Advances in the Diagnosis and Treatment of Chronic Pelvic Pain
An interview with Colleen Fitzgerald, MD, MS
Dr. Fitzgerald: Within the overarching diagnosis of chronic pelvic pain, there are a variety of subtypes, including interstitial cystitis (also known as painful bladder syndrome), vulvodynia, endometriosis, pelvic floor myofascial pain, and pelvic girdle pain (or musculoskeletal pelvic pain). In addition, patients with irritable bowel syndrome often have chronic pelvic pain.
These conditions are much more common than health care practitioners and patients realize, and they affect approximately 15% to 20% of women in the United States.1,2
Q: Why is chronic pelvic pain underdiagnosed and undertreated in the United States?
Dr. Fitzgerald: In our chronic pelvic pain program, the average duration of symptoms is 6 years when women finally seek care in our offices. I am the doctor women see after already visiting 10 other doctors who have told them, “Nothing is wrong.”
These conditions are underdiagnosed for a variety of reasons. First, I believe that women are socialized to accept pain as a normal part of being a woman, starting at the onset of menstruation. Then, many women think it is normal to have pelvic pain during pregnancy and after delivery. Even when this pelvic pain persists, women think that there is nothing they can do about it.
Second, most physicians are not adequately trained in pain management during medical school or residency. At our chronic pelvic pain program, we are working on this problem by training obstetricians/gynecologists (Ob/Gyns) and urologists so they have the tools to treat chronic pelvic pain.
Third, most pain specialists are not trained to do pelvic exams and to check for pelvic floor myofascial pain. A fourth issue is that chronic pelvic pain is a complex issue that cannot be addressed adequately in a 10- to 15-minute office visit. Patients have long histories, and it takes time to sort through what is going on with the patient. Unfortunately, most physicians just don’t have that time, which is a shame.
Within Loyola Medicine’s chronic pelvic pain program, patients see at least 2 providers, but usually 3 or 4, including Ob/Gyns, urologists, physiatrists, internists, physical therapists who specialize in pelvic floor physical therapy, and psychologists. Thus, our multidisciplinary model of care touches on all of the biopsychosocial aspects of dealing with chronic pelvic pain. Preliminary patient-reported outcome data in this clinic show that even patients who have had chronic pelvic pain for an average of 6 years experience improvements in pain and functioning as early as the first follow-up visit.
Dr. Fitzgerald: A woman’s pelvis has significant anatomic and physiologic differences from a man’s that place them at risk for chronic pelvic pain. In addition, female hormones influence the musculoskeletal system and how women process pain. Finally, labor and delivery is hard on the pelvic floor and abdominal core musculature.
In addition, peripheral and central sensitization is another potential cause of chronic pelvic pain conditions. Brain imaging studies are showing that many women with pelvic pain have abnormalities in pain processing that may stimulate the pelvic floor muscles to overreact.3,4
Chronic pelvic pain is a significant issue for men too. Pelvic pain is estimated to affect approximately 2.2% to 9.7% of men5 and typically is diagnosed as chronic prostatitis.
Q: How is chronic pelvic pain treated?
Dr. Fitzgerald: The standard treatment is pelvic floor physical therapy, which is conducted by physical therapists who are specially trained to treat the pelvic muscles vaginally or rectally. We use myofascial release vaginally to stretch out the muscles and then show the patients how to stretch and relax the muscles. Patients require an average of 12 sessions to treat chronic pelvic pain.
A big misnomer among patients is that chronic pelvic pain can be treated easily by doing Kegel contractions. Patients come to our clinic saying “If I’ve done my Kegels, why aren’t I better?” However, merely strengthening and doing Kegel contractions doesn’t resolve the pain. We need to show patients how to do pelvic floor muscle relaxation first and then how to appropriately contract the muscles.
Loyola, along with several other centers, conducted a randomized controlled trial in women with interstitial cystitis and showed that a significantly greater proportion of women showed moderate or marked improvement in overall symptoms with 10 sessions of pelvic floor myofascial physical therapy compared with women who received global therapeutic massage (59% vs 26%: P=0.0012).6
Neuromodulator treatments (eg, gabapentin [Neurontin, Gralise, others], pregabalin [Lyrica], amitriptyline, and nortriptyline [Pamelor, others], etc) and muscle relaxants also are effective. We generally do not use opioids for chronic pelvic pain because, in our experience, they have not been helpful. In addition, opioids can be constipating, which may lead to more pelvic pain. Many of the patients who enter our chronic pelvic pain program have been on opioids for years, and still report experiencing a pain level of 8 out of 10. I think many of these patients develop a tolerance to opioids as well as opioid-induced hyperalgesia hypersensitivity.
We also use peripheral treatments, such as vaginal diazepam suppository treatment, and pelvic floor trigger point injection. Several clinical trials are investigating the efficacy of onobotulinum toxin A (Botox) injection into pelvic floor muscles, and results are expected shortly.
We strongly support psychological assessment and cognitive behavioral therapy for these patients. Psychology can play a big role in helping patients get through the treatment we prescribe and cope with how the condition has affected their lives. In addition, patients may need sex therapy because their intimate relationships have been affected by pelvic pain.
Although surgical treatments for endometriosis can be helpful, most patients with other chronic pelvic pain conditions benefit from nonsurgical treatments. An ongoing pilot study at Loyola investigating acupuncture for interstitial cystitis has shown exciting preliminary findings. We intend to expand that study to look at the use of acupuncture for other chronic pelvic pain conditions. (See Traditional Chinese Medicine and Acupuncture).
Q: What should health care providers do if they do not have the time or expertise to manage patients with chronic pelvic pain?