Chronic Pelvic Pain

Chronic Pelvic Pain

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Chronic pelvic pain (CPP) is a diagnostic and therapeutic dilemma that can be frustrating for women, men, and healthcare providers. Read on to learn about this challenging multifactorial condition in women and men and guidelines for an integrated management approach.

As a primary care clinician, you are likely to encounter patients with vague complaints of long-standing pain localized to the pelvis, anterior abdominal wall at or below the umbilicus, or the buttocks, and that is unrelieved by medication.[1] The pain may be described as steady, fluctuating, dull, or sharp. For some patients, the pain is mild, while others complain of pain severe enough to interfere with normal daily activities. Many note accompanying sadness and depression. This article reviews how you might help your patients who turn to you for guidance and support when they are unable to manage this pain, despite conventional treatment.

Chronic pelvic pain (CPP) is defined by the American College of Obstetrics and Gynecology (ACOG) as “noncyclic pain of six or more months’ duration … and is of sufficient severity to cause functional disability or lead to medical care.”[2] CPP is “associated with changes in the central nervous system (CNS) that may maintain the perception of pain in the absence of acute injury.”[3] Although commonly assumed to be a strictly gynecologic problem in females, etiology of the ongoing pain can be urologic (eg, interstitial cystitis, bladder malignancy), reproductive (eg, endometriosis, pelvic inflammatory disease, chronic prostatitis), musculoskeletal (eg, abdominal wall myofascial pain, pelvic floor myalgia), gastrointestinal (eg, irritable bowel syndrome, constipation, inflammatory bowel disease), or neurologic or psychiatric (eg, depression, anxiety).[1,2,4,5] Complex and multifactorial, CPP is actually common in women and in men, and multiple contributing factors are often present in the same patient.

Physical and psychological conditions are often comorbid. Throughout pain literature, depression is associated with pain conditions, including CPP, but abnormal scores on standardized psychiatric profiles in patients with CPP return to normal when pain has been treated. Depression is not always the cause, but often its consequence.[6] The mechanisms of pain and depression differ between patients, but each affects the other, so that treating one will impact both.[7] If the patient is depressed, antidepressants may help both affective symptoms and pain symptoms; counseling and relaxation therapy, a stress management program, and biofeedback techniques can also reduce the frequency and severity of CPP. Depression, anxiety, fibromyalgia, and other pain disorders are frequently comorbid with CPP, and treatment must take in account multiple conditions.[8]

Due to its ambiguous nature, many primary care clinicians do not feel confident in their skills to diagnose or advise treatment for CPP.[9] Among nurse practitioners, one reason stated for their lack of knowledge was that CPP was not covered during their medical school curricula. There was, in fact, an increased likelihood that CPP would be recognized by practitioners with more professional and clinical experience, greater familiarity with the prevalence of CPP in females and were female themselves.[10] Another gap in CPP care is the need to instruct patients in self-management skills. The teaching of these self-management techniques helps with pain control thus improving patient retention rates and allowing more time to discover specific causes and triggers. Many times, CPP is a diagnosis of exclusion, and clinicians commonly prescribe antimicrobial agents, anti-inflammatory medicines, and alpha-adrenergic receptor antagonists for treatment, although the consistency of their effects has not been supported by clinical trials.[11,12]

CPP in Women

Acute pain in women is typically a symptom of underlying tissue injury and/or disease, but chronic pain may become the disease itself, making the underlying etiology more difficult to identify. It is estimated that 25% of women in the United States suffer from CPP, a prevalence that may increase to 35% in women with a history of pelvic inflammatory disease.[13,14] Chronic pelvic pain represents a clinically significant entity.[14] It is the reason for approximately 10% of all gynecologic consultations, 40% of laparoscopies, and 10% to 15% of hysterectomies. The most prevalent cause of CPP in women is interstitial cystitis.It is present in approximately 80% of cases and is often comorbid with endometriosis.[15] Complicating the workup is the reality that in 40% to 50% of cases of women with CPP, physical and sexual abuse may contribute to the patient’s pathology that may need a referral to help manage.[2] Also because some women’s family clinicians may not recognize CPP that is associated with musculoskeletal pain, a positive diagnosis may be gained only after referral to a specialist, such as a physical therapist or psychiatrist.[16] Still most cases of CPP are managed by primary care clinicians, typically with only 40% of women with pain referred to a specialist.[13]

History and Physical Exam

To reach an accurate diagnosis, an in-depth pelvic pain assessment and examination are required. The assessment should include a complete history of psychological issues (including information on comorbid anxiety, depression, somatoform disorders, and/or drug addiction), gynecological (including age of menarche, menstrual regularity, flow, severity of pain before and during menses, surgeries, pregnancies, infections, and unusual physical symptoms), GI, GU, and musculoskeletal concerns. A complete physical and lower abdominal/pelvic examinations are the next steps.[17,18] The goal of the pelvic examination is to independently evaluate visceral and somatic components of pain, and assess potential causes for the patient’s symptoms.[17,19] The pelvic exam should begin with a visual inspection of the external genitalia for lesions, and then a single-digit, one-handed exam, rather than a bimanual exam, should be administered to evaluate the size and shape of the pelvic organs. Next, a speculum exam of the vagina and cervix, and then a moistened cotton swab should be used to elicit point tenderness in the vulva and vagina. Then, the bladder, vaginal walls, levator muscles, cervix, bladder or other musculoskeletal structures, and adnexal structures are palpated to note position, mobility, any masses, and for tenderness. If the patient’s history includes pain when climbing stairs or driving a car, hip musculature should be palpated transvaginally with the patient externally rotating the thigh on that side against resistance. Finally, a rectal examination may show rectal or posterior uterine masses, nodularity, or tenderness in the pelvic floor.

The extensive time required for this detailed initial history and physical assessment explains why it is often best to establish with the patient from the start that the diagnosis and early therapy may be spread over several visits.

Laboratory and Imaging Tests

The choice of diagnostic laboratory tests for patients with CPP should be based on the clinical impression that emerges after a complete history and physical examination. Baseline diagnostic tests in women with CPP may include a pregnancy test, CBC, urinalysis, ESR, and DNA probes for gonorrhea and chlamydia. CT and MRI scans are useful for identifying structural problems in the lumbosacral spine and pelvis that may be causing the pain. Ultrasonography is another very effective way to evaluate cysts, tumors, and other masses in the abdominal and pelvic regions. Urodynamic studies are often performed to rule out abnormalities of the bladder, which are common causes of CPP. Laparoscopy has the greatest value when first-line treatment has failed. It is most beneficial for patients in whom surgical intervention is considered, including ablation of endometriosis lesions, ovarian cystectomy, salpingectomy, uterosacral nerve resection or ablation, uterine suspension, and hysterectomy.

CPP in Men

There are four classifications of prostate syndromes in men: acute bacterial prostatitis (ABP), chronic bacterial prostatitis (CBP), chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS), and asymptomatic inflammatory prostatitis (AIP). The most prevalent condition in men is CP/CPPS, in which chronic pain manifests in the perineum, rectum, prostate, penis, testicles, and abdomen. Recent evidence suggests that 8% of the 90% of males who suffer from the CP/CPPS prostatitis classification may be prone to a B2 phylogenetic group subject to prostatitis-causing uropathogenic Escherichia coli (UPEC) strains. Such a strain was found in a 2011 study by Rudick et al, the “first experimental evidence that a bacterial isolate from a patient with CP/CPPS can initiate and sustain the development of chronic pelvic pain, a distinguishing characteristic of CP/CPPS.”[20]

History and Physical Exam

The primary care clinician should conduct an assessment that includes a complete history (including information on comorbid anxiety, depression, somatoform disorders and/or drug addiction). Information should also be taken for lower urinary tract symptoms (irritative/storage and obstructive/voiding), pain (frequency, location, and severity), associated symptoms (fever or other pain), and allergies, medications, surgical history (especially urologic), and trauma.[11] As with women, the goal of a physical examination is to evaluate visceral and somatic pain components, and assess potential causes of symptoms. In men, the abdomen should be examined for evidence of a distended bladder and the back checked for costovertebral-angle tenderness. The external genitalia, perineum, and prostate should also be examined. A distended bladder indicates urinary retention.[20] The prostate should be gently palpated to check for tenderness, swelling and enlargement, softening (bogginess), firm induration, warmth, or nodularity, but prostatic massage should not be performed as it may be harmful.[20,21] Myofascial trigger points and pelvis/pelvic floor musculoskeletal dysfunction must be evaluated during a digital rectal examination (DRE), and prostate centricity may be determined if normal DRE pressure worsens pelvic pain.[11]

Laboratory and Imaging Tests

After a complete history and physical examination, baseline diagnostic tests in men with CPP should include a CBC, urinalysis, ESR, and DNA probes for gonorrhea and chlamydia. Diagnostic testing to differentiate the four types of prostatitis include localization tests and expressed prostatic secretions, urine Gram stain and culture, and when an obstruction is suspected, measurement of postvoid residual urine.[22] The use of the pre- and post-message 2-glass test and of the more time consuming classic 4-glass Meares-Stamey test is controversial in the literature.[21,22]

CPP Management for Women and Men

Single-treatment approaches often fail to adequately relieve pain, so a more comprehensive, multidisciplinary approach that incorporates pharmacotherapy, physical therapy, surgical, and psychological approaches to the treatment of CPP is likely more effective. Most patients with CPP have lived with pain for months or years, and have probably sought out multiple doctors in search of relief. They are frustrated with the chronic and debilitating nature of the disease and may challenge your findings and clinical advice. Here are some basic treatment strategies that may help circumvent some of your patients’ frustrations:

  • To avoid delays in diagnosis and repeated tests and procedures, encourage patients to find and stay with a single provider with whom they feel comfortable.
  • Multiple visits and treatment regimens may be necessary to establish a diagnosis and obtain good results. Reassure patients that in some cases no diagnosis is ever made, but that serious pathology can be eliminated and symptoms controlled.
  • Help patients set realistic goals. The goal of treatment should be improvement in the restoration of normal activity, not necessarily elimination of pain.
  • Ask patients about treatment goals. They may only want reassurance that they do not have a cancer or serious pathology.
  • Decide on a schedule with patients (weekly for 15-30 minutes) and stick to it. Do not allow longer visits, or patients to pressure you for a diagnosis or treatment option at the end of the first visit.
  • To avoid frequent visits to the Emergency Department or lengthy phone calls, schedule frequent brief office visits. This allows patients to address issues of importance and allows clinicians to monitor progress while maintaining normal schedules.

Clinicians who acknowledge the emotional, psychological, and structural aspects of CPP can provide patients with a lifeline and understanding that while a definitive diagnosis or cure is not always possible, you can help them manage the pain and provide psychological support. Your compassion, patience, and methodical approach indicate you believe they are in pain. Sometimes that factor alone is enough to bring a measure of clinical improvement and pain relief.

 

Updates by Jessica Hall
Updated March 15, 2012; Published October 2010

A version of this article appeared in print October 2010 on page 6 of the Primary Issues newsletter.

 

References

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