. fibroids. Pelvic duplex ultrasound (US) and/​or com.3 The term “PVI” is preferred to “PCS” pelvic congestion syndrome. intercourse.10 In this chapter. highlight the role of pain is associated with standing. uro- imaging modalities in the evaluation of patients logical surgeons.1. and ovarian cysts. 11 Incapacitating Pelvic Congestion Syndrome NEERAJ RASTOGI. it can include a pregnancy test and Pap smear to ensure be very challenging for physicians who deal with pregnancy or cervical cancer is not the cause for pain involving the pelvis. Usually.4 within the pelvis can occur with a number of Preliminary diagnostic laboratory tests are pelvic conditions. May-​ Thurner . The etiology of pelvic pain can be very difficult ment.1. Although noninvasive has been shown to be the underlying etiology in methods such as CT.1. collateral pathways to circumvent the obstruction. or endovascular embolotherapy with utiliza.14. lar insufficiency and endocrine and mechanical tion of sclerosant/​ coils. to with chronic pelvic pain. which includes congenital or acquired ovarian are increasingly gaining favor as helpful diagnos. we review the literature and results of various ological factor contributing to pelvic pain pathol. Procedural interventions. diagnosis is made in 60% of patients with pelvic mine whether there may be an anatomical problem pain. pelvic inflammatory disease. doctors. gynecologists.5 remains considered a diagnosis of exclusion. Additionally. Cross-​sectional imaging confirm a diagnosis of PCS. ligation of the pelvic caused by a combination of pelvic venous valvu- veins.2. Patients with the most effective method for both identification secondary PCS develop ovarian and/​or pelvic vein of pelvic venous pathology and its ability to pro. we have made an attempt to define that lasts for at least a six-​month duration. no definitive studies are useful to obtain in order to help deter. is tic tools. and ovarian venography. Pelvic varices are treatable Development of symptomatic varices is by using ovarian suppression. Taylor.3 Therefore. factors.6.13. Obstructing anatomical anomalies such including coil embolization of ovarian the vein. suggesting venous insufficiency as an eti. gastroen- puted tomography (CT) scans are usually the first terologists.

the drome and iliac vein compression/​May-​Thurner patients are asymptomatic in the morning. and pelvic tumors artery against the pelvic brim. “Nutcracker syn. and dilated ovarian vein (pink arrow) in coronal scan of the abdomen (C). ovarian and comfort arises during ambulation resulting from pelvic varicosities are seen after pregnancy. and syndrome may all lead to PCS. drome” is described as the left ovarian vein and in the premenstrual period. Diurnal variations are frequently reported. pain typically worsens over time during the day. most patients with PCS do not have amen.1). . Ovarian veins in premenopausal women are vic and ovarian veins that may be a predisposing exposed to high concentrations of estradiol and factor for venous thrombosis and pelvic pain. Additionally. leading to enlargement of the vein symptomatology. This in the pelvis.16 ondary to mass effect on the lumbosacral plexus.11. that typically increase intra-​abdominal pressure. with some woman. which may cause may lead to secondary PCS. Exacerbations of symptoms often occur flow. and upper thighs.1: Contrast CT scans show “nutcracker syndrome” with compressed left renal vein (blue arrow) between aorta (yellow arrow) and superior mesenteric artery (red arrow) in axial scan of the abdomen (A).10. or without dyspareunia and/​or post-​coital pain. secondary capacity of pelvic veins may increase by 60-​fold to superficial veins’ valvular incompetence. therefore. external vas. and over the non-​pregnant state due to increased blood giving rise to varicose veins. and/​or during preg- the left renal vein’s compression by the superior nancy. Importantly. The lower extremity venous hypertension. cular compression such as renal Nutcracker syn. where leg pain and dis- pelvic veins/​varicosities. Pelvic examination may demon- include mechanical factors such as damaged strate cervical motion and ovarian point tender- or absent venous valves that lead to retrograde ness. of the collateral pathways to relieve antegrade a few rare cases of combined PCS secondary obstruction. which contributes to PCS is associated with constant dull pain venous dilatation and valvular insufficiency. pooling and delayed clearance of blood in the pel- ces. Frequently. The spec- pelvic venous engorgement and thereby weakening trum is comparable to lower-​extremity varicose of the venous walls. Weight gain and anatomical changes in the after prolonged walking/​ standing or activities pelvic structures during pregnancy. venous distension may also cause pelvic pain in Heaviness just before the onset of menses. which results in the pelvic varicosities secondary to PCS. syndrome can occur due to left common iliac multiparous women are predisposed to develop vein compression from the right common iliac PCS due to significant increase in intravascular (A) (B) (C) FIGURE  11. pelvic varices (yellow arrow) in axial scan of pelvis (B). Incapacitating Pelvic Congestion Syndrome 97 syndrome. to be the result of the presence of ovarian and lation leads to venodilatation. uterine malposition. The symptoms usually continue to worsen mesenteric artery (Figure 11. Estrogen overstimulation may be responsible in more than 50% of women diagnosed with PCS. volume during pregnancy.14 Mechanical factors result in ovarian vein leading to symptomatic pelvic vari. sec- estrone compared to the peripheral circulation. Of CLINICAL PICTURE note. Clinical symptoms of pelvic congestion are likely orrhea or demonstrate hirsutism. wherein the ovarian iliofemoral deep venous thrombosis with or and/​or pelvic veins contribute to the development without the pelvic varices of PCS. In some cases left retro-​aortic renal to both May-​Thurner syndrome and NCS have vein may obstruct the drainage from the left been reported. May-​ Thurner after each subsequent pregnancy.13. Estrogen stimu. vulvar region. contributing factors to PCS may also occur.

and finally the right ovarian vein. Thurner syndrome). vic duplex sonography include: (1) visualization to maintain antegrade flow.g. Diagnostic criteria for pel- particularly at the terminus of the ovarian vein. or into the circumflex femoral varicosities.12.18 absence of venous valves in ovarian veins has Likewise. vagina.23 draining the bladder.21 Moreover. just below the right renal vein. the pelvic varices develop during been demonstrated in 15% of the PCS patients pregnancy and continue to progress in size during on the left and 6% on the right. explains why successive pregnancies may cause which empties usually into the inferior vena venous valves to break down and allow varices cava (IVC) antero-​laterally at a 45-​degree angle to extend to the adjoining pelvic venous plexus. (2)  the presence of pelvic varicocele relatively devoid of valves. and diagnose vein. vular incompetency has been recorded in more ment predisposes to venous valvular insufficiency. parous may explain treatment failure in patients of lower women. around uterus (uterovaginalis). the right e. even without pregnancy. Figure 11. Most other pelvic of enlarged ovarian veins. val- each term of gestation.19 ity increases by 60% due to mechanical com- pression of the gravid uterus and the vasodilator APPLIED CLINICAL action of progesterone. left ovarian vein. During pregnancy. resulting in pelvic venous extend over the buttock and posteromedial thigh congestion. information about visualized venous blood flow nal pudendal vein. resulting in vular incompetence leading to reversal of labial asymmetry. and rec- tum are interconnected and highly variable.13 The left ovarian plexus drains into to reversal of venous flow in the ovarian vein. Ovarian vein valvular incompetence leads valves. venous varicosities may be seen inter. and are reported in more than 10% of the patients (3)  endocrine/​ hormonal factors. Vulvar and perineal vic varicosities. Rarely. Congenital term of gestation. and then into the femoral vein. uterus. and communicate with both greater and smaller The diagnosis of PCS is defined by the saphenous veins. .18.98 Pelvic Pain Management volume and increased venous capacity with each patients.. A CT salpingo-​ovarian veins.14. These varices can pingo ovarian veins. It is important to understand that veins lis).2) and dilated and tortuous tional contributing factor involved in venous myometrial arcuate veins (>5  mm) commu- dilation of the pelvic venous anatomy in some nicating with pelvic varicose veins/​ varicocele. pelvic venous capac- extremity superficial venous insufficiency.. measuring >6 mm in venous plexuses and the internal iliac veins are diameter. which empties into the left with dilation of veins in the pelvis and develop- renal at an angle of 90 degrees. which drains into the great and therefore can be used to evaluate pelvic saphenous vein. (2)  mechanical venous obstruction.17.20 compression syndromes (e.5. three may play role in the delayed clearance of ficiency.g. both in the right and As a result. and rectum (recta- vein. The right ovar. ment of ovarian and internal iliac varices. Mechanical obstruction A N AT O M Y caused by the gravid uterus is a main contribut- Normal ovarian veins are usually less than five ing factor in the development of pelvic varicos- millimeters in diameter and have functional ities. varices extending onto the legs or is caused by a combination of factors:  (1)  val- in the vulvar area under soft tissue. vulva (vulvaris). duplex ultrasound is veins drain into the internal pudendal vein. then increasingly gaining favor as it provides dynamic into the inferior gluteal vein. and then into branches scan has greater sensitivity for showing pel- of the internal iliac veins.20 This is an addi. in the left ovarian veins.4 Vulvar or perineal varicosities flow. NCS and May-​ The main trunks of ovarian veins have valves. however.22. all with lower extremity superficial venous insuf. bladder ovarian vein may drain into the right renal (vesicalis). detect venous reflux. nally around the pelvis and sometimes externally The development of ovarian/​ pelvic varices at the buttocks. asymptomatic. Continued venous engorge. and these may accompany and reflect pelvic venous flow in the utero-​ovarian and sal- ovarian vein insufficiency. Ovarian vein reflux can also period. This ian plexus drains into the right ovarian vein. (>5  mm. The DIAGNO STIC IMAGING uterus and vagina drain into the uterine veins Both CT and duplex ultrasound of the pelvis and ovarian plexus via the utero-​ ovarian and provide excellent resolution of the uterus. They most commonly manifest presence of (a)  ovarian vein reflux and (b)  pel- during pregnancy and regress in the postpartum vic varicosities. then the exter. Of note. Missed diagnosis of PVI in such cases be present in healthy. than one-​third of patients.

20. the findings of non-​invasive testing. and should pression.3). ovarian and ing techniques such as CT and magnetic reso. Diagnostic laparoscopy is sometime used in patients with chronic pelvic pain to rule out other etiologies. analyze the ovary extending to the broad ligament and severity of the PCS.24 Pelvic ultrasonography is a good screen. (reno-​caval) and left common iliac vein are ing tool. Of note. and with (B) Doppler show markedly dilated veins (* and grey arrow) adjacent to ovary (+).3:  T2-​weighted MRI. and (3) reversed and slow flow (less and iliac. and rule out other potential etiologies not routinely be performed in patients who do for pelvic pain. Pelvic MRI typically demonstrates ventional radiologists now prefer MRI/​MRV as dilated.27 PCS can be a difficult diagnosis to make at primary care level and often requires a referral to a interventional radiologist or vascular sur- geon or a pain specialist. including internal iliac. iliac venography should not be used as first-​line nance venography (MRV) can be used to detect diagnostic tests. especially underlying malig. Contrast enhancement with gadolinium not only improves visualiza- tion. The diagnosis of PCS intensity projection (MIP) reconstruction shows dilated is best made with ovarian venography. but rather as means to confirm dilated pelvic varicosities. Most inter- nancies. coronal maximum with the missing diagnosis. but it can lead to a number of false obtained whenever an abnormality is visualized negative studies due to slow blood flow in on diagnostic imaging.2: Sagittal transvaginal ultrasound images of left ovary without (A). CT or duplex ultrasound of the pelvis has a relatively lower sensitivity—​13 and 20%. tortuous.26. arrow). especially pelvic endome- triosis.6 For ovarian veins (white arrow) and adnexal vein (grey compete evaluation. advanced imag. Pressure gradients across the renal vein. areas of venous com. not have severe symptoms of PCS. enhancing tubular structures a primary imaging modality to rule out other (enlarged pelvic veins) near the uterus and potential etiologies for pelvic pain. . Examinations performed in the supine position may not recognize PCS in 80–​90% of patients. Even though regarded pelvic varicosities. respectively—​for PCS compared with MRI/​MRV (59%) or diagnostic venogram. as the most informative method.4. and usually FIGURE 11.25 Likewise. and assess whether the pelvic sidewall (dilated utero-​ovarian and sal- pingo ovarian veins). particularly in the left ovarian performed. bilateral ovarian. left renal. bilaterally. venography is than 3  cm/​ s). but increases sensitivity if MR sequences are obtained while patients perform a Valsalva maneuver (Figure 11. Incapacitating Pelvic Congestion Syndrome 99 (A) (B) FIGURE 11. One or more imaging modalities may already have been used by the time PCS patients are referred to an interven- tional radiologist or pain specialist.5.

the com. sclerosing agents such as 3% sodium tetradecyl sulfate (STS) foam.27 Failed medical treatment or recurrence of symptoms is an indication for laparoscopic surgery or an endovascular pro- cedure such as ovarian vein coil embolization or embolotherapy using detachable balloons. and no definitive diagnosis is micro-​ puncture needle.4. Currently. Pain secondary to PCS veins. indicating that other causes of pelvic pain the most common clinical signs that should raise may coexist with pelvic varicosities. Diagnostic criteria on the selective posteromedial thigh varices.14 This provides a advanced into the inferior vena cava to select snapshot for classifying patients with PCS as fol- and image the ovarian and/​or pelvic veins fol.4:  Left ovarian venogram via a catheter Endovascular therapy has been validated with (top arrow) shows dilated ovarian (middle arrows) and standardized pain assessment surveys before and pelvic veins (bottom arrow). hysterectomy with or plus dilated left utero-​vaginal vein plexus. and dilated ovarian. alone or in com- bination with drug-​producing ovarian suppres- sion (medroxyprogesterone acetate [MPA:  30 mg per day. (2)  those with unusual vulvar or guidance. and without bilateral salpingo-​ oophorectomy). or Grade III  =  the same as II. The direct relationship between varices and ment. plus dilated right minimally invasive endovascular transcatheter utero-​vaginal plexus and right ovarian vein.5 Moreover. Pain caused by PCS can be managed by analgesics. right) can show reflux in healthy asymptomatic mon femoral vein is accessed using a 21-​gauge parous women.27 rograde ovarian or pelvic venous flow. (2)  ret. or “left-​to-​right” theory of PCS and graded the pel. surgical ovarian vein/​plexus. pelvic varicosities secondary to PVI. vic varicosities as follows:  Grade I  =  dilated left Treatment of PCS may be medical. PO for 6  months] or gonadotro- pin receptor agonists [GnRH. goserelin to be given parenterally 3. explained this phenomenon by the so-​ called intercourse. FIGURE 11. A  catheter is then usually made in 60% of patients. Venographic demonstration of ovarian chronic pelvic pain remains difficult to ascer- vein incompetency and pelvic varicosities are tain. Chemical ovarian suppression with MPA or GnRH blocks the direct vasodilator effect of estrogen. vaginal veins. The goal of the interventional treatment is elim- ination of ovarian vein reflux. (3)  the presence of pelvic varicosities and multiple T R E AT M E N T O P T I O N S tortuous. with incidentally detected lowing contrast injection under fluoroscopic pelvic varices. with or without direct sclerosis of enlarged pelvic varicosities. Grade II  =  the same as I. lows: (1) asymptomatic. complicating lower ovarian and pelvic venography are:  (1)  ovarian extremity superficial venous insufficiency with vein measuring >6 mm in diameter (upper limit or without pelvic pain. periuterine.6 mg.100 Pelvic Pain Management patient is a candidate for endovascular treat. (4)  stagnation variety of disciplines and may cause substan- and delayed clearance of contrast in the pelvic tial patient morbidity.23 embolization. and (5)  visualization of vulvoperineal is defined as noncyclical pelvic pain for at least or posteromedial thigh varices. monthly x 6 doses]).26 De Schepper six months’ duration associated with standing. venous collaterals from PCS has been encountered by physicians in a left-​to-​right/​contralateral reflux. and thereby provides relief of pelvic congestion and patients’ symptoms by reducing venous distention.4). (ligation of ovarian veins. suspicion for the diagnosis of PCS (Figure 11. after embolotherapy and during follow-​up using . or glue such as enbucrilate. ovarian veins (the left more commonly than the In order to perform venography. and (3)  PCS with painful of normal is considered to be 5  mm). cross-​ pelvic. many minimally inva- sive therapeutic choices with excellent results are available for these patients.

She com. The internal iliac vein embolization is performed after treat- ment of the ovarian vein. and 11. in some cases. two pregnancies via C section. Digital subtrac- over the pubic area for over ten years.6. Of note.7). female presented with chronic pelvic pain of moderate severity without dys- pareunia. with gross varicosities over the pubic area extending to the right labia majora. incom. a diagnosis of PCS of 2004. This was demonstrated bilateral enlarged ovarian veins treated with percutaneous transluminal angio- measuring greater than 6 mm in diameter. therefore. she was diagnosed with Based on patient’s history of chronic pelvic pain. embo- lotherapy of ovarian veins with and without internal iliac vein embolization is an effective endovascular treatment for PCS. formed that demonstrated a moderate stenosis ian venography under monitored anesthesia care of the left external iliac vein below the previ- in reverse Trendelenburg position. and remained asymptomatic sis (DVT) in the right lower extremity (RLE). repeat venography was per- The patient was scheduled for bilateral ovar. embolization of the iliac veins may also be required. and dif- fuse swelling of RLE. which was managed multi-​parous status.2. tion angiography (DSA) image shows dilated Rt. coils should be avoided in the internal iliac veins because of the risk of their migration to the lungs/​heart due to capacious iliac veins:  as seen in Cases 11. On complete evaluation. and varicose veins PCS confirmed on ovarian venography. ing in her left thigh.5. following. analgesics to get relief. A  left cedure demonstrated no significant change in renal venogram was performed in July 2007.1 A 36-​ year-​ old. CASE 11. Post-​ The patient continued to have persistent mild operative follow-​ up pelvic duplex imaging of swelling in the left thigh. and denied abdominal or urogynecological pain. embolized (Figures 11. 11. ovar- plained of continuous discomfort requiring daily ian vein (white arrow) with reverse blood flow. Initial venous duplex US of the RLE were consistent with normal phasic CASE 11. right hip Likewise. groin pain of moderate severity and dyspareunia tent superficial venous system with severe reflux requiring narcotic analgesics for over five years. and gross varicosities over with left common iliac vein stenting in March the pubic area/​vulval varices. involving the greater saphenous vein. and deep vein thrombo- pain was resolved. and an incompe. Associated symptoms included right FIGURE 11. left leg pain. and dys- the adnexal vasculature six weeks after the pro. Venography ously placed left common iliac stent. her fracture 12  years ago. Incapacitating Pelvic Congestion Syndrome 101 a visual analog scale (VAS).2 flow and good augmentation at all levels. Peripheral vascular exam showed normal distal pulses. Currently. Both plasty and stent placement in the left external veins were individually cannulated and coil iliac vein in October 2004. This should always be performed prior to varicose vein treat- ment of the lower limb if there are any. cycle. Ovarian and internal iliac veins are in close communi- cation. Due to persistent pelvic pain and swell- was considered. . May-​ Thurner syndrome. during a follow-​ up office visit.1 and 11. The patient’s past medi- cal history was significant for normal menstrual the size of the pelvic vasculature with Valsalva. pareunia requiring narcotic analgesics.5: A 36-​ year-​ old female patient with lower extremity swelling. as of the two-​year post-​procedural follow-​up. A 32-​year-​old female was referred to us for the petent deep venous system with severe reflux evaluation of recurrent post-​phlebitic pelvic and involving the popliteal vein.

6:  A 36-​year-​old female patient with PCS crest: 10. but pelvic pain and dyspareunia continued. . The patient’s leg FIGURE 11. A  left ovarian vein coil embolization was performed at the same outside hospital. firming grade III PCS (Figure 11. pelvis (arrowhead). ovarian vein arrow).102 Pelvic Pain Management swelling and pain were improved. and occluded left ovarian vein from previous embolization with- out any evidence of collaterals (Figure 11. Tornado coils were successfully deployed in the right which demonstrated retrograde filling of left ovarian and pelvic veins via collaterals. ovarian vein (white retrograde flow and cross-​pelvic collaterals con- arrow) without any reflux. and an intrauterine contraceptive device in the (black arrow) without any reflux.8  mm) with complete coil embolization of Lt.11). Plain X-​ray abdomen shows FIGURE  11. multiple PCS confirmed on ovarian venography. and below confirmed on ovarian venography. DSA image shows the iliac crest:  10.8:  A 32-y​ ear-o ​ ld multi-p ​ arous woman with unresolved incapacitating PCS and history of previous successfully stented May-​ Thurner syndrome and left ovarian vein embolization.8). Next.7: A  36-​ year-​old female patient with iliac stenting on the left side (white arrow). She was then scheduled for ilio-​ caval and ovarian venography.1  mm—​mean:  9.10). Preliminary iliocaval venography demon- strated patent iliac veins and patent IVC.9 mm. Subsequent right ovarian venogram revealed a patent but grossly dilated right ovarian vein (diameter above the iliac FIGURE 11. DSA image embolization coils blocking the left ovarian vein (black shows complete coil embolization of Rt. Complete procedural steps were recorded as follows:  Anterior–​ pos- terior spot fluoroscopic imaging of the abdo- men was taken in supine position (Figure 11. a pre-​procedural diagnosis of incompletely resolved PCS was con- sidered.4 mm. at iliac crest: 8. Due to persistent venous disability with pre- viously stented May-​Thurner syndrome and left ovarian vein coil embolization.9 and Figure 11. left renal venogram showed a patent left renal vein without hilar dilatation.

Incapacitating Pelvic Congestion Syndrome 103

FIGURE  11.9: DSA image from left renal venogra- FIGURE  11.10:  DSA image from inferior venacavo-
phy demonstrates a patent left adrenal vein (small gram and iliac venogram demonstrates patent IVC
white arrow) and renal vein without distension of its (black arrow) and iliac stents on the left side (white
hilar portion as opposed to NCS (large white arrow). arrow) with multiple embolization coils blocking the
Multiple embolization coils blocking the left ovarian left ovarian vein.
vein (black arrow) with absence of spontaneous retro-
grade flow in the left ovarian vein or any parapelvic
collaterals. Aforementioned findings did not represent
NCS (extrinsic left renal vein compression at the aorto-
mesenteric fork).

ovarian vein, starting from lower border of
the right iliac crest toward the level of entry of
the right ovarian vein into the IVC. Post–​coil
embolization selective right ovarian venogram
demonstrated occlusion of the right ovarian
vein (Figure 11.12). Follow-​ up pelvic duplex
images of the adnexal vasculature after two
months of the procedure demonstrated no sig-
nificant change in the size of the pelvic vascula-
ture with Valsalva. Likewise, during a follow-​up
office visit, her pain was resolved and remained
asymptomatic until the two-​ year post-​proce-
dural follow-​up. Persistent PCS despite left ovar-
ian vein embolization and iliac venous stentings
in the index case was likely due to unrecognized
coexisting right ovarian vein incompetency.
FIGURE 11.11:  DSA image during right selective ovar-
ian venography demonstrates the catheter in the patient’s
T R E AT M E N T R E S U LT S right ovarian vein with contrast traversing down into
Medical treatment suppresses the ovarian the dilated right ovarian vein (black arrow). Note the
function and/​or increases venous contraction; reversed/​caudal flow in the ovarian vein and retrograde
several studies have reported both MPA and filling of varicose veins in the pelvis lying around the
goserelin to be equally effective, with 71% of ovaries, uterus, bladder, and bowel (white arrow).

104 Pelvic Pain Management

satisfaction surveys for PCS coil embolization in
patients with chronic pelvic pain who initially
consulted for lower limb venous insufficiency (n =
202; mean age: 43.5 years; range: 27–​57; follow-​up
at 1, 3, and 6 months and every year for 5 years).
Patients with lower limb varices and chronic
pelvic pain (>6  months), >6  mm pelvic venous
caliber in ultrasonography, and venous reflux or
presence of communicating veins/​collaterals were
recruited prospectively.19 They used coil occlusion
alone, and targeted all refluxing veins, includ-
ing both ovarian and refluxing branches of both
internal iliac veins. Pain level was assessed before
and after embolotherapy and during follow-​ up
using a visual analog scale (VAS). Technical and
clinical success and recurrence of leg varices were
recorded as 100%, 93.85% (n = 168)  and 12.5%
(n = 24), respectively. VAS was 7.34 ± 0.7 prepro-
cedurally, versus 0.78 ± 1.2 at the end of follow-​
up (P < 0.0001). Complications were reported as
FIGURE 11.12:  A 32-​year-​old female patient with unre-
follows:  groin hematoma (n = 6), coil migration
solved PCS confirmed on right ovarian venography.
(n = 4), reaction to contrast media (n = 1), and
Post–​coil embolization final DSA image during Valsalva
post-​procedural pain (n = 23).
demonstrates sets of embolization coils—​all completely
In 2008, Gandini et al. reported the use of 3%
blocking the right ovarian vein (white arrow) without
STS as a sclerosant without using endovascular
any reflux.
coils in patients with PVI (n = 38; 2 mL of STS
mixed with 8 mL of air). These injected foam
the women reporting ≥ 50% reduction in pain until pelvic venous stasis was visualized. Total
score at less than one year follow-​up.28 Chemical injection volumes used were 30 mL and 20 mL
ovarian ligation is not without adverse effects; on the left and right, respectively. Of note, the
estrogen replacement therapy is often required. right-​sided incompetency was treated only when
It is unclear if the benefits of chemical ligation varices did not cross the midline from left to
for pelvic varices are long lasting. right. Clinical success rate was reported in 100%
Hysterectomy with removal of one or both of their cases. Lower procedural cost and less
ovaries was performed, with a response rate of radiation time are the benefits with a sclerosant-​
75%. However, studies reported residual pain in only approach over coil embolization.32
33% of patients after hysterectomy. This led to Kim et  al., in 2006, evaluated the long-​term
the advent of less invasive procedures such as clinical outcome of transcatheter embolotherapy
extraperitoneal surgical ligation or resection of in women with PCS caused by ovarian and pelvic
ovarian veins, as described by Rundqvist et  al.29 varices (n = 131; mean age, 34.0  years +/​–​12.5).
Laparoscopic ligation of bilateral ovarian veins Basal female hormonal levels were obtained before
gained popularity, with a response rate of 75%.30 and after the embolotherapy and compared.
However, the carbon dioxide insufflations into Percutaneous transfemoral venography con-
the peritoneal cavity during laparoscopy cause firmed the presence of ovarian varices in 127/​131
venous decompression, thus not allowing an (97.0%), and all were treated with embolother-
accurate estimation of pelvic varices, therefore apy. Of these, 108/​127 (85%) underwent internal
decreasing procedural efficacy. iliac embolotherapy. In 97/​127 at long-​term clini-
Surgical treatment for PCS has evolved dra- cal follow-​up (mean 45  months+/​–​18), the mean
matically since the 1980s. Successful bilateral pelvic pain level improved significantly, from
ovarian vein embolization using steel endovascu- 7.6 +/​ –​
1.8 before embolotherapy to 2.9 +/​ –​
2.8
lar coils was first reported by Edwards et  al. in after embolotherapy (P < .0001). Overall, 83%
1993.31 The procedure is usually performed at the of the patients exhibited clinical improvement
time of diagnostic venography. Recently, Laborda at long-​term follow-​up; 13% had no significant
et  al., in 2013, analyzed the clinical outcome and change; and 4% exhibited a worsened condition.

Incapacitating Pelvic Congestion Syndrome 105

No significant change was noted in hormone lev- that coil migration occurred in 3% (n = 2) of the
els after embolotherapy, and successful pregnan- cases (pulmonary circulation = 1 [retrieved with
cies were noted in two patients after ovarian and snare], and left renal vein = 1 [retrieved with
pelvic vein embolotherapy. snare]). Coil migration in rare circumstances can
Maleux et  al., in 2000, reported their results occur partly because of disparity between the
of ovarian vein embolization for the treatment size of coils and the size of dilated ovarian veins,
of PCS.33 In their study, all cases (n = 41; mean which can change in their diameters, depending
age, 37.8  years) had pelvic pain and varicosities on pelvic venous hemodynamics. A  guide cathe-
detected on ovarian venography. Of 41 cases, ter can be used to provide additional stability and
32 patients underwent unilateral embolization, support for coil delivery. However, in the setting
and nine patients underwent bilateral emboli- of incompetent veins, assessing the true diameter
zation. Embolizing material used were the mix- of the dilated vein can be a difficult task.
ture of enbucrilate + lipiodized oil (n = 40)  and
enbucrilate + minicoils (n = 1). They reported CONCLUSIONS
a technical success rate of 98%, with pain relief Most PCS patients are asymptomatic. In the
in 58.5% of their cases (mean clinical follow-​ recent past, an equivocal diagnosis of PCS/​
up:  19.9  months). Later, Kwon et  al., in 2007, chronic pelvic pain left many patients untreated,
evaluated the therapeutic effectiveness of ovar- leading to inappropriate use of opiate and non-​
ian vein embolization using coils for PCS.22 They opiate analgesics. Diagnosis of PCS is made by
enrolled 67 patients, all confirmed on ovarian clinical history, physical examination findings,
venography, and undertook left ovarian vein and imaging that demonstrates ovarian and pel-
embolization (n = 64), right ovarian vein embo- vic varicosities.
lization (n = 1), and bilateral ovarian vein embo- Patients with severe venous disability symp-
lization (n = 2)  using 0.035–​ 0.038  inch coils toms may benefit from an endovascular inter-
(5–​15 mm; average: 5.8 coils; range: 3–​8; COOK, vention after conservative medical treatment has
US). Fifty-​five of 67 patients (82%) experienced failed. In addition to being less expensive than
pain reduction with coil embolization alone; all surgery, endovascular ovarian vein embolization
were satisfied, and did not pursue any further offers a safe, effective, minimally invasive treat-
treatment (mean follow-​up: 44.8 +/​–​21 months). ment option that restores patients to their normal
Immediate complications of coil migration were quality of life. The procedure is highly successful
recorded in 3% (n = 2)  of the cases (pulmonary in blocking the retrograde blood flow, with tech-
circulation = 1 [retrieved with snare], and left nical success rate of 95-​–​100%. Overall, 85–​95%
renal vein = 1 [retrieved with snare]). of women have demonstrated improvement in
Results from studies mentioned above have their pain symptoms after the procedure.
demonstrated that PCS patients who underwent
ovarian vein embolization have an acceptable
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it may be that this develops independent of nothing to do with inflammation.4 Given that this condition is The term “prostatitis” may be confusing for this found in a relatively consistent rate across conti- condition. the presence of white blood cells in EPS. In a study of 30.000 population for prostatitis.8-​fold treatment of CPPS has evolved.7 While a history of STD seems to lead a challenge as these aspects include areas out. However.1 vic pain syndrome. 12 Male Pelvic Pain M I C H E L A . a large group of men with CP/​CPPS to asympto. immunological and psychological could be a first step. patients with CP/​ is considered a multifaceted chronic pain syn. inflammatory/​ autoimmune seminal plasma. The symptoms of CP/​CPPS are similar to that The NIH definition of CP/​CPPS is genito. Now it Network study (CPCRN). there have been no clinically significant differences demon. inflammatory. Category III is still CP/​CPPS are unknown. In comparing environmental factors specific to a given society. with. The Urological Disease in America ilar amounts of inflammation in either expressed study reported an annualized visit rate of 1798/​ prostatic fluid (EPS). G H O R M O Z C hronic prostatitis/​ drome (CP/​ chronic pelvic pain syn- CPPS) is a symptom complex characterized by pelvic pain. CP/​CPPS can present controls.1 The diagnosis and transmitted disease were found to have 1.1% for chronic prostatitis/​chronic pel- NIH classification of prostatitis as category III. with or without International d’Urologie indicated that prevalence of prostatitis-​ like symptoms ranged from 2. both groups had sim. A recent review for the International Consultation prostatic fluid and post prostate massage urine on Urological Disease (ICUD) and Societe or seminal plasma. of a true prostatic infection. post prostate massage urine 100. diagnostic history of urethritis compared to age-​matched challenges and treatments.5 (VB3). to greater risk of CP/​CPPS. There is also no dif- ference in the routine cultures of men with CP/​ EPIDEMIOLOGY CPPS and asymptomatic controls from urine. CPPS were found to have a significantly greater drome with varied presentations. P O N TA R I A N D E M M A N U E L A . etc.2% to 16%.000 male health profes- diseases which can produce pelvic pain such as sionals. trauma.2 Eight percent of men had . there is no evidence side of the usual scope of Urology. CP/​CPPS is included in the mating 7. Prostatitis results in a substantial number of phy- matic age matched controls. men who reported a history of sexually bladder cancer. with dence to support a possible role for infection. there is evi- subdivided as category IIIA. VB3 or neurological causes. including of an active STD in these men. and psychological factors. sician visits. or IIIB. This also implies the absence of other toms.2 The term prostatitis is a holdover from a time when it was assumed that ETIOLOGY men with pelvic pain had prostate inflammation The etiology and much of the pathogenesis of as the cause of the symptoms. with a median prevalence rate approxi- voiding symptoms. infec- urinary pain in the absence of uropathogenic tion has been commonly assumed by patients bacteria detected by standard microbiological and clinicians alike to be the cause of the symp- methods.3 after the infection resolves. Many years (and higher odds of prostatitis. The pain of CFP/​ CPPS may have nents. Infection strated between these two subclasses.8 Thus. or seminal plasma. with symptoms persisting factors that influence the disease process. non-​inflammatory.6 In the NIH spon- not so long ago also) it was thought to be just sored Chronic Prostatitis Collaborative Research an infection and treated by antibiotics. out the inflammatory cells. STD neurological.1 To date. Therefore.

10 Thus. on the efferent side showed that when on tourinary tract. Also significant cates that asymptomatic men appear to routinely was a history of vertebral disc disease/​surgery. Some men with CP/​CPPS have an lap of afferent nerve fiber distribution. The findings in men interferon-​γ in men with CPPS than controls. showed alterations in the heart rate variabil- lished in both types of mice.14 Men with CPPS demon. underscoring the over- conclusive. An informa- men with CPPS have inflammation related to tive animal model that provides a mechanistic the prostate. but may not by There is evidence for differences in the nerve themselves produce disease or symptoms. there was little change in men with CPPS. This indi. controls.24 In the study by Men with CP/​CPPS were 5 times more likely Zermann et al. trols. although infection was estab.12. Only about one third of men with demonstration is that of chemical irritation of clinical CPPS have been found to have prostatic rat prostate or bladder. 173–​192. detrusor sphincter dyssynergy in 73% of cases. Uropathogenic group of men with CP/​CPPS and controls con- bacteria including uropathogenic E coli (UPEC) firmed pilot data and again showed that men express virulence factors that produce the abil. a strain of the perineum but not the anterior thigh com- bacteria called CP1 from a man with CP/​CPPS pared to controls18. Whereas measures of that certain bacteria in certain individuals can parasympathetic activity decreased in the con- produce pelvic pain. the symptom that most contributed to the pelvic floor in men with CPPS showed that .23 An EMG study of cohort. men with CP/​ CPPS C57BL/​ 6J mice.20 FMRI increased T cell response to seminal plasma studies of the brain have shown differences in compared to controls.. it is clear that not all (or centralization) of the nerves. ness and tingling in the limbs.17 These data indicate the likeli. sem- inal vesicle secretory protein 2. have pathological tenderness of the striated pel- ease compared to asymptomatic age matched vic floor muscle and poor to absent function in controls in the chronic prostatitis collaborative ability to relax the pelvic floor efficiently with research network (CPCRN) study. and inflamma- at individual cytokines varies widely and is not tion in the other organ. This indicates alterations in induced and sustained chronic pelvic pain that the afferent autonomic nervous system. Studies persisted after bacterial clearance from the geni.16 with CPPS differ from those in other pain con- Men with CP/​CPPS have also been reported to ditions including low back pain. results the chronic pain. CPPS patients were found to to self-​report a history of nervous system dis. Thermal sensitivity tests given to the istics of the bacteria. it may be ity compared to controls. causes c-​fos expression at spinal cord levels L6 mation the degree of that inflammation does and S1 along with plasma extravasation at the not correlate with symptoms. What function of men with CP/​ CPPS compared to may be of importance are the specific character.9 In an animal model. and sympathetic activity increased in the con- Inflammation trols and decreased in men with CP/​ CPPS.22 have autoantibodies against human SVS2.19 The term prostatitis implies inflammation of the Both these studies support central sensitization prostate gland. Irritation of either organ inflammation on biopsy.108 Pelvic Pain Management uropathogenic bacteria and roughly 70% had the difference in neurological disease was numb- some form of bacteria in each group. Not all E coli will produce perineum and anterior thigh in a much larger the same infection or symptoms. CPPS are noted on urodynamic studies to have hood of autoimmunity in some men with CPPS.7 In this NIH a single or repetitive effort. have bacteria in the prostate. with CP/​CPPS were more sensitive to heat in ity to infect. However.11 In those with inflam. Interestingly the pelvic pain was 5 minute resting supine and standing blood produced in the NOD strain of mice but not pressure measurements. the relationship of gray and white matter in strate an increased lymphoproliferative response men with CPPS compared to controls.13 Data looking identical L6 and S1 dermatomes. This is normally seen in patients with supra- Neurological Causes sacral spinal cord lesions. develop B and T cell immune responses also cause spam in the pelvic floor.23 Men with to this protein.21 It is not to prostate antigens compared to controls. or are abnormalities that lead in greater activation of CD4 cells and release of to pain in the first place.15 known if changes in the CNS are as a result of A  region of the PAP molecule. which in mice Pelvic Floor Dysfunction deficient in the autoimmune regulator gene Neurological abnormalities are postulated to (aire).

There are no pathognomonic biological markers viduals on the basis of the psychosocial context or pathology for either CP/​CPPS or IC/​PBS. men with CPPS had (1) voiding symptoms can be obtained from the greater preliminary resting hypertonicity and AUA symptom score. of perceived stress in a study of men with CPPS and found that greater perceived stress during the Sexual Dysfunction 6 months after the health care visit was associated We have come to recognize the prevalence with greater pain intensity (p = . or pain radiating down the legs should prompt logical variables in this cohort showed that help.3 There is overlapping innervation and inhibit the suppression of significant pain of the bowel and bladder. frequency.33 A  more detailed assessment of systemic chronic pain syndromes. The clinical the common association of psychological stress importance is to remember to assess for symp- and symptoms.26 another symptom based syndrome whose current diagnosis is made when there is pain with bladder Psychosocial Factors filling.3 Fibromyalgia . syndrome. as in addition been previously diagnosed with CP/​CPPS. an evaluation with a lumbosacral MRI.27 It is known that stress with a diagnosis of ED were more likely to have has physiological consequences.34 One limitation to the NIH instability and (2) lowered voluntary endurance CPSI is that it does not have questions about pain contraction amplitude. be present in both conditions. bacte. men with CP/​ CPPS The possibility of lumbar-​sacral disk disease self-​reported a history of anxiety or depression should be assessed by history and physical twice as often as age matched controls with no exam. and/​or pain relieved by bladder emptying The same biological nociceptive process will result in the absence of other pathological conditions.7 Further detailed investigation of psycho. Interstitial have more tender points in areas outside of the cystitis or painful bladder syndrome (IC/​PBS) is pelvis as compared to controls. If any such symptoms Pain and Voiding Symptoms are present he should see a gastroenterologist. even after controlling for with CPPS.003) at 12 months.25 Men with CPPS also thought to be related to the bladder.36 A  case control study of a large age. in which biochemical changes alter the DNA and effect function. diarrhea. A  complaint of back pain with numbness pain. Male Pelvic Pain 109 compared to controls. National Institutes of Health Chronic Prostatitis Symptom Index (NIH-​CPSI) is helpful to assess Rheumatological pain location. and the relation of discom- Symptoms fort to bowel movements. Ullrich and colleagues used measures pelvic pain. mast cells release their sexual function in these men. and pain and disability Taiwanese health database showed that men during the first 6 months.32 experimental models results in inflammation of the other. but also raises the contents in response to stress28. symptom duration. severity and effect on Men with CP/​CPPS may be at higher risk for quality of life. Chronic stress questions about what common mechanisms may also changes DNA by epigenetic modifications. lessness/​catastrophizing predicted overall pain along with urinary symptoms and depression.38 Irritation of one in leading to chronic pain. Later studies have confirmed this toms of bladder pain in men who present with association. The term “stress prostatitis” was both are symptom complexes.30 GI The helplessness subscale of catastrophizing also Men with CP/​CPPS are more likely to have other predicts the mental subscale scores on the SF-​12 chronic pain conditions such as irritable bowel in these patients.37 This to many other stimuli such as cytokines.29 Some of these changes are Non-​urological Symptoms reversible and some are not. The same symp- used in the late 1980’s to describe CP/​CPPS given toms may co-​exist in one individual.35 in a different pain experience in different indi. both emphasizes the need for the assessment of rial toxins and hypoxia. Fibromyalgia and Chronic fatigue phizing may activate central attention centers syndrome.29 Neurological In the CPCRN study.31 It is postulated that catastro.03) and disability of sexual dysfunction in even young men (p = . as of that process.39 The evaluation therefore of men with E VA L UAT I O N CP/​CPPS needs to assess problems such as con- stipation.

Infection.38 points in the pain toms. non-​ as a cause of pelvic pain. ment in CPSI score vs. Other organisms thought to be potentially patho- tive hyperemia index. Neurological/​Systemic determined to be both statistically and clinically and Tenderness of skeletal muscle. placebo-​ controlled studies have Psychological Symptoms failed to consistently show meaningful benefit.47 Another study quotes Antibiotics up to a 75% response rate in patients who are Although the definition of CPPS is the absence culture positive for non-​uropathogenic as well of a uropathogenic source. Mycoplasma genitalium. This classi. the quality of life domain. antibiotics were associ- and can include several different types of symp. viously been treated with antibiotics. and a decrease of 0. gram-​ negative enteric bacteria such as E.7 points in includes the categories of Urinary. Even in young men.  aureus. This study uation of the urine.5% T R E AT M E N T and 72. meta-​analysis of 35 studies examining all treat- ments for CP/​CPPS found that total NIH-​CPSI UPOINT Classification symptom scores decreased by 1. placebo (−​5. that in all studies of antibiotics examined in this meta-​analysis.04 points in the void- colleagues in the UPOINT classification.  epi- cular dysfunction. and dence to the efficacy of antibiotic therapy in referral made for untreated hypertension. and Men in the CPCRN study were six times more Pseudomonas aeruginosa. it likely to self-​ report a history of cardiovascu. Pain infection. and had been Men should have a urinalysis to look for signs heavily pre-​treated with antibiotics. alterations in arterial stiffness and lower reac. These conditions should be terial prostatitis prostatitis (category II) include further evaluated by a rheumatologist.42 Post void residual urine compared patients with prostatitis-​ like symp- should be checked to rule out urinary retention toms and uropathogenic (Group  1) vs. 70. Psychosocial. Cardiovascular Klebsiella pneumonia. Bacteria classically accepted as uro- with significant fatigue may indicate chronic pathogenic and implicated in true chronic bac- fatigue syndrome.43 endothelium is unclear. This has been well outlined by Shoskes and domain. had positive clinical response.7 A  recent Enterococcus faecalis can probably also be report indicates that men with CPPS also have included on the list of uropathogenic bacteria. Untreated mental health issues end of treatment or end of follow-​up. These findings were Organ-​Specific.6 vs.8% in groups 1 and 2. Ureaplasma autonomic dysfunction and/​or localized to the urealyticum. Proteus mirabilis. insignificant and recommendations against their fication is a convenient way to remember the use could be inferred. genic include S. point reductions at 12 weeks follow-​ up).  saprophyticus. There are no published criteria for the psycholog. a decrease of 0. uncontrolled studies have lent cre- note should be taken of the blood pressure.45 It is important to note assessment and is also available online.110 Pelvic Pain Management manifests as pain in many areas of the body. but depression. trachomatis. When broken down into the individ- patients meeting the criteria for CPPS is variable ual NIH-​CPSI domains. uropathogenic (Group  2) bacteria localized to the prostate. but large randomized.41 This ing domain. measures of cardiovas. In recent years.46 of infection. and C. especially hypertension.8 with antibiotic It has become clear that the phenotype of treatment.40 Whether this is related to dermidis.44 A  2012 make treatment of chronic pain very difficult. Fluoroquinolones have demonstrated improve- ical evaluation of men with CP/​CPPS. many symptoms as uropathogenic bacteria with short symptom of CP/​ CPPS overlap with those of prostatic duration (mean 4 weeks) and without previous . ated with a decrease of 0. S.1 men should be queried about significant anxiety. respectively. patients had an average duration Lab Tests of symptoms measurable in years. However. or unevaluated hematuria. no statistical or clinical difference was found at sive behavior. ameliorating patients’ symptoms. has become accepted that the gram-​ positive lar disease. Small.  coli (the most prevalent gram negative pathogen). The One study of importance looked specifically diagnosis of hematuria should be suspected by at patients with average symptom duration of a positive urine dip but is confirmed by finding 8 weeks and only 41% of patients having pre- 3 or more RBC per hpf on a microscopic eval. S. At 6  months of follow-​up. and symptoms of obsessive compul. −​3.

especially if they with short duration of symptoms. The NIH-​CPSI survey was cant placebo effect. Of 5. placebo controlled study of prostate cancer risk mation of the prostate. certain group noted a significant decrease in CPSI total antibiotics.7 (95% CI 1. titis like pain. macokinetic properties allowing for high prostatic erectile dysfunction and possible the symptoms concentration make this class of antibiotic a good of CP/​CPPS as well.56 The proposed drugs are not recommended in cases associated mechanism of action of hormonal agents like with typical pathogens. the dutasteride turable from prostate specimens.4–​2. improved voiding param- raised in regard to these recommendations as eters and reduced intraprostatic ductal reflux.49 If there is no response at this randomized trial used the alpha blocker silo- time. men with CP/​CPPS. for the Medications for Neuropathic Pain response seen in patients without culture proof Patients with suspected neuropathic pain can be of bacterial localization.53 Alpha biotics in the absence of a positive urine culture blockers certainly can play a part of therapy in is not accepted therapy.48 Whether this is clinically significant is not clear. rate according to change in CPSI score. After 48  months. One limitation is the side Fluoroquinolones have been shown to be effec. Male Pelvic Pain 111 antibiotic treatment.49 The conclusion was however that alpha combination with alpha-​blockers.5–​10 ng/​ml therapy? First. treatment should be stopped. the evidence presented above. antibiotics may have a signifi. The recommendations at this point in our and the authors of the analysis concluded that understanding can be summarized as fol.55 treatment option. with a risk ration of 1. have score. treatment should be carried out for an naïve men. anti-​ tistically significant overall benefit (reduction in inflammatory medications were noted to produce symptom score) to antibiotic treatment. at least in part. finasteride and dutasteride involve regression One question that has consistently been of glandular tissue. Men must be tis for patients who are antibiotic-​naïve and those counseled about this possibility.49 An empiric blockers appear to achieve improvement in four week course of antibiotics is an accepted symptoms compared to placebo. using Tamsulosin or Silodosin. In a met-​ analysis of treatment trials. although an improvement in symptoms compared to pla- they admit that this may or may not translate to cebo. anti-​inflammatories should be used as part of lows:  antibiotics are not recommended in mutli-​modal therapy. a 5-​alpha reductase inhibitor may help reduce cyclines) and Mycoplasma (tetracyclines).43 The case has also been made that macrolides and tetracyclines may be used as 5 Alpha Reductase Inhibitor (ARI) second-​line agents in treating chronic prostatitis In older men with larger prostates. however. how can we explain the reduction using 0. 12.51 started on meds such as tricyclic antidepressants .48 Subsequent meta-​analyses Anti-​inflammatory Agents have been optimistic as well. There was a significant response addition 2–​4 weeks.56 been shown to have an anti-​inflammatory effect that may be responsible. their spectrum of activity (which includes both uropathogenic and PDE5 Inhibitor non-​uropathogenic bacteria) as well as their phar. no evidence of bacterial invasion or no inflam. finding a small sta.50 These pain and urinary symptoms.54. In addition to are younger and still in their reproductive years. be useful in Nickel reviewed clinical evidence on alpha block- patients who are antibiotic-​naïve and in those ers for treatment of CP/​CPPS and found mixed with short duration of symptoms.379 men. clinically meaningful benefit to patients. randomized.48 They may. with negative TRUS).52 patients who have a long duration of symptoms or in those who have failed previous antibiotic Alpha Blockers treatment. If a response dosin for treatment of CPPS in 151 alpha blocker is noted. Finally.6% had prosta- uropathogenic or not routinely cultured or cul.1). the use of associated with chlamydia (macrolides and tetra. double-​blind.51 Antibiotics may also be used to measure baseline and change in symp- effective by removing bacteria not considered tom severity.5 mg dutasteride versus pla- benefit we see in certain studies of antibiotic cebo in men at risk (age 50–​75. The most recent initial therapy.50 A repeated course of anti. particularly in results. Tadalafil can treat lower urinary tract symptoms. it relates to category III prostatitis is:  If there is REDUCE is a 4 year. PSA 2. effect of retrograde ejaculation usually seen in tive and are recommended in category III prostati. especially fluoroquinolones.

A  study from the NIH sponsored 10 weeks. about the condition) can prompt routing psycho- pregabalin may be effective.50 (95% CI = 1. Krieger Stanford has made significant contributions to and colleagues performed a sham acupunc- this area with their studies on myofascial release ture procedure in the setting of a randomized.69 For the sham.017). or to It has been well documented in recent studies those who would prefer to not take medications the effect of psychological variables on the pain for their discomfort. In the et  al examines the relationship between CP/​ IC studies.59 A  randomized placebo controlled ease prevalent in young men. catastrophizing (helplessness and hopelessness This suggests that in a subset of men with CPPS. The use of perineal injection of evidence precluded making firm conclusions Botulinum toxin has also been reported to relax in favor of acupuncture. 57% to 21% (P  =  0. away from the true acupuncture sites.58 The dose should over a three year follow up in 18. the dosage needed may vary. apy to address these issues. tender muscle/​trigger points.51). a better response was seen if the dose CPPS and risk of subsequent depressive disorder was increased up to 50 mg.71 In clinical practice.03). 63. Amitriptyline has been experience and quality of life in men with CPPS. monthly income.67 CP is already a dis- fibromyalgia. After trol the study. The authors con- Pelvic floor PT can also be combined with the cluded that the evidence for the efficacy of acu- use of skeletal muscle relaxant medications such puncture for treating CPPS was encouraging.60 However.36–​1. Referral to in men with CPPS. reach the primary endpoint. several Recognizing signs of depressive disorder and secondary endpoints were significantly improved. nee- One of the difficulties in assessing the effects dles shorter than standard were placed 0.68 Treatment of Pelvic Alternative Treatments Floor Dysfunction Several recent publications looked at the effect One area that has seen the greatest improve. gender. as Tizanidine or valium. that met criteria for inclusion. Tight muscles in the is unknown. start low. these psychological factors include traditional higher doses of 300 mg per day have been used therapy with a psychologist or psychiatrist. A  study of pre. patients undergoing myofascial therapy of electrical stimulation in addition to needle had a significantly greater response on global placement has also been used and shown to be assessment response than the therapeutic mas. an anti convulsant that is approved for CP was a significant predictor for development neuropathic pain in other conditions including of Depressive Disorder with a hazard ratio of post herpetic neuralgia. the sham group (p  =  0. but those <30 are trial of pregabalin in men with CPPS showed an at greatest risk of subsequent depressive disorder effect that approached significance but did not with a hazard ratio of 2.63 (95% CI = 1.5  cm of pelvic floor physical therapy is how to con.306 patients.18–​4. it can be suggested to individuals who do Psychological Therapy not respond to first line medical therapy. region.66 widely used in women with Interstitial cystitis57 A prospective.64 Although not and leucine encephalin levels were both higher powered or designed to be a definitive outcome in the acupuncture group (p < 0. but can be postulated to have an pelvic floor lead to tender areas.96). The use study.112 Pelvic Pain Management or anti convulsants. Some for diabetes and up to 450 mg per day for fibro.65 given the relatively few side effects of acupunc- ture. The mechanism of the improve- ment in diagnosis and treatment has been in ment in CPPS symptoms after acupuncture pelvic floor dysfunction. researchers are developing cognitive based ther- myalgia. 73% of the true acupuncture group UPPCRN group showed the feasibility of using had a clinical response. orally or as a rectal but the quantity and quality of the available suppository.61 Therefore. of acupuncture. Options for our patients with with CP/​ CPPS responded to 150 mg per day. Beta endorphin ing myofascial physical therapy. controlled clinical trial. diabetic neuropathy and 1. geographic up as needed and as tolerated. compare to 47% of global massage as a control for patients undergo. .70 A  systematic review of a physical therapist who is familiar with pelvic trials of acupuncture in the treatment of CPPS floor physical therapy techniques is an important identified 9 clinical trials involving 890 patients part of the treatment of many men with CPPS. superior to sham and advice and exercise alone sage group. usually 10 mg po qhs and then titrate After adjusting for age. and treatment of pelvic floor dysfunction 62. Although some men logical assessment. population based study by Chung but data in men with CPPS are lacking.01). The group from ameliorating effect on neuropathic pain. BPH and incontinence. gabalin.

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38:279. 2009. Electroacupuncture relieves pain 73.91:561. Lee SH. 72. Urology. a prospective study using UPOINT. Effects of in men with chronic prostatitis/​chronic pelvic pain exercise training and detraining in patients with syndrome:  three-​arm randomized trial. Urology.73:1036. de Hoyo M. fibromyalgia syndrome: a 3-​yr longitudinal study. Kattan MW. Nickel JC. chronic prostatitis/​chronic pelvic pain syndrome: 2012. prostatitis/​chronic pelvic pain syndrome. Shoskes DA. Sanudo B. 2011. Lee MS.116 Pelvic Pain Management 70. Urol Clin North Am. J Androl.33:15. for chronic nonbacterial prostatitis/​chronic pel. Quercetin for chronic 2010. Zhang J. Phenotypically directed multimodal therapy for vic pain syndrome: a systematic review. . Acupuncture 74.75:1249. 71. et al. Am J Phys Med Rehabil. Posadzki P. Carrasco L. et  al. 2012. Nickel JC. Shoskes DA. Lee BC.

described in of the physicians to whom these patients pres. After obtaining a detailed anti-​ inflammatory medications (e. trauma. dysfunctions of the piriformis looking in particular at range of motion. lumbar pelvic pain. Figure 13. and HIP testing muscle strength. and vic pain. pelvic pain clinic. Furthermore. such as endometriosis. The initial treatment of cia. The straight leg raise.1 While many distribution. including the groin. L E S L E Y E . a thorough physical examination. NSAIDs). the clinician must perform ness. The presenting symptoms. It will emphasize result in abnormal stresses in the hip joint. In all cases. and lumbar ple radiographs. International Association for the Study of Pain. developmental hip dysplasia and femoroacetab- view of some of the common musculoskeletal ular impingement. and useful treatment modalities. as occurs from herniated and treatment of problems of the muscle. including a history of trauma Saddle anesthesia. Hip pathology may manifest as pain in a vari- Additional imaging studies such as ultrasound. Initial evaluation of these disor- senting for evaluation at an academic chronic ders should be via history and a physical exam. This exam should prompt urgent imaging of the lumbar should include the following:  observing the spine and possibly neurosurgical evaluation. Diagnosis of bone abnormalities. or pelvis. result of these conditions is often osteoarthritis. radicular pain. physical exam findings. Musculoskeletal disorders are also plexus (L1–​S4). which may be the result of myriad conditions. and thigh. sensation. with or without referred should also be considered as a possible comor. Disorders of the spine may manifest as pel. these conditions is usually physical therapy and tively straightforward. not only those who have plexopathy. tumor. plexopathy stems from insult to the lumbosacral or pregnancy. respectively. buttock. poste- CT scans. Three such important disorders are osteoarthritis can often be achieved with sim- discogenic pain. such as degenerative joint disease. B O B B . patient’s gait and posture while seated. Management of osteoarthritis . that may result in such pain are congenital or orders. and reflexes. unreveal. thigh. and MRIs are often not required to rior pelvis. A B R E C H T. rapidly worsening weak- or athletic injuries. however. pain. study examining female pelvic pain patients pre. fractures.3 Some of the conditions make the diagnosis of most musculoskeletal dis. in turn. fas. groin. stems bid condition in patients with known causes of from insult to the lumbar nerve root. medical history. in which loss of the protective cartilage in the hip joint results in pain that is usually worse in SPINE the morning and with weight-​bearing activities.1. and sensory changes in a dermatomal rates of 14% and 22%. ovarian cysts. intervertebral discs.g. visualiz- ing and palpating the spine and pelvic joint. VA L OV S K A M usculoskeletal disorders should be con- sidered in all patients presenting with chronic pelvic pain. the approach is rela.2 Lumbar radicular pain. According to the already undergone an exhaustive. muscle and levator ani muscles were found to occur at strength. may be used to evaluate for nerve ent may not be well trained in the diagnosis root compression. patients may expe- a frequent cause of pelvic pain: according to one rience pain in the lower back. and incontinence of the bladder. or radiation. This chapter will provide a brief over. and connective tissue.. 13 Musculoskeletal Causes of Chronic Pelvic Pain C H R I S R . it intervertebral disk. given the often-​ lumbar discogenic pain stems from a lumbar multifactorial etiology of chronic pelvic pain. A N D A S S I A T. in which bony abnormalities disorders causing pelvic pain. ety of territories. ing workup.

degenerative joint disease. et  al. may .5 bilitation. walking. includes physical therapy and anti-​inflammatory and the insertion site of the adductors. Van der Windt DA. Treatment involves physical therapy treatment for this condition is conservative man. Physical examination for lumbar radiculopathy due to disc herniation in patients with low-​back pain. which the patient flexes the knees and hips at Coccydynia occurs approximately five times 90 degrees and then performs isometric adductor more often in women than in men and requires contraction against the examiner’s fist. seated position. or climbing COCCYX stairs. pain produced by direct pressure be hypermobility or hypomobility of the joint. the patient is positioned supine. Riphagen II. lying on one side. defined as inflamma. Simons E. often resulting from tenderness with palpation of the pubic symphysis arthritic changes at the sacroiliac joint. buttock. The specificity varied widely.1:  Straight leg raise test: To perform the straight leg raise. Image courtesy of James Bell. Conservative management is the main- muscles that attach distally to it. it is important upon exam to inquire about repetitive PUBIS activities and “the female triad” of amenorrhea. A single leg is then raised by the clinician. as well as the administration of non- Stress fractures of the pelvis may also result steroidal anti-​inflammatory drugs (NSAIDs). neoplasm. the pain may manifest have evaluated this intervention. provides weight-​ bearing support in the spring test is the most specific test for diagno. A positive a thorough work-​up to rule out referred pain pubic symphysis gap test consists of pain upon from the spine. if present. often marked by a prolonged Surgical repairs of coccyx fractures have been onset. or trauma Another test is the pubic symphysis gap test in leading to bruising. MRI may be used for diagnosis and staging of tion of the pubic symphysis and the abdominal fractures. or fracture. from 0. but no randomized controlled trials affected by this condition. the gender more frequently attempted. The direct ities. or SACROILIAC  JOINT scrotum. On physical examination. 2010. In females.92. running.1 to 1.g. A meta-​analysis found that the sensitivity of this test in a population with a high prevalence of disc herniation was 0. The mainstay of diagnosis.4 propensity of athletes to acquire this injury. X-​ray or MRI may assist in this performance of this procedure. Another possible cause of pain localizing to the osteopenia/​ osteoporosis.6 In males. indicating possible compression of the L4–​S1 nerve roots.(2):CD007431. and eating disorders. Cochrane Database Syst Rev. Reproduction of radicular pain at an angle of 30–​70 degrees is a positive result. should prompt an coccyx. This pain may stay of treatment. or thigh. These patients may also present with fever Another possible source of pelvic pain is the or chills. which. NSAIDs). to correct poor posture and for pelvic floor reha- agement. The etiology of coccydynia may sis: in this test.. in pelvic pain. which. the pain may manifest in the abdomen. along with the ischial tuberos- evaluation to rule out osteomyelitis. be worse with physical activity such as kicking.7 pubic area is osteitis pubis. including physical therapy.8 in the perineum.6 Given the agents (e.118 Pelvic Pain Management 90 75 60 45 30 15 0 FIGURE 13. on the pubic rami is considered a positive result. dislocation. there will be Sacroiliac joint dysfunction. perineum.

performed under fluoroscopy by interventional Hypertonicity of the pelvic musculature may pain management physicians. Treatment usually starts with behavior changes. cram- should report worsening of pain with provoca. posture. and pain in the perineum when sit- ting. high-​tone muscles noted during the pelvic exam. uri- nary or bowel incontinence. abduction. and physical ther- apy. that is flat. and back. Imaging is generally unrevealing.10 Diagnosis is usually achieved based on history and physi- cal exam. test. Myofascial pain syndrome is and groin. external rota. which can include biofeedback. diagnosis. banded. resulting in be either unilateral or bilateral. Another commonly involved muscle is the obturator internus. a condition affecting knee.com. hip. and the greater trochanter of the femur. It may be wors. While manner of pain around the sacroiliac joint and better known for causing chronic. but are not limited to. a procedure often standard. a variety of symp- The musculature of the pelvic floor is another toms may be present due to the important possible cause of chronic pelvic pain and may roles these muscles play in maintaining urinary and fecal continence. Musculoskeletal Causes of Chronic Pelvic Pain 119 result in sacroiliitis. and normal sex- ual function. radiating into the buttocks floor hypertonicity. or baclofen suppositories. lower back pain. such as Patrick’s or the nous muscles. The piriformis is a muscle tion of the patient’s sacroiliac joint pain. which. myofascial pain syndrome may FABER test (flexion. courtesy of Angela teus maximus with attachments at the sacrum Mark. In some cases. Regardless of the P E LV I C   F L O O R cause of the hypertonicity. cause of pelvic pain. The patient’s foot is PIRIFORMIS  MUSCLE positioned as depicted below the patient’s contralateral Piriformis syndrome. tizanidine. and located deep to the glu- Image modified from neckandback. the patient should complain of this when palpated. also present in the pelvic musculature. Commonly involved muscles include the levator ani resulting in pain in the coccyx. obturator internus. showing for instance. electro- myography may be obtained for confirmation. The myriad associated symptoms therefore include. plike pain in the trapezius and lumbar paraspi- tive physical exam tests.9 Identification and cessation diagnosis but should of course be considered to of the initiating trauma and trigger-​point injec- rule out other pathologies such as infection or tions consisting of the injection of local anes- tumor. be the result of pelvic or systemic disorders or could be a primary problem.2 Figure 13. such as avoidance of triggers. If those are unsuccessful.2:  Patrick’s test:  The Patrick’s test is per- formed with the patient supine. One tion of the hip). To make this classic “tender points” of muscle knots. A positive test will result in reproduc.11 FIGURE  13. Pressure is then applied to the patient’s knee and females more than males. thought to result from acute macrotrauma or ened by prolonged sitting or standing and may chronic microtrauma to muscles. as well as pain with bowel movements. soft-​tissue therapy. Treatment consists of an injection with thetic into these muscle bands are the treatment local anesthetic and steroid. additional available interventions include pharmacological therapy with amitripty- line. . it is not a requirement for piriformis muscles. a 71% prevalence of tender points either a normal-​appearing joint or non-​specific involving the levator ani. resulting in pain in the pos- terior thigh as well as rectal fullness. and arthritic changes. and dyspareunia.2 depicts the Patrick’s study of patients with chronic pelvic pain found. This pain is often described manifest as a myofascial pain syndrome or pelvic as in the lower back. is yet another possible contralateral hip. aching. and ultrasound therapy. but not past the knee. result in referred pain. with tender.

3:  Snapping hip maneuver.3. If hip maneuver may help diagnose iliopsoas syn- sciatic symptoms are produced with this maneu. The onset may be gradual or sudden. and anti-​inflammatory med- tenderness to palpation of the piriformis mus. or applying pres.12 The “Freiberg sign” refers the iliopsoas muscle. This condition may be seen to pain with passive internal rotation of the hip. One ting for long periods of time (particularly with of the tests indicative of iliopsoas tendonitis is legs crossed). trochanter deep to the gluteus maximus. in turn. Ludloff ’s sign. painful conditions associated with this muscle In type one. which lies deep to nerve by the muscle.15 Another muscle sometimes responsible for pel- vic pain is the iliopsoas. may be tenderness to palpation of the lesser Symptoms may be initiated or worsened by sit. These symptoms with pain starting in the buttock and sacroiliac may persist for years and be associated with a joint and progressing to symptoms resembling snap or click of the hip or groin. and which functions as a hip flexor. climbing stairs. stretching. onset. The snapping knee approximately four inches off the table. using proper form when performing repetitive and externally rotating the hip. indicating some impingement of the sciatic mation of the iliopsoas bursa. typically of gradual or an alternative nerve path. or those The “Beatty test” refers to placing the patient on with rheumatoid arthritis.14. Symptoms are similar the unaffected side while holding the superior to those of iliopsoas tendonitis. in which the patient sits with sure directly over the muscle. in athletes. Two athies deserve consideration when evaluating FIGURE 13. Treatment includes must be ruled out. with occa- ary to trauma or ischemia. a split sciatic nerve. patients with acute trauma. develops in the hip and groin. pain. abducting. and piriformis and the examiner places one hand on the ingui- syndrome is more likely. then the test is positive.15 Iliopsoas bursitis. Patients may present sional radiation to the knee. drome. the sciatic nerve is compressed due are iliopsoas tendonitis and iliopsoas bursitis. is inflam- cle. to a split piriformis muscle. therapy and anti-​inflammatory medications. heating or icing. Prior to accepting knees extended and then raises the leg approx- a diagnosis of piriformis syndrome. In iliopsoas tendonitis. On exam there sciatica.) Treatment includes physical inflammatory medications. Image courtesy of James Bell.120 Pelvic Pain Management There are two types of piriformis syndrome. In this maneuver. other causes imately 15 degrees. a muscle composed of N E U R O PAT H I E S the distal ends of the psoas and iliacus mus. Pain with this maneuver of sciatica such as degenerative disc disease is a positive Ludloff ’s sign. A  click in the activities such as running. rest. Type two is second. ications. the patient lies supine ver. intrabursal injections or even surgi- I L I O P S OA S   M U S C L E cal lengthening have been required. The “Lasegue sign” refers to resting. neurop- cles. Treatment includes last portion of the maneuver is a positive test.13 Prevention includes nal crease while passively flexing. and anti-​ (See Figure 13. In some cases. . physical therapy. Along with musculoskeletal disorders.

Musculoskeletal Causes of Chronic Pelvic Pain 121

a patient with pelvic pain. The causes of nerve only one side; patients are often able to indi-
injury resulting in a painful neuropathy are cate with a single finger the painful site at the
varied and include stretching, blunt trauma, lateral border of the rectus muscle from which
surgical trauma, fibrosis, and compression with the pain originates. Nerve blocks with local
hypoxia.16 By far the most important neuropa- anesthetic and steroid at these sites may be both
thy related to pelvic pain is that of the puden- diagnostic and therapeutic.18 Another entrap-
dal nerve, a mixed sensory and motor nerve ment syndrome involves the posterior femoral
originating from S2–​S4, which is discussed in cutaneous nerve, originating from S1–​ S3 and
detail in a separate chapter. Other important terminating as the inferior cluneal nerves, which
neuropathies include the closely related ilioin- supplies sensation to the caudal buttock and the
guinal, genitofemoral, iliohypogastric, and obtu- perineum. Here, compression at the insertions
rator neuralgias, as described in Table 13.1. The of the gluteus maximus and hamstring muscles
similarity of the anatomical territories affected may result in a neuropathy.19
by these blocks may require a diagnostic and A related nervous system disorder in which
therapeutic procedure to correctly identify the compression of nerve roots may result in pelvic
affected nerve. Either ilioinguinal or genitofem- pain is the Tarlov cyst. These cysts, also known
oral neuralgia may, for instance, be the culprit as perineurial cysts, are dilations of the menin-
in a patient with neuropathic pain in the inner ges between the perineurium and endoneurium
thigh and groin. Ultrasound-​guided block with in the posterior nerve roots which may grow
local anesthetic and steroid of the causative large enough to impinge on other neural struc-
nerve will result in pain relief. In a similar vein, tures. See Figure 13.4 for an anatomical illus-
a paravertebral block at T12–​ L1 may provide tration. The etiology of these cysts is unclear;
relief in ilsiohypogastric neuralgia, but less so theories include inflammatory cells in the cyst
for ilioginguinal or genitofemoral neuralgia. In walls, congenital malformation, or increased
addition, isolated muscle weakness may narrow hydrostatic pressure in the cyst walls. When
the diagnosis:  lack of a cremasteric relief may symptomatic, these cysts may cause radiculop-
suggest genitofemoral neuropathy, and dimin- athy, pelvic paresthesias, and incontinence of
ished thigh adduction may suggest obturator the bowel or bladder. Treatment includes anti-​
neuropathy.17 inflammatory medical management and physical
Nerve entrapment syndromes are an import- therapy. In refractory or severe cases, surgical
ant cause of neuropathic pain. “Abdominal cuta- treatment, including cyst resection at the neck
neous nerve entrapment syndrome” (ACNES) and surgical cyst fenestration, are available
refers to entrapment of the thoracoabdominal options.20
nerves terminating as the cutaneous nerves
supplying sensation to the abdominal wall. The CONCLUSION
thoracic corollary to this condition is intercostal Musculoskeletal and related nervous system
neuralgia. In ACNES, the most common entrap- disorders should be considered in all patients
ment site is at the lateral border of the rectus presenting with chronic pelvic pain, as the pri-
muscle, where the nerve passes through a fibrous mary or as a contributing cause of their discom-
ring and may be compressed, causing ischemia. fort. An anatomically structured approach may
This pain is usually well localized and affects be useful in narrowing a differential in these

TABLE  13.1  PERIPHERAL NEUROPATHIES ASSOCIATED WITH  PELVIC  PAIN
Somatic nerve Origins Sensory component Motor component
Ilioinguinal nerve L1–​L2 Inner thigh, groin, mons, labia,
penis, scrotum
Genitofemoral nerve L1–​L2 Inner thigh, mons, labia, scrotum Cremasteric reflex
Iliohypogastric nerve T12–​L1 Groin, symphysis pubic Transversus abdominus, internal
oblique
Obturator nerve L2,L3,L4 Medial thigh, groin Adductor longus, gracilis,
adductor brevis

122 Pelvic Pain Management

(A)
Myelin
sheath

Axon

Endoneurium
Perineurium

Epineurium

(B)

Tarlov cyst

Nerve roots

(c)

FIGURE 13.4:  Tarlov cyst: A. Tarlov or perineural cysts are dilations in the space between the perineurium and
endoneurium. B. These cysts may grow quite large, compressing adjacent neurovascular structures.
Image courtesy of Angela Mark.

patients. Consider disorders of bone (spine, 5. Rodriguez C, Miguel A, Lima H, Heinrich’s K.
hip, sacroiliac joint, pubis, coccyx), pelvic floor Osteitis pubis syndrome in the professional soccer
musculature, and pelvic neuropathies. Such an athlete: a case report: Journal of Athletic Training.
approach may identify important musculoskel- Oct–​Dec 2001;36(4):437–​440.
etal causes of pelvic pain and spare the patient 6. Hosey RG, Fernandez, MMF, Johnson DL.
unnecessary, invasive, and unrevealing tests. Evaluation and management of stress fractures of
the pelvis and sacrum. Orthopedics. 2008 April;
REFERENCES 31(4):383–​385.
1. Tu FF, As-​Sanie S, Steege JF. Prevalence of pelvic 7. Pepper M, Akuthota V, McCarty E. The patho-
musculoskeletal disorders in a female chronic pel- physiology of stress fractures. Clin Sports Med.
vic pain clinic. J Reprod Med. 2006;51:185–​189. 2006;25:1–​16.
2. Merskey H, Bogduk N. Classification of Chronic 8. Lirette LS, Chaiban G, et al. Coccydynia: an over-
Pain: Descriptions of Chronic Pain Syndromes and view of the anatomy, etiology, and treatment of
Definitions of Pain Terms. 2nd ed. Seattle, WA: coccyx pain. Ochsner J. 2014;14(1):84–​87.
IASP Press; 1994. 9. Gyang A, Hartman M, Lamvu G. Musculoskeletal
3. Lesher JM, Dreyfuss P, Hager N, et  al. Hip joint causes of chronic pelvic pain:  What a gynecolo-
pain referral patterns:  a descriptive study. Pain gist should know. Obstet Gynecol. 2013;121(3):
Med. 2008;9(1):22–​25. 645–​650.
4. Prather H, Camacho-​Soto A. Musculoskeletal eti- 10. Prendergast SA, Weiss JM. Screening for musculo-
ologies of pelvic pain. Obstet Gynecol Clin N Am. skeletal causes of pelvic pain. Clin Obstet Gynecol.
2014;41:433–​442. 2003;46(4):773–​782.

Musculoskeletal Causes of Chronic Pelvic Pain 123

11. Butrick CW. Pelvic floor hypertonic disor-
16. Perry CP. Peripheral neuropathies and pelvic

ders:  identification and management. Obstet pain:  diagnosis and management. Clin Obstet
Gynecol Clin N Am. 2009;36:707–​722. Gynecol. 2003;46(4):789–​796.
12. Boyajian-​O’Neill LA, McClain RL, et al. Diagnosis 17. Tipton JS. Obturator neuropathy. Curr Rev

and management of piriformis syndrome:  an Musculoskel Med. 2008;1(3):234–​237.
osteopathic approach. J Am Osteopath Assoc. 2008; 18. Applegate WV. Abdominal cutaneous nerve

108(11):657–​664. entrap­ment syndromes (ACNES):  a commonly
13. Robinson DR. Pyriformis syndrome in relation to overlooked cause of abdominal pain. Permanente
sciatic pain. Am J Surg. 1947;73:355–​358. J. 2002;6(3):20–​27.
14. Margo K, Drezner J, Motzkin, D. Evaluation and 19. Darnis B, Robert R, Labat JJ, et  al. Perineal pain
management of hip pain: an algorithmic approach. and inferior cluneal nerves: anatomy and surgery.
J Fam Pract. 2003;52(8):607–​617. Surg Radiol Anat. 2008;30:177–​183.
15. Tibor LM, Sekiya JK. Differential diagno-
20. Acosta FL, Quinones-​
Hinjosa A, Schmidt MC,
sis of pain around the hip joint. Arthroscopy. Weinstein PR. Diagnosis and management of sacral
2008;24(12):1407–​1421. Tarlov cysts. Neurosurg Focus. 2003;15(2):1–​7.

14
Pelvic Cancer Pain
J O N AT H A N S N I T Z E R , Y U RY K H E L E M S K Y, A N D K A R I N A G R I T S E N K O

EPIDEMIOLOGY on one’s course in treatment or stage of disease.
There is a variety of cancers involving both the Patients undergoing treatment for cancer had
viscera and the musculoskeletal structures of the a lower prevalence of pain, 59% compared to
pelvis, and these cancers can be either gender-​ 64% of patients with more advanced disease.6
specific or gender-​neutral. Some of the cancers Both groups, however, had significantly higher
occurring in both sexes include bladder, anal, rates of pain than patients who were successfully
rectal, colon, chondrosarcoma and osteosar- treated for cancer (33%).
coma. Gender-​specific cancers include prostate Cancer pain has also been associated with
and testicular cancer in men, and uterine, cer- emotional distress. Patients with depression
vical, ovarian, and vaginal cancer in women. have higher levels of pain than those who do
Cancers involving the pelvis are extremely com- not suffer from depression.7 Additionally, higher
mon and carry significant morbidity and mortal- pain scores are associated with significant cogni-
ity. For example, colorectal cancer is responsible tive impairment.8 Improving one’s mental health
for 10% of all cancers in the United States, with is directly correlated to treatment of the pain.8,9
approximately 147,000 new cases in 2009.1 More Untreated pain lowers one’s quality of life.10,11
recently, in the United States, there were 40,000 Additionally, there is evidence that earlier and
new cases of rectal cancer, 6,230 of anal cancer, comprehensive pain control may actually pro-
73,510 of bladder cancer, 241,740 of prostate long life.12 Ultimately, appropriate management
cancer, and 12,170 of cervical cancer in 2012. of a patient’s pain is essential to the overall suc-
Additionally there are approximately 46,000 new cess of therapy.
cases of uterine cancer each year.2 There are three general forms of pain that
The neoplasm itself, secondary to compres- occur in cancer patients:  somatic, visceral, and
sion of surrounding structures, or invasion of neuropathic. Somatic pain is due to direct stim-
surrounding tissue, may cause pelvic cancer ulation of nociceptors located in the skin and
pain. Pain may also occur as a result of treat- deeper musculoskeletal tissues. The pain is local-
ment (e.g., surgery, radiation, or chemotherapy). ized and is achy, throbbing, or sharp. Visceral
Specific agents known to cause neuropathies pain is due to abnormal distension, contractions,
include oxaliplatin, carboplatin, cisplatin, pacli- ischemia, or inflammation of viscera. The pain,
taxel, docetaxel, bortezomib, lenalidomide, tha- which is carried by autonomic fibers, is typically
lidomide, epothilone, and the vinca alkaloids.3 vague, dull, and poorly localized. Neuropathic
In one study, inpatients were found to have pain pain is due to compression of a nerve, direct
directly attributable to the tumor 78% of time, invasion of a nerve by the neoplasm, or neuro-
and only 19% of the time was the pain consid- toxic effects of medical treatments. The pain that
ered to be secondary to their treatment. In out- is described as shooting, electrical, and burning,
patients with cancer, the pain was attributed to is due to injury to the nerve itself.
the neoplasm 62% of time and 25% of time as
an adverse effect of treatment.4 Pain is extremely P E LV I C A N AT O M Y
common in cancer and occurs in over 50% of The anatomical pelvis is formed by the mus-
patients.5 Patients with cancer had pain as their culoskeletal components of pelvis and contains
presenting symptom 20–​50% of the time.5 The the pelvic viscera (e.g. bladder, urethra, vagina,
prevalence of pain varies significantly, depending adnexa, and rectum). The bony structure of the

which receives transverse colon. and. distal tion from the cavernous nerves. coccyx. the inferior plexus receives coccyx. a division of have both afferent and efferent nerve fibers. and fallopian tubes receive The pelvic viscera are supplied by both the sympathetic innervation from the uterovaginal sympathetic and parasympathetic systems and plexus or Frenkenhauser ganglion. The prostate capsule is densely inner- aortic bifurcation and extends from L4 to the vated and is very easily damaged by surgical sacrum. and both the inferior and superior hypogastric plexus the coccygeus and piriformis muscles. the parasympathetic ganglia are located cervical ganglia. of the spinal cord. The vagina. The plexus is located inferior to the plexus. The bladder. The greater gastric plexus. L1. Parasympathetic innervation is supplied receives motor parasympathetic fibers originating by the cranial nerves and the sacral segment in the S2–​4 level via the pelvic splanchnic nerves. visceral afferents back and forth from the inferior The pudendal nerve and obturator internus ten. The the inferior and superior hypogastric plexuses. glion impar just anterior to the coccyx. and S2–​4. and descending colon travel nerve fibers from inferior hypogastric plexus via through the plexus. The uterus. whereas the testes are innervated by the renal pathetic and parasympathetic fibers and noci. Posteriorly. testicular. the prostatic plexus. plexi of the pelvis are the superior and inferior and distal urethra receive innervation via S2–​4. The pelvic diaphragm receives innervation anterior border of the pelvis is defined by the from S2–​4 via the pudendal nerve. Both sym. Pain is commonly referred coccygeus muscles. The sacrum and ilium articulate. The inferior border of the pelvis aortic. The pelvic splanchnic nerves are sciatic foramen allows passage of the sciatic located just inferior to the bifurcation of the com- nerve. Pelvic Cancer Pain 125 pelvis consists of the hip bones made up of the In addition to its supply from the superior ilium. vulva. The hip originating at T10–​L2. forming splanchnic nerves. ureteral. and inferior is formed by the pelvic diaphragm. These fibers originate from diaphragm is composed of the levator ani and T10–​12. pubococcygeus muscle and the pubic symphysis. and the sacrum and hypogastric plexus. sympathetic nerves originate in the thoracic and These sympathetic fibers arise and enter the spinal lumber regions of the spinal cord from ganglia cord at T11–​12. sacral plexus. the prostatic plexus via the inferior hypogastric teric plexi. piriformis muscle. The bladder receives parasympathetic motor The posterior border of the anatomical pel. the sacrospi. plexus. renal. The trunk nous and sacrotuberous ligaments delineate the provides sympathetic fibers to the inferior hypo- greater and lesser sciatic foramina. and ovarian plexi. hypogastric. Anteriorly. The scrotum receives innervations from superior hypogastric plexus also provides the the inferior hypogastric and pudendal nerves. uterus. The sacral obturator foramen located between the ischium sympathetic trunk runs posterior to the com- and pubis allows the passage of the obturator mon iliac arteries and unites to form the gan- neurovascular bundle. The superior plexus divides to form the resection or locally invasive cancer. Cervical cancer pain is com- close to the pelvic organs. The penis receives autonomic innerva- ceptive impulses from the uterus. and mon iliac artery and carry parasympathetic and internal pudendal and inferior gluteal vessels. hypogastric plexus. uterine pain is that are located just anterolateral to the spinal often referred to the lower abdomen. . via the sacral splanchnic nerves and the pelvic sis. ischium. urinary The pelvis consists of multiple foramina. Both of these joints are travels with branches of the internal iliac artery extremely crucial in stabilization of the pelvis. superior hypogastric. the pubic bones articulate contributions from the sacral sympathetic trunk with each other. and provides innervation to the rectum. The tum.13 The uterus cord. The labia. fibers from S2–​ 4 and sympathetic fibers from vis is created by the sacrum. and pubis. don travel through the lesser sciatic foramen. The pelvic hypogastric plexuses. These muscles are extremely to the groin and may extend to the scrotum or important in supporting the pelvic viscera. The inferior hypogastric plexus the sacroiliac joint. as a result. cervix. forming the pubic symphy. The ureter has a complex bones and obturator internus muscle form the nerve supply and ultimately is innervated by the lateral border. The two main nerve monly felt over the lower back. Unlike the sympathetic gan. Pain from left and right hypogastric nerves and continues the prostate is commonly referred to the scro- to form the inferior hypogastric plexus. prostate. The superior hypogastric plexus is The prostate receives innervation through the extension of the aortic and inferior mesen. The cervix receives innervation through the para- glia. ovaries. and vagina.

in detecting a change in symptoms. VRS crucial to obtain a complete review of systems—​ and NRS were shown to have similar sensitivity particularly. anxiety. location. although As with all diagnostic work-​ups. treatments attempted. a strong concordance between the symptoms. examination than patients with stage I  can. Each tool has its own and cancer. nephrolithiasis. Revised Faces Pain Scale. complications of those treatments. for example. it is critical to have an organized.17 The physical exam should cover many sys. For example. Validated pain assess- indispensable. Goals in pain management are to maximize gynecological. urinary tract infection. The regimen also must fulfill the patient’s needs. Psychological evaluation of the patient is to cognitive limitations. cer. Consolability scale. it is important to and progression of therapy. When taking a history. in patients with hereditary genetic disorders such the evaluator needs to gain an understanding as BRCA. given its inherent the history is to begin to differentiate between the subjectivity. when possible.126 Pelvic Pain Management E VA L UAT I O N continue to play a crucial role in the diagnosis O F   P E LV I C of cervical cancer. gastrointestinal.18 Signs of pathological frac- C A N C E R   PA I N ture may indicate metastatic prostate cancer.15 A  proper social history is important of how the pain is affecting the patient’s activi- because of the relationship between certain habits ties of daily living (ADL).19 The differential diagnosis for pelvic pain is extre­ Digital rectal exam continues to play a role in mely diverse and involves many systems. There are various elucidate the basics of onset. and diverticulitis. The patient’s pain should be The patient should always be asked to describe evaluated on the initial visit and used on sub- his or her pain using his or her own words. Past Activity. duration. and depression. Moreover.22 ical fractures may be signs of metastatic prostate In children. and psychological cer patients. poker chip tool. including the Numerical Rating Scale (NRS). it is important to use reproducible types of pain:  somatic. to be judicious and goal-​directed when ordering tional disorders should always be taken seriously tests. patient functionality and to improve quality of Patients with stage II endometrial cancer had life. Verbal Rating Scale severity of symptoms. and prostatitis. many of the standard pain assess- cancer. ovarian cyst. medical history and family history are also essen. and Adjective Rating Scale (ARS). characteristics. and it is the phy- for bladder cancer. dysmenorrhea. it is important organic disease should be ruled out first. and gastrointestinal. appendicitis.23. and the Body Outline tial.24 In addition to monitoring pain. ectopic pregnancy. radiation. visceral. diagnostic imaging. . given the greater prevalence of ovarian cancer Pain Scale. more invasive diagnostic procedures torsion. emotional distress. especially addressing concerns of ment tools in children include the Face. urological.3) C A N C E R   PA I N after radiation therapy than non-​smokers. it is (VRS). endometriosis. questions concerning any gyneco. Simple daily ings on cervical palpation and rectal parametrial or twice-​daily dosing of medications is preferred. and overall Visual Analog Scale (VAS). back pain or patholog. Common the initial screening for prostate cancer. alleviating or aggravating fac.21 In a study logical. smoking is a risk factor advantages and disadvantages.16 Additionally. orthopedic.18 Additionally. urological. to support or confirm one’s differential diagnosis. sician’s job to use both the patient’s preferences tus may affect types of treatment modalities and and abilities to find the most effective scale. Legs. musculoskeletal. and be considered on the differential. Pharmacological Therapy tems. Medications should be given orally in prefer- significantly more abnormal physical exam find. assessment tools. Like sequent visits to monitor for the effectiveness the evaluation of all symptoms. mentary laboratory tests. Lastly.14 An essential part of When evaluating pain. Active smok- ers with cervical cancer were found to have much M A N A G E M E N T O F   P E LV I C higher complication rates (hazard ratio of 2. two assessment tools was found. smoking sta. or neuropathic. obstetrical. Pap smear and colposcopy based on the type of pain they are experiencing. comparing the use of VAS to NRS in lung can- neurological. tors. ence to other routes. detailed history and physical.20 causes of pelvic pain include pelvic inflammatory In many cases. stepwise approach that is centered on the patient All work-​up should start with a thorough and to avoid unnecessary invasive procedures. including the neurological. ovarian or testicular ultimately. Painless hematuria may indicate bladder ment modalities are inappropriate secondary cancer. func. validated self-​report assessment tools for pain. it is necessary to obtain compli- disease.

which would cause the patient to pain. Intraspinal administration is appropriate exceed 4 g in 24 hours. the individual should be opioid agonist. As a result. When choos. preferred approach to treatment of cancer pain. The combination medications provide patients. At Step 1. i. are par- superior analgesia by affecting nociceptive path.receptor (NMDA) antagonists. trans- of currently prescribed medications is required dermal. Adjuvant medications include anticon- which.vulsants. if the patient continues to have Using numerical rating. neuroleptics. When prescribing acetaminophen. cerebrovascular When starting a new opioid. the patient should be started on a pure with mild pain (1–​3). Unlike the prior two ing the appropriate initial therapy. For example:  acetamin.in order to avoid an overdose. primary indications. Rectal administration may be analgesics. taking a thor. step 3 medications have no ceiling effect ough history is necessary to avoid inappropriate or maximum dose. it is important to always be mindful of individual continues to have poorly controlled the time course of any changes in one’s regimen symptoms on the initial therapy.26 TCAs. for patients 7–​10).fentanyl. side effects. oid (Tramadol or meperidine). acetaminophen. Titrating opi- and central pain pathways. Meperidine result. There is a variety of choices of non-​opioid when possible. for moderate pain (4–​ 6). analgesic properties.tions enterally. and N-​methyl-​D-​aspartate non-​opioid medication. peptic ulcer disease. As a Step 2. Step 3. by decreasing When prescribing TCAs.ticularly effective for treating neuropathic pain. or intravenously. tricyclic antidepressants (TCA). NSAIDs should be oids requires close attention to details in order avoided or prescribed judiciously in patients with to avoid potentially life-​threatening side effects. Pelvic Cancer Pain 127 Medications can be given in both short-​acting the opioid requirement.effects of systemic opioids or is having poor dins. like anticonvulsants. The exact mechanism of acetaminophen be preferred when there is a desire to avoid is unknown. specifically gabapentin and pregabalin—​ are ibuprofen/​hydrocodone. are indicated for treating specific types is broken down in the liver to normeperidine.pies have diverse mechanisms of action. hydromorphone. Intravenous administration may erties. started on a non-​opioid analgesic. which both play a role in its analge. and address pain path- inhibitor.steps. a “weak” opi. adjuvant therapies can be added at any step started.oral administration is always the preferred route tions. Opioids may be adminis- drug administration. patients describe their pain or is having severe pain (on the order of pain on a scale of 0–​10. renal disease. a complete list tered orally. These medications rely on first-​order Managing a cancer patient’s pain requires kinetics for elimination. which are involved in both the peripheral pain control with escalating doses.25 Adjuvant medications in general have other avoided in patients already on antidepressants. The costeroids. Additionally. coronary artery disease. including aspirin. preferred when the patient is unable to take and NSAIDS. alpha2-​ adrenergic combination therapies include an opioid and a agonists.27 ways at different sites. Again. but they also possess some Meperidine is a synthetic pure opioid agonist. morphine. bisphosphonates.. first past metabolism or need for quicker onset. to avoid any overdoses or drug–​ drug interac.e. if not cleared. it takes approxi- disease.ways that opioids may not be effectively cover- sic properties. acetaminophen/​oxycodone. NSAIDs provide anal. Moreover. tramadol should be ing. rectally. etc. methadone. of pain. or a combination In addition to the medications used in steps of a non-​opioid and opioid analgesic should be 1–​3. and as a result have a a stepwise approach. The World Health ceiling effect largely determined by the max- Organization’s (WHO) three-​ step ladder is the imum safe dose of the non-​opioid medication. Acetaminophen is an antipyretic PO or the patient is unable to absorb medica- and analgesic without anti-​ inflammatory prop. or coagulopathy. can cause severe neu. Anticonvulsants—​ ophen/​hydrocodone. it is important to be . one curtails the risk of and sustained-​released formularies. or if the result. corti- rotoxicity and ultimately lead to seizures.acting analgesia for patients with severe chronic aminophen. intranasally. reduce the and a norepinephrine and serotonin reuptake dose of opioids needed. or acetaminophen/​effective for treating neuropathic pain in cancer codeine. subcutaneously.when the patient is unable to tolerate the side gesia by blocking the production of prostaglan. buccally. Different adjuvant thera- which is of limited use because of its short dura. and as tion of action and side-​effect profile. mately five half-​lives to reach steady state. it is extremely important to make sure patients Transdermal patches are ideal for providing long-​ are not taking other medications containing acet. Tramadol is both a weak opioid agonist to enhance the effects of the opioid.

increased intraocu. nitive dysfunction have been shown to both Epidural and intrathecal medications are decrease opioid usage and improve pain scores. most appropriate modality.29 The mechanism is believed when medical therapy is either insufficient or the to be secondary to anti-​ osteoclast activity. cortico. analgesia is usually administered as continuous sia. ranging from opioids alone. Historically. quality of life. cancer pain. fail to control a patient’s pain. NMDA receptors have been shown to play profile is considerably more favorable. be given. therapy of intrathecal opioids with a local anes- and spiritual and psychiatric counseling. and the other is targeted peripheral patients who may already be immunosuppressed. administered with greater proximity to its site of gesic effects of the antipsychotic. and increased risk of infections in ications. When conservative measures. action—​the central nervous system. shown to reduce pain scores. heat. a change to a secondary other healthcare workers should help patients amine may provide a more favorable side-​effect gain access to and coordinate a more complete profile. They are mainly utilized astatic bone pain. Of note. fluid retention. There patients. such as pharma- steroids are both orexigenic and an anti-​emetic. dosages are greatly reduced. The mechanism of action may be secondary to Unlike systemic opioids. But there is growing support and evidence for tal events in patients with metastatic disease.36. equiv- therapies should be used early and often in a alent opioid administration was significantly patient’s treatment regimen.29 earlier interventional therapy. but are not limited to. In addition to opioid therapy. Non-​pharmacological Management In a randomized control trial comparing the Cancer pain therapy should not be limited to use of comprehensive medical management ver- pharmacological therapy. Consequences of long-​term steroid ther.38 include. are effective for neuropathic. Corticosteroids are specifically useful Interventional Modalities for metastatic bone pain. These thetic is an effective option for improving cancer . which is of particular importance in cancer more invasive procedures may be needed. nations of opioid and local anesthetics. are two main categories of interventional treat- apy include weight gain. which shows that This utility is of particular importance for pros. are effective adjuvant therapies for met.28 Additionally. neurolytic therapies. selective serotonin reuptake treatment plan. and the side-​effect ties.31 extremely effective for providing analgesia. cological therapy.33 Additionally. side-​effects of medications are too significant. Bisphosphonates help delay and prevent skele. continuous intrathecal morphine for intractable ate. adrenal ment modalities used by anesthesiologists for suppression. exercise. dures have been considered the “fourth step” in steroids. these therapies should inhibitors do not appear to be as useful in the never replace the use of appropriate pharmaco- treatment of neuropathic pain. interventional proce- Bisphosphonates and calcitonin. Non-​ pharmacological with intrathecal morphine. combination apy.32 and other adjuvant therapies.32 NMDA antagonists have been shown to therapy. neuraxial analgesia is a decrease in patient anxiety or by direct anal. but rather requires sus comprehensive medical management plus a multidisciplinary approach. cold. surgical risk of fracture. As a result.128 Pelvic Pain Management aware of their side-​effect profile. it is important to neoplastic agents that place them at increased consider life expectancy. neuroleptics as a class have antiemetic proper. These therapies reduced in the morphine group. to combi- they have been shown to inhibit the develop. like cortico. Additionally. side effects.38 Additionally. it provides better pain control and reduction in tate cancer patients who are on treatments like the use of systemic opioids. the WHO pain ladder. it is crucial to utilize non-​pharmacological cancer pain.34.27 Corticosteroids logical or interventional therapies. and ultimately. somatic. there was a clinically significant treatments in addition to pharmacological and reduction in pain and side effects in the group interventional therapies.37 When choosing androgen-​ deprivation therapy and other anti-​ an interventional procedure. opioids ment of opioid tolerance. When appropri. and cost in order to select the patients who are also experiencing some cog. education. Neuraxial a role in central sensitization and hyperalge. specifically their psychological and behavioral therapies have be anticholinergic effects. A  plethora of different medications can decrease pain and opioid dosage. Unlike TCAs. One is intrathecal/​ epidural med- lar pressure. hyperglycemia. nerve blocks.30 Neuroleptics in cancer pain risks. If the patient is not toler. physical ther. acupuncture.35 Clinicians and ating the tertiary amines. and vis- ceral pain.

domized study of 30 patients. sepsis. the L4–​5 amine in combination with opioids improves interspace is identified by both exam and fluo- pain control and reduces opioid requirements. ziconotide. the nociceptive pathway of the pelvic viscera. secondary to the difficulty of needle placement.44 In a case series of three patients are directed medially toward the anterolateral with intractable pelvic cancer pain. unlike alcohol. The two most commonly used neurolytic tiation of therapy until time of death.43 A  system. allergy. In a the retroperitoneum just inferior to the aortic double-​blinded. the prone position. Once positioned. is crucial in trial comparing intrathecal ziconotide to placebo.40 painful on injection. Problems with neurolysis arise when neuro- ketamine. refractory. which can cause return used to enhance opioid therapy. The needle is betamethasone was given. greatly limit its clinical use. intrathecal aspect of the L5 vertebral body. After local anesthetic skin infiltration. and all of contrast in the midline region on AP view. trast in both the anteroposterior (AP) and lateral sions suffering from intractable pelvic cancer view. preexisting neurological deficits. neostigmine. the classic prone Nerve blocks are a targeted approach aimed SHPB was compared to a novel transdiscal at inhibiting the specific nerves involved in the approach for treatment of pelvic cancer pain.44 roscopy. randomized bifurcation and anterior to L4–​S1. Plancarte first introduced the effect profile. four had improvement in their pain symptoms and a smooth posterior contour corresponding and a >60% decline in their opioid usage. relief persisted from days to weeks. There are three main both the classic prone approach and transdiscal . cium blocker. bilateral 7-​inch 22-​G short beveled needles are mine may also lower pain scores and reduce inserted 5–​7  cm lateral to midline. is not decreased with intrathecal therapy. found in use to treat severe. a N-​type voltage-​gated cal. bral body. a diagnostic block with control in patients with severe cancer-​ related a temporary local anesthetic is preferred prior to pain. compared substances are alcohol (50–​ 100%) and phenol to their prior oral regimen. finding a 70% reduction in atic review of patients with cancer pain found VAS scores. been shown to act synergistically with intrathe. There is a vari- pelvic cancer). Alcohol may be preferred In addition to local anesthetics. the review suggests that neostig. they were given intrathecal phenol.40 Furthermore. dle. given its ease of injection through a smaller nee- vant therapies. chronic pain. the combination of continuous ety of other blocks that may be used separately or intrathecal morphine and levobupivacaine showed in combination with these blocks to provide pain significant improvement in pain scores from ini. increased intracranial pres. valvular disease. oral (6–​12%). Phenol provides the benefit of also use of opioids and their concurrent side effects being a local anesthetic and. there was a statistically and clinically significant As a result. the actual neurolytic block. vic cancer pain. Additionally. including clonidine. Clonidine has of the original pain or creation of new pain. appropriate ing for at least 5  days. plexi that can be blocked for pelvic cancer pain spective study of 55 opioid-​tolerant patients with relief:  superior hypogastric plexus.48 In pelvic cancer pain pathway. can be nal regeneration occurs. is FDA-​ approved for intrathecal The superior hypogastric plexus. Appropriate placement shows confinement pain.45 In a case series of four placement is confirmed by fluoroscopy with con- terminally ill patients with prior bladder diver. The iliac crest and transverse process act as demyelinating disease.43 Ziconotide’s side-​ vic cancer pain. infection at the site of the proce. inferior hypo- intractable cancer pain (including 13 patients with gastric plexus. with significant pain advanced approximately 1  cm past the verte- relief beginning in about 10 minutes and last. sure.42 Ziconotide. relief. patient refusal. and ganglion impar.41. obstacles to proper needle insertion.46 Contraindications is injected for diagnostic blocks and phenol or for use of epidural/​intrathecal anesthesia include alcohol for neurolytic blocks.39 In a pro. and steroids. local anesthetic block-​specific adverse effects.46 The to the anterior psoas fascia in the lateral view. Pelvic Cancer Pain 129 pain and reducing opioid requirements. especially its central nervous system SHPB in a small study of 28 patients with pel- effects. coagulopathy. the superior hypogastric plexus reduction in both pain scores and opioid usage block (SHPB) is a clear target for relief of pel- among the ziconotide group. The classic prone procedure has limitations dure. After negative aspiration. other adju. Given the uncertainty of the exact cause and cal opioids and local anesthetics to improve pain innervations of the pain. without any Once placement is confirmed. The needles opioid needs.47 The procedure is performed in that both intrathecal ketamine and epidural ket. placebo-​controlled. In a ran- and uncooperative patients.

two patients had a vascular puncture. Prior to the proce- herniation in the transdiscal group.49 Additionally. A  22-​ G Chiba needle is advanced in an out-​ with a 40. The average time of the procedure for Although the SHPB is an effective block for the neurolytic block was 5.50 prone position. the lower pelvic viscera. with a 43. VAS scores were 7. A  block of the inferior hypogastric plexus. 50% ethanol and . two patients had ineffec. and mostly secondary to pelvic cancer. the maximum procedure is performed in the supine position.21 ± 1.51 consumption at all time points was less in the Using a transsacrococcygeal approach under flu- ultrasound-​ guided SHPB group. Once S1–​S4 foramina are identified.31.130 Pelvic Pain Management approach. two weeks. two months.50 The block is performed with the prone approach group.50 Mean consumption of morphine prior to vic pain secondary to advanced gynecological the procedure was 106. ineal pain secondary to pelvic cancer.9 and was sig- cancers. Additionally. Additionally. all patients which runs along the ventral surface of the maintained a clinically and statistically signif- sacrum medial to the sacral foramen bilaterally. procedure. the transdiscal approach took an trolled pelvic cancer pain on opioid and adju- average of 32 minutes’ less time. and spread is confirmed under Similar to the IHPB. decrease in morphine occurred at one week. one performed when the patient cannot lie in the week. in the classic approach guidance. the lower pelvic organs. the risk of phine consumption significantly decreased injuring the intestines and common iliac arter- from baseline values at 24 hours. one week. located in the retroperitoneum at the sac- was a statistically significant (p < 0. the VAS scores and the daily mor. the ultrasound-​ week. Importantly. there an inferior hypogastric plexus block (IHPB).49 The except two months.11 minutes. a ganglion three months. and two months.51 visceral pelvic pain. scores from baseline. perineum.3% reduction from baseline usage. In the classic vant therapies. rupture. and two months. all patients had >50% reduction in their VAS lia. unlike the fluoros. one month. or genita. ies that exists with a SHPB is eliminated with one month.51 There were no clinically . a block of the ganglion real-​time sonography. lumbar vertebral body. and 25-​G spinal needle is advanced through the four patients had aspiration of urine during the medial bony edge of ventral sacral foramen. one month.8% reduction from baseline pain guided SHPB can be performed at bedside and scores. or phenol is injected bilaterally. the daily morphine impar block or neurolysis was performed.05) decrease rococcygeal junction. it does not always cover Approximately 12 minutes after the procedure. Following the In contrast to fluoroscopy-​guided SHPB. just anterior to the sacrococcygeal ligament. Optimal position is achieved when cephalad and no urinary injury nor vascular puncture in the caudad spread is seen along the presacral plane. patients with lower pelvic involves no radiation exposure.67 ± 32. The neu- nificant permanent adverse effects occurred in rolytic block was performed using 4–​6 ml of 8% the anterior ultrasound-​guided group. In study although the ultrasound group provided greater of 16 patients with chronic perineal pain (CPP) relief at one week. relief. the patients had a significant decrease anterior ultrasound-​ guided approach may be in their VAS scores (p < 0.25% bupiva. anterior ultrasound-​guided SHPB was nificantly reduced (p < 0.05) at 24 hours. transdiscal approach group. perineal cancer pain. a group. Position was confirmed with contrast. there impar. 6–​8 cc of 10% up CT showed no signs of discitis. dure. icant decrease in their pain scores throughout is a viable option for more complete coverage of the two months’ study. Once 1–​2  mm from the IHPB is a good alternative for lower pelvic or vertebral body. follow-​ After confirmation of position.49 Interestingly.50 Similarly. or perineal pain had the most significant pain randomized study of fifty patients with pel.50 Interestingly. a 22-​G needle was advanced the side-​effect profile was better in SHPB com. caine is injected. patient in the prone position under fluoroscopic tive blocks. an procedure. In a blinded.49 In both groups. oroscopic guidance. phenol. is a viable option for per- in the VAS scores compared to baseline. were no significant differences in VAS scores Neurolysis of the inferior hypogastric plexus or morphine usage between the two groups.50 of-​plane technique and aimed towards the fifth Although larger controlled studies are needed.48 was performed in 20 patients with poorly con- Interestingly. Additionally.51 Additionally. pared to the morphine-​only group.48 Of note. and no sig.7 ± 1. There were no failures of the block.05) at all time points compared to standard WHO therapy. The most significant results occurred at one copy or CT-​ guided approach.

a transsacrococcygeal ganglion impar patients experienced persistent motor. lumbar sympathectomy. and as Myelotomy is another modality that may be a result.58 A  retrospective case review 12 patients with severe pelvic pain secondary to of nine patients with pelvic cancer including rec- recurrent rectal cancer. all patients had failed ladder approach.58 There were no sequelae. response. The spinothalamic pathway decussates neal pain secondary to pelvic cancer. without adequate Neurosurgical interventions include dorsal rhi. but larger within the spinal cord one to two levels above randomized control studies are still needed. they are generally reserved for severely major complications. none of the pain.54 The patients were all on maximum toler. The individuals had tried a variety of other at 22  months. and palli- Surgical Management ative radiation/​chemotherapy. NSAIDs.53 table pain. Furthermore. and effective procedure for peri. As a result. transcutaneous electrical nerve stimu- obstruction. following the procedure. a punctate midline fering of patients with cancer. In a group function. the patients maintained lower weakness and incontinence prior to the proce- pain scores throughout the duration of the study dure. In the study. with significant reduction in visceral pain and tory perineal pain secondary to pelvic cancer medication usage. eight of the nine patients zotomy. lation.55 The importance of the midline of the modalities should be considered as adjuvant dorsal column compared to the classic spinotha. procedure has significant side effects. neu- neuraxial therapy with morphine combined rolysis of both sympathetic and parasympathetic with a local anesthestic. cordotomy involves VAS scores <3 for the entire six-​month follow-​ creation of a lesion in the anterolateral region up after the procedure. surgery. with complications including fistulas. autonomic. a minimally invasive may be performed percutaneously or via open procedure causing protein coagulation and ulti. these modalities reductions in pain scores and opioid use. therapies and not reserved for refractory pain lamic tract in the visceral nociception pathway is for the terminally ill. therapies. Pelvic Cancer Pain 131 significant complications of the procedure. will experience pain. many of these able opioid therapy and multiple other adjuvant patients can achieve adequate relief with phar- therapies. such as opioids. In myelotomy at the thoracic level was performed similar case series of three patients with refrac. block was performed.54 have been shown to lower opioid usage. gynecological.58 of six individuals with advanced pelvic cancer and lumbosacral plexopathies. RFA may be practically useful in patients have a life expectancy of less than 1–​2 years. and sarcoma of the ischium improve pain control. In the remaining patients. and abscess formation. cordotomy In a subset of pelvic cancer patients who are at a specific level will produce anesthesia one to not candidates for surgery. patients who have failed all other modalities and tive. The patients had a mean were treated with a cordotomy for their intrac- reduction of their pain by 86% at one week. quick. two levels below the site of the lesion. All three patients had VAS or sensory dysfunction from the procedure.56 In a case titioners to be familiar with the many available series of six patients with intractable visceral options. . myelotomy. Many of the patients had motor Furthermore. reduce associated side effects. including sive therapies are less desirable. Given had a reduction in their median daily morphine their invasive nature and inherent neurological use from 580 mg to 160 mg. RFA was attempted to tal. all patients had significant option for relief. neuraxial infusions. including antiepileptics and antide. and cordotomy.57 scores >8 prior to procedure and maintained In contrast to myelotomy. The procedure is classically reserved for mately cell death. tract. the axons’ point of entry. pudendal and caudal nerve blocks. an effective palliative option for intractable can.37 It is crucial for pain prac- unclear and currently under debate. Currently. dorsal rhizotomy S U M M A RY was utilized to treat their refractory neuropathic The majority of patients with pelvic cancer pain. steroids. ureteric ketamine.52 Transsacrococcygeal is of the spinal cord containing the spinothalamic a safe. including respiratory dys- resistant pain in terminally ill patients.57 In the study. In a study of respiratory failure. macological therapy using the standard WHO pressants. Cordotomy tion of the tumor (RFA).54 When compared to nervous systems provides a safe and efficacious their prior symptoms.54 Furthermore. may be a promising alterna.53 RFA has significant morbidity. radiofrequency abla. however. in order to maximally reduce the suf- pain secondary to cancer. The with short life expectancy when more inva. there is growing evidence that interventional cer pain.

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and physical should also not hesitate to inquire about any and/​or sexual abuse—​have little or nothing to history of emotional.. do with the “gynecological organs. physical. Liberman. 1993). This A thorough physical exam is also essential can complicate both diagnosis and treatment in the pre-​ operative evaluation. 2001). Society.000 women annually undergo derness or muscle spasm. available may account for only 20% of chronic pelvic pain free of charge from the International Pelvic Pain (Zondervan et  al. P R E -​S U R G I C A L 1996). tory should also identify the location of pain. timing of symptoms.. the gyne. it is critical that to a gynecologist (Mathias et  al. in mated at $880 million annually. including irritable bowel syndrome. The practitioner cystitis/​painful bladder syndrome. one as these types of trauma can manifest in CPP.” Indeed. Kuppermann.000 hysterectomies performed annually in America. such study found that gynecological conditions A  pelvic pain intake questionnaire. The external genitalia outpatient laparoscopy for work-​up of their pel. CPP is is thus imperative to understand the role of sur- a commonly encountered problem and may gery in the treatment of chronic pelvic pain. tion of the pelvic floor muscles to note any ten- approximately 130. and sexual abuse. A  vaginal exam should include palpa- A  2006 study revealed that in the United States.. should also be examined with a Q-​tip and pin vic pain (Tu & Beaumont. Surgical scars should be noted and account for a significant number of surgeries. both evaluation and treatment of pelvic pain sitting. 1996). supine. In primary care offices.. It (Howard. A  systematic options. indirect costs are estimated at more than $2 bil. the surgeon should all gynecological laparoscopies performed in the be speaking with the patient and asking frequent . Studies have demon. 1999). interstitial and pain severity and quality. affect up to one in seven women (Mathias. As many non-​gynecological causes can contrib- 1996)  and CPP accounts for 10% of all referrals ute to the development of CPP. D U K E A N D K A R E N WA N G C hronic pelvic pain (CPP) is defined as non-​ menstrual pelvic pain of at least six months’ duration that is severe enough to United States (Howard. and in severity. to note the presence of allodynia or hyperalge- ies estimate that CPP may account for 40% of sia. This may involve examining the cologist often feels compelled to intervene. etc. and other stud. while direct and addition to helping identify the source of pain. approximately 12% cite pelvic pain as the pri- cause functional disability or require treatment mary indication for surgery (Howard. In the United States. cated in the development of CPP. and many—​ its onset and duration. 1993). and patient in multiple positions:  standing. the same patient (Zondervan et  al. with multiple etiologies often present in Index and a pain Visual Analog Score. & Steege. 1993). Additional strated that there is also significant cross-​over of useful resources include the McGill Present Pain causes. 15 Surgical Treatment of Pelvic Pain A D A M R . can aid in the history-​taking. Direct a thorough history and physical be performed. approach should be used to attempt to dupli- Despite the multitude of non-​gynecological cate the patient’s symptoms. The history is especially important because. Lipschutz. healthcare expenditure related to CPP is esti. During the examination. The his- A multitude of causes have been impli. both in location symptoms that can contribute to CPP. Of the 600. 2003). palpated. Steege. 2006). it can help establish rapport and trust between lion annually (Mathias et al. 1996). 39% of women E VA L UAT I O N complain of pelvic pain (Jamieson. patient and provider (Howard.

21% reported continued but decreased pain. as discussed. then procedures such as pain. A 1995 study by Hillis and col- be mutually exclusive. Certainly. It is essential that. especially when the disease. if such conditions These two studies demonstrated that a can be identified. after six months. Alarmingly.. the role of hys- patient?” If the answer to either of these ques. A  large . then hysterectomy can provide of women with chronic pelvic pain have already relief. a “cure” for chronic pel. in unadjusted analyses. however. 1991). of surgical treatment for CPP. 1990). T O   T R E AT M E N T 21. it is estimated that 90% pre-​operatively. the majority experienced relief of pain. Despite these recom. a multidisciplinary approach in mind. mean. all attempts under the age of 30 were at increased risk should be made to maximize medical therapy for continued pain. patients with pelvic pain) (Stovall. uterus. Non-​ visual clues such as “guarding” are hysterectomy. 22% still complained of pelvic pain. A total of 308 both the practitioner and the patient understand women with pelvic pain for at least six months that. recently an area of study. It is also important that leagues mirrored Stovall’s findings. Pelvic pain specialists have long advocated a multidisciplinary “team” approach to the diag. 2003). Marchbanks. the assumption was that the majority of women would improve with uterine removal. At the one-​year follow-​ vic pain is often not achieved. identifiable uterine pathology such as fibroids atrists. This was a pose that. ing the patient to lead as close to a “normal” life and 5% reported unchanged or increased pain. This team of providers versy about its effectiveness. a symptom or a disease. but should be on minimizing symptoms and allow.. or endometriosis. causes of pain. 2006). dures can be performed. 2003). pain itself becomes larger-​than-​ expected number. women Prior to performing surgery. Some experts even pro. terectomy is controversial. A P P ROAC H Long-​term follow-​up (15–​64  months. the focus up. & tions such as interstitial cystitis. the patient should be reevaluated with performed in 1990 by Stovall and colleagues. while in adjusted analy- for at least 6–​12  months. not just a symptom. although the Controversy remains as to whether pelvic pain is vast majority of patients experienced relief. and counsellors. fied pelvic pathology (Hillis. 1995). prior to proceed- approach (Lamvu et al. rather.6  months) demonstrated that. Mainstays of medical ses. & though these two treatment pathways need not Crawford. an increased probability of persistent pain therapy include analgesics and antidepressants. Peters et al. and most Ninety-​ nine women underwent hysterectomy probably referred to a physician with expertise for pain that was presumed to be related to the in chronic pelvic pain. However. then surgery should be postponed. the should be performed to rule out concomitant surgeon ask two questions: (1) “Am I truly qual. Therefore. irritable bowel Peterson. Ling. ified to provide the most effective surgery my In patients without an identifiable uterine patient needs?” and (2) “Will surgery benefit the pathology contributing to pain. a thorough evaluation prior to performing surgery for pelvic pain. the etiologies of had some type of unsuccessful surgery for their CPP are often complex and rarely act alone. psychi. lysis of adhesions. unlike acute pain. and only relatively tions is no.. despite contro- 2013. Hysterectomy remains one of the mainstays firm the utility of this approach (Hooker et  al. The first major study as it is likely to do more harm than good. and neuroab- also important to note during the examination lative and neural release/​decompression proce- (Howard. If medical treatment is not majority—​about 75%—​of patients would expe- effective or the practitioner believes surgery will rience relief of pain with hysterectomy. if an includes pelvic floor physical therapists. At to assess outcomes of hysterectomy on CPP was that time. was observed in women who had no identi- but therapy should also target specific condi. syndrome. Hysterectomy nosis and treatment of CPP. underwent hysterectomy. Surgical Treatment of Pelvic Pain 135 questions about the location and severity of aid medical therapy. ing with hysterectomy. or adenomyosis can be confidently diagnosed mendations. and studies con. as possible. treatment the general population (as opposed to just those can focus on either the symptom or the disease. though the compared to pain improvement rates in other pathogenesis of this transformation remains studies examining hysterectomy outcomes in unclear (Howard. so pain prior to the utilization of a multidisciplinary it must again be stressed that.

. More import. 24  months after ing long-​term outcomes in patients undergoing hysterectomy for CPP. However. of the women reporting Presacral neurectomy is indicated in the treat- chronic post-​operative pain. Lamvu com. First performed in 1899. and a history of pain problems elsewhere in Presacral Neurectomy the body. and impaired quality of life a strong family history of breast and ovarian (Hartmann et al. 2012). Kahn. Kuppermann. at four months. When compared to the Bilateral oophorectomy for treatment of women who had neither pain nor depression.. Ingersoll & Meigs. A  questionnaire based study of 1. & Jensen. Worryingly. 1950).9% of women who devel- confounding variables that may contribute to oped pelvic pain after hysterectomy (as reported pain after surgery—​ notably. and multiple a prospective study of 90 women undergoing trials have shown relatively good pain improve- hysterectomy for benign reasons. In 11 women. known that certain surgeries such as thoracot. the decision to remove the for post-​operative pain were identified. and the risks may out- operative pain (Brandsborg. 14. in an earlier paper by the same authors). only 9.4% appropriate role for this operation can be found” of women with pain and depression continued (Stovall et al. Risk factors weigh the benefits. Moreover. that. to pre-​ operative factors. Tjaden. or pain associated with itself may play a role in the development of chronic pelvic inflammatory disease (Polan & chronic pelvic pain (Brandsborg. Certain women with pain and depression were three to experts advocate the removal of ovaries at time five times more likely to continue to suffer from of surgery for pelvic pain. delivery. 2004). ant is that these studies did not take into account given the staggering 14. Dueholm. Kehlet. the on these findings. Based DeCherney. prior cesarean discussion with the patient. 2011). 15 (16.135 Washington. It is well in the case of deep infiltrating endometriosis. pain. pelvic pain is even more controversial. Despite Te Linde & Scott. It has also been pointed out that both their pre-​operative pain.9% had no pain ment of severe and disabling midline pain sec- pre-​operatively. studies have major limitations. Nikolajsen. Grossardt. As there before and one year after hysterectomy and is no clear evidence that bilateral oophorectomy found that 32% of women had chronic post-​ improves pelvic pain. Their conclusion was that persistent the multidisciplinary approach to treatment of pain after hysterectomy is most often related pelvic pain had been established. however. Malkasian. includ. de women examined pain characteristics both Andrade. amount of pain is an area of concern. probably because pain was probably related to post-​surgical dis- they were performed before an understanding of comfort. as it is Hillis and colleagues’ finding that 5% of well established that endometriosis is hormon- women experienced an unchanged or increased ally responsive (Martin & Ling. pain as main indication for surgery. However. Schlaff. indeed. & Melton.7%) continued to 1955. and mastectomy with axil. would continue have CPP.3% of women with hysterectomy for chronic pelvic pain so that the pain only had continued symptoms.249 women with pain and/​or phetic:  “Physicians must be vigilant in monitor- depression demonstrated that. comparison group (Lamvu. 1990). 2009). and neither had a pain-​free pain is probably small (Brandsborg. Rocca. 1948. more ety. research is still ongoing as to whether death in women who have undergone bilateral surgery itself can lead to the development of oophorectomy (Grover. and that the relative ments that both studies suffered from a small contribution of surgery to the development of cohort of patients. especially that affecting the uterosacral liga- omy. patients may lary lymph node dissection are associated with continue to experience pain and dyspareunia a risk of developing chronic post-​surgical pain despite estrogen reduction (Redwine. ovaries should be left up to the surgeon after ing pre-​ operative pelvic pain. They noted ment rates—​ up to 85% in some cases (Black. the same authors performed procedure has been well studied. anxi. 1999).136 Pelvic Pain Management number of patients. the pain mimicked to suffer. and history of abuse. (Schnabel & Pogatzki-​ Zahn. conclusion to their 1990 paper thus seemed pro- a 2004 study of 1. 2010). 1996. Stovall and colleagues’ confounders cannot be underestimated. ments or the rectovaginal septum. depression. The influence of these investigation is needed. and in the other four. amputation. indicating that hysterectomy ondary to endometriosis. cancer or if endometriosis is present. . 1994. increasing the vast number of hysterectomies performed evidence is demonstrating an increased risk of annually. 2006). & pain. to be symptomatic. 2012). especially if there is dyspareunia. while 19. 1980).

before eventually anastomosing with ing complete resolution of pain. Fifty-​ two patients had laparoscopic presacral From here. Zullo et al.500 patients (Cotte.000 patients esti- nerves known as the “superior hypogastric mated a nearly 80% success rate of open pre- plexus. 1986). imme- superior hemorrhoidal.2%) report- plexus. One of the earliest ran. from the area of dissection. 2003) of the anatomy of the interiliac triangle. The opening is extended to the aortic bifurcation Constipation has been observed in 3–​ 4% of superiorly and the sacral promontory inferiorly. Belts. 49 (94%) reported to become the middle and lower hypogastric improvement in pain. Subsequent papers have found similar tubes. In a some patients.. Additionally. 1990).. It is unclear whether this urgency Presacral neurectomy may be performed open is responsive to anticholinergic medications.” Moreover. Surgical Treatment of Pelvic Pain 137 Kimball. injuries. Stone. Running through the center of the If the procedure is performed laparoscopically pre-​lumbar space are the inferior mesenteric. 1949).. Bleeding is not usually brisk. patients and in most cases can be success- The retroperitoneal fatty tissue is removed. 1996. and defecatory dys- major arteries are identified. the peritoneum function. and midsacral arteries. The plexus Magelssen. Urinary retention with need for catheter- and sharp dissection are used to coagulate and ization was reported in 50% of patients in one excise the nerves. and one of the structures is damaged. The Major complications with presacral neu- interiliac triangle is bordered laterally by the rectomy are fortunately rare (Cotte. all the pelvic plexus. diate laparotomy is necessary. courses out beneath the bifurcation of the aorta. The peritoneum is then Other studies demonstrate a very low rate of uri- closed with a running absorbable suture. and proximal fallopian 1992). uterine corpus. and the nerve plexus is visualized. procedure requires intimate understanding Chang. 1948). and blunt 2003). one of the earliest not pre-​sacral. Uterosacral Nerve Transection domized trials of patients with endometriosis and and Ablation midline pelvic pain found 15/​17 patients under. Cotte noted only one ureteral injury over the pre-​lumbar space is incised vertically. A  successful—​and complication-​free—​ results with the laparoscopic technique (Chen. The tri. Notably. one patient had a long-​term plexus of nerves. as the interiliac triangle is bordered by angle is defined cephalad by the bifurcation of the aorta and common iliac arteries and veins. It is important that all nerves study. The common iliac artery and ureter on the right most important to consider are major vascular and the common iliac vein on the left. in a review of 1. A 25-​year what is being removed is actually a plexus of retrospective study of nearly 10. it is actually pre-​ lumbar. urinary difficulties. any oozing in this area. complication of urinary urgency and had lost but it is important to meticulously coagulate the sensation of a full bladder (Lee et  al. as they lie under area of dissection. but has been performed recently laparoscopically with excellent results. the sympathetic nerves transmit pain from the and there were no major complications (Nezhat. it runs over the sacral promontory neurectomy.. patients undergoing surgical excision of endo- The term “presacral nerve” is a misnomer. is grasped with atraumatic forceps. In 1992. cervix. The superior hypogastric plexus papers addressing laparoscopic presacral neurec- is a direct extension of the aortic plexus and tomy was published by Nezhat and colleagues. compared to none of the nine relatively low complication rate to the procedure. and of these. there is a at 42  months. metriosis only (Tjaden et  al. Chu. These can visualization. Additional complications include ureteral Once visualization has been established and injury. 1986. sacral neurectomy. Troublesome Further complicating the procedure is that the bleeding can be encountered if the middle rectosigmoid and mesocolon often lie over the sacral vessels are damaged. & Soong. the aorta. & Rock. with 27 (51. fully treated with medical therapy (Lee. & Benson. It is often necessary to suture the usually be coagulated or ligated to provide mesocolon to the sidewall to deviate it away hemostasis. Zullo et  al. though this had resolved in all patients within the interiliac triangle are removed. in by post-​op day 7 (Ingersoll & Meigs. nary urgency. These structures typically the hypogastric plexus and just above the peri- cover the left ureter and can impair general osteum of the sacral promontory. this may be an 8–​ 10-​ cm-​long review of 50 patients. 1990). Relief of pelvic pain and dysmenorrhea by going open presacral neurectomy to be pain-​free uterosacral nerve transection was first described . 1949). Afferent fibers accompanying patients were discharged home within 24 hours.

Hulsey. nical aspects. Laparoscopic uterosacral nerve the role of adhesiolysis in the management of ablation—​ or LUNA as it’s popularly called—​ pelvic pain. this study orrhea and pelvic pain. In both trials. autoimmune pain compared to those without pain (25% vs. adhesions in intestinal obstruction and infer.. randomized prospective studies comparing A very recent double-​ blind RCT compared LUNA to laparoscopy alone have unfortunately laparoscopic adhesiolysis to laparoscopy alone. due to dif- of pain was similar in both groups (Daniels ficulty with enrollment and lack of continued et  al. an early review of two small ran. and mechanical trauma (such as long-​ 17%. However. Farquhar.. with the relief of symptoms rapidly dimin. Trimbos. In the first. at this writing. and 50% improvement (Peters. disease. six months. and quality of life was was abandoned before recruitment had reached not improved. An addi- there have been reports of ureteral transection tional study randomized 100 patients to lapa- and prolapse (Check. olysis in the treatment of pelvic pain. 2003). there was no difference between the groups with tion of nerve is destroyed. complication rates are extremely low. Typically a 2–​3  cm por. possibly due to regrowth that an “erroneous conclusion” had been reached of uterine nerves (Chen et  al. Thus lysis of adhesions—​ like Recent controversy surrounding the use of syn- hysterectomy—​ remains a controversial part thetic mesh in pelvic organ prolapse surgery has of the surgical treatment plan for chronic pel. additional study of the topic is needed. 2013). due to tech. Steege & Stout. including viral infection. diagnostic laparoscopy Anecdotal evidence from experienced sur. the adhesions and pain (Howard. (Roman. 1991. group compared to control. In addition.. 1996). observational studies as well as conscious pain-​ “Entrapment” of the nerve may also occur as a mapping also suggested an association between result of pelvic floor muscle spasm. Khan. At failed to demonstrate a benefit to the proce. only two ran- lar procedure until the more recent advent of domized prospective studies exist that explore laparoscopy. tility (ten Broek et  al. 2009). indeed. Clearly. 1990). hypothesis that adhesiolysis was beneficial and ishing over a few years. 2006). 1992). Unfortunately. Other than surgery. multiple causes have demonstrating a higher incidence of adhesions been implicated in the etiology of pudendal at time of laparoscopy in women with pelvic neuralgia. there may be insufficient data to justify abandon- Adhesiolysis ing the procedure all together. Thus.. However.. & Hulsey. Though most should not be used as an adjunct treatment in experts agree that adhesiolysis probably does not the management of pelvic pain. 2003). In the hands of the Meta-​ analysis demonstrates the clear role of experienced surgeon. 2014). Both of evidence” of the effectiveness of LUNA when these studies recommended abandoning adhesi- compared to controls (Proctor. Sutton & efficacy (Doyle. pain and quality of life but there was no signif- and. Performed transvaginally. their role in the development of chronic pelvic pain Pudendal Nerve Decompression is unknown. roscopic adhesiolysis vs. alone. icant difference in improvement rates between domized studies concluded that there was “some the two cohorts (Swank et  al. 2011).. brought much attention to the role of pudendal vic pain.138 Pelvic Pain Management by Doyle in 1963. LUNA funding (Cheong et  al. respectively) (Howard. Latthe. Trimbos-​ Kemper. LUNA is technically regard to pain—​ both groups reported about a less difficult than presacral neurectomy. & Hermans. 1955). it may be of some benefit. Additional distance cycling) (Campbell & Meyer. Marpeau. uterosacral ligaments. it has been criticism of the second paper noted that there demonstrated that the effect of LUNA is short-​ was insufficient statistical power to reject the null lived. 2005). 2000. However. though Admiraal. and pressure . 48 women with pelvic involves the destruction of afferent pain fibers pain were randomized to adhesiolysis or expect- exiting the uterus and coursing through the ant management. However. MacDonald. At nine months to one year. an improvement in Visual Analogue dure. 1993). & technique treated dysmenorrhea with 85–​ 90% Sanchez. neuralgia in the development of chronic pelvic ative factor in CPP stems from an early study pain. The notion of adhesions as a caus. & Johnson. El-​ Minawi. add a surgical benefit to the patient with CPP. Two large. Vercellini et  al. it was not a particularly popu. However. Both groups reported improvement in geons demonstrated potential for the technique. time to recurrence the statistically powered sample size. LUNA failed to decrease Scale (VAS) scores was noted in the adhesiolysis either the severity or the frequency of dysmen. 2009.

and. indeed. Here. & understanding of the anatomy of the pudendal Nour.8% As the ischial spine is also the attachment for the (Flynn. third.. ropathic pain in the S2–​S4 distribution at 3. The ligament is tran- there is risk of permanent damage. itching. as injury here can be In the event that conservative therapy is unsuc. gluteal region over the area of the sacrotuberous diately recognized or the patient’s initial com. the bladder reflection. the often the most utilized surgery for apical nerve passes behind the lateral part of the sacro- prolapse—​ estimated the development of neu.. This complex must be completely cally 12–​16 weeks. Desai. Surgical Treatment of Pelvic Pain 139 from surrounding sacrospinous and sacrotu. life-​ threatening. The best arcus tendineus fascia pelvis. In the criteria are: event that mesh from a previous surgery is dis- covered in this area. gabapentin. nerve becomes necessary.  Michael Hibner and colleagues advocate pudendal nerve placing a segment of Neuragen (Origin Biomed. ligament. 2007). not actual surgical trauma lesser sciatic foramen and enters Alcock’s canal. Halifax. following pelvic surgery is about 2%. No objective sensory loss on clinical healing process (Hibner et al. buttocks. a nerve-​ 3. surgical decompression of the pudendal tinued until the arcus tendineus fascia pelvis . to the pain prevent re-​scarring of the nerve and help in the 4.. identified and respected. Most experts agree as 70% of patients. narcotics. 2010). 2002). then this is also resected. of which is a fascial sheath on the medial aspect of 183 patients who had uterosacral suspension—​ the obturator internus muscle. great care must the surgical skill level of most gynecologists. 2008) Nieves. physical therapy. & Amundsen. The space of Retzius is entered by mak- ing a trans-​peritoneal incision 2–​3  cm above Patients meeting these requirements are gener. & Hoffman. Labat. The first of the two decompression meth- gery should be immediately taken back to the ods is a transgluteal approach first described operating room for release of the compressing by Robert (Robert. & suture or mesh. examination The second type of decompression method 5. Conservative treatment areolar tissue is dissected away bluntly. Canada). it is here that the treatment is often prevention. which may be present in as many with conservative therapy. any nerve is at risk of injury or entrapment during pel- patient complaining of new-​ onset neuropathic vic reconstructive procedures such as sacrospinous pain—​burning. The gluteal muscle is then separated plaints are minimized or ignored by the surgeon with gentle dissection until the sacrotuberous as being part of normal post-​ operative pain. and the pudendal nerve is then identi- Criteria have been proposed (Nantes criteria) fied underneath. and be taken to identify a possible aberrant obtu- also because there is less chance of complication rator vein. Worsened by sitting Inc. though then exits the pelvis through the greater sciatic most of these injuries are due to retractors or foramen. The five essential diagnostic the piriformis muscle to Alcock’s canal. Riant. 2. from nerve entrapment. or posterior leg after prolapse sur. 1. Pain in the anatomical territory of the Dr. An incision is made across the of pudendal nerve compression are not imme. (Cardosi. The nerve then reenters the pelvis via the patient positioning. stabbing—​in the vulva. Weidner. 2010). Dissection continues later- a reasonable timeframe should be given to see ally until the obturator neurovascular bundle improvements with conservative therapy. typi. One study. From here. allow- is preferred because the technical aspects of ing development of the retropubic space. Positive anesthetic pudendal nerve block involves a laparoscopic approach described by (Labat et al. Khalfallah. and Once the space of Retzius is entered. ligament is encountered. nerve distribution. and fourth sacral nerve roots. the loose pudendal nerve blocks. 2006). identification of loose ally first treated conservatively with pelvic floor areolar tissue confirms the correct entry point. fixation. The patient is not woken at night by protecting tubing made of a collagen matrix. In patients in whom symptoms Hamel. Nova Scotia. is identified. The pudendal nerve arises from In general. the incidence of nerve injury the second. The pudendal nerve is then to identify true pudendal neuralgia by pudendal decompressed along its entire length. Cox. Robertson. sected. pudendal nerve decompression can be beyond Cooper’s ligament is identified. Posterior dissection is con- cessful. This involves a keen berous ligaments (Hibner. spinous ligament and posterior to the ischial spine.

09. Here. B4374. de Bisschop E. 78(1):50–​53.1016/​ Surgical decompression of the pudendal j. Cox CS. that are no clear-​cut recommendations regard- Additional approaches such as the perianal ing the role of surgery in the treatment of pel- and trans-​ischiorectal (Bautrant et al. Soong YK. Black WT. Chang SD. Because of this. However. J Reprod Med. Reading I.4% of the surgery group. then portions of the sacrospinous liga. Turkish study analyzed 27 patients who under- Brandsborg B. CONCLUSION 14(1):36. and these Check JH. Chronic pelvic pain syndromes—​ tend to be highly specialized pelvic pain centers. were Brandsborg B. A  retrospective epidemiological and clinical aspects. and never pushing any best. Hoffman MS. Avci. doi: 10. improved (50% of the surgery group reported [Modern algorithm for treating pudendal neural- improvement in pain at 3 months versus 6. Kehlet H. (2006).” I would suggest instead that amount of fibrotic tissue is present that may surgery is an integral part of the armamentar- be contributing to entrapment of the pudendal ium of available treatments and can be a highly nerve. If a significant failure of medicine. (1955). Ultimately. Bailey S. worldwide that can offer this modality. Obstet Biol Reprod (Paris). (1996). no complications were Campbell JN. Referral to these and laparoscopic uterine nerve ablation for pri- surgeons is appropriate for the patient requiring mary dysmenorrhea. 41(7):463–​466. 2014). conservative therapy (16 in each arm). this technique should only be attempted Comparison of laparoscopic presacral neurectomy by specially trained surgeons. 2005). In patients followed for tors for pain persisting 4  months after hysterec- more than six months.3% of the non-​surgery group. Should women with chronic pel- vic pain have adhesiolysis? BMC Women’s Health. Presacral neurectomy: report of At 12  months. Ledger W. Mechanisms of neu- encountered (Erdogru. If mesh is present. effective one in the right hands. (2014). Nikolajsen L. the more complicated Am J Surg. The first RCT of its kind patient. Chu KK. Additionally. South Med J. 48(2):120–​126. A prospective study of risk fac- laparoscopic approach. it is grasped at its Cholera. more outcomes-​based prospective trials are per. surgical Until the technique becomes more common and therapy. 25(4):263–​ 268. Clin Exp Obstet Gynecol. 38(1):10–​13. Postoperative the anatomy as well as a high level of surgical neuropathies after major pelvic surgery.2%).2% of gia: 212 cases and 104 decompressions]. Chen FP. Gabriel García Márquez’s protagonist insertion into the sacrospinous ligament and remarks. Obstet skill. traditional and novel therapies:  part I. pared with 13. it ment can be resected here until the pudendal must be stressed to patient and physician alike nerve is completely free of scarring. Jr. Thirty-​ two patients were assigned to important when approaching pelvic pain. Meyer RA. Dueholm M. ropathic pain. a significantly REFERENCES higher proportion of the surgical group was Bautrant E. the convoluted nature identified. reduction in VAS score tomy. 71. . (1949). Pain following hysterectomy: improved (Robert et  al. Vaini-​Elies V.1097/​ of >80% was achieved in 13 of the 16 patients AJP. 70 cases. “The scalpel is the greatest proof of the resected to free the attachment. Sadek K. there are very few centers Gynecol. Beneficence—​ that fundamental tenet was performed by Robert using the trans-​gluteal of medicine—​ still applies.1186/​1472-​6874-​14-​36 The more that is discovered about the complex Cotte G. 100(2):240–​244. doi:  10. 59(1). (2012). Clin J Pain. 32(8 Pt 1):705–​712.2006. (2002). went pudendal nerve decompression using the Jensen TS. pudendal nerve decompression. At three months. Neuron. (2011). J Gynecol the non-​ surgery group). and it is especially approach. (2009). Cheong YC. In the novel Love in the Time of resected.021 nerve requires an intimate understanding of Cardosi RJ. no com. Dan Med J. surgical decompression vs. (2003). 2003) have vic pain. Advocates ent options. utilizing or being part of a multi- for both techniques insist their approach is the disciplinary approach.neuron. and any surrounding scar tissue is ing outcomes.. the practitioner must be been described. an advocate for the patient. Technique of presacral neurectomy. com. & Akand. but the aforementioned tech. formed. presenting differ- niques are those most commonly used. 52(1):77–​92. doi: 10. Li TC. and there is unfortunately a paucity of data particular treatment—​ especially surgery—​ on a regarding outcomes. et al.140 Pelvic Pain Management and its attachment to the ischial spine are the treatment becomes. the pudendal nerve may be of the disease makes for convoluted data regard- visualized.0b013e31819655ca (81. etiology of pelvic pain. Additionally. plications were reported in the surgical group..

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Successful intervention for model that theorizes how particular psychologi- one and not the other will be difficult. amplification. Symptom-​related anxiety and central pain ampli- tle consensus in the literature about whether fication have been repeatedly linked in several organic or psychological factors are primarily disorders. and difficulty disengaging from that psychological factors are primary. cal variables may contribute to the maintenance the pain physicians must be adept in recogniz. and treating concurrent psycho. failure The majority of investigators have suggested of inhibition. whether they precede. depression. including endometriosis. are greater in chronic pelvic pain patients.5 as logical disorders. Other com. lower interest of a father figure in the with chronic pelvic pain have included major daughter’s life. including pain-​ research. anxiety. and reported a promi. in spite of the available abundant certain pain-​related cognitions. a theoretical model to explain why some people . therefore. evaluating. The various implicated in the etiology of chronic pelvic pain. awareness are also commonly seen. and catastro- icant role of psychological disorders in chronic phizing. ing. a conceptual a result of. This led improving physical impairments are fundamen- the investigators to suggest a psycho-​pathological tal. the pain. or occur as the fear-​avoidance model (FAM). costly condition for which diagnosis and management are often difficult because of the U N D E R S TA N D I N G THE  PSYCHOLOGICAL COMPONENTS complexities of causative factors and the multi. in medical literature. The evaluation and More and more models integrate psychological treatment of chronic pelvic pain have been both factors found in persistent pelvic pain with our a clinical challenge and a source of controversy current neurobiological understanding of pain. of musculoskeletal pain. and and negative perceptions of menarche or puberty chaotic family backgrounds. 16 Chronic Pelvic Pain and Psychological Disorders MOHAMMED ISSA AND RAHEEL BENGALI C hronic pelvic pain (CPP) is a prevalent. Although treatment approaches directed at nence of emotional disturbance in them. related fear. conflicts with regard to sexuality. FAM was first introduced by Lethem et al.1 They investigated the psychological background Fear-​Avoidance Model (FAM) of 36 women with chronic pelvic pain without of Chronic Pelvic Pain apparent physical cause. Society and the scientific behavioral interventions directed at decreasing community. pain-​related anxiety. somatization disorders. still have difficulty valuing the signif. restriction of activities.3 Low The first contributions of psychological and self-​esteem and body perceptions with poor body biological factors in chronic pelvic pain were dis. while a painful stimuli can influence an individual’s expe- small number of studies point to organic causes. O F   P E LV I C   PA I N tude of involved structures. increasing evidence suggests that women etiology to chronic pelvic pain.4 cussed in the literature by Duncan and Taylor. Chronic emotional distur- ment disorders have been repeatedly reported in bances early in life might be associated with the patients with chronic pelvic pain. There continues to be lit. mechanisms of facilitation. These variables are the cornerstone of pelvic pain. development of chronic pelvic pain. with chronic pelvic pain may fare better with a Chronic pelvic pain has an important impact treatment approach that incorporates cognitive-​ on the quality of life. rience of pain and result in increased distress and Childhood sexual abuse and adult sexual adjust.2 Conflicts mon psychosocial conditions seen in patients with parents.

further exacerbat. sexual and physical abuse. placing an individual at risk for a potentially painful stimulus during intercourse reinjury. and the degree WITH  CHRONIC of neuroticism. chronic psychological distress compared with tively self-​evaluate the ability to deal with pain controls. ual and physical abuse have also been shown to evidence has shown that overall pain sensitivity subsequently lead to somatization. The intensity of these psychosocial ing thoughts about their pain. pain sensation (rumination). suggest that women with vulvodynia may have “Pain catastrophizing” describes how an enhanced pain sensitivity. This healthy women. Russo et  al. suggesting that increased attention to and disability. while pain ratings and anxiety results in the development of chronic pain and scores were significantly higher. anxiety.15 Studies have shown an association (helplessness). FAM nificantly with hypochondriacal beliefs. Women with vulvodynia reported more pain-​catastrophizing. It leads to preventive often have a characteristic psychological pat- behaviors. and to nega. or both. pareunia). disuse. with various psychosexual dysfunctions such while they disengage from neutral stimuli. Walker et  al. depression.10 This est and affection. tern: a sad childhood. and deconditioning. whereas others who variables associated with chronic pelvic pain. was based on the central idea of fear of pain and Previous studies have documented significantly was developed to provide an understanding of high levels of affective disorders in patients with how exaggerated pain perception contributes to chronic pelvic pain.18 These patients nent in the FAM of pain. tion and severity of the abuse.144 Pelvic Pain Management recover from a painful injury. thoughts regarding intercourse-​ related pain. especially how these variable may contribute to nitions develop chronic pain. and dyspareu- nia. The initial model the maintenance of different types of pelvic pain.7 It involves the tendency to focus on the are more likely to have histories of depression. perpetuation of negative-​related cogni.14 These results disability. which also correlated sig- the maintenance of chronic pain problems. including avoidance of and hyper. the experience of intercourse. be a risk factor for the development of chronic In general. and threat of pain (magnification). exhibit certain pain-​related behaviors and cog. and arousal. to exaggerate the somatization. may interfere with sexual arousal and diminish tions and behaviors. pain-​related anxiety. and lack of parental inter- vigilance for perceived impending pain.12 and fear of physical activities that are assumed A recent study revealed that catastrophizing was to cause pain.20 highlighted the P E LV I C   PA I N importance of recognizing that medically unex- Several recent studies have shifted the focus from plained physical symptoms may be a proxy for the biomedical mechanisms to the psychological psychiatric distress. Women with vul- “Pain-​related fear” refers to fear of the sen.9 sequelae appears to be correlated with the dura- Pain-​related anxiety is the third key compo. These variables are believed hypervigilance for pain during intercourse (dys- to lead to avoidance/​ escape behaviors. lack of orgasm. and its presence is thought to mediated pain processing. with vulvodynia were found to have signifi- ing negative pain-​related cognitions about these cantly lower heat pain thresholds compared to activities.13 Women they believe will cause pain. The patient’s marital and/​ or may result in patients’ directing their attention sexual relationships have often been unsuccess- toward the potential threat of a painful stimulus ful. agoraphobia.16. vodynia also reported increased catastrophizing sation of pain. chological variables to intercourse and sexual iors:  pain-​related fear.19 have shown that the number PA I N -​R E L AT E D of non-​organic causes of pelvic pain is linearly PSYCHOLOGICAL correlated with both the number of lifetime VA R I A B L E S A S S O C I AT E D anxiety disorders. disuse. as loss of libido. and was enhanced in patients who had catastrophiz.11 Other includes three central components that contrib. . perhaps due in part individual responds to an actual or impending to changes in central nervous system (CNS)-​ pain experience. fear of movement or reinjury.8 There is considerable evidence of 30–​ 80% between psychological comorbidi- of the association between catastrophizing and ties and chronic pelvic pain. women with chronic pelvic pain pain.6 People with pain-​ related fear the only variable that contributed a substantial are likely to avoid activities or movements that variance to intercourse-​ related pain.17 Childhood sex- pain intensity in pain conditions and disabilities. studies have examined the relationship of psy- ute to the cycle of fear and avoidance behav.

bloating.22 found that 72% of patients having a current diagnosis of major depres- with pelvic pain reported sleep disorders. and somatic symptoms than controls.29 found that 53% of patients with more anxious. constipa. pain (like cancer) and/​or to uncertainties about treatment options and prognosis. Brauer et  al. dizziness. difficult to exclude the vic pain have associated anxiety. hostile. Although there that sexual abuse was reported more frequently appears to be an association between chronic pel. Chronic Pelvic Pain and Psychological Disorders 145 Depression chronic pelvic pain compared with those with Pain and depression can be closely linked. lubri- Somatization Disorders cation.30 Payne et al. Accordingly.15 reported that vic pain and depression. These results also been linked to a personal and/​or family his. and a more general association similar behaviors. may affect arousal in women despite Physical and Sexual Abuse their level of sexual dysfunction. Both other types of pain and with control groups (52% may be mediated by the same neurotransmit. and 51% sion and somatoform pain disorder compared were clinically depressed.5% of patients with chronic pel. of an experience associated with pain. Up to 87. dyspareunia. and the development of pain or result from it.sexual dysfunction. They also give rise to pelvic pain. and endorphin. Slocumb et  al.23 found with those with no abuse or less severe abuse.27 Chronic somatic com. It is. In another study.26 There is arousal even in the absence of reported sexual also an association between somatization and a dysfunction.arousal with the threat of a painful stimulus. suggesting that the threat of pain may decrease weakness. dysmenor. and sexual desire than women without Patients with multiple physical complaints that pain. such as behavioral and social between physical abuse and chronic pain. breathlessness. Women withdrawal with limited interaction. depressed. physical abuse was more common than sexual abuse in the majority of these cases. Patients with the extent of decreased sexual arousal between chronic pelvic pain have an increased incidence women with dyspareunia and women without of upper abdominal pain. including gynecological problems. rhea. low back pain. Asking about Sexual Desire and Arousal what the patient believes or fears is the cause of Evidence suggests that women with chronic their pain may be more suitable in assessing their pelvic pain exhibit lower levels of sexual desire anxiety in the context of chronic pelvic pain than and arousal than healthy women. and that they had more catastrophizing are out of proportion to an organic cause of thoughts and hypervigilance related to pain with pain and cannot be fully explained by a known intercourse. it Childhood physical and sexual abuse has been is important to ask patients about their levels noted to be more prevalent in women with of sexual desire and arousal when screening for . Anxiety However. nausea.suggest that the negative emotional appraisal tory of alcohol abuse. have both with and without dyspareunia. chronicity.21 Nolan et al.25 reported that women with vulvodynia experi- enced more difficulty with sexual arousal.28 There is a specific asso- ters. respectively). and menstrual irregularity. both groups exhibited less tion. in many cases it is still 39% of patients with chronic pelvic pain had unclear whether the depressive symptoms precede been physically abused during childhood. many studies have failed to adopt com- Pain intensity positively correlates with anxiety parative groups of patients with pain of equal severity.15 gynecological patients with pelvic pain to be Toomey et  al. in this study. such as intercourse.33 history of sexual trauma in women with non-​ demonstrated that negative appraisals were also somatic pelvic pain. there was no difference in coexisting somatization disorder. and 12%. than physical abuse. and have more chronic pelvic pain reported previous abuse. Interestingly. Brauer et  al.32 assessed how fear of general medical condition may be given the a painful stimulus may affect sexual arousal by diagnosis of “somatization disorder.24 “Anxiety” may possibility that psychological disturbances may refer to fears of missed pathology as the cause of have arisen from long-​term experiences of pain. Rapkin et  al. Depression with pelvic pain who had a previous history of was found to predate the symptom of pain in 75% sexual abuse had a significantly higher risk of of cases.associated with diminished arousal in women plaints. ciation between major sexual abuse and chronic serotonin. such as noradrenaline (norepinephrine).” Up to 70% using the threat of pain at a distal location (the of women with chronic pelvic pain may have a ankle).31 using a general anxiety questionnaire. therefore. diarrhea.

In addition to rehabilitative interventions. function in patients with chronic pelvic pain. including catastrophizing. In addition. these protocols cognitive-​behavioral therapy. should be given. even when they do not pain.146 Pelvic Pain Management psychological variables. which can ive. Follow-​ up appointments alter the treatment approach used.” Anxiety and depression can ical factors and attentional bias to pain during also be reduced when psychosocial functioning intercourse may affect sexual functioning and improves. and sympathetic. including women with chronic pelvic pain. because requesting patients to their continued use over the course of treatment return “only if pain persists” can reinforce pain can help assess whether changes in pain-​ related behavior. activities. should be initiated first if any signs of psychopa- These scales are likely to provide important infor. and anxiety. suggested to help in breaking up the harm- vic pain. and attitudes toward and resultant dyspareunia. However. study of pelvic congestion. Sex thera- psycho­logical variables. psychodynamic-​ interpersonal ther- provider. Hypnosis has been ment intervention for women with chronic pel. do not yet appear to be widely a sex counselor or therapist is recommended for used by physicians to complement traditional women who have pelvic pain complaints and interventions. and hypnosis have therapist. should be designed to include interventions that grated into the comprehensive treatment of actually simulate intercourse rather than just the women with sexual pain disorders.37 should be sexual dysfunction on intimate relationships. there have not yet chronic pelvic pain. . 1. as well as palliative repeatedly demonstrated to be an effective treat. thology are present. and the presence of these variables should apy or other interventions for pain and sexual influence how treatment interventions are deliv. catastrophizing. recommendations. to cause pain. behaviors. fear. Despite these simple vaginal dilation exercises. including return to work.41 mation about the presence of psychological vari. For ered. Am J Obstet Gynecol.38. with the goal Available evidence suggests that psychological of encouraging patients to engage more in such factors play an important role in the percep. reduction in pain intensity.35 the Fear of Pain Questionnaire.34 report sexual dysfunction or intimacy problems Screening questionnaires for pain-​ related secondary to pelvic pain complaints.40 included in routine practice during evaluation and Psychological assessment and psychotherapy assessment of patients with chronic pelvic pain. during periods of 1952. Physicians should be able been trials comparing the efficacy of a graded-​ to identify such variables with proper screening exposure protocol with cognitive-​behavioral ther- tools. and improved sexual activity. self-​ coping skills. collaborative psychosexual treatment of women such as fear of pain. such as a clinical psychologist or sex apy.39 Cognitive coping strategies should ful and well-​ established pain reflexes through include education about how certain psycholog. biofeedback therapy.64:1–​12. the approach to patients with ables. chronic pelvic pain must be therapeutic. Referral to ety about pain. should be inte. interventions that target psy. Different psychotherapeutic approaches psychological variables have occurred and may such as depth psychotherapy. support- in patients with chronic pelvic pain. Psychological interventions. with chronic pelvic pain is essential. These strategies also should include specific instructions about decreasing hypervigilance REFERENCES and expectations of painful stimuli during activ. such as relaxation training. Another psychological intervention that has PSYCHOLOGICAL been studied extensively in patients with chronic A P P ROAC H TO   C H RO N I C low back pain is graded exposure to activities P E LV I C   PA I N associated with pain-​ related fear. and gradual exposure to activities reported report pain with intercourse. chological factors and pain-​ related cognitions. For women with chronic pelvic pain tion of pain. In summary. Taylor HC. increased other activities for which patients may report social activities. pain. one of these activities experimental and sexual stimuli in women with is often intercourse. Duncan CH. or anxi.36 arousal problems. “synaptic ablation. systemic psycho- signal the need for referral to another healthcare therapy. such as the Pain Catastro­ pists may be helpful in addressing low libido or phizing Scale. been shown to be effective in achieving symp- Cognitive-​ behavioral therapy has been tomatic relief from pain. in addition to the effects of and the State-​Trait Anxiety Inventory. A psychosomatic ities reported to cause pain.

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and seek help from an orthopedist organs. rectum—​ and includes the perineum. vic pain. gastroenterology. thra.6 This chapter is on evaluation and vis. lifting. it has Since the complex actions of normal pelvic floor proven to be an invaluable part of treatment muscle function—​ tightening. Multiple systems appear to be involved.​A B B AT E A N D A M Y   S T E I N C hronic pelvic pain is estimated to affect one in four women—​ particularly reproductive women.7–​25. and contribute to sexual arousal approach to pelvic floor muscle dysfunction. Both evaluation causing pain in the pelvic. for tailbone pain due to sitting in later matu. While the dysfunction affects many systems P E LV I C A N AT O M Y. (Table 17. which later see a colorectal specialist for chronic consti. the sacrum. affecting it should be executed. and anus. maintain continence. any dysfunction giving rise to such therapy evaluation should consist of and how pain can have a wide-​ranging impact.1). bladder. squeezing. Because pelvic floor physical therapy is capa- rience it—​ while chronic prostatitis and male ble of treating all the musculoskeletal impair- pelvic pain affect 9% of the male population. and sexual functions as well as the various forms of treatment.1 ments that contribute to pelvic pain.2. from The four are joined at four joint surfaces—​the muscular weakness. The dysfunction may begin as early as in child.7 The abdominal perito- head back to the gynecologist for dyspareunia neum extends down to cover the reproductive as an adult. and the coccyx. and a gynecologist for her inability to wear a tampon. in the anatomy of specialties as urology. urogynecol. abdominal. the paired posterior impairments.5. back. and rectum from above. prostate in men. 17 The Physical Therapy Approach to Pelvic Pain Evaluation L I L A B A R T K OW S K I . ogy. increased tone. or skeletal anterior pubic symphysis. vagina. the pelvic floor and its dysfunction. allow for bladder and Chapter  18 is on physical therapy treatment bowel emptying. repro- not uncommon for a teenaged patient to consult ductive organs in women. yet with the mobility and stability of the trunk. The endopelvic portion of the pelvis cradles hood and continue throughout the life cycle. distinct bony segments—​the two paired innom- muscular and musculoskeletal systems within inate bones (ilia). We begin. then define and describe bladder. and colorectal disorders. bowel. and and treatment of pelvic floor disorders require lower-​extremity regions of the body. Dynamically.4% expe- a single cause—​a pelvic floor muscle problem—​ may be the source of all these symptoms. and the sacrococcygeal joint. to . and surrounding the pelvis—​for example. for musculoskeletal causes of functional pel- and relaxing—​“support all organs within the pel. with patients with such pain or dysfunction tend to the context within which the physical therapy consult doctors representing such overlapping approach is applied—​that is. among whom some 14. It is the pelvic organs—​bladder and urethra. the pelvis functions to assist rity. then in college turn structure to the triad of pelvic orifices—​the ure- to a urologist for urinary urgency and frequency. It is why postgraduate training. and orgasmic function” as well as assisting with We discuss first what the pelvic floor physical childbirth. serves to support the viscera as well as give pation and defecation pain. however. It can arise from The skeletal structure of the pelvis comprises four abnormalities occurring throughout the neuro. its potential causes are many and P E LV I C D Y S F U N C T I O N S are often difficult to determine.4.3. sacroiliac joints. gynecology.

or after a bowel Pain before. hip pain hip pain Referred Sacroiliac Joint pain/​ Referred Sacroiliac Joint Dysfunction Pain/​Dysfunction Tailbone pain Tailbone pain Piriformis pain Piriformis pain provide for the transfer of weight-​bearing forces ability of the pelvis to function is greatly influ- between the trunk and the upper and lower limbs. the midsection.1  MEDICAL SYSTEM BASED MUSCLE OVERACTIVIT Y SYMPTOMS System Female Male Urology Urinary urgency Urinary urgency Urinary frequency Urinary frequency Pain with urination Pain with urination Burning with urination Burning with urination Chronic UTIs—​feeling Erection pain Post-​coital UTI—​feeling Post-​ejaculatory pain Penile-​shaft pain or numbness Gastroenterology Abdominal pain Abdominal pain Abdominal bloating Abdominal bloating Inability to pass gas Inability to pass gas Flatulence Flatulence Colorectal Pain before. and the thoracolumbosacral . or after a bowel movement movement Tenesmus Tenesmus Chronic constipation Chronic constipation Incomplete bowel emptying Incomplete bowel emptying Rectal burning Rectal burning Gynecology Dyspareunia: initial penetration pain. and to assist in childbirth. includ- to protect the pelvic organs and the attachments ing the pelvic floor muscles. Sacroiliac. The the hip muscles.150 Pelvic Pain Management TABLE  17. deep thrusting pain Post-​sex pain with or without urinary urgency/​frequency Vaginal burning Reproductive pain without an organic diagnosis Orthopedic Unexplained back. the diaphragm and the abdominal muscles. during. Sacroiliac. enced by the soft tissues that attach to it. and ligaments in and around deep. during. both superficial and for muscle. Unexplained back. deep thrusting pain Post-​sex pain with or without urinary urgency/​frequency Vaginal burning Reproductive pain without an organic diagnosis Urogynecology Pelvic organ prolapse Urinary urgency Urinary frequency Pain with urination Burning with urination Chronic UTIs Post-​sex UTI—​feeling Dyspareunia: initial penetration pain. fascia.

11 that the soft tissue of the pelvic floor is divided Support within the pelvis is multifaceted. all the physical space available within the bony The endopelvic fascia serves to suspend the pel. and sexual dys- ficial transverse perineal muscles of the ante. Illustration #2 Female Pelvic Floor Anatomy Clitoris Urethra Ischiocavernosus Vagina Bulbocavernosus Vestibule Perineal body Transversus perineum Anus Levator ani: Pubococcygeus Anal sphincter Iliococcygeus Gluteus maximus Coccyx bone FIGURE 17. More superficial is the uro. and the rectum. vaginal.9 The topmost layer comprises the pel.9 the bony pelvis. or age. bladder. the pelvic floor muscles function musculoskeletal systems within and surround- to support the pelvic organs. connecting the When these support systems shorten and/​ or perineal body to the ischiopubic rami and secur. which support cles.12 while the viscerofascia9. Heal Pelvic Pain by Amy Stein. also greatly influences their positioning.8 Some authors suggest performance (see Figures 17. bowel.10 Distal to ported most inferiorly by the pelvic floor mus- that are the levator ani muscles. DPT . composed pends the organs. which respiratory diaphragm and decreasing distally. and nerves. with and anal openings.10 sus- These fascial structures are complex. the pressure being greatest just inferior to the genital diaphragm. into layers.1 ness. the pressure within the abdominal cavity the viscera and are part of the urethral. Articular and fibrous cartilage support and bind vic viscera and its supportive endopelvic fascia. to assist in both ing the pelvis can cause pelvic floor dysfunction.3 and 17. function. including the support system of assist in “uploading” the spine and pelvic-​spinal the bladder and urethra. organ prolapse. rior urogenital triangle and the anal sphincter A range of abnormalities—​ muscular weak- of the posterior anal triangle (see Figures 17. an affinity for one another due to the serous tic fibers. multi- ing the distal urethra. Most superficial are the ple pregnancies. the bowel. increased tone. ischiocavernosus. the result can be pelvic bulbocavernosus. and super. occurring throughout the neuromuscular and As a whole. The organs themselves have of loose connective tissue. smooth muscle. Equally influential are the pelvic vis. Physical Therapy Evaluation of Pelvic Pain 151 muscles.2). blood vessels. or perineal membrane. fecal and urinary continence.8 Though the pelvic viscera are sup- vic viscera from the pelvic sidewalls. abdominal.1:  Female Perineum and Pelvic Floor Muscles. and back pain. and to contribute to sexual arousal and organs. reproductive stability. or skeletal impairments—​ and 17. and pelvic. more closely fluids in and around them. elas. even as they occupy resembling a mesentery than skeletal ligaments.4).8 crosses the anterior pelvic outlet. weaken due to such causes as surgery. to pelvic confines. to provide support cera and their fascial attachments within the for the rectum and inhibition to the bladder. confines.

a fall.2:  Male Perineum and Pelvic Floor Muscles. Illustration #1-Female Urogenital System (midsagittal section) Colon Sacrum Abdominal Ovary muscles Uterus Rectum Bladder Coccyx bone Pelvic bone Cervix Urethra Vagina Levator ani muscle Urethral sphincter Anus muscle Pelvic floor Labia majora muscles FIGURE 17.3:  Female Pelvic Floor Muscles-​Midsaggital. DPT . or childbirth determine. DPT and the underlying cause of pelvic pain and the pelvis. Singular events can cause changes in often leave the pelvic floor with lasting abnor- the physiology or biomechanics in the region of malities that require effective care. Heal Pelvic Pain by Amy Stein. Heal Pelvic Pain by Amy Stein. Events such as abdominal or pelvic related symptoms is therefore often difficult to surgery.152 Pelvic Pain Management Illustration #4 Male Pelvic Floor Anatomy Ischiocavernosus Bulbocavernosus Perineal body Transversus perineum Anus Levator ani: Pubococcygeus Anal sphincter Iliococcygeus Gluteus maximus Coccyx bone FIGURE 17. an acute infection.

improper sitting postures can also commonly bination of the two in and around the genital leave the pelvic floor structures compromised20. A noxious stimulus can trigger pelvic floor tional voiding to such inflammatory conditions dysfunction—​ and vice versa:  pelvic floor dys- as endometriosis. over time.13. example. bladder.16. yeast infections. can play a part as additional muscular pain.15 and function can trigger a noxious stimulus. Heal Pelvic Pain by Amy Stein. Over pelvis. or a com. as lichen sclerosus. leaves the as well as on bowel. once narrowing or scarring of a fascial nerve canal. region. the pelvic floor muscles dysfunctional. DPT Moreover. the lumbo-​ sacral region). with a short- tion. with a lifelong phobia about public toilets may chological. ious and can range from childhood dysfunc.18 Chemotherapy and radiation often hemorrhoids. burning. ening of sarcomeres and with subsequent and gen causing vaginal atrophy. normal pelvic floor tone is restored. and sexual func. Or. result in ongoing discomfort that causes pelvic tions. and/​or sexual abuse19 can develop an overactive pelvic floor from delaying leave lifelong abnormalities in and around the the urge to empty his bowel and bladder. patients may habituate a pelvic have a lasting impact on pelvic floor function floor holding pattern that. We also know that the torments of psy. especially low estro.17 to neuro. squamous cell hyperplasia.21 Scarring and adhesions can occur. Examples of this include bladder infec. floor muscle guarding and overactivity of the cal conditions or sexually transmitted diseases muscles. and such dermatologi. For inflammatory bowel disorders. or connective tissue managed and the musculoskeletal dysfunction is restrictions around the vaginal introitus22 or addressed. a young man well. creating increased tension in the pelvic All of these conditions and eventualities may floor. or around nerves can also leave But pelvic floor dysfunction can be insid.6. (genital warts).4:  Male Pelvic Floor Muscles-​Midsaggital. pelvic floor muscles hypertonic. increasing the . Hormonal imbalance. these disorders are properly diagnosed and myofascial trigger points.4 Typically. Physical Therapy Evaluation of Pelvic Pain 153 Illustration #3 Male Urogenital System (midsagittal section) Sacrum Bladder Abdominal muscles Rectum Pelvic bone Coccyx bone Urethral sphincter muscle Pelvic floor muscles Urethra Penis Prostate gland Testicle FIGURE 17. and prolonged and ders can cause either itching. and Such biomechanical abnormalities as foramenal vulvar interepithelial neoplasia. physical. condyloma acuminatum as can shortening of the pelvic floor muscles. Muscular changes occurring with poor time.14 interstitial cystitis. bowel and bladder retention disorders posture. in response to the chronic pain of pathic pain. skeletal misalignment (especially in become a much bigger problem. genital region. a range of other pelvic pain disor.

Patients may or may not present with an fair number of studies can be found. decreased blood flow. reten- pelvic floor issues is in the realm of urogynecol. and/​or chronic constipation. The posterior femoral cutaneous nerve orig- ceral referral pattern for the pudendal nerve is to inates from the dorsal portion of S1–​ S2 and the lower uterine segment. vagina. upper vagina. recognize that “good clinical practice tion with pudendal nerve stimulation. The genitofemoral nerve originates from preferences … [as well as] respect. male scrotum. . the perineal nerve. too. The ilioinguinal nerve originates from L1 THE and refers to the upper and medial portions of N E U R A L G I A   FA C T O R the thigh and to the lateral part of the scrotum Thanks to the constellation of nerves of the pel. and the levator ani muscles. The vis. and L1. cycle of noxious stimuli. a orgasm. the ventral portion of S2–​ S3. Its motor innervation is incontinence. with a lim. and of improvement upon standing or sit- before normal function can be regained. as is pain during or after physical therapy and pelvic floor dysfunction. (RTCs). urgency. A  common perineum. The motor branch of the nerve supplies portion of the thigh. L1 and strong ethical grounding. The visceral referred pattern innervates part of the rectum and the sur. They may present with bladder A large portion of the literature dealing with and bowel symptoms of frequency.3. and constipation. tion. and divides into two branches. always should be individualized and should be There are other nerves in the thoracolum- based on a combination of clinical experience. They may complain ogy and deals with pelvic prolapse and incon.35 and labia majora in females.37. sitting.6.24.29 sexual dysfunc. and the superior posterior por- at the sacrotuberous or sacrospinous ligaments tion of the lower leg. Dyspareunia tinence. with sensory distribution to the lower tains 80% sensory and 20% motor fibers. improper behavioral Patients thus affected may complain of an patterns. with the visceral referred the external anal sphincter. the Alcock’s canal. site for adverse pudendal nerve tension may be popliteal fossa. gluteal region. how.31. sphincter muscles of pattern to the fundus and lower uterine region. both physically and psychologically. the perineum.28. it may cause is the pudendal nerve. scrotal skin in males and the mons pubis and tion. distal ureter. and hemorrhoids. The iliohypogastric nerve emerges from T12 nates from the sacral plexus (S2–​S4) and con. dealing with the specifics of ral branch supplies the anterior portion of the pelvic floor dysfunction as it relates to chronic upper thigh.6. Its physiological abnormalities can also be a major motor distribution is to portions of the abdom- factor in pelvic pain. The genital branch supplies the pelvic pain syndromes.) and uterine fundus. ever. however. It refers to the cervix. adverse neural tension due to the labia majora and mons pubis in females. and the dorsal nerve of the clitoris or from L2–​L3 and refers to the lateral and anterior penis.34. bladder. Its visceral innervation is to the in that constellation in terms of the problems proximal tube and uterine fundus. ting on a toilet seat. is to the ovaries and the distal fallopian tubes in rounding skin. of the sacroiliac joint. The femo- do exist. the bladder.23. and to the testicles in men. The pudendal nerve is also the only peri­pheral ited number of randomized controlled studies nerve that has both somatic and autonomic fibers.154 Pelvic Pain Management possibility of recurrent urinary tract infections.27. labia. and testicles in males and the lateral part of vic floor region.33. of pain in the genital or anal region. Bo and her colleagues have published A  person can therefore experience increased an excellent and highly recommended book heart rate and blood pressure. The at the obturator internus muscle. which abdominal muscles. It origi. pain. empathy. and rectum.30.25 When reviewing the literature on is a common complaint. lack stringent study protocols. and perspira- They.”2 Many other studies L2. and The lateral femoral cutaneous nerve arises urethra. and pelvic floor dysfunction must be increase in symptoms with tight clothing and with addressed. The abdomen and the superior gluteal region. decreased motility describing evidence-​based physical therapy care.26.36.2 of the colon.21.32 painful bladder syndromes. The are for example only and by no means represent visceral referral pattern is to the proximal tube all published data. bosacral region that can cause abdomino-​pelvic knowledge from high-​quality RCTs and patient pain. innervating women. abnormal pudendal nerve motor latency test.39 One of the chief actors inal muscles. and the upper part of the lumbar plexus. most. and sensory pudendal nerve branches into three with motor innervation to portions of the smaller nerves:  the inferior rectal nerve.38 (The references provided here the lateral portion of the bulbocavernosus. the posterior thigh.

or from connective tissue the paravertebral soft tissue is consistent from restrictions surrounding the nerve. with an inflammation associated with visceral ner. The sciatic nerve originates from L4–​S2 with sensory innervation to the posterior thigh. The result is myospasticity and abnormalities as narrowing of a foramen or palpable tissue texture changes. gastric nerve’s origin is at T10–​L2. The afferent stimulation proceeds sharp and shooting pain. neurons return to the spinal cord. and it ends with somatovisceral reflexes. As the Guide to Physical . REFLEXES gastric plexus. pelvic. and it may manifest itself a referred pain pattern from the ongoing inter- as sensations of itching. A viscerosomatic reflex might begin floor. The inferior stitute a possible explanation for pelvic floor hypogastric nerves contain both sympathetic nerve abnormalities and can be used as diagnos- and parasympathetic fibers from S2–​ S4. convergence. S O M AT OV I S C E R A L The superior hypogastric.40 The spinal cord in turn helps transmit the flexor muscles. burning. one individual to another. visceral afferent neurons. in response to visceral pathology. and foot. E VA L UAT I N G P E LV I C hormonal imbalances. The location of canal where the nerve travels. leg. both affecting the organs and giving tion of L2–​L4 and has a sensory innervation with rise to a pain pattern and to possible central sen- the anterior and medial thigh and a motor inner. All con. and the sacral sympathetic trunk. which is why both these physiological or biomechanical changes viscerosomatic and somatovisceral reflexes are could be the result of a traumatic fall or injury.41 of abdominal. sitization. and tic tools for exploring such normalities. the sacral and pelvic splanch. spinal cord. from such biomechanical motor neurons. cold. from overactive or shortened neurons. Other important nerve bundles that inner. skeletal malalignment. it is believed that these reflexes to and four or five small sacral ganglia anterior to the from the abdomino-​pelvic region become much sacrum and terminates at the coccyx. ing afferent stimulation results in irritability of Adverse neural tension anywhere in the the internuncial neurons of that spinal segment. and vice versa. more sensitized with the increased sensitivity of nect the spinal cord to portions of the pelvic the nerves. the reflex between the visceral pathology and cial trigger points. it will result in the nerve supplies. which then diffuse to the ventral horn pelvic floor muscles. The afferents of these information to determine a proper diagno- nerves can converge on the dorsal horn of the sis and plan of care.6. emotional or physical abuse. There are two possible results of this vation of the quadriceps and hip flexor muscles. The ganglion of impar originates as plete. of trau- matic childbirth. and pelvic organs in some man. These afferent splanchnic nerves. nuncial firing. Although the evidence is thus far incom- vic cavity. this activates the internuncial from adhesions. the T R E AT M E N T peripheral nervous system of the pelvic floor can To begin with. and with motor innervation to the V I S C E R O S O M AT I C A N D hamstring muscles. they therefore con- as the inferior hypogastric plexus. F L O O R DY S F U N C T I O N and of other related first causes. pelvic region may result in nerve irritation and When the afferent activity from the offending subsequent neuralgia in any or all areas that organ is sufficiently stimulated. and the ongo- nic nerves. The tension may derive nal cord segment. they supply a portion of the viscera of the pel. tingling. In turn. and the ganglion of impar are Viscerosomatic reflexes at the spinal cord level bundles of nerves that all contain fibers of the can result in somatic dysfunctions that develop sympathetic nervous system. from myofas. or thigh surgery.39 FOR  PHYSICAL THERAPY Whatever the root origin of the tension. Either a dysfunction in the viscera The obturator nerve emerges from the will express itself somatically—​ a viscerosomatic ventral portion of L2–​ L4 and refers from reflex—​or a dysfunction at the body’s surface will the groin area down the inner thigh area. its be expressed to the viscera as a somatovisceral motor innervations are the adductor and hip reflex. pathology and then result in activation of noci- vate portions of the pelvic viscera are the lumbar ceptive. The superior hypo. Physical Therapy Evaluation of Pelvic Pain 155 The femoral nerve arises from the dorsal por. or as overactivity of across synapses to the dorsal horn at the spi- the innervated muscles. perineum. the inferior hypo. of diagnostic use. symptoms of the visceral and somatic systems. it is a given that any such eval- refer the pain to the somatic innervation or to uation requires complex interpretations of the visceral innervation.

is lumbosacral and peripheral nerve mobilization. and range of motion ment of cognitive-​behavioral approaches will be (ROM) associated with connective tissue dys. core and lower extremity mobility and stability. alignment. and lower-​extremity muscles. visceral abnormalities. evaluation. after collecting the patient’s history and spino-​sacral. “The physical thera. abdominal. dysfunction. muscle performance. Musculoskeletal dysfunctions can tors. • Visceral mobilization assessment the practitioner can observe and assess his or • Core assessment her gait-​pattern. guided imagery. . motor func. dysfunction typically follows the completion of basic medial diagnostic tests addressing the pel. and myofascial and/​or affect a patient’s physical complaints trigger point release of the surrounding muscles and to classify the systems pattern at work in and tissues. • Myofascial restriction and trigger point Is the individual slumped.43 All these observations can enrich the practitioner’s understanding of A plan of potential treatment options will the patient’s condition and level of pain—​even then be directed toward the physical cause of the before a single question has been asked. lean- assessment ing to one side? How quickly and easily does • Connective tissue assessment the patient rise from the chair? Is the patient • Scar tissue assessment holding his or her abdomen in pain? If so. as the patient walks to the treatment room. hip. how • Spinosacral and peripheral nerve severe does the pain seem to be? What is the assessment strength of the patient’s handshake? In addi- • Pelvic floor muscle evaluation tion. bladder and bowel health. but spe- vic pain patients fall into the Musculoskeletal cialized training in neurodynamic treatment. as vulvar skin inflammation (integumentary fiber-​filled foods. and treat- tion. a pelvic ing toileting posture. stride length.156 Pelvic Pain Management Therapist Practice puts it. Assessment of Posture and Gait At a minimum. prognosis. tion in the use of self-​massage techniques. and the weight-​bearing patterns through assessment the lower extremity. For example. sitting extra tall. regardless of the other system be given bladder and bowel retraining. as well as dietary changes for pattern) or burning symptoms from nerve com. and intervention—​ in a manner dysfunction.”42 The initial itation of the pelvic floor. patients are edu- of pelvic pain. dynamic movement. including pelvic floor muscle over- pist integrates the five elements of patient/​client activity. Most typically. discussed in other chapters and does not form function. the musculoskeletal category is cated in appropriate sitting postures and may usually dominant. heel-​to-​toe foot • Biofeedback and real-​time ultrasound strike. gluteal. or a ening exercises of certain muscles to improve musculoskeletal pattern.42 Assessment of a musculoskeletal part of this chapter. Treatment may consist of rehabil- designed to optimize outcomes. and holding pattern. and sexual positions that can avoid pain. This • Posture and gait assessment is when the therapist can observe the moment-​ • Biomechanical and joint mobility in-​time information embodied in the patient’s assessment sitting position. actually cause all of the symptoms that seem to Central sensitization and reprocessing may also come from other patterns. but will not be limited to: A practitioner’s evaluation begins at the moment of greeting the patient in the waiting room. or neuromuscular pattern. also perform range-​ of-​ motion and strength- integumentary. They may be educated in pain patient may present with such symptoms the basics of water intake and of eating healthy. performing a detailed objective examination. T H E E VA L UAT I O N vic pain patient’s complaints and ruling out any First Impressions: Visual serious pathology or disease. includ- patterns that are present. to determine how the physical findings cause connective tissue mobilization. Pattern 4D: impaired joint mobility. Restoration of sexual pression (neurovascular) along with complaints activity is a key goal that may require educa- of dull or achy abdominal and pelvic pain (mus. the evaluation should include. be part of the treatment paradigm. pel. aim. dila- culoskeletal). diagno. Pelvic floor physical therapists may the patient’s case—​a cardiovascular/​pulmonary. and the associ- management—​examination. In patients who present with the complexity Depending on their symptoms. ated musculoskeletal issues that accompany the sis.

whether there is a long-​ aim is to note any areas of dysfunction—​in par- standing compensation that has been driving the ticular. loss of hip range of motion.20 According to King Baker. The central ner. ligaments. insidious. prior strain (obturator internus. maximus. and whether the injury tor. can have taken years to lying. or unknown in nature. within the 24-​hour pain cycle. and ligaments that also contribute musculoskeletal injuries thought to be benign to chronic pelvic pain. the examin- patient from cranium to foot and noting these ing practitioner checks via touch for symmetry gripping postures. and standing—​as the lumbar spine loads manifest itself in pelvic pain symptoms. the physical therapy practitioner can check for pelvic bony Biomechanical and Joint symmetry across all planes. The patient’s history as well. The intake should also explore other discs.” a neutral other practitioners. but it may indeed be with the sacrum. . years ago. taking into consideration the for the range of motion of specific joints. those that stand out as needing to be pain. “the chest-​gripper” overactivation of affect patients’ pain patterns can be a clinical the external and internal obliques. they progressed to the point that the patient While pelvic pain may arise from the structures sought or was referred to physical therapy as a themselves. past surgical history. so noting the compensatory pos. the bony pelvis is made up of pelvic pain. anterior pelvic tilt. All pelvic articula- culoskeletal injuries:  a severe ankle sprain from tions are weight-​bearing in all positions—​sitting. With palpation. varies widely. pelvic floor myalgia/​spasm). piriformis. weakness in the leva- rent and past complaints. phology and mobility. medications. spine on the superior pole. checks muscle tone. A  female who is four months post-​ a complex relationship of articulating structures—​ partum and presents with sexual dysfunction the two innominates that make up the pubic sym- may not see the relationship of her current pain physis at the anterior portion of the pelvis with to falling off a slide and sustaining a coccyx two posterior portions of the bone that articulate fracture at the age of eight. what worsens or improves shortening. abdominal. Even a millime- Mobility Assessment ter of excess movement in any plane of motion Postural assessment of the patient is an import. The sacrum articulates with the related to the presenting symptoms. leg length/​ pelvic Ask the patient to describe his/​her complaints postural asymmetry. it’s some patients feel their symptoms worsen at the not uncommon to find abnormalities in the tho- end of their day. intrapelvic muscle past medical history.limeters of movement are a limiting factor or tor spinae.44 and as femurs compress through the acetabula during weight-​bearing tasks. piriformis. and because of common innervations. the physical therapist must in bony landmarks. and gluteus was traumatic. morning. determining if those mil- the “back-​ gripper” overactivation of the erec. hip joints.Moreover. cur. coccygeus. and seemingly unrelated to the symptoms of As noted above. others when they awake in the racolumbar vertebrae. and any positions or actions that plays a major role in all of chronic pelvic pain syn- exacerbate or relieve symptoms. or the “co-​ challenge to the treating physical therapist or contraction brace—​the trunk-​gripper.can cause severe pain due to abnormal mus- ant and effective clinical tool. This requires cataloguing the patient’s and levator ani trigger points. Further inspection of the pelvis to assess addressed early on in the treatment plan. looks for torsions within the explore how the postures may be affecting the pelvis or spine.cle and nerve tension.12 In assessing the this determination.46 posture in which there is co-​activation of the Palpation is the methodology for making trunk flexors and extensors. and screens patient’s pain and. articulating the lumbar joint dysfunction. That is why coccyx on its inferior pole and with the lumbar it is essential to press the patient about old mus. dromes. coccygeus. Physical Therapy Evaluation of Pelvic Pain 157 The Intake the bony relationships as well as neuromuscu- The aim of the intake process is to determine lar control must also be taken into account as how the patient’s symptoms started and how potential sources of symptoms. it may also be the result of abdominal remedy. and these minor move- vous system’s neuromuscular reaction to pain ments may not appear in radiographic images. posture the symptoms. joint capsules. and iliopsoas adaptive current pain level. for example. for example.45 By comparing spe- Examination cific bony landmarks on the pelvis. medical testing and outcomes. as sacroiliac joints vary from person ture of a patient in pain signals the nature of to person and between genders in terms of mor- his/​ her neuromuscular response—​ for example.

51. function. We have seen fascial restrictions as cra- etal muscle or muscle fascia and are an nial as the rib cage and as caudal as the knee .” The position of the femur and inability of Connective Tissue Assessment the hip to externally rotate may cause this tear Connective tissue needs to be assessed in the and could be a causative factor in pelvic pain. abdominal. It is therefore important sure for 10–​20 seconds over the suspected trig- that the practitioner conduct a full assessment ger point to allow the referred-​pain pattern to of hip ROM in all planes of motion. bone is out of alignment. accurate palpation with 2–​ 4  kg/​ cm2 of pres- currence of pelvic pain. The physical bladder. physical therapy evaluation because it envel- ops everything within the body and because Myofascial Restriction and Trigger its extensibility can become restricted or can Point Assessments be misused by something as basic as prolonged Myofascial trigger points are found in skel. can be the result of pelvic floor trigger and vice versa. as well as bladder and bowel dys- tion can mimic pelvic floor muscle overactivity. coccygeus. bowel. and sexual activity. inflammation in the area. In addition. they are easily susceptible ROM and muscle length of the lower extremi. quadriceps. then extremely prevalent cause of persistent pain move to a slumped position.50 Precisely because of connective tissue restriction. Dyspareunia. of the points and myofascial restrictions are noted. result in symptoms in the rectum. posterior pelvic region. and poor sleep or nutrition. Trigger points resulting in or from pelvic pain rical mobility of the pelvic bones. the practitioner can perform a biomechani. to developing myofascial trigger points. or stepping up on a aching pain referred to any structure from focal step. dull. have been well documented and can be found in ment or scoliosis may also be noted. piriformis. adductors. thigh and leg. and hamstrings.49 and/​or after delivery that is caused by a labral tear. deep. the lumbar spine. and or superficial pain. Asking the sion. trigger points typically Assessment of hip ROM is also clinically rele. tender points in taut bands of skeletal muscle. cyx. the internal and exter. each plays the following muscles: levator ani muscles. gluteals. aching. quadratus lumborum. or the anterior portion may result in more urogenital pain.52 groin pain. nal muscles could be stretched or shortened. and pro- therapist performing an evaluation of a patient’s vide stability and mobility of the trunk with pelvic pain symptoms must therefore assess joint the lower extremities.5. sitting. and of the is advisable to conduct both an internal mus- acetabulum. a less than opti. patient to execute a functional task like stepping Trigger points are characterized by deep forward to simulate walking. tion and movement and thus identify such areas those taut bands are the actual trigger points. pelvic organ or at minimum a contributing factor in pelvic disease. and sacrum.12 Poor align. of dysfunction as pelvic obliquity and asymmet. coc- vant. as hip pathology can refer pain into the pos. obtu- a role above and below the pelvis. paraspinals. iliotibial band and tensor fascia lata. In the ties. If a pelvic rator internus. repetitive overuse. Current research shows there is a Diagnosis of a trigger point depends on relationship between hip labral tears and the con. along with develop. anus.47 Symptomatology of hip dysfunc. a form of nerve the pelvic floor muscles support the pelvic and compression that can lead to compensations abdominal organs. to ensure that all trigger checking the integrity of the hip capsule. or from sym- pain.158 Pelvic Pain Management By instructing the patient to sit tall. lets the physical therapist check pelvic posi. pain with sitting. or to shift weight disorders within the abdomino-​pelvic region—​ in standing or to shift weight by standing on one exacerbated even further by poor posture. Pelvic floor myofascial trigger points typ- Deficits in normal muscle length and full ically occur when the muscles are overloaded joint range of motion are a possible cause of from trauma. Trigger points in the anterior terior pelvis and thigh. to produce such symptoms as points and can cause sharp.48 assessment of muscle function of the patient Women can develop “hip pain during pregnancy performing a functional task. Restrictions within any joint or decreased pathetically mediated tension resulting in a muscle length or muscle glide can create areas holding or guarding pattern. assist with functions of the above and below the area of pain. poor leg.49 mal condition that can create pain. and the thorax. body mechanics. Hip pain of a non-​arthritic origin in cle assessment and an external biomechanical post-​partum women has gained recent attention. it wearing surfaces of the femoral head. urinary urgency/​frequency. and nerves may be compressed.6. the groin. psychological stress or depres- cal assessment of the external pelvis.

superficial nerves that traverse the anterior por. Rectal scarring to note rotations. S1. thereby slowing colon transit time. it is ate any grade of vaginal and rectal tearing can important to assess T10 through L5 vertebrae create vaginal and/​or rectal pain. compress those specific nerve roots and thereby ness or its opposite—​i.e. burning. through ity of organs. iliohypogastric (T12 and L1). nerves. and S4 that make up the pudendal nerve. these reasons. they can interfere with the normal mobil. If it does It is thus essential for the practitioner to exam. and S2. genitofemoral (L1). and decreas. For example. swelling. the obturator internus is The practitioner can assess these dysfunc. skin rolling. can be assessed externally (partially) and inter- around bony prominences. decreasing ischemia. the bladder. and sacral plexus). supply sensation to the lower abdomen. for example—​to severe keloid For example. the only muscle interior to the pelvic walls that tions using connective tissue and myofascial is innervated with slips of L5. Scar throughout the thorax54. genitalia.. fascial restriction. These Pelvic Floor Muscle Evaluation actions can establish the amount of decreased For the pelvic floor muscle evaluation. These all symptoms of urinary urgency and frequency.44. overactivity in tissue surrounding the scar. and through fascia nally (which can be more uncomfortable) and . and fascia. the perineal branch. therefore. bony landmarks. simple—​a pimple. the Pfannenstiel incisions. and while they are essential for heal. restoring tissue ing. Within the pelvis. an assessment of the spinosacral ing adverse reactions in viscera. prevents normal filling. Physical Therapy Evaluation of Pelvic Pain 159 joints in patients who present with pelvic pain. gluteus regions. muscle shortening and create symptoms in the above-​mentioned areas. This assessment will form the basis nal nerve systems as well as in the nerves of the of a treatment plan of connective tissue massage lower extremities can cause symptoms of itch- aimed at improving circulation. During vaginal scars from normal childbirth that cre. a patient with a unilateral pelvic scarring. of the colon. and eliminat. Scar Tissue Assessment Patient symptoms can direct the physical thera- Scar tissue formation is a necessary healing pist performing the evaluation to the appropriate function after any skin or soft-​tissue injury or branch of the pudendal nerve—​the inferior rectal following surgical incision. and numbness. increased muscle tension in from hemorrhoidectomies can create pain and the paraspinals. a physical therapy evaluation. or the dorsal branch. upper Abdominal scar tissue can constrict portions thigh. the practitioner can determine through tissue restrictions can progress into a source light touch or deep pressure which branches of of abdomino-​ pelvic pain. and ring shifts (rib placement) tissue immobility in both men and women. which thereby limits bladder exten. fracture presents to the clinic as being continent ing. the abdomino-​ pelvic area’s external and inter- lar bundles. and some deep-​ tissue manual assessment. L3. and peripheral nerves is essential. the lumbar. Muscle coordination A nerve should traverse through a foramen. ing adverse neural tension in peripheral nerve As noted above.12 that might irritate or tissue within muscle can create muscle weak. ili- scars can run deep and tend to compress near oinguinal (L1). S3. Scars range from branch. around bony may result. not. and muscle strength. and lateral and posterior femoral cutaneous sibility. These palpation. and lateral. and posterior portions of the thighs. Entrapment or compression within prominences or in areas of complex neurovascu. or underactive). these C-​ section specifically. muscles. and creates nerves (L2.53 Moreover. this can create genital other nerve branches must also be evaluated—​ and pelvic pain.43.44 like dental floss through clean teeth. and to evaluate Spinosacral and Peripheral tissue integrity. and muscle length from origin to insertion.43 For integrity. when the nerve are still supplying sensation. if the nerve is entrapped or compressed ine connective tissue extensibility in areas prone within a nerve tunnel.54 release mobilization (MFR). Superficial episiotomy scars and the internal and can thus also cause pelvic pain. the prac- mobility and shortening of the tissue under and titioner’s aim is to assess muscle tone (overactive around the scar tissue. with regard to stool but not to urine. anterior. one of the innervations of branches.44 the pelvic floor is supplied by the sacral nerves of S2. neurological symptoms to being restricted—​for example. nerve assess- Nerve Assessment ment. While the pudendal nerve and the other tion of the pelvis become entrapped in the scar sacral nerves are the first to come to mind tissue of cesarean section scars from traditional when considering pelvic and genital nerves.

tions are then compared one to the other. on external visual palpation—​ensures that each side of the internal examination of the vagina. patients are typically directed to perform an excur- sion test that can measure their ability to relax. healthy. to the anterior surface of the coccyx and its After assessing the patient using the cot- position as well as the coccygeus and the inter. Through external palpation using a cotton swab. or bowel-​and bladder-​related.160 Pelvic Pain Management can be assessed vaginally in women and rectally dermatological changes. Caution must be exercised upon entering pelvic floor muscles. In proceeding to internal vaginal palpation in titioner should direct the patient to perform an female patients. tion if the problem is right-​sided vs. It should feel a little slip- open with no prolapse noted. practitioners must also look To assess pelvic floor muscle coordination. it should be docu- both male and female patients:  in the female.) of both hands—​not just the dominant hand for For the female patient. in women. (Note:  Performed by male patients in the pation uses no speculum and applies no cork-​ hook-​lying position. thus external tissue to assess the tone of the underly- ensuring a comprehensive evaluation of all the ing muscle. it can be surmised that there is some prolapse The feel of a normal. and iliococcygeus muscles need practitioner can assess reflex in the perineal area to be fully examined in order to assess the full and/​or anal area. and coordination. and firm. the labia minora pelvis is examined in turn. Are the muscles completing the task at hand? If the practitioner can detect areas of pain and there is no muscle lengthening. If the labia sit somewhat that of smooth velvet. performs a Valsalva the vagina to ensure against eliciting pain pre- maneuver.57 and enter with the index finger of the tissue is moist or atrophic and to note any the other gloved hand. ton swab. palpation completion of the excursion test. separate the labia with the thumb and should assess tissue integrity to determine if index finger. the puborectalis. Even gentle pressure can cause the Asking the patient to repeat this test once or patient to wince in pain. ing each side of the rectal meatus in turn. pery. mented as mild. Upon entering the vagi- inal estrogenization. left-​sided Both the vaginal and rectal evaluations and whether it is located in the upper urogenital include visual and palpable external and internal diaphragm area or the anal triangle area.56 The visual examination nal vault.43 The reflex may be absent in muscle length and tone of the vaginal pelvic patients with muscle overactivity and spasm43 or floor muscles. with the lubricated finger . The prac. When assessments.55 maturely.43 The External Pelvic Floor This test enables the practitioner to assess muscle Assessment: Palpation activity. this internal vaginal pal- ment. diaphragm and the superficial fibers of the deep pelvic floor muscles with the second digit pro- The External Pelvic Floor vides the ability to assess tone of the muscle and Assessment: Visual restriction of the external fascia. moderate. plump. nor a bulge at the assess tissue tenderness. Unlike a physician’s twice should provide the practitioner with suffi. By strok- the rectal side of the deep transverse perineal. there may be vag. examination that looks for space-​ occupying cient information to make a quick muscle assess. then relaxes the muscles again. lesions or pathologies. sexual. and the two evalua- should sit somewhat closed. Cotton-​swab palpation can also some or all of the functions of the pelvic floor—​ tell the physical therapist performing the palpa- sphincteric. If the labia sit open. relaxes. a systematic approach is essen- excursion test in which the patient contracts the tial. from an anterior or posterior compartment reproductive vaginal vault can be likened to beyond the opening. In observing the vagi- in both women and men. The rectal evaluation is required in pain is present on palpation. or severe. it could be an also lets the practitioner note any hypersensi- indication of pelvic floor muscle overactivity and tivity of the vestibular area and the surrounding a signal that the patient is having difficulty with vaginal tissue. nal external tissue. normal muscle firing. this excursion test enables screwing motion of the palpating finger. External palpation of the urogenital pelvic floor muscles. at the skin as a potential source of pain. The use a practitioner to assess the male perineal area. the practitioner digitally palpates the nal and external anal sphincter muscles. A  rectal examination gives access with neurological involvement. The external visual examination in both male and female should make a general muscle The Vaginal Assessment: Palpation assessment of the urogenital triangle. lubricated.

be anywhere within the 360-​degree rectal open- voked pain. or hemorrhoids may be should not feel like a significant step down. taking note of the position of the enables assessment of the peri-​urethral space on urethra to avoid it. On enter- the finger pad side up cranially. Such de-​innervation may of tightness and shortening. the rectal opening and surrounding tissues. along with a notably thick or thin skin does. and the ischiocavernosus. If no 12 o’clock position—​ and the perineal body at puckering is noted. a burning sensation during urination. thereby curtailing dysfunction. this may be an area of de-​ the bottom portion of midline (6 o’clock). once within the rectal compartment. the muscles will gloved finger at the rectal opening for a moment have no give when pressed upon. one from each cause patients symptoms of urinary retention or side. If using the right lying position. think of the straining. to use no apist assesses the puborectalis and the integrity cork-​screwing motion of the palpating finger. and/​or abdomino-​pelvic pain. texture:  these may indicate bowel movement For accurate muscle assessment. the obturator internus an excursion test. The external anal side with the urethra at the top of midline—​the sphincter can be almost one inch deep. ment. the practitioner then cues the may feel like guitar or banjo strings. not puckered. tal phalangeal joint) to assess the external anal tive and must be palpated gently. with subsequent symptoms of fecal incontinence. If the pelvic floor mus. this is called a “dovetail sign. the reflex so that the examination and treat- Returning to the perineal body and turning ment will be a bit more comfortable. Four muscles are ity. located siotomy tears may show dovetail signs years later. you are examining the right side of the ier to spread apart the butt cheeks to observe patient’s vaginal vault. decreased fascial move- originating here:  two superficial transverse per. Ask the patient .” where examination should proceed muscle by muscle flaccidity of the muscle causes the skin to look in order to determine trigger point areas. ping down a bit into the vaginal vault. Normal muscle tone will show tight internal pelvis as divided into right side and left puckering of the outside skin. the physical ther- cles are overactive and have been shortened over apist performing the evaluation should rest the a prolonged period of time. closer to the vaginal opening. adjacent and a layer deeper. this practitioner can note areas of muscle overactiv- should feel moderately firm. and the fibers before entering. Where the will observe contraction and coordination of the obturator internus ends at the fascial layer of the rectal pelvic floor muscles. hook-​lying. the tip of the examining finger. hugging the pubic The patient should be directed to execute rami. The tissue should this can cause discomfort to the patient. The very prominent coccygeus The practitioner performing internal rectal pal- runs toward the ischial spine parallel with the pation must be sure to allow the anal reflex to sacrospinous ligament. bowel. the practitioner ing the rectal canal. Physical Therapy Evaluation of Pelvic Pain 161 pad down. the physical ther. that may indicate muscle overactivity. as of the vaginal-​rectal septum. but it Skin tags. At the edge of the bowel. the male or female Enter the vaginal vault either to the right or is placed in either a prone. It should feel like drop. The innervation. archis tendonius levator ani (ATLA). and the deep transverse perineal muscle. areas smooth. during which the practitioner is on the lateral wall of the ilium. the ilio- coccygeus begins and travels down the midline The Rectal Assessment: Palpation into the coccyx. also one from each side. Gently lay the pad of your either side of the urethra. diminish before entering. Within the pelvis. These muscles will insert on the ischial The Rectal Assessment: Visual tuberosity on either side. The prone position makes it eas- hand. the examiner enters. trigger point areas. For the visual assessment.43 Starting at the crus of the clitoris ing. This palpation sphincter for tone and length. This may patient to bear down and bulge. As the patient result in symptoms of bladder. within the lower portion of the labia minora. have equal side-​glide mobility when comparing After applying a significant amount of gel to sides within the pelvis. addressing the com- second digit as deep as the first knuckle (distal pressor urethra and surrounding tissue. and areas of tenderness and pain that can ineal muscles at the outer layer. the examiner palpates to can palpate the structures and muscles of the the approximate depth of the first knuckle (dis- urogenital diaphragm. The urethra is very sensi. if it noted. and must take care. small fissures. or side-​ left side of the perineal body. The phalangeal joint) onto the perineal body. and areas of pro. Women with a history of stage III or IV epi- are two muscles—​the bulbocavernosus. or sexual bulges.

normal tissue will feel the internal anal sphincter on the edges motion. iner to determine its level of flexion. For example. i.43 The anterior disk disease. although it is most common coccyx in a posterior-​anterior direction to assess in women as a result of pregnancy. women patients. the patient may tend to experience a feeling fied through palpation—​and should be treated. a French osteopath and both the strength of the external anal sphincter physical therapist. While men may complain of ble to assess visceral mobility in all pelvic pain chronic constipation and low back pain. The separation can mine the coccyx’s ability to move toward flexion. the ability of of insertion to the second knuckle. in the musculoskeletal system can create a slew To examine and assess the coccyx. Organ manner—​ known as “paradoxical pelvic floor dysfunction can present as provoked pain to cor- function. “optimal function of the restored following scar tissue release therapy pelvic floor muscles will not be achieved while that was causing only a portion of the patient’s any significant diastasis of the abdominal wall pain. finds the coccyx. overactive. For example. the muscles themselves can occupy Core Assessment space. a facilitated segment gives awareness of stool in the area. through the examiner touches the edge of the puborec. According to the theory.” If the muscles feel very overactive and responding segmental levels.. organs must move the contraction gently pulls the examiner’s finger to stay healthy. advancing age. degenerative terior to find the bony landmark. fascial attachments. pelvic floor muscles to overcompensate. and recti. it can contraction. pelvis.. This separation of the right and left sides how much either or both coccygeus muscles of the rectus abdominus can occur in men and are pulling. closure of any diastasis is critically were generating the pain. In addition. a two-​ of different dysfunctions in the back. cesarean section—​ in pregnancy. add complaints of urinary incontinence. The external digit sacroiliac joint. discs. incontinence. Should tribute to pelvic pain and weakness disorders the coccyx be positioned more posteriorly. each internal of the palpating finger and can assess its boggi. ask the patient to tion as a form of manual therapy based on his bear down. handed technique is required. If rounding tissues. developed visceral manipula- and its ability to relax. giving the patient the feeling that he or Weakness in the core muscles or an imbalance she is sitting on a golf or tennis ball. it is useful and advisa. a visceral mobility assess. This may dromes. ligaments.”62 . (a vertebral body rotation). important in rehabilitation of this region. whether it It is important also to assess for diastasis is midline or deviated to the right or left.e.12. while the internal palpating These dysfunctions may eventually lead to such finger is turned pad side up to gently sink pos.e. It can con- the glide of the coccyx toward extension. As Fitzgerald showed that full colon transit time had not been and Kotarinos assert.61 and pelvic pain.60 of tenesmus or incomplete emptying. If particu- larly tight. loss of core stabilization can cause the take longer in patients with muscle overactiv. with the spine and other sur- talis. that is an appropriate ity of the viscera become dysfunctional. and hip joints. and pelvic floor muscles. and eventually cause pain. It provides information on muscle become apparent as a viscerosomatic reflex at a strength and on the firmness of the tissue that segmental level. which can be identi- firm. pelvic ment of a patient with chronic constipation organ prolapse. Ask the patient to contract the muscles.58. become ity. the examiner each organ to display an inherent.162 Pelvic Pain Management for a contraction at this point in order to assess Jean-​Pierre Barral. relationship with its adjacent organ and. and with skeletal connections. Again. At the distal tip of the finger. organ rotates on a physiological axis and has a ness or firmness. The examiner can also mobilize the women of all ages. the due to the synergistic effect of the abdominal opposite—​a posterior-​anterior glide—​will deter. and prolapsed pelvic face of the coccyx will be felt when the muscles organs.59 When the mobility and motil- toward the pubic bone. and at this point increase the depth theory of visceral mobility—​ i. other disorders as osteoarthritis. In relation to abdomino-​pelvic pain syn- and fascia have relaxed sufficiently. when provoked can be are acting appropriately or in an uncoordinated a segmentally related visceral pathology. Palpation of the coccyx enables the exam. which creates spinal it should tell the examiner whether the muscles pain at the T10–​L2 areas. visceral restrictions were still present and remains. occur at different points within the life cycle and may be caused by trauma—​as with an abdom- Visceral Mobility Assessment inal surgery or an emergency infra-​ umbilical Because visceral restrictions have musculo. Like joints.

Using an ultrasound transducer and placing pation to be certain that the finding of muscle the head supra-​pubically enables the practitioner shortening or overactivity holds. Biofeedback has to view the bladder neck.”66 muscle tension and change unwanted muscle RTUS uses assorted ultrasound technolo- activity through muscle downtraining. External sensors is then directed to lift a leg so as to simulate tend to be unreliable due to the “cross-​talk” of walking—​the Active Straight Leg Raise (ALSR) external muscles. If the supine patient patterns or muscle overactivity. lateral abdomen can demonstrate the recruit- nal sensors can be used. For exam- sensors—​an intra-​vaginal sensor for women or ple.”65 and this can be misleading if bio. but inter-​rater reliability of results is poor. With expert muscle overactivity can have either “heightened or “translation” of the findings. mine muscle overactivity. the practi- ing a visual or audible sense of muscle events or tioner will view movement of the bladder. randomized research studies have of the muscles of the trunk as it relates to demonstrated that patients who present with the functional task of walking. ment of the transverse abdominus and of toms and the severity of the internal pelvic floor how the external and internal obliques func- muscle overactivity. as the RTUS can inquiry. in patients who present with chronic low and performance (The Association for Applied back and pelvic-​girdle pain. Physical Therapy Evaluation of Pelvic Pain 163 Digital palpation along the rectus where the Real-​time ultrasound (RTUS) is another two sides join is convenient and widely used in clinical tool that can provide both the clinician the clinic to determine if a patient has diastasis and the patient the “dynamic study (real-​time recti. may shut muscles down. It has become evident iological activity in order to improve health that. and muscle holding patterns. With appropriate cueing by the practitioner. That is why surface the patient can work on recruiting the correct electromyography (SEMG-​ assisted biofeedback) muscles. mus. Asking the patient gives patients a window into their bodies.64 gies and varying external and internal sensors For use with a pelvic pain patient. of the compensations for this loss of neuromus- pation that assesses muscle activity by helping cular control can be pelvic floor muscle overac- to make patients aware of their breath. images) of muscle groups as they contract. ing the pattern required. which holding patterns and showing patients how their demonstrates the symmetrical or asymmetrical actions can change long-​standing habits. as used in med. or suggest another line of nary urgency and frequency. redirecting the muscle.”66 One effectively used in conjunction with digital pal. feedback is the sole methodology used to deter. not to Ultrasound Assessment mention large injuries. Inc “altered neuromuscular control as opposed to [AAPB]). an ultrasound probe held on a patient’s intra-​rectal sensor for men or women—​or exter.”66 A more objective measurement is the use of cal. in so the subtleties of muscle behavior so that they doing. provid. picture on a screen. propriate firing patterns. This pation skills that can confirm the diagnostic find. internal to provide a range of information. firing patterns of the pelvic floor muscles. the RTUS helps the patient ical research. and normaliz- results should always be interpreted in conjunc. it is most decreased strength or functional capacity. By using an ultrasound unit that can capture a ipers and real-​time ultrasound. can cause edema that Biofeedback is a process that enables an indi.63 reeducate and recoordinate his or her muscle-​ firing patterns using neuromuscular cueing Biofeedback and Real-​Time techniques. to contract the pelvic floor muscles. and an outline certainly proven to be a useful clinical tool that of the pelvic floor muscles. depending on symp. actually demonstrate to a patient that his or her feedback findings26 and an essential ingredient in bladder is indeed empty or barely full. For pelvic pain patients. test—​the examiner can see the firing pattern Small. The aim is to assess holding tion during an activity. thus creating inap- vidual to learn how to change her/​ his phys. tion with intra-​vaginal or intra-​rectal digital pal. But pal. it can also help them reduce voluntary can be discussed and modified. can also be a useful tool for patients with uri- ings of biofeedback. RTUS can serve as an adjunct to “display cle activity. this picture can decreased muscular electromyographic response identify which muscle is overactive or which to a stimulus. Even small muscle injuries. bladder. provides a visual and scientific “contradiction” of . may not be activated enough during the task. It thus the practitioner’s toolkit. are an essential complement to the bio. tivity. the issue is one of Psychophysiology and Biofeedback.

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McPartland vestibulitis syndrome: a critical review. Prendergast S. The Hesch Method of Treating Sacroiliac review. Med Hypotheses. Nelson CA. MD:  Williams & Fletcher E. J Reprod Med. PA: Saunders. PM&R. Baltimore. The prevalence of sexual Pubis. Curr Urol Rep. Nelson CD. Scheltinga MR. 2003. Goetsch MF. Richards DD. 43. Modified thiele massage as therapeu. Raab R.4(1):4–​13. tis:  an observational study. 49. Chicago. Peters KM. 53. Physiological regulation through 1997.15(3):299–​312.274(5):297–​302. Joint Dysfunction:  Integrating the SI. Schmidt RA.46(4):773–​782. J Sex Med. Bergeron S. Vulvar 40. Assoc. Exploring Form. 2009. Henderson:  Self-​publish. J Am Osteopath vodynia. Dysfunction: The Trigger Point Manual. ness of physical therapy treatment on women com. Clohisy JC.64(5):862–​865. Linden W. Dalton E. training is an effective therapy of stress urinary or 55. Hunt D. Arch Gynecol Obstet. American Physical Therapy Association. Physical therapy for vulvar vestibuli. HJ. Basic and dysfunction and associated risk factors in women Intermediate Workbook. 2007. terior pelvic and groin pain. 2009. Neurourol Urodyn. JM.70(1):16–​18. Wilkins. 46. Lord MJ. Rehman I. 2002. Myofascial syndromes.7(6):450–​455. 4th ed. Carrico DJ. no 1.273(2):93–​97. vic floor rehabilitation in treatment:  a literature 45. Corton MM. 2012. Verit FF. Guide hypothesis to explain the diagnostic relationships to Physical Therapist Practice. mality. 2006. tation: State of the Art Reviews. Freedom From Pain Institute. urgency. RM.1(9): Diokno AC. Bo K. Early Ther. pelvic pain: treating the pelvic floor versus the epi. Hesch J. Dumoulin C.111(4):839–​846. 2007. Philips HC. with chronic pelvic pain:  a cross-​sectional study. 2008. Pagidas K. thral syndrome:  evidence for a muscular abnor- nence in women:  a Cochrane systematic review. Mein EA. Lower Extremities. Hendriks vior and interstitial cystitis. Rosenbaum TY. Textbook of Anatomy. 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Occidental.7(2): Prevalence of diastasis recti abdominis in a uro. WA: Eastland Press. PA:  Churchill Livingstone Elsevier. Urogenital Manipulation. of calipers and ultrasound imaging to measure ment of urinary incontinence. Guzman-​Rojas R. of the Lumbopelvic Region:  A  Clinical Approach. Ultrasound Imaging for Rehabilitation Pelvic Floor Dysfunct. out provoked vestibulodynie and the impact of a 61. Van Dillen LR. 60.43(7):495–​503. Martin A. MD: Lippin­ assessment outcomes in women with and with- cott Williams & Wilkins. Autumn 2008. McLean L. Anderson R. Pelvic floor dysfunction—​ does menopause Dysfunct. CA: 59. 2007. Glonek T. 6th ed. 1003–​1022. Barral JP. Russell J. Pelvic floor muscle Osteopathic Family Medicine. Wise D. Chiarello CM. Trutnovsky G. Concurrent validity 57. Spitznagle TM. J Orthop Sports Phys Ther. Nelson KE. Dietz the short pelvic floor. Leong FC. Rehabilitation of the Philadelphia. 2013. A Headache in the Pelvis: 58. National Center for Pelvic Pain. 2012. 65.14(4):269–​275. 64.76(2):134–​138. physical therapy program. Int Urogynecol J Pelvic Floor HP. 62. II: Treatment of the patient with 2007. What is visceral manipulation? Directions A New Understanding and Treatment for Chronic in Physiotherapy. Whittaker JL. 1993. Pelvic Pain Syndromes. Seattle. 2007. J Sex Med. In:  Therapeutic interrecti distance. Pelvic floor muscle exercise in the treat.166 Pelvic Pain Management 56. gynecological patient population. .18(3):321–​328. Management of Incontinence and Pelvic Pain: Pelvic 2013. 63. 2010. Int Urogynecol J 66. Goldfinger C. Gentilcore-​Saulnier E. duration matter? Maturitas. Organ Disorders. 2003. Kotarinos R. Baltimore. Somatic Dysfunction in Pukall CF. Haslam J. London: Springer 2007: 89–​94. FitzGerald MP. Chamberlain S. McAuley JA. short pelvic floor.

tive tissue and joint mobilization.22.27. pelvic floor physical ther- apy has proven to be an invaluable component and other modalities that may be suggested by the treating physical therapist to complement these treatment approaches. 18 The Physical Therapy Approach to Pelvic Pain Treatment A M Y S T E I N . In this review of the interventions aimed at rehabilitation.9. B C B . tion scale should be used during and after each Treatment may consist of a range of such treatment session and home program in order to manual therapies as neural mobilization.3.2.10 painful bladder that generate the pain.23. behavioral thera. monitor the patient’s symptoms and progression.” fine sheet of connective tissue that surrounds.25 A  conserva.1.16. therapeutic exercises for M A N UA L T H E R A P I E S range of motion (ROM) and for core strength. low-​ level laser. M P T. . myofascial rience. But we wholeheartedly endorse the work of Kari ized manual therapy is clinically beneficial.10.15.  IF A s mentioned in the physical therapy eval- uation chapter. the ethical grounding. syndromes.8.18. physical therapists feedback.P ​ MD. connec. real-​ time ultrasound.31 Bo and her colleagues.7. Such validated treatment for men. to deal with the many physical abnormalities dromes. and myofas.5.17 a large por- tion of the literature is in the realm of urogynecology It is appropriate that the role of the short. however.4. pain- and deals with pelvic prolapse and incontinence.3 As one expert states. women. and we applaud its affirmation that Myofascial Release and Myofascial “good clinical practice always should be individualized Trigger Point Release and should be based on a combination of clinical expe. pies for muscle retraining.13. Through their increasing involvement in treating ening. all published data. references provided are for ondary.6 sexual dysfunction. D P T.13.19.11. Research is now showing that special- example only and by no means represent all published data. The references provided throughout this chapter cial trigger-​point release to address the medical are for example only. and strong found in skeletal muscle or in the fascia. whether manual therapy techniques and modalities commonly the somatic abnormalities are primary or sec- used by physical therapists. treatments to address central sensitization. empathy.1. knowledge from high-​quality RCTs and patient pain is associated with myofascial trigger points preferences … [as well as] respect. and/​or sexual func- biopsychosocial aspects of the patient’s pain.14 and incontinence. and children.24. chronic pelvic pain (CPP). bowel. physical therapy tools as the Visual Analog Scale (VAS) pain offers a holistic approach to help address the scale26 and a bladder. should be repeatedly reassessed for improve- tive and extremely effective treatment option ment or progression.1. and an assortment of modalities like bio. As noted in the evaluation c­ hapter 17. Whatever the rec- of treatment* for the musculoskeletal causes of ommended treatment. have developed valuable tools of manual ther- apy that can provide both mobility and effective * While there are a range of studies dealing with pelvic analgesic response throughout the body tissues floor dysfunction as it relates to chronic pelvic pain syn.20 ful and/​or hypertonic pelvic floor in the devel- Many of these studies. and by no means represent aspects of chronic pelvic pain. lack stringent study opment of chronic genitourinary conditions protocols and offer only a limited number of random- has now begun to inform physiotherapeutic ized controlled studies (RTCs).21. the patient’s symptoms functional pelvic pain.12. Evidence-​Based Physical Therapy for the Pelvic Floor.

Techniques of strumming. organs. and assist in relieving any nerve irrita. are located. vibrations.168 Pelvic Pain Management separates. to tenderness. found that a significantly higher tone. ROM. Once they myofascial trigger points.28 genic bladder inflammation. oscillations. achieving an overall improvement in rounding muscles may become altered. Stretching restrictions are key components of pain in as and such proprioceptive neuromuscular facilita- many as 93% of patients in a pain clinic. point release. or connects muscles. and relaxation and lengthening. symptoms.29 Muscles containing trigger have been found to be highly effective. through a com- muscles.30 As a result.1. reported a 72% improvement—​ described as sure to reduce fascial restrictions can reduce “moderate to marked”—​ in chronic pelvic pain the pain. Heal Pelvic Pain by Amy Stein. ficial tissues. direction.24. and a reduction in pelvic a skilled practitioner actively palpates and floor hypertonicity through manual release of locates them in the muscle tissue. the therapist must address super- ble and electrically active muscle spindles in gen. and kneading.31 Weiss reported an 83% reduction tially disturbing the proprioceptive.1:  Myofascial trigger point release technique. nociceptive.13 And Anderson et  al.24 rise to characteristic referred pain in clear and Manual therapies of myofascial and trigger consistent patterns. bony contours. and to auto. and myofascial shortening have shown that these trigger points and tissue and lengthening may also be used. in symptoms. FIGURE 18. and other muscle a highly irritable spot in a nodule occurring in a energy techniques will also help facilitate muscle palpably taut band of the muscle or fascia. poten. improve range of motion. muscle play. stripping of other soft structures of the body—​ and studies the muscle fibers. trigger points can give manual treatment. pelvic floor muscles and paradoxical relaxation.28 The nodule containing these muscle tone while looking for restrictions at the trigger points feels like a knot or a small lump depth.23. nomic phenomena. as demonstrated in Figure 18. relax the and urinary symptoms in men. proportion responded to treatment with myofas- terns. the application of sustained pres. and angle of maximal limita- that can range from the size of a pinhead to the tion. the muscles have to work cial physical therapy versus global therapeutic harder to produce the same effects. may also be recommended as an adjunct to the Whatever their size. In all these manual biopsy tests have shown them to be hyperirrita. bination of myofascial trigger point release of the tion or compression. Trigger point injections and dry needling size of a pea. loss of coordination. and the sur.28 tion as contraction/​relaxation. and eral muscle tissue. and substitution pat. In women points are characteristically short with limited with interstitial cystitis/​painful bladder syndrome.23. a decrease in central Trigger points can go unrecognized unless nervous sensitization. are weak. DPT . techniques. reciprocal inhibi- Travell and Simons define a “trigger point” as tion. including a reduction in neuro- and autonomic functions of the affected region. massage. and present with increased Fitzgerald et  al. active release technique.

abnormal tone. genitals. With each treatment. increases. bladder. may be contributing. and manipulation movement and to help mitigate the pain. decreasing pain.2:  Connective Tissue Mobilization. fibrous bands of rect the mobility dysfunctions. As an example. Visceral manipula- The manipulation creates a sensation of a sharp tion uses gentle palpation and manual therapy scratch—​the so-​called “nails” sensation—​and the to evaluate and correct the imbalances. and buttocks.23.32 These areas ous connective tissue restrictions. tighter the tissue. restrictions rounding tissue may be causing or to which it in the inferomedial buttocks and the ischiorec. DPT .24 tal fossa may also contribute to the patient’s pain and cause sensitivity to tight clothing and Visceral Manipulation underwear. the limb. and the bowels.24 chronic irritation and pain. When that ability is lessened or restricted over sion. the body is measured by its ability to move. and they can adhere to the internal the tissue and to increase ROM in the joint or anatomy.24 Trigger points and any neu. the system itself becomes damaged. a French the tension is released.2. must therefore be mobilized to allow proper tions should be assessed. When Developed by Jean-​ Pierre Barral. as demon. They may be superficial layer of skin over the other to release tension in or deep.23. They are aimed scar tissue that form between surfaces within at restoring the body’s mobility and inherent FIGURE 18. thereby easing any pain the scar or sur- back. It is effective for a range of subcutane. the blood flow to the area osteopath. Barral’s techniques of vis- Scar Tissue Mobilization ceral manipulation both identify and can cor- Scar tissue and adhesions. lower extremities. these restric. including the reproductive organs. or displacement may seated positions. along with several of his colleagues. and ultimately allowing standing that the health of any system in more movement to occur. which in turn may lead to tive tissue manipulation. there is further reduction in connective tissue ten. internal organs. conditions as endometriosis or any abdom- strated in Figure 18. and strumming between fingers and thumbs Pelvic pain patients typically present with on and around the scar have been shown to connective tissue abnormalities in and around loosen the surrounding tissue and the scar the abdomino-​pelvic region. the sharper the sensation. and this reduction can be maintained. may result from such pelvic pain Connective tissue manipulation. itself. Physical Therapy Treatment of Pelvic Pain 169 Connective Tissue Manipulation the body.23. Heal Pelvic Pain by Amy Stein. result in disharmonious movement between ral tension also commonly respond to connec. an extended period of time. and upon the assumption of certain Adhesions. should be performed as indicated throughout Such manipulative mobilizations as stroking the course of pelvic floor physical therapy. thereby removing toxins from that visceral manipulation is based on the under- region. is the movement of one ino-​pelvic surgery.

scar tissue or swollen compart. while thrust 71% improvement in overall symptoms. Indeed. restrictions. includes note that skilled stretching and mobilization of releasing the tension in both systems simulta. including visceral manipulation. a bulging disk. sexual function and pelvic pain. or ments—​will cause pain.3 Physical ther.170 Pelvic Pain Management motility—​and thereby restoring also the health The technique is a gentle. nerves. now included in the multidisciplinary approach to treating women with vulvodynia. and move as we move.38 Joint Visceral manipulation allows therapists to normalization is therefore often necessary—​ deal with the tension that occurs throughout along with soft-​ tissue corrections. Hartmann’s research showed that when impairment is present. joint capsules. developing holding patterns. etc. and respiratory joints. Also.40. it is commonly the pudendal nerve puncture34.12. therapists treating women with localized pro- cera and the musculoskeletal systems interact voked vulvodynia. therefore. it is important to be true. fixations.) that in promised. Effective treatment.36—​that is. in turn. the overall contributing to the adverse neural tension. visceral manipulation is aimed at aimed at freeing up a specific compromised adhesions. serotonin. glide. ical therapists. and both conditions metabolism is improved and the production of can cause or contribute to pelvic pain. because of networked innervation. thyroid. specifically within the abdominal use is widespread. which require advanced training. it’s not this. stretch. As effect of treatment is to create a response in the noted in the evaluation chapter. and tissues—​a sacroiliac dysfunction. and adrenal glands. Thyroid-​ stimulating hormone and Joint Mobilization Follicle-​ stimulating hormone (TSH. pelvic pain.39 Oscillations and included in a treatment regimen that led to a vibrations may also be applied. a 62% techniques. is therefore recommended. associated joints may indeed be indicated when neously.44 Neural mobilization helps restore mobility This overactivity could be the result of the person to the neural tissue through manual treatment. and other surrounding nerves that may be com- mitters (endorphins. visceral manipulation was rococcygeal articulations.37 Anything Pelvic floor muscle retraining helps develop or that interrupts the normal movement of neural improve motor control for bladder. connective tissue thorax. discs. and Joints in and around the pelvis may be hyper- adrenaline. nerve from its surrounding structures.43. the reverse will also purely isolated problems. especially in the spine. flossing-​ like tech- of the body’s systems. fering from chronic pelvic pain. Barral’s reason. and ligaments also lead to chronic pelvic tract. which is essential to facilitate healing. ent with overactive pelvic floor muscles.30. hips. abdomen.35. according to King Baker’s work. Stability exercises may also be apy. hip the blood vessels. serotonin is increased by his manual techniques. Barral’s studies suggest that tissue mobile or hypomobile.41 People suf- a muscle spasm. organ ptosis.3 and that the visceral spasm therefore produces Pelvic floor disorders must not be seen as muscular pain and tension. and any imbalance of joint mobil- ing is simple:  Since it is rare that just a single ity and stability need to be addressed if they are organ system in the body is affected.33 pain. pituitary. which eventually . as demonstrated in Figure 18. treating women with vulvodynia (either local. digestive tract. and viscero. improvement in sexual function. pubic symphysis. bowel. neural mobilization can free these turn will stimulate the hypothalamus. It is suggested that the vis. and pelvis. producing hor- mones like. dyspareunia. and may displace the myelin sheath.33 nique with active or passive muscle release. with chronic tissues similar to the analgesic responses of acu.22 B E H AV I O R A L T H E R A P I E S F O R   P E LV I C F L O O R M U S C L E Neural Mobilization R E T R A I N I N G :   M OTO R The nervous system is a continuous structure L E A R N I N G A N D M OTO R throughout the body that should slide. and sacroiliac and sac- ized or generalized).42. CONTROL bend. stimulates greater cerebral activity uncommon to find that abnormalities in the and increased activity in the smooth muscles of lumbar vertebrae. and a 50% should only be performed by qualified phys- increase in quality-​of-​life issues. will decrease blood supply any urgency-​frequency dysfunction tend to pres- to the nerve. Specifically. FSH). In addi- spasms throughout the visceral systems of the tion. reportedly used by 78% of and pelvic organs. to stimulate neurotrans. its the viscera. myofascial trigger points.3.

relaxing the pelvic ful muscles through manual therapy will in many floor muscles with voiding and with intercourse cases allow for proper ROM. lengthening these pain- proper motor control—​e. however. avoided. if the patient is experiencing only pain and not and such strategies as the operant learning leaking. to functional length. imagery. Education and training should focus on is urinary or fecal leakage. muscle reeducation may be required. in turn. If the leaking does not subside.4).3:  A Stability Exercise. it is likely that the pelvic floor model and cognitive behavioral therapy should muscles are not weak.. and relaxing the pelvic floor and exercises can be administered under the guidance is achieved through verbal cueing.45 Stress of the pressure and stress it places on the pelvic management. A  female should not be rushed. of the tools that will help the process. and straining should be avoided because sively stretch the tissues at the introitus. Heal Pelvic Pain by Amy Stein. and home—​for example. This.g. breathing with modifications that can help with physiological voiding. Toileting and surrounding muscles and tissues. traction. of an experienced pelvic floor physical therapist. elongating.e. Such behavioral modifica- tions as scheduled voiding. stretching (i. perpetuates a continued cated in the case of overactive or shortened pelvic cycle of dysfunction and pain. and other techniques. external massage. Distraction. relaxation breathing. pelvic floor floor muscle. helping . with a to further elongate the shortened pelvic floor stool under their feet for certain toilets. Physical Therapy Treatment of Pelvic Pain 171 FIGURE 18. relaxing by taking a walk. This is learned by practice ger points are eliminated and muscles are restored in discerning the difference between contract. biofeedback. once trig- out of fear of pain. and practicing yoga for patients with a long history of overactive and meditation are all examples of behavioral pelvic floor muscles.. pelvic pain. but rather are shortened or be integrated into the treatment approach in tight. floor muscles. These exercises help strengthen the Behavioral therapy is therefore a necessary pelvic floor muscles in the case of incontinence. or use of a dilator or internal massage device—​ Patients need to be in a comfortable and sup- to help eliminate myofascial trigger points and portive position for voiding—​ commonly. urge control. posture Bladder and Bowel Retraining retraining. and biofeedback are some quieting. DPT result in shortened muscle fibers and connective Pelvic muscle exercises (Kegels) are not indi- tissues. The pelvic floor muscles need to be Patients can also apply helpful techniques at relaxed during bladder and bowel emptying. a partial squat should be with pain at the vaginal introitus can also pas. Pelvic floor if the patient presents with a paradoxical con- stretch shown in Figure 18. If there pain. and the leakage may rather than contracting or “tensing” the muscles subside. Muscle reeducation can be a slow process soaking in a hot bath. and pelvic floor muscle exercises may further order to help break this cycle of dysfunction and exacerbate the shortening and tightening. and pelvic floor muscle relaxation Regulation of bladder and bowel function is an and self-​massage prior to or following sexual essential part of the treatment of abdomino-​ activity are also key to pelvic floor rehabilitation. then pelvic floor muscles ing. adjunct to pelvic floor muscle rehabilitation.46 muscle relaxation.

which will help decrease frequency urge-​delay and progressive timed voiding. ameliorate any tissue For bowel retraining.48. Internal and external massage may Bowel Reeducation help reduce tender points.49 In addi- in order to progressively expand bladder capacity.47 Soluble and insoluble fiber and a suffi- retention. and overactivity. The physical thera. and relax and lengthen these mus- must be avoided. movements. caffeine. Heal Pelvic Pain by Amy Stein. bladder and bowel frequency. it is important to educate the patient on timed voiding. cient amount of water should be added to the patient’s diet when appropriate to facilitate easier Bladder Reeducation and softer bowel movements. increasing contractile activity When pelvic pain is a factor in sexual dysfunc- with already overactive pelvic floor muscles may tion. Some stud- ies have shown that Kegels help inhibit bladder Restoration of Sexual Function reflex. tenderness. often exhibit hypersensitivity.172 Pelvic Pain Management FIGURE 18. For example. tion. ture that creates optimal pelvic floor relaxation. car. Physical therapists typically . Establish a set time In addition. training in the elimi. tion. and lessons in the need to rehydrate thereby increase the anorectal angle. bladder reeducation should include for voiding each day. squatting or placing a stool under bonated beverages—​ strictures against restricting the patient’s feet may increase hip flexion and water intake. as well as delay false bladder urges. urgency. pelvic floor muscles and connective tissues further shorten or tighten the pelvic floor. hesitancy. In cases of bowel frequency and pist needs to guide the patient through progressive urgency. which may require muscle reeducation in sensitive tissue. the tone of the muscles and desensitize hyper- cles. and teach a supportive pos- reminders against pushing. nation of dietary irritants—​alcohol. such techniques as breathing with voiding This reeducation should be followed at home and and colon massage may further facilitate bowel over an extended time period. DPT the muscles relax so as to eliminate post-​void patients presenting with a paradoxical contrac- dribble. and internal massage tools may help normalize nation in the abdominal and pelvic floor mus. but again. dilators the patient has full awareness of and coordi. As part of the at-​home program. so it is essential to make sure cles. constipation and straining restrictions.4:  Pelvic Floor Stretch. and pain.

restores the muscle to a position of optimal oper- The nociceptor can change from being simply ating mechanics. which travel tense.6. Cardiovascular Exercise is that “the pain response operates within the Cardiovascular fitness has been proven to entire system of nociceptive input.52 patients with sexual dysfunction experienced a significant improvement in symptoms. according to Hilton. mon in patients suffering from chronic pelvic pain. pelvic pain.53 smaller stimulus sets off the action potential. because it gradually form of functional plasticity of the nociceptor. thus. an increase in sen. and central sensiti. the increase results in passive mechanical stretching through sarcomero- hypersensitivity. As seen are demonstrated in Figures 18. it thus becomes hypersen. and hyperalgesia. Sarcomerogenesis is sitivity of peripheral nerve endings. cation on pain. Hip. Care through imaging techniques and electrophysiol. has proven to be an dynia and similar disorders. bution of each dynamic system.5 and 18. This multipronged has shown a significant improvement in sexual approach to addressing central and peripheral function through physical therapy treatment in sensitivities. central sensitization constitutes an increase tissues or tissues with trigger points or connec- in excitability in the synaptic neurons in the cen. It may include such techniques cises and techniques to restore those functions as relaxation training.”52 The nocicep.3 while 70% of male effective strategy for the pelvic pain patient. mindful- to normalcy is also recommended. Recent studies suggest that a a noxious stimulus detector to a detector of restoration of normal architecture and physiolog- non-​noxious stimuli. The action potential in the impaired or lengthening of the musculotendinous unit when surrounding nerve endings is decreased. it is there that the can also assist in alleviating pelvic pain affecting pain is registered. Physical Therapy Treatment of Pelvic Pain 173 instruct a patient in the use of a dilator along to the spinal cord and cross the synapse to the with instruction in relaxation techniques and dorsal horn. trunk. Nociceptor neuron sensitivity sexual activity. The heart of the matter. If the achieved with the guidance of a trained physi- patient has experienced changes in bladder and cal therapist addressing the issue through edu- bowel function. mechanical dysfunctions. A cardio fitness regimen should therefore be tive input is driven by afferent fibers that travel incorporated into a pelvic pain patient’s weekly . Intervention and treatment options are ing and flexibility and is essential to increasing guided by the estimation of the relative contri. ing the tight or shortened muscles found in many specifically in the brain and spinal cord. tion of new sarcomere units. assigning the appropriate exer. is modulated by a large variety of mediators in Behavioral training techniques incorporated the extracellular space. may also be suggested. A couple examples of stretches to increases in nociceptive sensitivity. ical function might be possible through a gradual sitive. Central sensitization Exercises are helpful in stretching and lengthen- involves changes in the central nervous system. the patient feels more pain Stretching with less provocation. such as using ice after sexual activity or in chronic pelvic pain patients.51 genesis. This can be taking a hot bath. simply put. “reorganize” and “reeducate” the neuromatrix egies. due pelvic pain patients. and overall well-​being. represents a critical to muscle function. These fibers use either glutamate or using biofeedback to teach the muscles not to substance P as neurotransmitters. Skeletal muscle responds to tral nociceptive pathways. allodynia. which is the creation and serial deposi- Peripheral sensitization. tive tissue restrictions. guided imagery. and yoga. It is a boon to condition- zation. peripheral increase endorphins and enhance mental health neurogenic sensitization. and pelvic floor stretching via pathways to the thalamus. This sensitization issue needs to be addressed vic floor muscles at set times throughout the day along with the dysfunction itself. in combination with tissue and bio- as many as 87% of women suffering from vulvo. Research ness meditation. Other strat. must be taken to avoid overstretching any soft ogy. a stretched at a rate of 1 mm per day. the aim is to and especially during sexual activity. blood flow and thus for the healing process.50 THERAPEUTIC EXERCISES ADDRES SING CENTRAL Both stretching and cardiovascular exercises S E N S I T I Z AT I O N are recommended therapies for patients with Both central and peripheral sensitization is com. into the at-​home program can help relax the pel.

until they can of the body out to the extremities. or four days per week for cles and fascia of the trunk.6:  Hip External Rotation Stretch. consist of cardio exercise five days a week for pelvis. The relation- work up to the AHA-​recommended guidelines. Heal Pelvic Pain by Amy Stein. facilitating movement from the center in intervals throughout the day. hip. that regimen should The stability of the body’s core—​ the spine. DPT routine. and abdo- 30 minutes per day.5:  Hip Flexor Stretch. FIGURE 18. ships among the muscles of the pelvic floor. As recommended by the American Core Stabilization Exercises Heart Association (AHA). For the more severe cases. DPT . and shoulder girdle that the mus- 20 minutes per day.174 Pelvic Pain Management FIGURE 18. Heal Pelvic Pain by Amy Stein. men support—​is what maintains an individual’s the patient may have to do the cardio routine mobility. pelvis.

and resulting dysfunctions. visual BOX 18.7 connection among them can be seen in the co-​ Patients with diastasis recti should also not contraction of the pelvic floor and abdominal perform any abdominal exercises until the sep- muscles that occurs in coughing.21 Until the and internal rotation exercises. certain muscles and lapsed pelvic organs. skeletal malalign. Physical Therapy Treatment of Pelvic Pain 175 deep back. cases. depending on the patient’s needs. which are listed in strengthening. they also play worsen symptoms in a patient experiencing pain or a significant role in pelvic floor disorders. performance-​ dependent.”54 In order to correct these faulty postures degenerative disk disease. cific abdominal exercises or. the plank and side plank. deconditioned muscles allowing for hip joints. determine the specific lengthening or strength- But if trigger points. trans- verse abdominus. instantaneous. such postures are a “contributing cause back. Some of these modalities promote healing metric contractions. create a slew of different dysfunctions in the Indeed. pain.23 Core strengthening exercises may also be Weakness in the core muscles or an imbal. with vary- Examples of some core exercises may include ing and often highly individual and subjective transverse abdominus and abdominal oblique iso. Exercises that strengthen tissues may need lengthening. squats.1. Kegel pel. the patient. while others need and balance the core muscles. discs. floor dysfunction and pelvic pain. pelvis. and hypertonicity in the muscles. and research has shown that they leg raise (as shown in Figure 18. diaphragm • Back muscles: erector spinae. some physical thera- vic floor exercises (if appropriate and only after the pists will continue to use modalities as an adjunct hypertonicity of the pelvic floor and the pain have to treatment. through surgery. pelvic tilt.” (as shown through both a physiological improvement and a in Figure 18.3). in more extreme tate the abdominal/​pelvic musculature (includ. injury. hip external can positively impact pain conditions. and of weak. While Kegel Used as an evaluation tool to assess muscle exercises are effective in strengthening the pelvic activity. external and internal obliques. quadratus lumborum • Gluteal muscles: maximus. adductors. incontinence. or inflammation). sacroiliac joint. “bridge. which can result in pain in and around imbalances in the pelvis with formation of trigger these areas. fascial restrictions. and pro. appropriate for correcting the faulty postures ance in the musculoskeletal system can therefore so common in patients suffering pelvic pain. ening needs for each individual patient. pelvic lead to such other disorders as osteoarthritis. and abdomen play an it is important to remember that they may actually important role in this function.7) quadruped with opposite arm and placebo effect. results. ing scarring. or back pain. diaphragm. And at all times. external rotators. A healthcare provider with exten- Box 18. may therefore also prevent pelvic floor sive training in the musculoskeletal system can disorders or mitigate them once they occur. subsided). or aration of the right and left rectus abdominus laughing. they have been overemphasized in the past. This co-​contraction is normal—​unless muscles has been corrected. exer- ment. The with hypertonic or shortened pelvic floor muscles. once the pain symptoms have subsided. evidence shows otherwise. ligaments. abdominal. quadriceps and hamstrings • Pelvic floor muscles . core strengthening exercises in these specific areas are not advised—​at least not until T R E AT M E N T M O D A L I T I E S the dysfunction is resolved. or acute injury have been identified in cises can further address core stability. visual/​auditory biofeedback provides floor. A range of mechanistic modalities may effectively tion should be taken lest strengthening exercises augment the physical therapy approach to pelvic increase any pelvic. cau. medius and minimus • Hip flexors. sneezing. and as a result. These dysfunctions may eventually points and hypertonicity. multifidus. either through spe- there are active trigger points that further irri.1  THE CORE MUSCLES • All of the abdominal muscles:  rectus abdominus.

13. and muscle control. activity and transmit the information to a moni.55. intensity and low-​ frequency sound waves. causing bio-​stimulation awareness. intensity wave lengths either in scanning or spot biofeedback has been proven to be more effec. It has been used for acute and local inflam- incoordination may be an issue. It has been shown to relieve minor mus- tive than laxatives. LLLT uses power densities lower and restoring proper bladder and bowel func. showing most clinical benefits. thereby reducing pelvic pain terizing tissues. preventing mation.176 Pelvic Pain Management FIGURE 18. as well as for vestibular tenderness. the patient is able to show any abnormal muscle activity. thus reinforcing the “lesson. in evaluating the firing pattern of muscles in a toms. and normalizing the pattern. blood brings more oxygen to the cells and helps ment modality for reeducating patients in how reduce inflammation. even though work on recruiting the correct muscles. break up scar adhesions. such information can also assist the at the cellular level to eliminate trigger points.” If the muscles is overactive or which muscle is not activated are shortened.7:  One-​legged Bridge. and increase vaginal or rectal sensor is used to detect muscle lymph flow. decrease muscle electrodes are placed perianally or an internal spasms. By “feeling” which muscle pain. On the monitor.58 cle and joint aches temporarily. symptoms of overactive pelvic floor muscles. form. and contrib. the patient can see what the feedback tool for muscle reeducation. activity. the muscles from fully relaxing. This visual feedback offers the kind of body patient performing the Active Straight Leg Raise awareness that enables patients to “teach” their (see Evaluation Chap 17)  becomes a cueing overactive muscles to relax.57 In cases of pelvic floor dyssynergia.23. by increasing the patient’s ton light without heat. the same information the examiner found the patient is experiencing his or her pain symp. warming the tissues and thus dilating the blood however. Heal Pelvic Pain by Amy Stein. that if it proves difficult for the patient vessels to deliver more oxygen to the affected to contract and relax the pelvic floor muscles. which in turn reduces tool for the patient. relax muscles. For exam- muscles are doing during rest. redirect- the patient may be experiencing pain and other ing the muscles.56. DPT and/​or auditory information regarding the Low-​ level laser therapy (LLLT) emits pho- function of muscles. Real-​time ultrasound can be used as a bio- tor. patient in controlling and self-​ regulating that the increased local microcirculation of the muscle activity.24 electrical stimulation itself alleviates chronic . It is believed. to reduce pain For pelvic floor muscle dysfunction. uting to pelvic pain and to bladder and bowel There is very little evidence to date that dysfunction. forms of laser therapy used for cutting or cau- cles appropriately. coordination. area. As distinct from other to use their pelvic floor and abdominal mus. It is therefore an excellent treat. than those needed to heat tissue and emits low-​ tion. Therapeutic ultrasound transmits low-​ There are no set measurements of strength. the biofeedback may not enough during the task. however. and while ple. either and stiffness.

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the precise etiology is large. to antiquity. there are no high-​quality (i. patients may improve with stimulation that did assess neuromodulation as an interven- of the central nervous system or centrally acting tion for CPP did not include a control. VA L OV S K A C hronic pelvic pain (CPP) is an intermittent or constant pain in the lower abdomen or pel- vis of at least six months’ duration causing signif- urge incontinence.. non-​ obstructive urinary retention.000 implants occurring in the last Dysfunction in myriad organ systems (e. Current Food and Drug Administration In CPP. 19 Implantable Devices for the Treatment of Pelvic Pain C H R I S R . W E I S H E I P L .5 years. This complex region receives sympa- successfully used implanted sacral neuromodu.. thus sig- medications. manifesting as somatic or visceral pain. urgency-​ frequency. prospective. in 1976 physiology. as well F O R   T R E AT M E N T   O F   C P P as the short follow-​up duration. A L I S O N M . Additional issues included a wide varia- ery of opioids for patients with CPP.1–​24% of the worldwide female population. A systematic review in injury (similar to complex regional pain syn. or occur in the absence of an actual for the treatment of CPP.6 innervation from S2–​S4 via the pudendal nerve. when.2 Given that CPP can be nociceptive..4 The first doc.8 In the interim. until high-​quality History and Contemporary studies arrive. tion in the definition of CPP. parasympa- patients. endo. in 1995.3 This chapter will address various nificantly limiting the inferences that could be stimulation modalities as well as intrathecal deliv. 100Hz). and fecal incon- tinence. thetic innervation from the T1–​L2 nerve roots lators to treat urinary incontinence in paraplegic via the superior hypogastric plexus.7 SNS implantation for CPP remains an metriosis. A B R E C H T. to CPP. when Brindley et al.g. dal neuralgia. Understanding how SNS works requires an umentation of sacral nerve stimulation came a understanding of pelvic neuroanatomy and pain few millennia later.5 Later. found that the few studies drome). not known. with more than half of the 2. the outcome mea- surements (e. off-​label intervention. usually limited to 12 weeks. inflammatory bowel syndrome. SF-​36 quality-​of-​life questionnaire). Implantation of SNS has increased icant functional disability and affects an estimated significantly recently. A N D A S S I A T. and somatic of fecal incontinence. 3. 2012 by Tirlapur et al. yet in most cases.g. multi-​ center. puden. drawn. injury to lower abdominal or pelvic (FDA)–​ approved uses of SNS include urinary organs. the pain scores via the McGill S A C R A L N E RV E questionnaire vs. randomized. the Visual Analog Scale (VAS) S T I M U L AT I O N   ( S N S ) vs. . interstitial cystitis) can contribute Unfortunately. neuromodulation continues to be Use of SNS used to effectively treat women with intractable Electrotherapy for pain management dates back chronic pelvic pain. in ad 46. came the description of thetic innervation from the S2–​S4 nerve roots sacral nerve stimulation (SNS) for the treatment via the pelvic splanchnic nerves. controlled) trials that evaluate SNS specifically neuropathic. the court physician of Roman emperor Claudius documented in his Proposed Mechanisms of Action Compositiones the treatment of headaches using of Neuromodulation electric eels (40–​100V.e.1 estimated 125.

however. wherein the leads are directly inserted into the a negative predictor of successful stimulation. Brigham and Women’s Hospital. the of the pelvic nociceptive or neuropathic afferent patient keeps a diary documenting VAS record- signals responsible for the patient’s pain. of the disinfected area and a half sheet onto the tion. First. geographic variation in hinge on the “gate theory” of analgesia proposed the depth of sedation used during these proce- by Melzack and Wall in 1965. These sacral nerve The exact mechanism by which SNS and stimulator trials performed at our institution. yet off-​label.11 Prior to a SNS trial. IPG. applied along the sacrum. placement in the operating room at a later date. gical practice at our institution. cause depolarization patient carries during the duration of the trial. and nerve The following is a brief description of the sur- blocks using local anesthetics or steroids (e. The basic steps for this procedure are usually as follows:  Place Therapeutic Trial of SNS Prior the electrodes. using fluoroscopic guidance. If at the end of this ably an oversimplification. Chlorhexidine prep is preventing ambulation. representa- pudendal nerve blocks). is prob. pelvic floor physical therapy. At our institution. If present. olution. create an impulse pulse gener- to Implantation ator (IPG) pocket. but patients appear anecdo. we align x-​rays. the therapeutic trial is considered a suc- CPP receive relief with neuromodulation leads cess. treatment for trial after correction of the placement. therefore. for SNS Implantation ment.g. Antibiotic prophylaxis is adminis- these disorders should be psychologically and.11 patients with chronic pelvic pain. This theory sug.12 pain Aβ fibers is able to inhibit the transmission In either way. the clinician should empha. operate the neurostimulatory device as well as We use the sacral transforaminal technique.. and tunnel the leads to the Prior to the trial. There are no known tive of the national standard practice for these evidence-​based prognostic factors for successful procedures. The appropri- ate patient has already tried other interventions. Implantable Devices for Pelvic Pain 181 may ultimately develop into injury to the nervous improvement. To place the electrodes. of pain episodes. other well-​established modalities of neuromod. pared skin. with tally to have better results if they lack severe the patient resting on an abdominal pillow to neurological deficits such as spinal cord injury reduce lumbar lordosis. other relevant findings. for period the patient reports a greater than 50% instance. patients should also undergo a psychological Sterile towels are then positioned at the border evaluation to determine if the patient has addic. neuromodulation. but probably not complete res- system itself. or anxiety disorders contribut. . perhaps due to sympa. depression. with local anesthesia and minimal seda- not completely understood. Surgical Technique including but not limited to medical manage. but it is thought to tion. this assessment should deter. The temporary lead is then removed. if tered prior to incision according to institutional needed. Moreover. the of smaller-​diameter pain Aδ and C fibers. functional status. ings. manifesting as neuropathic pain. the prone position is employed. are done in the ulation such as spinal cord stimulation work is clinic. Recent studies. pharmacologically treated prior to the guidelines. whether the patient has history of sexual abuse. deep seda- gests that the activation of large-​diameter non-​ tion or general anesthesia are also employed. the placement of the leads should be checked.11 sacral foramina (S3 and S4). During this period. have shown that some patients with relief. patient’s legs. the patient is scheduled for permanent lead thetic and visceral pain fibers following an atyp. Ioban is then applied over the pre- ing to the patient’s pain syndrome. size the goal of increased functionality and infiltrate local anesthetic to the superficial skin. Patient Selection as in an estimated 11–​18% of therapeutic trials. in many European countries.9 The electrode is maneuvered into the sacral foramen electric current delivered by the sacral nerve and linked to an external stimulator that the stimulator may. for SNS Implantation lead migration occurs and may call for a repeat SNS is an effective. including the buttocks. and any This prevailing explanation. however. analgesic use. ical path. There is.10 If the patient experiences less than 50% relief. of pelvic non-​nociceptive fibers and inhibition usually lasting a week. dures. cefazolin 2 g is trial. and placed as high as T6/​7. administered to patients without a beta-​lactam mine if the patient has the cognitive ability to allergy.

17 In the modern system. and S4 levels. who experienced a sustained and greater than sible treatment for coccygodynia. After the electrodes are placed. taking care to not make the pocket too non-​dermatomal distribution of pain. each treated for over a decade with mul- surgery13 and trauma. neuro- direction to the S2.13 or extremities. injury from delivery. Multiple of this condition include nerve injury from lower studies have demonstrated this modality’s effi- abdominal and pelvic surgery or trauma. (CRPS). placement deep so that recharging the IPG is not inhibited of the stimulating electrode directly at the site of by deep tissue. and CPP. A  case series in 2006 significant and long-​lasting relief for patients with described six female patients with chronic pelvic ilioinguinal neuralgia following lower abdominal pain. which man. The PROCESS RCT and physical therapy are not effective. however.182 Pelvic Pain Management and insert an introducer at the sacral foramina. space either percutaneously with fluoroscopic nal neuralgia. arachnoid space was used to treat a patient with chronic pain. with an gate control theory of pain in the 1960s. wherein the epidural needle Use of SCS and the leads are inserted in a cranial-​to-​caudal As described in the previous section.15 Pain relief may be achieved by them to stay in the correct position without placing stimulating electrodes over the course of using an anchor. in many cacy in treating a variety of chronic pain con- instances. stimulator with leads placed along the affected der. and genitals. The etiology placed at either T11 or L1.16 In cases of coccygodynia with buttock). usually manifesting as neuropathic guidance or surgically with direct visualization pain with hyperesthesia in the upper medial thigh. Peripheral neuromodulation is also a pos. S T I M U L AT I O N ( S C S ) the wound is closed. connect with subcutaneously located impulse inguinal region. geal joint. F O R T R E AT M E N T O F C P P nique include lead migration because no anchors are used. History and Contemporary rograde technique. Other surgical options include the ret. the anesthesiologist providing sedation so that the first published use of spinal cord stimulation patient is comfortable. The electrodes are tined. modulation sprang from Melzack and Wall’s cedures are done in the operating room. In ditions. indicating when a platinum electrode placed in the sub- correct placement. SPINAL CORD otic solution and ensuring adequate hemostasis. Other off-​label uses include peripheral ralgia may undergo implantation of a permanent vascular disease. provided Class  I  evidence nerve stimulation targeting the ilioinguinal nerve of efficacy in the treatment of failed back sur- is an alternative to surgical techniques such as gery syndrome (FBSS). with minimal morbidity and relatively patients for whom pharmacological management decreased healthcare costs. causes include osteoarthritis of the sacrococcy- We then place the electrodes through the intro. the peripheral nerve corresponding to the pain- we then create an IPG pocket (usually along the ful dermatome. The first commercially avail- Additional Targets for Peripheral able stimulators sent radio frequency messages Neuromodulation to stimulator electrodes placed directly on Peripheral neuromodulation using targets other the dorsal columns. peripheral in 2007.19 Another case report of this condition is often unclear.18 SCS has FDA approval inguinal neurectomy. matome in the area of greatest pain.14 tiple medications and nonsurgical interventions. which allows the pelvic floor. 50% reduction in their pain after an SCS was ifests as pain around the coccyx. yet aware enough to alert (SCS) for the treatment of pain was in 1967. for instance. refractory angina pectoralis. the interventionalist to paresthesias. with most implants occurring to After a patient-​selection process similar to the one treat FBSS and chronic regional pain syndrome described for SNS. S3. and spasm of ducer. Targeting the Multiple reports have supported the use ilioinguinal nerve at L1 has been shown to provide of SCS to treat CPP. Finally. After irrigating with antibi. which is not effective in all for the treatment of chronic pain of the trunk patients and may cause problematic paresthesias. The known causes pulse generators via tunneled wires. These pro.  15 leads from sacral roots to buttock and connect the leads to the IPG. but known describes a woman with debilitating vulvodynia . patients with ilioinguinal neu. the exact cause is not clear. One such example is ilioingui. we tunnel the stimulating pain may be more effective. than the sacral nerve is also available to treat pain in multi-​lead electrodes placed in the epidural the pelvic territory. Potential risks of this tech.

Infection incidence was 4. resting on an abdominal pillow to reduce coming years will translate into a higher quality lumbar lordosis and thereby facilitate access to of life for patients with CPP. the patient keeps a diary documenting columns of the spinal cord. under minimal sedation so with roughly two-​thirds of those cases requir. a retrospective case series of 26 patients with chronic visceral neuropathic pain in the abdo. paddle-​lead SCS for lower abdominal pain. surgical placement in the operating room would fit. most patients undergo percutaneous. superficial infections. mostly post-​ teria. trodes in the clinic. Chlorhexidine prep is applied . the patient receives instruction on how to The established use of neuromodulation in adjust the SCS settings. were performed due to “visceral pain” or “neu. a multicenter tation is similar to that of SNS implantation. Growing evidence pain and the SCS settings that provide the most suggests. tional research in neuromodulation. per. Similarly. including. goes home with a temporary SCS system attached haps explaining the relatively high rate of lead to an external programmer.21 Also noteworthy.5%. Prior to discharge migration. as well as to confirm of their mean sitting time at a mean follow-​up of that they have the capacity to manage the SCS 15 months. In the patient who has met these cri- from these procedures were mild. Most of the implants studied in this instead of in the clinic. physical therapy Of the 20 of these patients with a positive test and medical management with multiple agents. pain score is again considered a successful trial. In the subsequent week the treatment of chronic pain targets the dorsal or two. pain relief. These rates institution. all experienced greater than 50% reduction in and other comorbidities frequently associated their pain and a statistically significant doubling with chronic pelvic pain. this recent study times necessary if significant scarring from suggesting an anterior approach is important to previous back surgeries prevents the passage of mention because it emphasizes the need for addi. In either case. as prospective study followed 27 patients with described above. the patient trial were for CRPS-​related extremity pain. the epidural space. the next step is a therapeutic trial of SCS. the patient is again in the prone doubt.23 The ance. and lead migration requiring reprogramming. our preferred method as well as the national spinal cord targets in this study were T9/​10 for standard for pain physicians with a background upper abdominal pain and T10/​ 11 or T11/​ 12 in anesthesiology. cal assessment to address any depression. These patients with CPP should chronic pelvic pain with pudendal neuralgia not have already undergone extensive interventions. a Therapeutic Trial of SCS Prior review of 707 SCS cases at the Cleveland Clinic to Implantation from 2000–​ 2005 revealed a 22.6% incidence The therapeutic trial of SCS prior to implantation of lead migration and a 6% incidence of lead is again similar to that of the SNS trial. Without a In either case. phase who underwent permanent implantation These patients should also undergo a psychologi- of the SCS at the level of the conus medullaris. or spinal stenosis. the percutaneous leads into the epidural space. While the rest of this implantation via direct visualization is the pre- chapter will address the standard SCS approach ferred method of neurosurgeons and is some- targeting the dorsal columns. In contrast. For instance. this trial may require ropathic pain. though. new advances in neuromodulation in the position. relieved by pudendal nerve compression surgery.” the categories into which CPP direct. however.22 home. Implantable Devices for Pelvic Pain 183 and pelvic pain for over a decade on high doses Patient Selection for SCS of methadone and other opioids who was able Implantation to wean herself off all opioids several months The patient-​ selection process for SCS implan- after SCS at L3. scoliosis. A  reduction of at least 50% in VAS ulation may also provide pain relief. have probably decreased with improvements in fluoroscopically guided placement of the elec- the SCS hardware. the complications implant. The following is a brief description of percuta- tion after spinal cord stimulation—​regardless of neous SCS implantation with fluoroscopic guid- whether the target was dorsal or ventral. At our breakage requiring re-​implantation. In rare cases of severe epidural scarring.20 More recently. anxiety. only about 15% of these implants pain. but not limited to. that ventral spinal cord stim. Surgical Technique for SCS men showed a statistically significant reduction Implantation in visual analog pain scores and opioid consump. surgical pain. the patient can inform the proceduralist when the ing re-​implantation due to a deep infection. Of distracting induced paresthesia covers the area of note.

As with SNS anesthetic. (See Figure 19. these procedures are done in the a Tuohy needle with a loss of resistance technique operating room under the care of an anesthesiolo- to air or saline. ing the electrodes to the IPG. flank. The epidural electrode leads are gist so that the patient can tolerate the procedure then threaded through the epidural space to the but also indicate correct lead placement to the desired level using fluoroscopic guidance. . or lumbar paraspinal applied over the prepared skin. For antibiotic area. based on the patient’s habitus and prefer- prophylaxis. in the case of a B-​lactam allergy. the IPG in turn CPP).1:  Spinal cord stimulator overview. infiltrate the superficial tissues with local is controlled via an external device.1 for an overview Leads of spinal cord stimulator Extension wire Impulse generator FIGURE 19. T11 being our usual goal for these patients with Once the incisions are sutured. thereby connect- give clindamycin. The electrodes are then tunneled from the cefazolin. leads are anchored to the fascia to decrease the tion of the IPG pocket. The back incision The basic steps are as follows:  Identify the and IPG pocket are closed after proper antibi- intended vertebral level using fluoroscopy (with otic irrigation and ensuring adequate hemostasis. with sterile towels at risk of lead migration. The interventionalist. and identify the epidural space using implantation. we usually give a single dose of ences. we back incision to the IPG pocket. The IPG pocket is made the border of the disinfected area and Ioban in either the buttocks.184 Pelvic Pain Management broadly to the back and to the planned loca.

24 Since then. treatment of chronic pain via IDDS. local anesthetics. and calcium channel blockers—​ the FDA in 1995 granted approval only for intrathecal morphine via intrathecal drug delivery systems (IDDS) in the treatment of chronic pain. including neuromodulation therapies intrathecal opioid administration may allow and medication management.25 Most IDDS in use today treat chronic malig- nant pain.2:  Medtronic InterStim II Neurostimulator. See Figure treat chronic non-​ malignant pain.3 for an image of tined leads.24 A  prospective three-​ year study of 58 History and Contemporary Use patients with chronic.) ment of non-​ malignant chronic pelvic pain. our practice.26 In their ultimate site of action. multiple studies have shown that IDDS can cause a statis- tically significant and sustained (lasting multiple years) reduction in pain. but IDDS have been shown to provide statis- I N T R AT H E C A L O P I O I D tically significant results in patients with non-​ THERAPY FOR  THE malignant visceral pain disorders. the calcium channel ziconotide has also received approval for the FIGURE 19. a group into T R E AT M E N T   O F   C P P which patients with chronic pelvic pain would fit. In addition. No studies 19. a process that deployed. vic pain as their primary diagnosis—​ showed nal cord’s dorsal horn laid the groundwork for that intrathecal opioid therapy provided a sta- the practice of intrathecal opioid administration. but not limited to. requires skin puncture.3: Medtronic tined leads prior to being for intrathecal pump refilling. implantable devices for intra- thecal opioid administration are not a first-​ line treatment for patients with CPP. IDDS are reserved for patients ing the absorption. reduction in enteral analgesic intake. see Figure have specifically examined IDDS in the treat- 19. non-​ malignant pain—​ a of Intrathecal Pumps (ITPs) cohort that did include a few patients with pel- The discovery in 1976 of the μ opioid at the spi. and improvement in functional status in patients with nociceptive. . Implantable Devices for Pelvic Pain 185 chronic pain—​including. opi- oids. By largely bypass. The ideal patient has already undergone an extensive