INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Chronic pelvic pain (CPP) is a common problem and presents a major challenge to health care providers because of its unclear etiology, complex natural history, and poor response to therapy.

CPP is poorly understood and, consequently, poorly managed. This condition is best managed using a multidisciplinary approach. Management requires good integration and knowledge of all pelvic organ systems and other systems including musculoskeletal, neurologic, and psychiatric systems.

A significant number of these patients may have various associated problems, including bladder or bowel dysfunction, sexual dysfunction, and other systemic or constitutional symptoms. Other associated problems, such as depression, anxiety, and drug addiction, also may coexist.

In the United States, estimated direct medical costs for outpatient visits for CPP (women aged 18-50 y) is approximately $881.5 million per year (Mathias, 1996).

Pathophysiology

The pathophysiology of CPP is complex and multifactorial. It remains unclear.

Frequency

United States

CPP is a common problem. It affects approximately 1 in 7 women (Mathias, 1996). In one study of reproductive-aged women in primary care practices, the reported prevalence rate of pelvic pain was 39% (Jamieson, 1996). Of all referrals to gynecologists, 10% are for pelvic pain (Reiter, 1990).

International

A similar prevalence of CPP has been described in other countries (Zondervan, 1999).

Mortality/Morbidity

As with other chronic pain, CPP may lead to prolonged suffering, marital and family problems, loss of employment or disability, and various adverse medical reactions from lifelong therapy.

Race

In one study, being African American was found to be a risk factor for pelvic pain (Jamieson, 1996).

Sex

CPP is most common among reproductive-aged women. Common causes of CPP in men include chronic (nonbacterial) prostatitis, chronic orchalgia, and prostatodynia.

Age

CPP is most common among reproductive-aged women, especially those aged 26-30 years (Jamieson, 1996).

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

The proposed definition of chronic pelvic pain (CPP) is nonmenstrual pain of 3 months duration or longer that localizes to the anatomic pelvis and is severe enough to cause functional disability and require medical or surgical treatment. Most authorities agree that patients should be diagnosed with CPP if they have pain primarily located in the pelvis for more than 3 or 6 months duration.

Patient history is important in cases of CPP. Because of the complex etiology and, often, the presence of associated disorders, a general approach with a thorough history that directs further evaluation and appropriate consultations is needed. Perform a detailed review of systems, including reproductive, gastrointestinal, musculoskeletal, urologic, and neuro-psychiatric. As needed, ask specific questions, especially if the patient has an associated disorder. A thorough past history also is important to avoid repeating invasive and expensive procedures.

• Focus history on characterizing the patient's pain, which can lead to appropriate diagnostic and therapeutic plans.
• • Location of pain: The location of pain is an important part of the history. Ask the patient to describe the pain location and type on a pain diagram (anteroposterior and lateral view of human picture).
  • Precipitating factors: Ask questions about factors that provoke or intensify pain. This may provide clues for possible etiologies or associated disorders. For example, in pelvic congestion syndrome, pain is related to posture and is worse at the end of day. In endometriosis, pain commonly is reported during or after intercourse.
  • Alleviating factors: Alleviating factors may exist. For example, rest may decrease pain of musculoskeletal or adnexal origin.
  • Quality of pain: Various terms can be used to describe the quality of pain. Such terms include throbbing, pounding, shooting, pricking, boring, stabbing, lancinating, sharp cutting, lacerating, pressing, cramping, crushing, pulling, pinching, stinging, burning, splitting, penetrating, piercing, squeezing, and dull aching.
  • Pain distribution: Spreading or radiation of pain also is important in the evaluation of neuropathic pain.
  • Severity or intensity of pain: Use some type of rating system to evaluate pain severity or intensity with a degree of objectivity and reproducibility. Different types of pain scales may be used. Numerical scales are more useful and reliable. The visual analog scale is one of the commonly used numerical scales.
• Obtain a history specific to different systems and disorders.
• • Gynecologic and obstetric: For example, excessive bleeding with menses suggests uterine leiomyomas or adenomyosis. History of previous surgery may suggest intra-abdominal or pelvic adhesions. Patients with cervical stenosis usually have a history of chronic cervical infection or treatment with cryosurgery/laser surgery/loop excision or endometrial resection. Having multiple sexual partners is a risk factor for pelvic inflammatory disease.
  • Urologic: A detailed history to evaluate the urological system is important. For example, as compared to patients with pelvic pain, patients with interstitial cystitis report urgency and increased frequency of urination as the most distressing features.
  • Gastrointestinal: For example, deflecting sigmoid adhesions are common in women with CPP and frequently are associated with gastrointestinal symptoms.
  • Musculoskeletal: History of vaginal delivery with prolonged second-stage episiotomies or tears may suggest pelvic floor relaxation disorder.
  • Neurologic: Constant burning pain is a common complaint in patients with pudendal neuralgia. Patients may report dysesthesia and vulvodynia but usually not dyspareunia.
  • Psychologic: A good psychosocial or psychosexual history is needed when organic diseases are excluded, or coexisting psychiatric disorders are suggested. Obtain sufficient history to evaluate depression, anxiety disorder, somatization, physical or sexual abuse, drug abuse or dependence, and family problems, marital problems, or sexual problems. Sexual abuse occurring before age 15 years is associated with later development of CPP (Lampe, 2000). Somatization is a common associated psychologic disorder in women with CPP. Somatization scales can be used for evaluation.

Physical

Good rapport, tolerance, and an open-minded approach are important in the evaluation of any patient with chronic pain. A thorough systematic examination usually suggests an appropriate diagnosis and therapy.

• Obstetric-gynecologic and other system examinations could be long and stressful. Detailed examination of obstetric-gynecologic and other systems can be performed in different positions. Usually, this includes standing, sitting, supine, and lithotomy positions.
• Lithotomy examination usually includes the following:
• • Visual inspection of the external genitalia
  • Basic sensory testing and evaluation for trigger points
    • A cotton-tipped swab can be used for precise sensory and tender-point evaluation of the vestibule, vaginal cuff, cervical os, paracervical region, and cervical region.
    • Single-digit examinations of the vulva, pubic arch, levator ani coccyx, introitus, urethral, trigonal, cervix, paracervical areas, vaginal fornices, uterus, and adnexa are indicated.
  • Colposcopic evaluation of the vulva and vestibule
  • Sims retractor or single-blade speculum examination of the vagina and pelvic muscles
  • Bimanual pelvic examination
  • Rectovaginal examination
• Perform detailed examinations for other systems (eg, gastrointestinal, urologic, neurologic, musculoskeletal) as required. For example, gait and posture evaluation, spine examination, and sensory and motor examination often are useful.
• • Betty maneuver (for piriformis syndrome): When abduction of the thigh against resistance is requested, the patient will report pain.
  • Obturator sign (dysfunction of the obturator muscles or fascia)
  • Straight-leg raising test (possible herniated disc, radiculopathy)
  • Psoas sign: If pain is elicited during flexion of hip against resistance, this may suggest dysfunction of the psoas muscles or fascia.
  • Patrick or faber (flexion in abduction and external rotation) test for hip evaluation

Causes

Various reproductive, gastrointestinal, urologic, and neuromuscular disorders may cause or contribute to CPP. Sometimes, multiple contributing factors may exist in a single patient.

• Extrauterine reproductive disorders
• • Endometriosis
  • Adhesions
  • Adnexal cysts
  • Chronic ectopic pregnancy
  • Chlamydial endometritis or salpingitis
  • Endosalpingiosis
  • Ovarian retention syndrome (residual ovary syndrome)
  • Ovarian remnant syndrome
  • Ovarian dystrophy or ovulatory pain
  • Pelvic congestion syndrome
  • Postoperative peritoneal cysts
  • Residual accessory ovary
  • Subacute salpingo-oophoritis
  • Tuberculous salpingitis
• Uterine reproductive disorders
• • Adenomyosis
  • Chronic endometritis
  • Atypical dysmenorrhea or ovulatory pain
  • Cervical stenosis
  • Endometrial or cervical polyps
  • Leiomyomata
  • Symptomatic pelvic relaxation (genital prolapse)
  • Intrauterine contraceptive device
• Urologic disorders
• • Bladder neoplasm
  • Chronic urinary tract infection
  • Interstitial cystitis
  • Radiation cystitis
  • Recurrent cystitis
  • Recurrent urethritis
  • Urolithiasis
  • Uninhibited bladder contractions (detrusor-sphincter dyssynergia)
  • Urethral diverticulum
  • Chronic urethral syndrome
  • Urethral caruncle
• Musculoskeletal disorders
• • Abdominal wall myofascial pain (trigger points)
  • Compression fracture of lumbar vertebrae
  • Faulty or poor posture
  • Fibromyalgia
  • Mechanical low back pain
  • Chronic coccygeal pain
  • Muscular strains and sprains
  • Pelvic floor myalgia (levator ani spasm)
  • Piriformis syndrome
  • Rectus tendon strain
  • Hernias (eg, obturator, sciatic, inguinal, femoral, spigelian, perineal, umbilical)
• Gastrointestinal disorders
• • Carcinoma of the colon
  • Chronic intermittent bowel obstruction
  • Colitis
  • Chronic constipation
  • Diverticular disease
  • Inflammatory bowel disease
  • Irritable bowel syndrome
• Neurologic disorders
• • Neuralgia/cutaneous nerve entrapment (surgical scar in the lower part of the abdomen; usually iliohypogastric, ilioinguinal, genitofemoral, and lateral femoral cutaneous nerves)
  • Shingles (herpes zoster infection)
  • Degenerative joint disease
  • Disk herniation
  • Spondylosis
  • Abdominal epilepsy
  • Abdominal migraine
  • Neoplasia of spinal cord or sacral nerve
• Psychologic and other disorders
• • Personality disorders
  • Depression
  • Sleep disorders
  • Sexual and/or physical abuse
• Common causes of CPP in men
• • Chronic (nonbacterial) prostatitis
  • Chronic orchalgia
  • Prostatodynia

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Reproductive system
Adenomyosis
Adhesions
Adnexal tumors
Cervical stenosis
Dyspareunia
Endocervical and endometrial polyps
Endometriosis and endosalpingiosis
Uterine leiomyomas
Ovarian retention syndrome
Ovarian remnant syndrome
Pelvic varicosities and pelvic congestion syndrome
Vulvodynia
Pelvic floor relaxation disorders
Accessory and supernumerary ovaries

Urinary system
Chronic and recurrent urinary tract infections
Urolithiasis
Pelvic floor dysfunction
Urethral diverticula
Chronic urethral syndrome

Gastrointestinal system
Chronic intermittent bowel obstruction
Colitis
Chronic constipation
Diverticular disease
Inflammatory bowel disease
Irritable bowel syndrome
Peritoneal abscess

Other diseases
Hernias (eg, obturator, sciatic, inguinal, femoral, perineal, spigelian, umbilical)
Neoplasia of the spinal cord or sacral nerves
Mononeuropathy and nerve entrapment
Abdominal epilepsy
Abdominal migraines
Pelvic floor pain syndrome
Rectus abdominis pain
Faulty posture
Bipolar affective disorder and depression
Chronic visceral pain syndrome
Chronic fatigue syndrome
Substance abuse
Spinal malformation
Spinal tumors

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• The decision to perform laboratory or imaging evaluations is based on the need for confirmation of the diagnosis and to help rule out other potentially life-threatening illnesses. Certain investigations sometimes are needed to provide appropriate and safe medical or surgical treatment.
• Complete blood cell count and sedimentation rate: These tests provide nonspecific findings, but the results can be sensitive indicators of inflammation or infection and, occasionally, malignancy.
• Serum drug screen: Perform this if any suggestion of prescription or street drug abuse is present.
• Urine test
• • Urinalysis and urine culture are relatively inexpensive and noninvasive and should be performed when necessary.
  • If hematuria is present, carefully evaluate the condition with a history, physical examination, urine culture, urine cytology, cystourethroscopy, and intravenous pyelography or CT scan.
  • If malignancy is suggested, perform urine cytology in addition to urinalysis and culture, especially if the patient smokes.
• Sexually transmitted disease testing
• • Testing for sexually transmitted diseases in women with chronic pelvic pain (CPP) includes cervical cultures or smears, syphilis serology (rapid plasma reagent, microhemagglutination-Treponema pallidum), hepatitis B screening, chlamydial polymerase chain reaction, and HIV testing.
  • Other tests used to help rule out specific infections may include vaginal cultures, vaginal wet preparations, vaginal pH, and urine analysis and culture.
• Hormone assays: Follicle-stimulating hormone level, estradiol level, and gonadotropin-releasing hormone agonist stimulation testing can be helpful in cases of ovarian remnant syndrome.
• Thyroid-stimulating hormone testing
• • This is used for evaluation of hypothyroidism, especially in a patient with depression.
  • Perform stool guaiac testing in patients with gastrointestinal symptoms and in patients older than 50 years. Testing stool specimens for ova and parasites also may be helpful in selected cases.

Imaging Studies

• Magnetic resonance imaging
• • MRI is a noninvasive tool that can provide excellent structural information without any radiation harm.
  • Intravenous contrast can be used when inflammation, infection, or malignancy is suggested.
• CT scan: This is useful in patients with pelvic masses and sometimes is helpful in differentiating an ovarian mass from a uterine mass, but it is more expensive than sonography.
• Ultrasonography
• • This is a noninvasive diagnostic tool and could be helpful in many patients with CPP.
  • It commonly is used to help identify pelvic masses or cysts and their origin, pelvic varicosities, and hernias (spigelian hernias).
• Plain film radiography
• • Obtaining chest and spine radiographs may be useful in fractures, infections, tumors, and other structural abnormalities.
  • Flat and upright abdominal radiographs may be obtained to help rule out intestinal obstruction and pelvic infection (eg, tuberculosis).
• Herniography (perineal hernia herniography)
• Bone scan
• Hysterosalpingography
• • Hysterosalpingography (HSG) is not a first-choice diagnostic tool for endometriosis; however, it may be useful in patients with infiltrative endometriosis of the uterosacral ligaments. Adolescents with endometriosis also can be evaluated for obstructive anomalies.
  • HSG may be useful in cases suggestive of endometrial polyps, Asherman syndrome, and adenomyosis.
• Barium enema radiography, colonoscopy, sigmoidoscopy, upper gastrointestinal series, and anorectal manometry
• • These can be used to evaluate a gastrointestinal etiology of chronic pain.
  • Anorectal balloon manometry can be used to assess colonic transit time.
• Vaginal sonography
• • This is useful in patients with possible pelvic congestion syndrome.
  • Transuterine venography commonly is recommended.
• Voiding cystourethrography: When interstitial cystitis is suggested, consider cystoscopy with hydrodistention.
• Double-balloon cystourethrography: This is a more sensitive diagnostic test than voiding cystourethrography for diagnosing urethral diverticula in women (Jacoby, 1999).

Other Tests

• Endoscopic procedures used commonly in the evaluation and treatment of patients with CPP include laparoscopy, cystourethroscopy, hysteroscopy, sigmoidoscopy, and colonoscopy.
• Laparoscopy can be used as a diagnostic tool in patients with CPP, as follows:
• • More than 40% of laparoscopies are performed for the diagnosis of CPP.
  • More then 60% of women with CPP have at least one condition detectable by laparoscopy.
  • Most commonly, diagnoses made via laparoscopy include endometriosis, pelvic adhesions, and chronic pelvic inflammatory disease. Other diagnoses include ovarian cysts, hernias, pelvic congestion syndrome, ovarian remnant syndrome, ovarian retention syndrome, postoperative peritoneal cysts, and endosalpingiosis.
• Urodynamic testing can be performed if chronic urethral syndrome or interstitial cystitis is suggested in a patient with CPP.
• Nerve-conducting velocities and needle-electromyographic studies are used to help evaluate compression or entrapment neuropathy and pelvic floor function.
• Cancer antigen 125 (CA125), used as a diagnostic test, has low sensitivity and specificity.
• • CA125 may be elevated with diseases associated with pelvic pain, such as endometriosis or leiomyomata.
  • CA125 levels also are elevated with malignancy (eg, ovarian, endometrial, colon, or breast cancer), pelvic inflammatory disease, pregnancy, and menses (Howard and Perry, 2000).
  • Perform electroencephalography if the rare disorder of abdominal epilepsy is suggested.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical Care

Treatment of pelvic pain is complex in patients with multiple problems. It usually requires specific treatment and simultaneous psychological and physical therapy. A good relationship should be established between the physician and the patient. Treatment of chronic pelvic pain (CPP) must be tailored for the individual patient.

The goals of treatment must be realistic. They should be focused toward restoration of normal function (minimal disability), better quality of life, and prevention of relapse of chronic symptoms.

• Pharmacotherapy
• • Pharmacotherapy consists of symptomatic abortive therapy to stop or reduce the severity of the acute exacerbations and long-term therapy for chronic pain.
  • Initially, pain may respond to simple over-the-counter (OTC) analgesics such as paracetamol, ibuprofen, aspirin, or naproxen. If treatment results are unsatisfactory, the addition of other modalities or the use of prescription drugs is recommended.
  • If possible, avoid use of barbiturate or opiate agonists. Also discourage long-term use and overuse of all symptomatic analgesics because of the risk of dependence and abuse.
  • Tizanidine may improve the inhibitory function in the central nervous system and can provide pain relief. Therapy with tizanidine is not considered the standard of care
  • Amitriptyline (Elavil) and nortriptyline (Pamelor) are the tricyclic antidepressants (TCAs) used most frequently for chronic pain.
  • The selective serotonin reuptake inhibitors (SSRIs) fluoxetine (Prozac), paroxetine (Paxil), and sertraline (Zoloft) also are prescribed commonly by many physicians. Other antidepressants such as doxepin, desipramine protriptyline, and buspirone also can be used.
• Physical therapy
• • Physical therapy techniques include hot or cold applications, positioning, stretching exercises, traction, massage, ultrasound therapy, transcutaneous electrical nerve stimulation (TENS), and manipulations. Heat, massage, and stretching can be used to alleviate excess muscle contraction and pain.
  • Pelvic floor training also may be recommended.
• Psychophysiological therapy
• • Psychophysiological therapy includes reassurance, counseling, relaxation therapy, a stress management program, and biofeedback techniques. With these modalities of treatment, both frequency and severity of chronic pain may be reduced.
  • Biofeedback may be helpful in some patients when combined with medications.

Surgical Care

• Various minimally invasive techniques may provide pain relief. These techniques include the following:
• • Trigger point injections: These injections are used mostly for localized trigger points (myofascial pain or neuroma).
  • Peripheral nerve blocks: Specific peripheral nerve block with local anesthetic and steroids may be helpful in selected cases.
• Neuroablation of selected nerves can be performed by using different techniques, including thermocoagulation (radiofrequency ablation), cryoablation, or injection of chemical agents (alcohol, hypertonic saline, phenol).
• • An intrathecal morphine pump may be used, but careful selection for appropriate patients is very important.
  • Sacral nerve stimulation may be effective in the treatment of therapy-resistant pelvic pain syndromes linked to pelvic floor dysfunction (Everaert, 2001).
• Various surgical procedures may be considered to treat CPP. Surgical procedures include presacral neurectomy (superior hypogastric plexus excision), paracervical denervation (laparoscopic uterine nerve ablation), and uterovaginal ganglion excision (inferior hypogastric plexus excision).

Consultations

Consultation with a psychologist, urologist, neurologist, and gastrointestinal specialist or other appropriate specialists is very important, especially before considering invasive or aggressive management.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Pharmacotherapy consists of symptomatic abortive therapy to stop or reduce the severity of acute exacerbation of pain and long-term therapy for chronic pain.

Drug Category: Analgesics

Generally used in mild to moderate pain; however, also may be effective for severe pain.

Drug Name	Ibuprofen (Advil, Motrin)
Description	Inhibits inflammatory reactions and pain by decreasing activity of cyclooxygenase, which is responsible for prostaglandin synthesis.
Adult Dose	400-800 mg PO q8h while symptoms persist; not to exceed 3.2 g/d
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding
Interactions	Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Category D in third trimester of pregnancy; caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy

Drug Name	Naproxen (Aleve, Naprosyn, Naprelan)
Description	For relief of mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing activity of cyclooxygenase, which results in a decrease of prostaglandin synthesis.
Adult Dose	275 mg PO tid or 550 mg PO bid
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency
Interactions	Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; NSAIDs may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Category D in third trimester of pregnancy; acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug

Drug Category: Opioids

Commonly used for many pain syndromes.

Drug Category: Anticonvulsants

Certain antiepileptic drugs (eg, the GABA analogue gabapentin) have proven helpful in some cases of neuropathic pain. Other anticonvulsant agents (eg, pregabalin, clonazepam, topiramate, lamotrigine, zonisamide, tiagabine) have been tried in CPP.

Drug Category: Tricyclic antidepressants

Increase synaptic concentration of serotonin and/or norepinephrine in the CNS by inhibiting reuptake by the presynaptic neuronal membrane. Newer agents include Cymbalta.

Drug Name	Amitriptyline (Elavil)
Description	Analgesic for certain chronic and neuropathic pain.
Adult Dose	25-100 mg PO hs; not to exceed 150 mg/d
Pediatric Dose	Children: 0.1 mg/kg PO hs; increase as tolerated over 2-3 wk to 0.5-2 mg/d PO hs Adolescents: 25-50 mg/d PO initially; increase gradually to 100 mg/d in divided doses
Contraindications	Documented hypersensitivity; patient has taken MAOIs in past 14 d; history of seizures, cardiac arrhythmias, glaucoma, and urinary retention
Interactions	Phenobarbital may decrease effects; coadministration with CYP2D6 enzyme system inhibitors (eg, cimetidine, quinidine) may increase levels; inhibits hypotensive effects of guanethidine; may interact with thyroid medications, alcohol, CNS depressants, barbiturates, and disulfiram
Pregnancy	D - Unsafe in pregnancy
Precautions	Caution in cardiac conduction disturbances and history of hyperthyroidism, renal impairment, or hepatic impairment; avoid using in patients who are elderly

Drug Category: Selective serotonin reuptake inhibitors

Selectively inhibit presynaptic serotonin reuptake with minimal or no effect in the reuptake of norepinephrine or dopamine. SSRIs can be used in second-line or third-line treatment of painful diabetic neuropathy. Good for patients who already are depressed.

Drug Name	Sertraline (Zoloft)
Description	Considered an alternative to TCAs, with fewer adverse anticholinergic and cardiovascular effects.
Adult Dose	50 mg/d PO in am with 50-mg/d increments q2-3d to 100 mg/d, if tolerated; not to exceed 200 mg/d
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity
Interactions	Increases toxicity of MAOIs, diazepam, tolbutamide, and warfarin
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Caution in preexisting seizure disorders and in those who have experienced a recent MI, have unstable heart disease, or have hepatic or renal impairment; anxiety, insomnia, drowsiness, tremor, anorexia, and anorgasmia and other sexual dysfunctions have been reported; nausea, flulike symptoms, and agitation also are noted but resolve within a few weeks

Drug Name	Paroxetine (Paxil)
Description	Considered an alternative to TCAs, with fewer adverse anticholinergic and cardiovascular effects.
Adult Dose	10 mg/d PO and titrate up to 50 mg/d
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity; concurrent administration with MAOIs or administering within 14 d of discontinuing an MAOIs
Interactions	Phenobarbital and phenytoin decrease effects; alcohol, cimetidine, sertraline, phenothiazines, and warfarin increase toxicity
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Caution in history of seizures, mania, renal disease, and cardiac disease; anxiety, insomnia, drowsiness, tremor, anorexia, and anorgasmia and other sexual dysfunctions have been reported; nausea, flulike symptoms, and agitation also are noted but resolve within a few weeks

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Inpatient Care

• Hospitalization usually is not required for patients with chronic pelvic pain (CPP); however, the need for hospitalization depends on the invasiveness of the treatment choice for pain control and on the severity of the case.

Further Outpatient Care

• Patients with CPP generally are treated in an outpatient setting and require a variety of health care professionals to optimally manage their condition.

Complications

• Like other chronic pain, CPP may lead to prolonged suffering, marital or family problems, loss of employment, disability, and various adverse medical reactions from lifelong therapy.

Patient Education

• The patient and the patient's family should have a good understanding about the multifactorial nature of chronic pain. They need multidisciplinary and comprehensive management plans.
• Instruct the patient to avoid uncomfortable stressful positions and bad posture. Also recommend regular exercise, good sleeping habits, and balanced meals.
• Try biofeedback and relaxation techniques.
• For excellent patient education resources, visit eMedicine's Bone Health Center, Muscle Disorders Center, Kidneys and Urinary System Center and Women's Health Center. Also, see eMedicine's patient education articles Chronic Pain, Bladder Control Problems, Female Sexual Problems, Endometriosis, and Pain During Intercourse.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Good rapport, tolerance, and an open-minded approach are important in the evaluation of any patient with chronic pain.
• Patients with chronic pelvic pain (CPP) may exhibit exaggerated pain behavior or sensations that seem to be hysterical or appear nonanatomic or nonphysiologic; however, these patients always must be taken seriously and appropriate conservative steps should be taken.
• Obtaining a thorough past history is important to avoid repeating invasive and expensive procedures.
• Consultation with a psychologist, urologist, neurologist, and gastrointestinal specialist or other appropriate specialists is very important, especially before considering invasive or aggressive management.

Special Concerns

• Appropriate caution must be taken during treatment of patients with the following characteristics:
• • Poor response to prior appropriate treatment
  • Unusual unexpected response to prior specific treatment
  • Avoidance of school, work, or other social responsibilities
  • Severe depression
  • Severe anxiety disorder
  • Excessive pain behavior
  • Frequent physician changes
  • Noncompliance with past treatment
  • Drug abuse or dependence
  • Family, marital, or sexual problems
  • History of physical or sexual abuse
• Pregnancy
• • The use of medication during pregnancy is not contraindicated, but it should be limited and carefully justified.
  • Initially, pain should be managed with nonpharmacologic measures such as reassurance, rest, hot or cold applications, positioning, stretching exercises, massage, ultrasound therapy, TENS, relaxation therapy, and biofeedback. If pain does not respond to a nonpharmacologic approach, symptomatic drugs may be used carefully.
  • Acetaminophen and codeine (alone or in combination) can be used during pregnancy.
  • Nonsteroidal anti-inflammatory drugs such as ibuprofen and aspirin may be considered during the first trimester of pregnancy, but they should be avoided especially during the last trimester. They may constrict or close the fetal ductus arteriosus and may cause maternal and fetal bleeding.
  • Limit benzodiazepine and barbiturate use. Do not use ergotamine, dihydroergotamine, and sumatriptan.
• CPP in men: Chronic (nonbacterial) prostatitis, chronic orchalgia, and prostatodynia are common causes of CPP in men of any age.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

• Baker PK. Musculoskeletal origins of chronic pelvic pain. Diagnosis and treatment. Obstet Gynecol Clin North Am. Dec 1993;20(4):719-42. [Medline].
• Ben-David B, Friedman M. Gabapentin therapy for vulvodynia. Anesth Analg. Dec 1999;89(6):1459-60. [Medline].
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