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15 Articles in Volume 15, Issue #7
Advances in the Diagnosis and Treatment of Chronic Pelvic Pain
Call for Standardization and Quality Assurance for Medical Marijuana Products
Chronic Pain and Falls
Is There a Role for NSAIDs in Patients With Cardiovascular Disease?
Legal Considerations of Medical Marijuana
Letters to the Editor: Antibiotics and Microbiome, Hormone Panel
Marijuana: Does it Cause Cognitive Impairment During Driving?
Medical Marijuana Dispensed by Pharmacists in Connecticut
My Policy on Marijuana
NSAID Sensitivity
Pharmacogenetics and Pain Management
Recommending Medical Marijuana for Pain Conditions
The Inhumane and Dangerous Game of Forced Opioid Reduction
Traditional Chinese Medicine & Acupuncture
Untreated Pelvic Pain Common Among Young Women

Advances in the Diagnosis and Treatment of Chronic Pelvic Pain

While chronic pelvic pain is prevalent in women, it is often underdiagnosed and inadequately treated. The differential diagnosis and the role of pelvic floor physical therapy are key factors in the successful treatment of the many types of chronic pelvic pain.

An interview with Colleen Fitzgerald, MD, MS

Q: What is chronic pelvic pain and how common is it in the United States?

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.

Q: Why are chronic pelvic pain conditions so prevalent in women? 

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?

Dr. Fitzgerald: Health care providers should not be discouraged when baseline laboratory testing and imaging looks normal in a patient with chronic pain and should understand that there is still more work to do. They should think of pelvic floor physical therapy as first-line treatment and should refer patients to a provider who specializes in this treatment. The American Physical Therapy Association’s Section on Women’s Health offers a physical therapist locator to find qualified specialists. In addition, providers can refer patients to physiatrists using the American Academy of Physical Medicine and Rehabilitation’s PM&R locator (http://www.aapmr.org/patients/findphysician/).

Q: Can you describe the diagnosis of pelvic floor myofascial pain?

Dr. Fitzgerald: Pelvic floor myofascial pain is muscle pain in the pelvic floor muscles, also known as the Kegel musculature. Although research suggests that approximately 20% of women who present with chronic pelvic pain will have pelvic floor myofascial pain, upwards of 60% of women in our program have pelvic floor myofascial pain. I think that if you know what you are looking for, you’ll find it.

If a woman presents with chronic pelvic pain and has no abnormalities on pelvic ultrasound (eg, no ovarian cysts or fibroids) and a normal laboratory workup, then typically we perform a detailed physical examination including a musculoskeletal exam externally and a pelvic floor muscle exam vaginally and/or rectally, in which we test for pelvic floor muscle tenderness and the ability of the muscles to contract and relax. Most patients with chronic pelvic pain have difficulty with muscle relaxation and diffuse pelvic floor muscle tenderness when we press on the muscles. It is not necessarily an issue of pelvic muscle strength.

Traditionally, our patients with interstitial cystitis, endometriosis, (see Untreated Pelvic Pain) and vulvodynia have more diffuse tenderness. In some women, the pain may be more unilateral than bilateral, especially a woman who have had an injury to the pelvic floor muscle during labor and delivery. Our research also has shown that women who have low back pain tend to have problems with pelvic floor muscles on the same side as their low back issue. The muscles in the pelvic floor may be overcompensating for the lumbar spine issue. In addition, the pelvic floor muscles may overreact in response to visceral pain syndromes such as interstitial cystitis.

We have standardized our approach to assessing pelvic floor muscle tenderness, and I am training the Ob/Gyns and the urology residents at Loyola to perform a quick internal examination and to look for what is driving the pelvic floor muscles to overreact. Ideally, Ob/Gyns should regularly screen for pelvic floor myofascial pain during routine gynecologic examinations. It is easy to do and takes approximately 1 to 2 minutes.

Q: What causes pregnancy-and postpartum-related pelvic pain?

Dr. Fitzgerald: Approximately 50% to 75% of women have pregnancy-related pelvic pain, also known as pelvic girdle pain. This pain should not be considered normal and should be treated. While the pain is disabling in 30% of women, many women are told to apply a heat pack and that the pain will go away with time. Unfortunately, 10% to 25% of these women will go on to develop chronic postpartum pelvic pain. I believe that if we treat the condition acutely, we may be able to decrease the prevalence rates of chronic postpartum pelvic pain.

Chronic pelvic pain is defined as pain lasting more than 6 months. If a woman has had sacroiliac joint pain during pregnancy and then has an injury to the pelvic floor muscles with labor and delivery, she may be seen at her 6-week postpartum checkup and told that the pain will go away. By the time she is seen again 1 year later, she has gone from acute to chronic pain. We have to get the word out that this is not acceptable. That 6-week postpartum visit is critical for us to counsel women to come back in if they have painful intercourse or persistent pelvic/low back pain.

We are examining biomechanical and inflammatory causes of pregnancy-related pelvic pain. While many women call pregnancy-related pain sciatica, studies have shown that true sciatic nerve problems occur in only 1% of pregnant women and that most women actually have musculoskeletal pain in the region of the sacroiliac joint.

The hormonal influences in pregnancy (ie, relaxin) also have been theorized to cause pelvic girdle pain. However, not every pregnant woman has pelvic pain, so the cause cannot just be hormone-related. Perhaps, the hormonal environment of pregnancy puts patients who do not have good muscular support at increased risk for an acute injury to the joints or ligaments of the pelvis.

In addition, approximately 10% of women who deliver vaginally sustain a levator ani tear, or a levator ani evulsion, meaning that the Kegel muscles tear. Research has shown a relationship between this tear and long-term incontinence,7,8 and we are investigating how this tear may potentially perpetuate chronic pelvic pain.

Q: How is pregnancy- and postpartum-related pelvic pain treated? 

Dr. Fitzgerald: These conditions are treated with external physical therapy and bracing of the sacroiliac joint. Therapy is focused on pelvic stabilization, improvements in motor control and ergonomics, and teaching patients how to move symmetrically. When treated acutely during pregnancy, patients often only need 4 to 6 sessions of physical therapy. When the pain turns into chronic pelvic pain, more sessions may be needed.

Aquatic therapy is a fantastic exercise for women with pelvic-girdle pain because the pelvis is completely offloaded, and women can better activate the core muscles that, ultimately, will lead to pain relief.

One of our ongoing studies is examining the effects of injecting a corticosteroid into the posterior sacroiliac ligament during pregnancy. Notably, there never has been a single pain medication study conducted during pregnancy.

An interesting study involving more than 10,000 women found that use of Cesarean section (C-section) to “protect the pelvic” during delivery in women with severe pregnancy-
related pelvic pain was not effective.9 In fact, women with C-section were more likely to have persistent pelvic pain at 6 months postpartum. Although we don’t know the exact cause of this outcome, it may be related to sensitization in patients with chronic pain: even if you preserve womens’ musculoskeletal pelvis by avoiding vaginal delivery, because these patients are taking a surgical hit with C-section, the sensitization is exacerbated. That paper really changed our thinking.

Q: Is zero pain an achievable goal in the treatment of chronic pelvic pain? 

Dr. Fitzgerald: Women should be extremely hopeful that with a multi-disciplinary approach, we can significantly reduce their pain and improve functioning. In fact, functional measures might be a better way to increase our success in the treatment of chronic pelvic pain.

I tell patients that zero pain may not be achievable, but if we can significantly reduce the pain level by 50% to 75% and improve functioning to 90%, then that is a win. Patients may have periodic flares, and we educate them on ways to quickly get out of that flare. But I am hopeful that, someday, we’ll have a treatment that will get patients to zero pain.

Q: What gaps in knowledge on chronic pelvic pain do you hope future studies will uncover?

Dr. Fitzgerald: Pelvic pain traditionally has been thought of as an organ-based diagnosis (ie, a problem with the uterus, ovaries, or bladder). Moving away from that way of thinking, we are examining how the nervous system, both peripherally and centrally, and the musculoskeletal system influence chronic pelvic pain.

In addition, research is focusing on how to improve the diagnosis of chronic pelvic pain conditions through quantitative sensory testing of the pelvis, objective measures of the pelvic floor muscles, and functional brain imaging. Preliminary data suggests that we may be able to use neuroimaging biomarkers to predict which patients with acute conditions will develop chronic pelvic pain.

A few years ago, we published studies on a prototype vaginal pressure algometer to objectively quantify pelvic floor tenderness.10 Now, we are working on a second-generation device that has a surface electromyography in it that will be able to measure overactivity and hypertonicity of the pelvic floor muscles. We also can use it before and after physical therapy and/or neuromodulator treatment to measure outcomes.

We are hopeful that research in these areas will advance the care of patients with chronic pelvic pain.

—Reported by Kristin Della Volpe

Last updated on: March 6, 2017

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