Health

Unfortunately, there are no quick fix medical treatments for chronic pelvic pain. A combination of treatments typically works best for patients.

Medications
Medications for pelvic pain are often the same drugs used for other chronic pain states. They can include non-steroidal anti-inflammatory drugs (like ibuprofen), opioids (like hydrocodone), and antiepileptics (gabapentin) or antidepressants (amitriptyline) which because of their effect on neurotransmitters, seem to have some effect on chronic pain because nerves are thought to be diffusely sensitized even if they are not damaged.

Hormonal treatments in the form of oral contraceptives (“the Pill”), gonadotropin releasing hormone agonists (GnRH) (nafarelin, goserelin, leuprolide) and progestins are utilized primarily in the treatment of pelvic pain related to endometriosis. Oral contraceptives suppress ovulation, markedly reduce uterine activity, and reduce the pain associated with your period and as a result they may reduce pain related to other gynecologic conditions. GnRH agonists down-regulate pituitary gland production resulting in decreased estradiol levels. One side effect of these drugs however is bone loss.

Injections
• Muscle trigger point injections: anesthetic (lidocaine), steroid, botulinum toxin
• Pelvic joint injections: (sacroiliac joint, sacrococcygeal joint, pubic symphysis) lidocaine and steroid injections
• Nerve blocks: hypogastric nerve plexus, ganglion impar, pudendal nerve with x-ray guidance, ilioinguinal or genitofemoral
• Acupuncture: nothing injected, dry needling performed

The long-term positive effects of these injections have not been well studied and often are used in conjunction with other treatments for CPP like physical therapy. Typically they can be more helpful in making the diagnosis of the anatomic pain generator than providing long-term pain relief.

Rehabilitation
The rehabilitation team in treating the pelvic pain patient is comprised of the physiatrist as the team leader, physical therapist, occupational therapist, psychologist and nurse educator. Pelvic pain has a significant impact on a patient’s ability to function. It can affect  bowel and bladder function, sexual appreciation, and activities of daily living (ADLs). It can directly impact one’s social life, ability to work, recreational activity, not to mention future pregnancy decisions. Therapeutic goals for the pelvic pain patient are realistically set based on severity of disability and patient preference.

Physical therapy is often the mainstay of treatment for musculoskeletal disorders of both the external and internal pelvis. This treatment carries little risk and no long-term side effects unlike others such as medications, injections and procedures. Pelvic floor physical therapy is more than just Kegel exercises. In fact, strengthening of these muscles is often the last step in a physical therapy program. Muscle and joint problems often are seen together and good physical therapists will address all musculoskeletal issues and provide a patient with a home exercise program. You should not become dependent on physical therapy. Physical therapy is a treatment offered to an individual in order to give them independence not only from their pain but from the medical system. The idea that you have had pelvic pain for years and so physical therapy may take a year is not supported by any research. In fact, there are only a few studies that have been done on physical therapy and pelvic pain because of the subjective nature of treatment protocols. It is widely used in most clinical settings however and more research is underway.

For patients with significant soft tissue impairments and/or pain, the therapist may  provide  manual therapies, such as massage, myofascial release, joint mobilization, and manual stretching,  Patients must be actively involved in their care, and participate in treatments, including stretching, posture training, and therapeutic exercise. They learn self-correction techniques for pelvic obliquity.

Internally, the PT educates the patient on proper activation and relaxation of pelvic floor muscles. Relaxation training of the pelvic floor muscles with manual and surface EMG biofeedback (sEMG) is utilized and monitoring electrical activity of muscles is employed. The patient visualizes activity on an LCD or computer screen and learns to control the activity. This is similar to external forms of biofeedback used in other chronic pain conditions, however an internal probe may be used. Massage and stretching along with internal manual muscle release of the pelvic floor is done by the therapist and instruction of self-massage techniques using dilators can be taught. Often electrical stimulation devices are added as modalities which may be used for both pain management (similar to a TENS unit) as well as to facilitate pelvic floor muscle contraction. Both home biofeedback and electrical stimulation units can be ordered. Vibratory devices are used by some patients as well. Pelvic floor muscle training is usually the last step in physical therapy once pain is under better control, and muscles are in their optimal state. Strengthening is the same as in the incontinent patient. (see incontinence section)

Interdisciplinary Pain Program
A chronic pain program in an interdisciplinary setting (where all members of the rehabilitation team are talking and planning the treatment together) has been found to be successful in other chronic pain states such as low back pain and has been utilized in chronic pelvic pain. This is where a patient participates in a daily program for several weeks. The treatment in the program includes medication management, physical therapy, occupational therapy, therapeutic recreation, psychology, biofeedback, community reintegration, and vocational (job) training. Sometimes pelvic floor physical therapy will be done in the context of a pain program. This is not the same as in an anesthesia pain program where medications and injections are primarily used.

Procedures
These treatments affect the nerve reflex axis and are thought to therefore block pain signals. They are not well studies in CPP but have been used.
• Sacral neuro-modulation
• Spinal cord stimulation

Surgery
For CPP this primarily includes laparoscopy for the removal of adhesions associated with endometriosis and hysterectomy for uterine pain. Non-surgical options are typically prescribed first in treating CPP. Surgical denervation is sometimes utilized called presacral neurectomy with fair results. Superior hypogastric plexus blockade prior to this surgery may offer good predictive value. LUNA (laproscopic uterosacral nerve ablation) represents another surgical option. This procedure involves the excision of the inferior hypogastric plexus (a coalescence of sympathetic and parasympathetic nerves).