Chronic Pelvic Pain Chronic Pelvic Pain William Ledger School of Women’s and Children’s Health and the University of New South Wales, Sydney, Australia William D Schlaff Jefferson Medical College, Thomas Jefferson University, Philadelphia, PA, USA Thierry G Vancaillie University of New South Wales, and Women’s Health and Research Institute of Australia, Sydney, Australia University Printing House, Cambridge CB2 8BS, United Kingdom Cambridge University Press is part of the University of Cambridge It furthers the University’s mission by disseminating knowledge in the pursuit of education, learning and research at the highest international levels of excellence www.cambridge.org Information on this title: www.cambridge.org/9781107636620 © Cambridge University Press 2015 This publication is in copyright Subject to statutory exception and to the provisions of relevant collective licensing agreements, no reproduction of any part may take place without the written permission of Cambridge University Press First Published 2015 Printed in the United Kingdom by TJ International Ltd Padstow Cornwall A catalog record for this publication is available from the British Library Library of Congress Cataloguing in Publication data Chronic pelvic pain (Ledger) Chronic pelvic pain / [edited by] William Ledger, William Schlaff, Thierry Vancaillie p ; cm Includes bibliographical references and index ISBN 978-1-107-63662-0 (paperback) I Ledger, William L., editor II Schlaff, William D., editor III Vancaillie, Thierry G., 1955– , editor IV Title [DNLM: Pelvic Pain Chronic Disease Pain Management Pelvic Inflammatory Disease WP 155] RG483.P44 617.5′5–dc23 2014023811 ISBN 978-1-107-63662-0 Paperback Cambridge University Press has no responsibility for the persistence or accuracy of URLs for external or third-party internet websites referred to in this publication, and does not guarantee that any content on such websites is, or will remain, accurate or appropriate Every effort has been made in preparing this book to provide accurate and up-to-date information which is in accord with accepted standards and practice at the time of publication Although case histories are drawn from actual cases, every effort has been made to disguise the identities of the individuals involved Nevertheless, the authors, editors and publishers can make no warranties that the information contained herein is totally free from error, not least because clinical standards are constantly changing through research and regulation The authors, editors, and publishers therefore disclaim all liability for direct or consequential damages resulting from the use of material contained in this book Readers are strongly advised to pay careful attention to information provided by the manufacturer of any drugs or equipment that they plan to use Contents List of contributors vi Chronic pelvic pain: spectrum of the disorder Thierry G Vancaillie Pelvic anatomy and neuroanatomy: relevance to chronic pelvic pain 11 Roger Robert Vulvodynia Ross Pagano 10 Interstitial cystitis/bladder pain syndrome 102 Audrey Wang Investigating chronic pelvic pain: ultrasound 27 Alison Richardson and Nick Raine-Fenning Investigating chronic pelvic pain: surgical approaches 40 Margaret E Harpham and Jason Abbott Medical treatments for endometriosis-related pain 51 Brett Worly and William D Schlaff Endometriosis: surgical approaches to stages I and II Dimitrios Mavrelos and Ertan Saridogan 89 60 Endometriosis: surgical approaches to stages III and IV 71 Corinne Owers and Ian Adam 11 Pelvic inflammatory disease and chronic pelvic pain 124 J Biba Nijjar and Sawsan As-Sanie 12 Chronic pelvic pain and sexual dysfunction: cause and effect 130 William D Petok 13 Complementary therapies for women with chronic pelvic pain 140 Andrew Flower, George Lewith, Jörgen Quaghebeur, and Ying Cheong 14 Management of idiopathic chronic pelvic pain 148 William D Schlaff Index 155 Psychological considerations and therapies in patients with chronic pelvic pain 79 Andrea Mechanick Braverman v Contributors Jason Abbott, B Med FRANZCOG FRCOG PhD Associate Professor at the School of Women’s and Children’s Health, University of New South Wales, and gynaecologist and laparoscopic surgeon at the Royal Hospital for Women, Sydney, Australia Ian Adam, FRCS MBChB Consultant Colorectal Surgeon, Department of Surgery, Sheffield Teaching Hospitals, Sheffield, UK Sawsan As-Sanie, MD MPH Assistant Professor, Department of Obstetrics & Gynecology, Director, Minimally Invasive Gynecologic Surgery and Fellowship and Director, Endometriosis Center, University of Michigan Health System, Ann Arbor, Michigan, MI, USA Andrea Mechanick Braverman, PhD Clinical Associate Professor of Obstetrics & Gynecology and Clinical Associate Professor of Psychiatry & Human Behavior at the Thomas Jefferson University, Philadelphia, PA, USA Ying Cheong, MBChB BAO MA MD MRCOG Associate Professor of Obstetrics and Gynaecology Faculty of Medicine, University of Southampton, vi Consultant in Obstetrics and Gynaecology and Director, Complete Fertility Centre Southampton, Southampton, UK Andrew Flower, PhD MBAcC MRCHM Practitioner and Researcher, Complementary and Integrated Medicine Research Unit, Department of Primary Medical Care, University of Southampton, Southampton, UK Margaret E Harpham, BMed Fellow at the Royal Hospital for Women, Sydney, Australia William Ledger, MA DPhil (Oxon) MB ChB FRCOG FRANZCOG CR Head, School of Women’s and Children’s Health and Professor of Obstetrics and Gynaecology, and the University of New South Wales, Sydney, NSW, Australia George Lewith, MA MD FRCP MRCGP Professor, Complementary and Integrated Medicine Research Unit, Department of Primary Medical Care, University of Southampton, Southampton, UK Dimitrios Mavrelos, MD MBBS MRCOG Academic Clinical Lecturer in Reproductive Medicine, Institute for Women’s Health, Faculty of Population Health Sciences, University College London, London, UK J Biba Nijjar, MD MPH Clinical Instructor, Department of Obstetrics & Gynecology at the Thomas List of contributors Jefferson University Hospital, Philadelphia, Pennsylvania, PA, USA Sciences, University of Nottingham, Nottingham, UK Corinne Owers, MB/ChB PGCertMedEd MRCS Postgraduate Research Student at the School of Health and Related Research, Sheffield Teaching Hospitals, Sheffield, UK Roger Robert, MD Neurosurgeon at the Clinique de Neurotraumatologie, CHU Nantes, Nantes, France Ross Pagano, MD Head of Unit (Vulvar Disorders) at the Royal Women’s Hospital, Victoria, Australia William D Petok, PhD Independent Practice, Baltimore, MD, USA Jörgen Quaghebeur, DO Professional Osteopath, Klein Bekken Kliniek, UZA, Edegem, and Lecturer, the Flanders International College of Osteopathy, Antwerp, Belgium Nick Raine-Fenning, MRCOG MBChB PhD Associate Professor and Reader in Reproductive Medicine and Surgery, Division of Obstetrics and Gynaecology, Queens Medical Centre, School of Clinical Sciences, University of Nottingham, Nottingham, UK Alison Richardson, BN (Hons) MSc PhD PgDipEd RNT Clinical Research Fellow in Reproductive Medicine and Surgery, Division of Obstetrics and Gynaecology, Queens Medical Centre, School of Clinical vii Ertan Saridogan, MD PhD FRCOG Consultant in Reproductive Medicine and Minimal Access Surgery, University College London Hospitals, Institute for Women’s Health, London, UK William D Schlaff, MD Paul and Eloise Bowers Professor and Chairman at the Department of Obstetrics and Gynecology, Jefferson Medical College, Thomas Jefferson University, Philadelphia, PA, USA Thierry G Vancaillie, MD FRANZCOG FFPMANZCA Clinical Professor in Gynecology at the University of New South Wales, Sydney, and Director, Women’s Health & Research Institute of Australia, Sydney, Australia Audrey Wang, MBBS (Syd) FRACS (Urol) Consultant Urologist, Westmead Hospital, Sydney, Australia Brett Worly, MD Assistant Professor at the Department of Obstetrics and Gynecology, Ohio State University, Columbus, OH, USA 146 Chapter 13: Complementary therapies Therapies such as acupuncture, Chinese herbal medicine, and hypnotherapy may have roles to play in the treatment of dysmenorrhea, endometriosis, irritable bowel syndrome, and pelvic inflammatory disease, either as adjuncts or as alternatives to conventional treatments Unfortunately the current evidence lacks rigor and the available trials are frequently small, poorly designed, and inadequately reported As a consequence, we can only consider this preliminary evidence This area clearly requires further more rigorous investigation Research into CAM therapies will, however, take time and require considerable resources, so women with CPP seeking alternatives to conventional treatments are likely to seek advice and treatment before the necessary research is undertaken Patients wishing to use CAM options should be informed of the very provisional nature of the evidence supporting these approaches They should also be encouraged to only receive treatment from professionally registered CAM practitioners using, in the instance of herbal treatments, approved herbal suppliers and herbal products with a good manufacturing practice certification This will ensure that, while the effectiveness of CAM interventions remains unproven, these treatments are unlikely to harm and may contribute to relieving the symptoms of this problematic condition References Witt C, Pach D, Brinkhaus B, et al Safety of acupuncture: results of a prospective observational study with 229 230 patients and introduction of a medical information and consent form Forsch Komplementmed 2009;16:91–7 Royal College of Obstetricians and Gynaecologists Greentop Guideline No 41: The Initial Management of Chronic Pelvic Pain London: Royal College of Obstetricians and Gynaecologists, 2012 Zondervan KT, Yudkin PL, Vessey MP, et al Prevalence and incidence of chronic pelvic pain in primary care: evidence from a national general practice database BJOG 1999;106:1149–55 Smith CA, Zhu X, He L, Song J Acupuncture for primary dysmenorrhoea Cochrane Database Syst Rev 2011;(1): CD007854 Stones W, Cheong YC, Howard FM, Singh S Interventions for treating chronic pelvic pain in women Cochrane Database Syst Rev 2005;(2):CD000387 Paterson C, Dieppe P Characteristic and incidental (placebo) effects in complex interventions such as acupuncture BMJ 2005;330:1202–5 Tang JL, Zhan SY, Ernst E Review of randomised controlled trials of traditional Chinese medicine BMJ 1999;319:160–1 Wang G, Mao B, Xiong ZY, for the CONSORT Group for Traditional Chinese Medicine The quality of reporting of randomized controlled trials of traditional Chinese medicine: a survey of 13 randomly selected journals from mainland China Clin Ther 2007;29:1456–67 10 Lim B, Manheimer E, Lao L, et al Acupuncture for treatment of irritable bowel syndrome Cochrane Database Syst Rev 2006;(4):CD005111 MacPherson H, Thomas K, Walters S, Fitter M The York acupuncture safety study: prospective survey of 34 000 treatments by traditional acupuncturists BMJ 2001;323:486–7 11 Zhen HL, Wang Y, Liu XJ [Observation of the therapeutic effect of warming needle moxibustion on chronic pelvic inflammation of cold-damp stagnation type.] Zhhongguo Zhen Jui 2008;28:736–7 12 Wang XM On the therapeutic efficacy of electric acupuncture with moxibustion in 95 cases of chronic pelvic infectious disease J Trad Chin Med 1989;9:21–24 13 Flower A, Liu JP, Chen S, Lewith G, Little P Chinese herbal medicine for Chapter 13: Complementary therapies endometriosis Cochrane Database Syst Rev 2009;(3):CD006568 14 Meissner K, Bohling B, Schweizer-Arau A Long term effects of traditional Chinese medicine and hypnotherapy in patients with severe endometriosis: a retrospective evaluation Forsch Komplementmed 2010;17:314–320 15 Zhu X, Proctor M, Bensoussan A, Smith CA, Wu E Chinese herbal medicine for primary dysmenorrhoea Cochrane Database Syst Rev 2008;(2):CD005288 16 Liu J, Yang M, Liu Y, Wei M, Grimsgaard S Herbal medicines for the treatment of irritable bowel syndrome Cochrane Database Syst Rev 2006;(1):CD004116 17 Bensoussan A, Talley NJ, Hing M, et al Treatment of irritable bowel syndrome with Chinese herbal medicine: a randomized controlled trial JAMA 1998;280:1585–9 18 Shen BQ, Situ Y, Huang JL, et al A clinical study on the treatment of chronic pelvic inflammation of Qi stagnation with blood stasis syndrome by Penyangqing capsule Chin J Integr Med 2005;11:249–54 19 Zhang Q, He JL, He SS, Xu P Clinical observation in 102 cases of chronic pelvic inflammation treated with Qi Jie granules J Trad Chin Med 2004;24:3–6 20 Liu RF, Yang XN Effect of Penqianyan granule on the immune function of patients with chronic pelvic inflammatory disease of blood stasis and Shen deficiency 147 syndrome type Chin J Integr Trad West Med 2007;27:841–3 21 Wieser F, Cohen M, Gaeddert A, et al Evolution of medical treatment for endometriosis: back to the roots? Hum Reprod Update 2007;13:487–99 22 Ferreira PH, Ferreira ML, Maher CG, Herbert RD, Refshauge K Specific stabilisation exercise for spinal and pelvic pain: A systematic review Aust J Physiother 2006;52:79–88 23 Marx S, Cimniak U, Beckert R, Schwerla F, Resch KL Chronic prostatitis/chronic pelvic pain syndrome Influence of osteopathic treatment: a randomized controlled study Urology A 2009;48:1339–45 24 Franke H, Hoesele K Osteopathic manipulative treatment (OMT) for lower urinary tract symptoms (LUTS) in women Systematic review and meta-analysis J Bodyw Mov Ther 2013;17:11–18 25 Montenegro ML, Mateus-Vasconcelos EC, Candido dos Reis FJ, et al Thiele massage as a therapeutic option for women with chronic pelvic pain caused by tenderness of pelvic floor muscles J Eval Clin Pract 2010;16:981–2 26 Champaneira R, Daniels JP, Raza A, Pattison HM, Khan KS Psychological therapies for chronic pelvic pain: systematic review of randomized controlled trials Acta Obstet Gynecol Scand 2012;91:281–6 Chapter 14 Management of idiopathic chronic pelvic pain William D Schlaff 14 Introduction Chronic pelvic pain is generally defined as pain of the pelvis, lower abdomen, and/ or back and upper leg lasting for six months or more The scope of chronic pelvic pain in the USA is daunting Up to 20% of women of reproductive age will complain of chronic pelvic pain of greater than one year in duration, and a very large number of gynecological visits to healthcare providers are related to pelvic pain [1] Depending on the gynecological practice, 30% or more laparoscopies and perhaps 15–20% of hysterectomies are performed for treatment of chronic pelvic pain [2] The fact that many of these treatments are ineffective in reducing pain reflects the incomplete understanding of the basis of pain and the treatment methods that are most effective in different circumstances A patient’s description of chronic pelvic pain is often vague and inconsistent, which reflects the numerous factors that can contribute to the symptoms It is regrettable that the diagnosis of chronic pelvic pain is often approached as a specific entity without distinguishing between the many symptoms that are typically associated with specific etiologies This observation reinforces the critical importance of a comprehensive and thoughtful history in evaluating patients with chronic pelvic pain It is far too common for patients to be characterized based on what is often an anatomical or visual manifestation having little or even nothing to with the symptoms experienced by the patient [3] It should be appreciated that chronic pelvic pain associated with minimal objective endometriosis may in fact be no different from chronic pelvic pain in women who have a visually normal pelvis The goal of this chapter is to address pain that is not specifically related to endometriosis Chronic Pelvic Pain, ed William Ledger, William D Schlaff and Thierry G Vancaillie Published by Cambridge University Press © Cambridge University Press 2015 148 Chapter 14: Idiopathic chronic pelvic pain 149 Taking a focused history The key to identifying the best approach to evaluating a woman with chronic pelvic pain starts with a careful and thoughtful history addressing the many symptoms that can be involved History and physical examination have been covered in earlier chapters, although in this chapter it is appropriate to point out factors that may have significant bearing on whether a patient’s pain is likely to be caused by endometriosis or not Key components of the history should aim at differentiating the specific basis of the various etiologies of the pain, which certainly may include endometriosis but may come from a variety of other sources The overlap between endometriosis-related pain and interstitial cystitis is well known and is discussed in Chapter 10 Similarly, there is a significant overlap between endometriosis and irritable bowel syndrome Other causes of pain from a gastrointestinal source are generally well known and can include inflammatory bowel disease among others Musculoskeletal or pelvic floor irritation is commonly the source of pain, and it is important to try to tease out this diagnosis As clinicians develop a broader appreciation and understanding of these problems, they also begin to appreciate the limitations in diagnosing what may be the most common source of chronic pelvic pain – neuropathic pain The classic history and physical examination in patients with endometriosis are discussed in previous chapters and will not be emphasized in great detail here Patients with endometriosis typically present initially with symptoms of dysmenorrhea associated with their menstrual periods Depending on the location and extent of lesions, they may have direct anatomically related complaints, such as dyspareunia caused by painful uterosacral nodules Pain may gradually progress to become notable at times other than during menses and is typically described as vague and achy when this occurs Patients who have moderate to severe endometriosis, often with adhesions and possible endometriomas, will frequently describe this evolution of symptoms The clinician should have a high suspicion that a patient’s symptoms are unrelated to endometriosis in those cases where there is minimal or very transient response to effective treatments, even when endometriosis has been documented by previous surgical evaluation These patients typically have American Society for Reproductive Medicine (ASRM) stage I (minimal) disease, which leads to a very plausible notion that patients with stage I disease may practically be equivalent to patients who have a normal pelvis The concepts discussed above are illustrated by two seminal papers, one by Chris Sutton and colleagues [4] and a second by Frank Ling [5] The first study involved performing laparoscopy in women suspected of having endometriosis and prospectively randomizing them to aggressive surgical destruction of endometriotic lesions or simply recording the findings without surgical intervention The patients were followed in a double-blind fashion postoperatively; the physician evaluating postoperative pain was unaware of the patient’s group assignment The investigators found no significant difference in response at three months, although the response rate at six months was higher in the treated group Perhaps most interestingly, the likelihood of response was correlated with the extent of disease, contrary to what is often suggested Those with the most endometriosis had the highest rate of responding, and those with the least (ASRM stage I) responded in a manner similar to patients treated with a placebo for endometriosis (i.e 40%) [4] Ling randomized 100 women suspected of having endometriosis to three months of treatment with a gonadotropin-releasing hormone or placebo prior to definitive laparoscopy Laparoscopy 150 Chapter 14: Idiopathic chronic pelvic pain confirmed that most of the patients did indeed have endometriosis, and that the majority of women with endometriosis and treated with the analog had responded, compared with less response in the placebo group [5] Interestingly, the small group who had no endometriosis at laparoscopy (i.e normal appearing pelvis) responded to analog and placebo in similar proportions Previous chapters have described typical findings in those women with bladder and gastrointestinal problems Those with musculoskeletal or pelvic floor abnormalities will usually describe pain with movement and/or radicular pain They may also have back pain or pain with sitting, twisting, or exercise It is often difficult to identify the precipitating factor for musculoskeletal pain, but the clinician should nevertheless strongly consider a musculoskeletal etiology if suggested by the symptom complex Chronic neuropathic pain is characterized by chronic and often non-specific symptoms that have not been diagnosed by focusing on the histories as described above, or those with early stages of endometriosis who not respond to commonly effective treatments Acute pain transmission is often described as adaptive; it is valuable for a woman feeling a hot surface to remove her hand in order to avoid being burned In contrast, chronic pain neuropathy is a maladaptive pain response in which there is chronic activation of afferent pain fibers without any acute stimulus These patients typically respond to annoying but not painful stimuli with dramatic symptoms far out of proportion to the stimulus itself A number of theories of the etiology of this type of pain have been suggested, including viral infections such as herpes, but at present there is no clearly accepted explanation There are a number of hints that should lead the clinician to suspect that the patient has chronic neuropathic pain rather than endometriosis-related pain For example, patients with chronic neuropathic pain will often describe pain that cannot be easily related to a physiological provocation (e.g menses) or an anatomical distribution that is easily explained In contrast to those with endometriosis-related pain, women with neuropathic pelvic pain typically describe little or no relationship between their menstrual period and their discomfort The pain may be described as evanescent, lasting only seconds to a minute, or, at the opposite extreme, as constantly present Surgical and medical therapy will often provide transient or no relief at all In many cases, patients will describe some initial benefit with treatment but will find less and less benefit over time or with retreatment In the USA, these patients often describe a history of multiple surgical procedures for treatment of endometriosis with each one providing less benefit than the one before until there is no benefit at all Scrutiny of the operative reports will often reveal minimal endometriosis (or “possible endometriosis”) at the initial laparoscopy, treated with some type of destructive therapy Pain relief is usually limited, perhaps a year or less, and a subsequent laparoscopy may show similar peritoneal findings with new adhesion, which may well be related to the initial surgical treatment Pain relief is typically of shorter duration following a second surgery, and subsequent surgeries often show no or minimal new findings, which may, in fact, be related to the surgeries themselves These patients often describe associated symptoms such as abdominal or vaginal pain, and vaginismus resulting in dyspareunia They may have additional symptoms often diagnosed as fibromyalgia and/or chronic fatigue syndrome As the symptoms become more severe, the patient is commonly unable to pursue her usual activities of daily life Chapter 14: Idiopathic chronic pelvic pain 151 Physical examination Typical physical findings of patients with endometriosis are described in previous chapters When specific physical findings are present they will often be in the distribution of the lesion(s) The best examples would be painful uterosacral nodules and/or endometrioma, or pain with attempting to move pelvic organs fixed by inflammatory endometriotic adhesions It could be presumed that the latter discomfort would be associated with putting stretch on inflamed tissues The clinician may find hints that pain is from a musculoskeletal source simply by observing the patient’s posture Musculoskeletal pain will often be manifest by splinting to one side, or by reduced range of motion Asking the patient to twist or stretch from a fixed posture may also be helpful A screening neurological examination is occasionally helpful in identifying patients with some type of radicular pain or neuropathy In contrast to patients with endometriosis-related pain, women with neuropathic pain often have a physical response significantly out of proportion to the anticipated response from the examination Such patients often have tremendous discomfort simply with digital insertion of an examining finger in the vagina, with placement of a vaginal speculum, or when a pap smear is obtained Palpation of the abdominal wall will often produce significant tenderness out of proportion to physical findings Isolated trigger points, specific areas that are particularly tender to palpation with an instrument such as a cotton swab (Q-tip) are common Isolating the source of the pain to the abdominal wall rather than the pelvis can often be accomplished by examining the patient before and after straight leg raising If specific areas of tenderness are identified on abdominal examination and are still tender (or even more tender) when the patient raises her legs off the table, the clinician can inform the patient that the pain is arising from the abdominal wall rather than the pelvis The apparently excessive response to minimally uncomfortable stimuli is often felt to represent a “ramping up” of painful signals from the spinal cord to the thalamus, which is often seen in chronic pain syndromes The clinician should presume that the woman who has chronic and prolonged pain as well as hyper-responsiveness to examination, as described above, is likely suffering from neuropathic pain rather than directly from endometriosis-related pain Management Further diagnostic or treatment steps may be indicated once the clinician has completed the history and physical examination as described Laparoscopy is usually recommended for those with a specific history or physical findings suggestive of endometriosis Depending on the findings, diagnostic imaging (usually ultrasound or MRI) may be considered prior to surgery In the USA, many women without specific findings are started empirically on a course of oral contraceptive pills, and those who have inadequate or no response almost always undergo laparoscopy It is possible that more careful attention to the associated findings as described in this chapter could help some women to avoid surgery that is destined to provide little benefit to them If the clinician believes the pain is arising from a specific musculoskeletal source, approaches such as stretching, physical therapy, yoga, and acupuncture may prove helpful Treatment with anti-inflammatory medications may enhance response to these physical approaches Myofascial pain appears to be a significant component in up to 152 Chapter 14: Idiopathic chronic pelvic pain 75% of patients who report chronic pelvic pain [6] A number of possible causes of myofascial pain have been suggested, including chronic irritation from posture or musculoskeletal irritation or injury It is apparent that psychosocial stress can exacerbate myofascial pain by increasing muscle tension A specific “pelvic pain posture” has been described characterized by notably rounded shoulders with the head directed forward, exaggerated lumbar lordosis, forward tilt of the pelvis, hyperextended knees, and a line of gravity displaced interiorly in the lower extremities and pelvis It has been suggested that this posture may produce a shortening or increased tone of the iliopsoas, piriformis, and obturator muscles and sacroiliac joint strain The chronic irritation may lead to hyperirritability of nerve fibers and may respond to rest, heat, non-steroidal anti-inflammatory drugs or muscle relaxants Heat, massage, or icing the area can sometimes reduce myofascial pain Physical therapy with a specific focus on posture and/or stretching has been recommended and can be helpful Whether from these or other etiologies, abdominal wall trigger points are commonly seen in women with a myofascial component These trigger points can cause referred pain when compressed on physical examination, usually with a Q-tip If trigger points not respond to the approaches described, local injections may be performed directly into the area of the identified trigger point A number of different anesthetic formulations have been described for trigger point injections These include 1% lidocaine with epinephrine, which may be mixed in a 1:1 ratio with 0.25% bupivacaine Some physicians add corticosteroids to the formulation Typically the trigger points are identified with Q-tip palpation and marked on the abdomen A narrow (usually 26–30 gauge) needle is used to inject 2–3 ml of this solution into each trigger point Injections are generally repeated weekly initially and less frequently as improvement occurs Response rates have been reported between 50 and 90% following several months of treatment [7] Irritable bowel syndrome typically is characterized by greater than three stools per day or less than three per week Other symptoms include abnormal stool form described as lumpy kind of watery, kind of hard; abnormal stool passage with straining, urgency, or incomplete evacuation; bloating; or other non-specific gastointestinal symptoms [8] Celiac sprue should be excluded The diagnosis of irritable bowel syndrome is usually entertained based on history and the absence of any specific gasgtrointestinal etiology Primary treatments for irritable bowel syndrome start with the cessation of smoking Easy approaches include avoiding caffeine, carbonated beverages, lactose, sorbitol, and chewing gum Antispasmodics such as dicyclomine or selective serotonin reuptake inhibitors such as fluoxetine may be considered Non-specific treatments of constipation and/or diarrhea may also be helpful [9] The largest group of women referred to chronic pain specialists in the USA contains those who have not had a satisfactory response to previous medical or surgical therapy – that is, women with idiopathic chronic pelvic pain Treatment of these patients is usually approached empirically using some or all of the approaches described above The next steps in treating these patients include the following Medical treatment Pharmacological treatments are often recommended, particularly in association with a multidisciplinary approach including some of the other therapies described Medications are typically prescribed on a regular as opposed to “as needed” (prn) dosing Chapter 14: Idiopathic chronic pelvic pain 153 regimen Non-steroidal anti-inflammatory drugs are most widely used, sometimes with anxiolytics when there is a significant component of anxiety Tricyclic antidepressants such as amitriptyline or imipramine can be beneficial in doses much lower than those used in treatment of depression A typical starting dose of 25 mg orally at night for one week can be increased by 25 mg weekly to a maximum dose of 100 mg at night Neuromodulators such as gabapentin have been used with significant benefit Typical dosages of gabapentin are 300 mg daily increasing over one or more weeks to a total dose of 300 mg three times a day Maintenance dose can be as much as 2700 to 3000 mg daily in three divided doses The clinician should not prescribe more than 1200 mg in a single dose More recently, oral pregabalin has been used in the same setting at an initial dose of 50 mg per day gradually increasing to a maximum dose of 100 mg three times a day (300 mg/day total) The selective serotonin reuptake inhibitors, including sertraline up to 50 to 150 mg every morning and fluoxetine up to 20 to 40 mg every morning, have been effective as have the selective serotonin–norepinephrine reuptake inhibitors venalaxine (up to maximum of 225 mg/day) or duloxetine (divided doses up to maximum of 60 mg/day) Physical therapy Physical therapy is often recommended and can be beneficial in pain control The goal is generally to reduce pelvic muscle tone and decrease patient anxiety by direct treatment of muscle spasm and introduction of home exercise to help with pain relief and reduce stress Electrotherapy, biofeedback, vaginal dilators, and pelvic floor exercises have been recommended Physical therapists generally try to mobilize the nerves or muscles believed to be under tension, often with connective tissue manipulation and myofascial release While this approach has been shown to be successful, there are few controlled data to help to identify and specify the most effective approaches Acupuncture Acupuncture is often used successfully to treat primarily dysmenorrhea, although data about its success in non-menstrual chronic pelvic pain are not as clear The mechanism is not established, but many patients derive benefit from this approach Similarly, sacral nerve electrical stimulation via implantable devices has been used in very difficult chronic pelvic pain with varying degrees of success These approaches show promise, although the primary indications and best treatment plans are not well established Behavioral modification and psychotherapy Previous chapters have reviewed a number of associated social and psychological contributors to pelvic pain along with their possible treatments and will not be further discussed in this chapter Conclusions Chronic pelvic pain is often attributed to physical findings or diagnoses such as endometriosis even when the findings not correlate well with the nature of the symptoms Clinicians must be sensitive to pain from other sources, including the gastrointestinal tract and musculoskeletal system It is important to strongly consider a chronic neuropathic origin of the pain, particularly when the symptoms are not very suggestive of a 154 Chapter 14: Idiopathic chronic pelvic pain specific etiology or when medical or surgical treatment aimed at endometriosis provides little or no benefit Extensive or extirpative surgery is not advised in such women Rather, a number of alternative approaches to treatment should be considered as described in this chapter Finally, it is important to avoid the too-simplistic pitfall of attributing chronic neuropathic pain to minimal endometriosis when the patient does not respond adequately to the usually effective treatments for endometriosis References endometriosis Pelvic Pain Study Group Obstet Gynecol 1999;93:51–8 Mathias SD, Kuppermann M, Liberman RF, Lipschutz RC, Steege JF Chronic pelvic pain: prevalence, health-related quality of life, and economic correlates Obstet Gynecol 1996;87:321–7 Carter JE A systematic history for the patient with chronic pelvic pain JSLS 1999;3:245–52 King PM, Myers CA, Ling FW Musculoskeletal factors in chronic pelvic pain J Psychosom Obstet Gynaecol 1991.12(suppl):87–98 Slocumb JC Neurological factors in chronic pelvic pain: trigger points and the abdominal pelvic pain syndrome Am J Obstet Gynecol 1984;149:536–43 Williams RE, Hartmann KE, Sandler RS, et al Recognition and treatment of irritable bowel syndrome among women with chronic pelvic pain Am J Obstet Gynecol 2005.192:761–7 Longstreth GF, Thompson WG, Chey WD, et al Functional bowel disorders Gastroenterology 2006;130:1480–91 Howard FM The role of laparoscopy in chronic pelvic pain: promise and pitfalls Obstet Gynecol Surv 1993;48:357–387 Sutton CJ, Pooley AS, Ewen SP, Haines P Follow-up report on a randomized controlled trial of laser laparoscopy in the treatment of pelvic pain associated with minimal to moderate endometriosis Fertil Steril 1997;68:1070–4 Ling FW Randomized controlled trial of depot leuprolide in patients with chronic pelvic pain and clinically suspected Index abdominal wall trigger points 152 abnormal pain acupuncture 141–2, 153 adenomyosis 28–9 adhesiolysis 128 adhesions 36 and chronic pelvic pain 127–8 laparoscopy 44–5 alternative therapies see complementary alternative medicine American Urological Association 103 amitriptyline chronic pelvic pain 153 IC/BPS 112–13 vulvodynia 96 ampicillin 126 anal nerve 17 anastrazole 53–4 anticonvulsants and chronic pelvic pain 153 vulvodynia 97 arbitrary inference 84 aromatase inhibitors 57 autonomic nervous system 20 central nervous system centers 21–6 in pain experience 25–6 parasympathetic 5, 24 central nervous system centers 21–3 in pain experience 25 pelvi-perineal distribution 24–5 sympathetic 5, 23–4 in pain experience 25 spinal centers 21 beads-on-a-string sign 30 behavioral modification 111 chronic pelvic pain 153 biofeedback 153 vulvodynia 97 bladder biopsy 109 capacity 109 diary 108 morphology 109 bladder pain see interstitial cystitis/bladder pain syndrome bladder pain syndrome see interstitial cystitis/ bladder pain syndrome Bladder Pain/Interstitital Cystitis Symptom Score 108 body image 135 border nerves 14, 20 botulinum toxin type A (onabotulinumtoxinA, Botox) IC/BPS 116–17 vulvodynia 97 bowel preparation 75 brainstem reticular formation 22 candidiasis, vulvovaginal 92, 95 carbamazepine 97 carbon dioxide laser 64 catastrophizing cefotaxime 127 cefotetan 126 cefoxitin 126, 127 ceftizoxime 127 ceftriaxone 127 central sensitization Chinese herbal medicine 142–4 chlorpactin 115 chocolate cyst 44 chondroitin sulfate 114 chronic fatigue syndrome 105 cimetidine 113 clindamycin 126 clitorodynia 93 cognitive behavioral therapy chronic pelvic pain 83–4 sexual dysfunction 137 vulvodynia 98 see also psychotherapy cogwheel sign 30 complementary alternative medicine 111, 140–7 acupuncture 141–2, 153 Chinese herbal medicine 142–4 definition 140 manual therapies 144–5 massage 145 osteopathy 144–5 physiotherapy 97, 111, 137, 144 see also psychotherapy coping with chronic pain 85–6 cyclosporine A 117 cyproterone acetate 53–4, 55–6 cystectomy 117 CystoProtek 113 cystoscopy 45–6, 109, 115 method 46 danazol 53–4, 56 dermatan sulfate 114 dermoid cysts 31, 32–3 dermoid mesh sign 33 dexamethasone 128 diagnosis of chronic pelvic pain 1, 2, 125 Diagnostic and Statistical Manual Female Orgasmic Disorder 136 Female Sexual Interest/ Arousal Disorder 130, 136 Genito-Pelvic Pain/ Penetration Disorder 130, 132, 133 Hypoactive Sexual Desire Disorder 130 dienogest 53–4, 55 155 156 Index dietary modification 111 dimethylsulfoxide 114 disc excision 74 dorsal nerve of clitoris/penis 17 doxycycline 126, 127 duloxetine 153 dyschezia dysfunctional thoughts “all or nothing” thinking 84 catastrophizing disqualifying of positive 84 emotional reasoning 85 “should” statements 85 dysmenorrhea 2, 4, 6, 7, 149 acupuncture 141 Chinese herbal medicine 143 dyspareunia 6, 7, 105, 130, 149 entry 93 history 130–1 dysuria 105 electroexcision 61–2 electrocautery 64 emotional component of pain endometriomas 31, 34–5 surgery 72 endometriosis 7–8, 28, 149 Chinese herbal medicine 143 classification, American Society for Reproductive Medicine 61 etiology 51 future directions 58 history 149 laparoscopy 43, 44 long-term management 58–9 painful intercourse 133 stage I/II 60–70 stage III/IV 61, 71–8 endometriosis, medical treatments 51–9 aromatase inhibitors 57 danazol 53–4, 56 gestrinone 53–4, 57 GnRH agonists 56–7 NSAIDs 52 oral contraceptive pill 52, 53–4 progestogens 55–6 selective progesterone receptor modulators 57 endometriosis, surgical treatment excision vs ablation 66–7 postoperative therapy 58 preoperative therapy 58 sharp excision 61–2 stage I/II ablation 63–6 electrocautery 64 Helica Thermal Coagulator 64–6 laser 64 PlasmaJet 66 stage I/II excision 61–2 electroexcision 61–2 harmonic scalpel 62 laser 62 outcome 67–9 pain relief 67 recurrence 68 reproductive performance 68 stage III/IV 71–8 bowel involvement 71–2 bowel preparation 75 complications 77 disc excision 74 fibrosis after surgery 75 extensive disease 73–4 intestinal integrity 75 laparoscopy vs open surgery 75 multidisciplinary approach 77 outcomes 75–6 radicality 76–7 rectal anatomy 75 rectal shave 73 segmental rectal resection 74 stage of severity 71–2 superficial lesions 72 technical issues 79–88 epithelial dysfunction 105 ergotropic bundle 22 estrogen deficiency 92 European Society for the Study of Interstitial Cystitis 103 external genital pain 105 Female Orgasmic Disorder 136 Female Sexual Interest/ Arousal Disorder 130, 136 fibromyalgia 105, 107 fibrosis 75 fluoxetine 153 fulguration 116 gabapentin chronic pelvic pain 153 vulvodynia 97 gastrointestinal endometriosis 71–2 genital exploration exercises 137 Genito-Pelvic Pain/ Penetration Disorder 130, 132, 133 gentamicin 126 gestrinone 53–4, 57 glomerulation 109 gluteal region 15–16 gluteus maximus 15 glycosaminoglycan replenishment agents 115 glycosaminoglycans 105 GnRH (gonadotropinreleasing hormone) agonists 56–7 Gore-Tex surgical membrane 128 gynecological causes of pelvic pain 28–36 adenomyosis 28–9 adhesions 36 cystadenomas 31 dermoid cysts 31, 32–3 endometriomas 31, 34–5 endometriosis 7–8, 28 ovarian cysts 31–2 pelvic congestion syndrome 35 pelvic inflammatory disease 29–31 harmonic scalpel 62 Helica Thermal Coagulator 64–6 heparin, intravesical 114 heparin sulfate 114 historical perspective Hunner’s lesions 45, 105, 109 fulguration 116 hydrodistension 115 hydroxyzine 113 hyperbaric oxygen 117–18 Hypoactive Sexual Desire Disorder 130 hypogastric plexus 24 hypothalamus 22 hypotherapy 145 hysteroscopy 46–7 risks 48 Index IC/BPS see interstitial cystitis/ bladder pain syndrome idiopathic chronic pelvic pain 148–54 history 149–50 management 151–2 acupuncture 153 behavioral modification and psychotherapy 153 medical treatment 152–3 physiotherapy 153 physical examination 151 imipramine 153 inferior cluneal (gluteal) nerve, perineal branch 18–20 innervation 11–26 autonomic nervous system 20 morphogenesis 11–14 pelvic/perineal structures 16–26 perineum 13–14 somatic 16–21 see also specific nerves Interceed 128 intercourse, painful see painful intercourse International Continence Society 103 interstitial cystitis/bladder pain syndrome (IC/BPS) 37, 45, 102–23 Bladder Pain/Interstitital Cystitis Symptom Score 108 chronic 92 clinical evaluation 107 definitions 102–4 American Urological Association 103 European Society for the Study of Interstitial Cystitis 103 International Continence Society 103 National Institute of Diabetes and Digestive and Kidney Diseases 103 epidemiology 104–5 Essic classification 104 etiology 105 autoimmune 106 environmental 107 epithelial dysfunction 105 genetic 107 hormonal involvement 107 nerve conditions 107 pelvic floor dysfunction 107 gender prevalence 104, 107 history 108 laboratory tests 108 painful intercourse 133 physical examination 108 symptom evaluation 108 treatment 110–18 first line 111 second line 111–15 third line 115–16 fourth line 116 fifth line 116–17 sixth line 117 contraindications 118 urodynamics 108–10 intestinal integrity 75 intravesical instillations 114–15 intravesical lidocaine testing 110 investigations see surgical investigations; ultrasound irritable bowel syndrome 37, 105, 149, 152 painful intercourse 133 treatment acupuncture 142 Chinese herbal medicine 143–4 Kegel exercises 137 Kolliker’s pelviperineal spur 11 laparoscopy 9, 41–5 adhesions 44–5 chronic pelvic pain 41 diagnostic 27 endometriosis 43, 44 limitations 43 method 43–4 normal 42–3 range of outcomes 41–2 risks 48 157 laser therapy 62, 64 leukotriene receptor antagonists 114 leuprolide acetate 53–4 levator ani muscle 11, 12 levator ani syndrome levonorgestrel intrauterine system 53–4, 56 lidocaine, intravesical testing 110 lidocaine-releasing intravesical system 114 limbic cortex 22 massage 145 mechanism-specific therapy medroxyprogesterone acetate 53–4 metronidazole 127 mifepristone 53–4 migraine monoclonal antibodies 114 montelukast 113 morphogenesis 11–14 mucinous cystadenoma 31 multimodal pain management 112 musculoskeletal pain 8, 37, 151 myofascial pain 107 myofascial syndromes 26 naproxen sodium 53–4 negative sexual attitudes 133 neocortex 23 nerve supply see innervation neuroplasticity neuromodulators 153 neuropathic pain 37 chronic 150 nociceptors 4, 5, 126 nocturia 105 non-gynecological causes of pelvic pain 37 interstitial cystitis 37 irritable bowel syndrome 37 musculoskeletal and neuropathic 37 non-menstrual pelvic pain 6, non-steroidal antiinflammatory drugs see NSAIDs normalcy of pain 2, nortriptyline 96 157 158 Index NSAIDs chronic pelvic pain 153 endometriosis 52 menstrual symptoms 142 O’Leary–Sant score 108 onabotulinumtoxinA see botulinum toxin type A oral contraceptive pill endometriosis 52, 53–4 idiopathic chronic pelvic pain 151 orthosympathetic nervous system see autonomic nervous system osteopathy 144–5 ovarian cysts 31–2 ovarian endometrioma 44 oxygen, hyperbaric 117–18 pain abnormal electrochemistry 3–4 emotional component external genital 105 experience of 80–1 interpretation multimodal management 112 nociceptors 4, 5, 126 normal 2, rational component reaction signaling 4–5 stimulus painful bladder syndrome 9, 103 see also interstitial cystitis/ bladder pain syndrome painful intercourse 7, 130, 133 endometriosis 133 IC/BPS 133 irritable bowel syndrome 133 pelvic inflammatory disease 133 see also dyspareunia parasympathetic nervous system see autonomic nervous system partner support 81–3 pathophysiology 2–6, 124–5 patient education 111 158 pelviperineal diaphragm 11 pelvic bone 14 pelvic congestion syndrome 35 pelvic floor dysfunction 107 pelvic floor exercises 153 pelvic inflammatory disease 29–31, 124–9 diagnosis 125 ovarian involvement 31 painful intercourse 133 pathophysiology 124–5 treatment 125, 126, 127 acupuncture 142 pelvic pain posture 152 pelvis 14 penetration phobia 133 pentosan polysulfate (Elmiron) 113 perineum 12 anatomy 14 innervation 13–14 physicians’ role 87 physiotherapy 144 chronic pelvic pain 152, 153 IC/BPS 111 sexual dysfunction 137 vulvodynia 97 piriformis 15 piriformis syndrome 18 PlasmaJet 66 posterior horn postmenopausal atrophy 92 potassium sensitivity test 110 pregabalin chronic pelvic pain 153 vulvodynia 97 prevalence 6–8 probenecid 127 progestogens 55–6 promethazine 128 psychodynamic therapy 83, 84 psychological interventions 145 chronic pelvic pain 83–5 vulvodynia 98 see also specific techniques psychotherapy 83–5, 153 behavioral modification 111 chronic pelvic pain 153 cognitive behavioral therapy 83 chronic pelvic pain 83–4 sexual dysfunction 137 vulvodynia 98 psychodynamic therapy 83, 84 research 86 pudendal nerve 12–13, 16–18 anatomy 16–17 physiopathology 17–18 stimulation 116 rami communicantes 25 rectal resection 74 rectal shave excision 73 reflexes religious traditions/taboos 134 Rokitansky nodules 33 sacral neuromodulation 116, 153 sacral-rectal-genital-pubic laminae 24 sciatic nerve 15 sclerotomes 11 selective negative focus 84 selective progesterone receptor modulators 57 self-care 111 self-treatment capability sensate focus exercises 138 Seprafilm 128 serous cystadenoma 31 sertraline 153 sexual abuse, and pelvic pain 79, 145 sexual dysfunction 8, 130–9 cause 132–4 dyspareunia 6, 7, 105, 130, 149 entry 93 history 130–1 effect 134–6 history 130–2 treatment 136–9 see also specific treatment modalities vaginismus 130, 131–2 sexuality, and chronic pelvic pain 86–7 sodium hyaluronate 115 somatic innervation 16–21 selective serotonin reuptake inhibitors 153 sterilization, and pelvic pain Index sulbactam 126 superior cluneal (gluteal) nerve 20–1 support partner 81–3 physician’s role 87 surgery endometriomas 72 endometriosis stage I/II 60–70 stage III/IV 71–8 vulvodynia 98 surgical investigations 40–50 consequences 47–8 contraindications 48–9 cystoscopy 45–6 hysteroscopy 46–7 indications 40–1 limitations 47 selection of 41 see also laparoscopy sympathetic nervous system see autonomic nervous system symptomatology tanezumab 114 testicular pain 14 thalamus 22 thoracolumbar junction syndrome 20 treatment 2, 9–10, 125, 126, 127 mechanism-specific therapy self-treatment capability see also specific conditions and modalities tricyclic antidepressants chronic pelvic pain 153 vulvodynia 96 trophotropic bundle 22 ultrasound 27–39 negative 37–8 urinary diversion 117 urinary frequency 105 urinary incontinence 105 urinary urgency 105 urine microscopy 108 urodynamics 108–10 159 vaginal dilators 137, 153 vaginismus 130, 131–2 venlafaxine 153 Veress needle 43, 44 vestibulodynia 131 provoked 89, 91 visual analog scales 108 vulvar vestibulitis syndrome 90, 131, 132 vulvodynia 89–101, 131, 133 etiology 91–3 evaluation 93–6 management 96–8 drug therapy 96–7 physiotherapy 97 psychological interventions 98 surgery 98 topical agents 97 presentation 93 terminology and classification 90 vulvovaginal candidiasis 92, 95 Wisconsin Symptom Instrument 108 159 ... involve pelvic pain The dissociation between endometriosis and pelvic pain has been recently confirmed by a study performed on 57 subjects suffering chronic pelvic pain [4], showing that the pain. .. Interstitial cystitis/bladder pain syndrome 102 Audrey Wang Investigating chronic pelvic pain: ultrasound 27 Alison Richardson and Nick Raine-Fenning Investigating chronic pelvic pain: surgical approaches... III and IV 71 Corinne Owers and Ian Adam 11 Pelvic inflammatory disease and chronic pelvic pain 124 J Biba Nijjar and Sawsan As-Sanie 12 Chronic pelvic pain and sexual dysfunction: cause and effect