Professional Documents
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Chronic Pelvic Pain
Chronic Pelvic Pain
Adnexal mass
B
women with chronic pelvic pain who were evaluated for Chronic pelvic inflammatory disease/chronic
B
existing bladder pain syndrome and endometriosis, 48% Ovarian remnant syndrome
B
Pelvic adhesions
B
Vulvodynia
B
Pathophysiology
c Gastrointestinal
Recent evidence supports the importance of central BCeliac disease
sensitization in perpetuating chronic pain syndromes. BColorectal cancer and cancer therapy
Central sensitization occurs when peripheral pain pro- BDiverticular colitis
vokes an exaggerated response by the interneurons, which BInflammatory bowel disease
amplifies the pain perception. The resulting pathologic BIrritable bowel syndrome
changes involve the central nervous system’s response to c Urologic
BBladder cancer and cancer therapy
noxious stimuli, the activation of specific brain regions, BChronic or complicated urinary tract infection
the hypothalamic–pituitary–adrenal axis, and the auto- BInterstitial cystitis
nomic nervous system, all of which increase psychologic BPainful bladder syndrome
distress (16). Central sensitization explains why patients BUrethral diverticulum
with chronic pelvic pain feel pain in response to innocuous Neuromusculoskeletal
stimuli (allodynia) and feel a heightened response to
c Fibromyalgia
painful stimuli (hyperalgesia). The abnormal central pro-
c Myofascial syndromes
cessing of sensory information can explain why endome- Coccydynia
B
triosis pain can persist despite effective treatment (17). Musculus levator ani syndrome
B
c Postural syndrome
Differential Diagnosis
c Abdominal wall syndromes
The differential diagnosis for chronic pelvic pain is Muscular injury
B
Neuropathic pain
B
ease (9). For example, a chronic pelvic pain patient’s Substance-induced or medication-induced
B
pain may not improve until her endometriosis is treated, depressive disorder
reactive pelvic floor myalgia is addressed, central sensi- c Anxiety disorders
VOL. 135, NO. 3, MARCH 2020 Practice Bulletin Chronic Pelvic Pain e99
definition of this condition, and diagnostic criteria are
Box 1. Common Conditions Associated variable (19). Further research is needed to establish
With Chronic Pelvic Pain (continued) greater consistency in diagnosis and homogeneity in
c Somatic symptom disorders treatment studies.
BSomatic symptom disorder with pain features
BSomatic symptom disorder with somatic
characteristics
Clinical Considerations
c Substance use disorder
BSubstance abuse
and Recommendations
Substance dependence
< What is the initial evaluation for a patient who
B
VOL. 135, NO. 3, MARCH 2020 Practice Bulletin Chronic Pelvic Pain e101
found to have treatable musculoskeletal disorders iden- chronic pelvic pain. These medications can be prescribed
tified by a physician specializing in physical medicine by obstetrician–gynecologists.
and rehabilitation (37). Antidepressant medications are most commonly
prescribed, alone or with psychotherapy, for management
Cognitive Behavioral Therapy of moderate to severe depression. Antidepressant medi-
Although pelvic pain may be due to an inciting event, the cations also have been evaluated in nondepressed
chronicity of pain predisposes patients to depression, patients with chronic pain syndromes. Although no
anxiety, and social isolation. And, depression worsens studies have established the benefit of antidepressant
the quality of life for women with chronic pelvic pain use for improvement in chronic pelvic pain specifically,
(38). Instead of attempting to determine which order is a systematic review of 37 double-blind randomized trials
primary, or blaming one condition for causing the other, found that SNRIs and tricyclic antidepressants were
both need to be treated with equal urgency. superior to placebo for improving depressive symptoms,
Cognitive behavioral therapy is a goal-oriented pain, and quality of life in patients with neuropathic pain
therapy and, when used in conjunction with medical syndromes such as fibromyalgia and diabetic neuropathy,
and physical therapies, has the advantage of addressing with a number-needed-to-treat of 24 patients for one to
the effects of depression and pain on relationships and experience a clinical improvement. The analgesic effec-
other aspects of well-being. The evidence that supports tiveness of SNRIs and tricyclic antidepressants was not
the benefit of cognitive behavioral therapy and other evaluated separately in subgroup analyses (45).
counseling approaches for the treatment of chronic pelvic Cochrane reviews of individual antidepressants show
pain comes primarily from studies in which counseling is that duloxetine (an SNRI) is superior to placebo for the
a component of multidisciplinary care (39, 40). Studies management of neuropathic pain from diabetic neuropathy
of patients with other chronic pain syndromes show and fibromyalgia (46), whereas trials of venlafaxine (a selec-
small-to-moderate benefits of cognitive behavioral ther- tive serotonin reuptake inhibitor with weak SNRI properties)
apy when compared with no therapy (41). Patients learn for neuropathic pain showed strong placebo effects and high
to modulate their thoughts and manipulate their environ- potential for selection bias (47). No published trials have
ment to lessen their pain perception and improve coping established the efficacy of duloxetine or venlafaxine in the
skills. treatment of chronic pelvic pain in women.
Emotional well-being should be assessed at every Tricyclic antidepressants (eg, amitriptyline, nortrip-
visit and professional counseling should be considered tyline, and desipramine) are commonly used to treat
and offered to every patient with chronic pelvic pain. It is neuropathic pain. However, there is only weak evidence
critical that the patient understands that referral does not of efficacy (48–50). A 2009 double blind randomized
mean that the pain is psychosomatic or any less real. controlled trial (RCT) found that gabapentin and nortrip-
Instead, counseling enables patients to obtain support in tyline worked better in combination than either drug
parallel with the other treatments being recommended to worked in isolation for chronic neuropathic pain (51).
address the chronic pelvic pain generators. Based upon their effectiveness for other neuropathic
pain syndromes, gabapentin and pregabalin are recom-
Sex Therapy mended for the treatment of neuropathic chronic pelvic
Although there may be a myofascial component to pain. These medications can be prescribed by obstetrician–
genito–pelvic pain, this condition may require the addi- gynecologists. Neuropathic medications have a role in the
tional expertise of individual counseling, couples ther- medical management of chronic pelvic pain once under-
apy, or sex therapy to overcome the specific psychosocial lying visceral etiologies have been addressed and a neu-
barriers to recovery (4, 42). Sex therapy can be a useful ropathic component of the pain syndrome has been
adjunctive treatment to physical therapy to assist couples diagnosed (52). However, many studies are not specific to
in the return to normal, pain-free intercourse; female chronic pelvic pain and are small or retrospective in nature
orgasmic disorder and genito–pelvic pain have been (53). Because neuropathic pain is often associated with
shown to improve with sex therapy (43, 44). tissue injury, it is critical to assess for and treat concurrent
myofascial dysfunction. Treatment with neuropathic
< What is the role of neuropathic medications in medications may improve the effectiveness of physical
the treatment of chronic pelvic pain? therapy and myofascial dysfunction by improving senso-
rineural tolerance of stimuli.
Based upon their effectiveness for other neuropathic pain Calcium channel alpha 2-delta ligand medications
syndromes, serotonin–norepinephrine reuptake inhibitors (gabapentin or pregabalin) are common treatments for
(SNRIs) are recommended for patients with neuropathic chronic pelvic pain. Although there is a lack of evidence
VOL. 135, NO. 3, MARCH 2020 Practice Bulletin Chronic Pelvic Pain e103
raises the possibility that needle insertion itself may manipulation showed weaker evidence of benefit. None of
produce a strong placebo effect or be effective on its own the studies focused on women with chronic pelvic pain (66).
(60). Trigger point injections are beneficial for pelvic Preliminary evidence from a single-arm trial that evaluated
floor muscle spasm refractory to pelvic floor physical the success of a group-based therapeutic yoga program for
therapy and medications (61) and may be more beneficial women with chronic pelvic pain showed clinically important
than ischemic compression physical therapy alone for the and statistically significant improvements in baseline pain,
treatment of abdominal wall trigger points in patients emotional well-being, and sexual function after 6 weeks of
with chronic pelvic pain (59). Patients should be coun- yoga practice (67).
seled regarding expectations and anticipated concurrent Selective cannabinoids (ie, synthetic cannabinoids that
therapies before starting injections. contain only tetrahydrocannabinol [THC] and cannabis-
based extracts that contain a combination of THC and
Botulinum Toxin Injections cannabidiol [CBD]) for chronic neuropathic pain have been
The evidence is inconclusive regarding the value of the focus of several recent systematic reviews (68, 69). A
botulinum toxin injections for myofascial pain syn- systematic review of 11 randomized trials that included
dromes from all sources (62). Therefore, their use should 1,219 patients showed a statistically significant but clinically
be reserved for the treatment of myofascial pelvic pain small benefit averaging less than 1 point on a 0–10-point
refractory to physical therapy (63). pain scale (68). Another review included the findings from
24 randomized trials (1,334 patients) in a meta-analysis that
Other Procedures showed inconsistent improvements in pain across trials, with
There is limited evidence to support laparoscopic uterosac- most showing no effect (69). Participants in the trials had
ral nerve ablation and presacral neurectomy in the treatment heterogeneous diagnoses including multiple sclerosis, dia-
of chronic pelvic pain. A large RCT found no improvement betic neuropathy, brachial plexus injury, and
in pain scores or quality of life after laparoscopic uterosacral chemotherapy-induced pain. None of the studies in either
nerve ablation in chronic pelvic pain (64). Most studies that review focused on women with chronic pelvic pain (68, 69).
evaluated presacral neurectomy included patients that had
dysmenorrhea, and there is insufficient evidence to support < What is the role of laparoscopic adhesiolysis
nerve interruption in the treatment of chronic pain (65). in the management of chronic pelvic pain?
< What are the roles of complementary, alterna- The routine use of laparoscopic adhesiolysis is not
tive, and integrative medicine therapies in the recommended for the management of chronic pelvic
treatment of chronic pelvic pain? pain. Laparoscopic adhesiolysis is not helpful for the
treatment of chronic pelvic pain after visceral gyneco-
Data from randomized trials are needed to evaluate logic causes such as endometriosis, adenomyosis, and
whether complementary and integrative therapies studied adnexal disorders have been excluded. However, intra-
for other chronic pain disorders are effective for chronic operative findings may support the role of adhesiolysis in
pelvic pain. However, based on evidence of benefit for specific circumstances such as bowel stricture and dense
the treatment of nongynecologic chronic pain, acupunc- adhesions tethering the uterus.
ture and yoga can be considered for the management of Adhesions are common in patients who have
chronic pelvic pain of musculoskeletal etiology. undergone previous abdominal surgery and in patients
Complementary and integrative therapies have been with inflammatory conditions such as pelvic inflamma-
studied in patients with chronic musculoskeletal and neuro- tory disease and endometriosis. Pelvic adhesiolysis was
pathic pain syndromes of the head, neck, back, and once a common procedure in patients undergoing
extremities as well as fibromyalgia. These therapies can be laparoscopy for chronic pelvic pain (70). Early uncon-
biologically based (natural compounds), mind–body (such as trolled studies showed large magnitude, short-lived im-
relaxation, yoga, and tai chi), manipulative (such as massage provements after lysis of adhesions, whereas later
and osteopathic manipulation), and bioenergetic (acupunc- randomized trials show no benefit when compared with
ture) (32, 66). A systematic review of 32 studies of chronic diagnostic laparoscopy (71), which challenges the value
pain management included six randomized trials of acu- of laparoscopic adhesiolysis for chronic pelvic pain and
puncture that showed strong evidence of benefit for reducing the presumption that adhesions cause chronic pelvic pain.
pain and opioid use in patients with chronic musculoskeletal A systematic review of two RCTs and 11 cohort studies
pain. One of the trials showed short-term benefit of auricular on laparoscopic adhesiolysis found a lack of evidence of
acupuncture in pregnant women with low back and posterior benefit, an increased risk of bowel injury, and a high rate of
pelvic pain. Studies of yoga, relaxation, tai chi, massage, and negative laparoscopies (defined in the review as no
VOL. 135, NO. 3, MARCH 2020 Practice Bulletin Chronic Pelvic Pain e105
setting: 1-year prospective cohort. Am J Obstet Gynecol 2018; tion in female chronic pelvic pain: a blinded study of exam-
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64. Daniels J, Gray R, Hills RK, Latthe P, Buckley L, Gupta
J, et al. Laparoscopic uterosacral nerve ablation for alle- The MEDLINE database, the Cochrane Library, and the
viating chronic pelvic pain: a randomized controlled trial. American College of Obstetricians and Gynecologists’ own
LUNA Trial Collaboration. JAMA 2009;302:955–61. internal resources and documents were used to conduct
(Level I) a literature search to locate relevant articles published
65. Proctor M, Latthe P, Farquhar C, Khan K, Johnson N. between January 2000—May 2019. The search was
Surgical interruption of pelvic nerve pathways for primary restricted to articles published in the English language.
and secondary dysmenorrhoea. Cochrane Database of Sys- Priority was given to articles reporting results of original
tematic Reviews 2005, Issue 4. Art. No.: CD001896. DOI: research, although review articles and commentaries also
10.1002/14651858.CD001896.pub2. (Systematic Review were consulted. Abstracts of research presented at
and Meta-Analysis) symposia and scientific conferences were not considered
adequate for inclusion in this document. Guidelines
66. Lin YC, Wan L, Jamison RN. Using integrative medicine
published by organizations or institutions such as the
in pain management: an evaluation of current evidence.
National Institutes of Health and the American College of
Anesth Analg 2017;125:2081–93. (Level III)
Obstetricians and Gynecologists were reviewed, and
67. Huang AJ, Rowen TS, Abercrombie P, Subak LL, Schembri additional studies were located by reviewing
M, Plaut T, et al. Development and feasibility of a group- bibliographies of identified articles. When reliable
based therapeutic yoga program for women with chronic research was not available, expert opinions from
pelvic pain. Pain Med 2017;18:1864–72. (Level II-3) obstetrician–gynecologists were used.
68. Meng H, Johnston B, Englesakis M, Moulin DE, Bhatia A. Studies were reviewed and evaluated for quality
Selective cannabinoids for chronic neuropathic pain: a sys- according to the method outlined by the U.S.
tematic review and meta-analysis. Anesth Analg 2017;125: Preventive Services Task Force:
1638–52. (Systematic Review and Meta-Analysis)
I Evidence obtained from at least one properly de-
69. Aviram J, Samuelly-Leichtag G. Efficacy of cannabis- signed randomized controlled trial.
based medicines for pain management: a systematic review II-1 Evidence obtained from well-designed controlled
and meta-analysis of randomized controlled trials. Pain trials without randomization.
Physician 2017;20:E755–96. (Systematic Review and II-2 Evidence obtained from well-designed cohort or
Meta-Analysis) case–control analytic studies, preferably from
70. Tu FF, Beaumont JL. Outpatient laparoscopy for more than one center or research group.
abdominal and pelvic pain in the United States 1994 II-3 Evidence obtained from multiple time series with
through 1996. Am J Obstet Gynecol 2006;194:699– or without the intervention. Dramatic results in
703. (Level II-3) uncontrolled experiments also could be regarded
71. van den Beukel BA, de Ree R, van Leuven S, Bakkum EA, as this type of evidence.
Strik C, van Goor H, et al. Surgical treatment of adhesion- III Opinions of respected authorities, based on clinical
related chronic abdominal and pelvic pain after gynaeco- experience, descriptive studies, or reports of expert
logical and general surgery: a systematic review and meta- committees.
analysis. Hum Reprod Update 2017;23:276–88. (System- Based on the highest level of evidence found in the data,
atic Review and Meta-Analysis) recommendations are provided and graded according to
72. Molegraaf MJ, Torensma B, Lange CP, Lange JF, Jeekel J, the following categories:
Swank DJ. Twelve-year outcomes of laparoscopic adhe- Level A—Recommendations are based on good and
siolysis in patients with chronic abdominal pain: a random- consistent scientific evidence.
ized clinical trial. Surgery 2017;161:415–21. (Level I)
Level B—Recommendations are based on limited or
inconsistent scientific evidence.
Level C—Recommendations are based primarily on
consensus and expert opinion.
VOL. 135, NO. 3, MARCH 2020 Practice Bulletin Chronic Pelvic Pain e109