Therapy for Chronic Pelvic Pain Syndromes (CPP)

Various reproductive, gastrointestinal, urologic, sympathetic, musculoskeletal and neuromuscular disorders may cause or contribute to Chronic Pelvic Pain (CPP). Multiple contributing factors may exist in a single patient. Most women experience pelvic pain at some time during their lives. In one study of reproductive-aged women in primary care practices, the reported prevalence rate of pelvic pain was 39% (Jamieson, 1996). Treatment for Pelvic Pain generally falls into conservative management, pain management or surgical intervention categories.

Consultation with pain management, psychologist, urologist, neurologist, and gastrointestinal specialist are often needed. Patients with CPP may exhibit exaggerated pain behavior. Their behavior may seem hysterical or appear non-anatomic or non-physiological to others. However, the conditions of these patients must be understood and treated appropriately. Good rapport and an open-minded approach using the latest technologies are important in the evaluation of any patient with chronic pain and especially chronic pelvic pain.

Typically, conservative management begins with the use of a non-steroidal anti-inflammatory drug (NSAID) to reduce inflammation. These modalites may block pathways that are responsible for prostaglandin synthesis, known aggravators of CPP. Acupuncture, reflex therapy, applied ultrasound, phonophoresis or iontophoresis, topical corticosteroid and analgesic combination, massage and relaxation techniques, psychological counseling; external nerve stimulation therapy and low intensity laser therapy are all modalities to be considered in the care of these individuals.

Diagnostic-Therapeutic Injection Procedures:

A variety of interventions and therapies are offered for the myriad of conditions that can cause pain. Each patient presents a unique challenge and occasionally multiple interventions or combinations may be trialed before success is obtained. There is no specific diagnostic test for this condition. The following lists examples of commonly performed interventions to diagnose and treat CPP. Successful treatment depends on the diagnosis. In general, prolonged conservative treatment is usually successful in treating CPP.

Peripheral Injections: trigger point Injections, nerve block, and ligament injections.

Lumbar or Hypogastric Sympathetic Blocks: Useful to identify sympathetic mediated pain syndromes or pain with referred pelvic pain.

Radiofrequency Nerve Ablation: Radiofrequency thermocoagulation is used to ablate these nerves.

Cryoanalgesia: Probe inserted percutaneously to produce anesthesia at the nerve roots has been used with success. This works best when used on a regular basis with prolonged freezing.

Facet or Sacroiliac Joint Injections: May help rule out pain from other etiologies that have referred pelvic pain.

Caudal Epidural Injection: Fluoroscopically guided procedures with local anesthetics and steroids have been effective. The injections may need to be repeated to provide long-term relief.

Discogram Injection: Helpful in identifying patients who have discogenic pain syndrome with referred pelvic pain.

Alcohol Neurolysis: Chemical or permanent destruction of the nerve root.

Spinal Cord Stimulation Therapy and Intrathecal Narcotic Therapy: Sacral nerve stimulation may be effective in the treatment of therapy-resistant pelvic pain syndromes linked to pelvic floor dysfunction.

Surgical Procedures: May be considered to treat CPP. Surgical procedures include presacral neurectomy (superior hypogastric plexus excision), paracervical denervation (laparascopic uterine nerve ablation), and uterovaginal ganglion excision (inferior hypogastric plexus excision), spinal cord stimulators have been used effectively in treating recalcitrant chronic pelvic pain syndromes. Ask your family doctor or gynecologist about an appropriate referral.