How is chronic pelvic pain treated?

It is important to set realistic expectations regarding treatment outcome. For instance, it may not be possible to completely eliminate pain but if pain can be reduced and coping mechanisms can be improved, quality of life can be greatly enhanced. Hence, with chronic pain, a pivotal concept is that of managing pain rather than curing pain.

A wide range of treatment options may be required for pelvic pain depending on the underlying cause (or causes). Where necessary, it is important to involve other health care professionals in addition to the gynaecologist (e.g. pain specialists, physical therapists, urologists, gastroenterologists and psychologists) to effectively manage all aspects that may be associated with chronic pain.

Oral analgesics:
Regular use of analgesics such as non-steroidal anti-inflammatory drugs (NSAIDs), paracetamol or co-dydramol may be helpful. Supervised use of the opioid group of analgesics (e.g. codeine, oxycodone and tramadol) may also be beneficial.

Hormonal treatments:
Treatments that suppress ovarian function have been shown to be very effective, especially when pain occurs in a cyclical pattern as in the case of painful periods (dysmenorrhoea). Options include the oral contraceptive pill, progesterone (e.g. provera and ralovera), danazol and GnRH agonists (e.g. buserelin, leuprolide and goserelin). Another hormonal treatment that may be effective is the Mirena intrauterine system, which is a progesterone-releasing intrauterine device (IUD). Hormonal treatments may be used in conjunction with laparoscopic surgery for treating endometriosis.

Laparoscopic surgery:
In some studies, endometriosis was found at laparoscopy in more than 30% of cases of chronic pelvic pain. Laparoscopic surgery is an effective approach for removing endometriotic deposits and any associated endometriotic cysts (or “chocolate cysts”).

Adhesions may be found in 25-50% of women with chronic pelvic pain but it is controversial whether they definitely cause pelvic pain. Laparoscopy is a highly effective approach for releasing adhesions that may be restricting the free movement of structures such as bowel.

Additional procedures aimed at reducing pain may be performed at the time of laparoscopy including presacral neurectomy, laparoscopic uterine nerve ablation (LUNA) and appendectomy.

Drugs targeting the nervous system:
Some drugs target pain pathways at the level of the spinal cord. These include gabapentin, carbamazepine, phenytoin and clonazepam.

Other treatments seek to inhibit pain more centrally. These include opiates and some drugs used for treating depression including paroxetine and amitriptyline.

Treatment for myofascial problems:
Myofascial trigger points may be injected using local anaesthetic agents (e.g. procaine and lidocaine) and botulinum toxin. Injection may be combined with percutaneous electrical stimulation via the inserted needle.

Physical therapy (or manual therapy) involves direct finger pressure, stretching and mobilization of fascia at sites where muscles are affected. This may be combined with the use of ultrasound and heat.

These treatments should be accompanied by a home exercise and stretching program.

Treatment for IBS:
This may involve dietary modifications such as inclusion of stool bulking agents and increasing intake of clear fluids. It may also be beneficial to avoid certain foods such as dairy products, cabbage, beans, grain, lactose, fructose and a group of carbohydrates called FODMAPs (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols). Around 40% of patients with IBS have lactose intolerance. Avoid caffeinated and carbonated products as they can cause bloating as can gum-chewing and smoking since they lead to more swallowing of air.

If pain is the predominant symptom, antispasmodic medications may be of benefit. Antispasmodics include mebeverine (e.g. Colofac), anticholinergics (e.g. Bentyl and Buscopan) and Peppermint oil. Peppermint oil also decreases abdominal distension and flatulence.

Long term use of stimulant laxatives is not recommended.

Treatment for interstitial cystitis:
Distension of the bladder at the time of cystoscopy may be beneficial in 20-30% of cases.

Pentosan polysulfate sodium (Elmiron) acts as a bladder protectant and may be helpful in around 30% of patients.

Psychological treatments:
There are strong interactions between chronic pain and psychological problems. It is important to involve trained psychotherapists when needed in the assessment and management of chronic pelvic pain. Cognitive behavioural therapies are the treatment of choice for developing effective pain-coping strategies. Treatment of co-existing conditions such as depression is important for controlling pain.

Complementary and Alternative Medicine:
Transcutaneous Electrical Nerve Stimulation (TENS) may be beneficial for dysmenorrhoea.

Acupuncture, massage, physiotherapy, ultrasound and biofeedback training may benefit chronic pain.