Myth: The pain is all in my head.
Fact: There are many different physical causes of pelvic pain, including nerve disturbances, pelvic neuropathy, irritable bowel syndrome, hernia, interstitial cystitis, endometriosis, fibroids, and more. Pelvic pain becomes chronic often because of changes in the nervous system, tissues, or muscles. Chronic pain of any type is complicated by psychological factors such as depression or anxiety.

Myth: Only women suffer from pelvic pain.
Fact: Chronic pelvic pain is most common in women, but men may suffer from pelvic pain related to chronic prostatitis, chronic orchalgia, or prostatodynia.

Myth: Only women who have been sexually abused suffer from pelvic pain.
Fact: 10% of all visits to a gynecologist are because of pelvic pain. Women who have never been sexually abused may develop chronic pelvic pain; however sexual abuse before age 15 is associated with later development of chronic pelvic pain.

Myth: There’s usually only one cause of pelvic pain or one simple test to diagnose it.
Fact: Unfortunately, there are many causes of pelvic pain, and diagnosing it often is a process of elimination. Pelvic pain can result from diseases or disorders of the reproductive organs, urologic disorders, musculoskeletal disorders, gastrointestinal diseases or disorders, and neuropathy.

Myth: There is no effective treatment; just live with it.
Fact: There are many ways to treat chronic pain and improve functioning and quality of life. People with chronic pelvic pain often find that their pain is best managed by a variety of treatments, including medications, surgery, injections, cognitive behavioral therapies, and more.

Treatment Options

Medications

Anti-Inflammatory
For mild pain, the recommendation includes the use of acetaminophen or a nonsteroidal anti-inflammatory agent (ibuprofen, naproxen sodium).

Opioids
Opioids are reserved for patients who do not have pain relief from initial therapy. For patients with unresolved chronic pain, the use of long-acting opioids, including methadone, have proven very effective.¹ Providing long-term opioids to patients with chronic pelvic pain is a controversial topic. For the most part, physicians in multiple specialties in all regions of the United States have little concern about tolerance, dependence or addiction when prescribing opioids to treat chronic pain. The doctor must be aware, however, that prior addiction and some aspect of sexual abuse are prevalent in the chronic pelvic pain population. Doctors should use an informed consent as it allows these patients to autonomously choose to accept the risk of addiction and accept responsibility to be aware of the increased possibility of dependence. This allows for the sharing of responsibility and provides patients with self-confidence.

Anti-depressants
Tricyclic antidepressants are effective as an additional therapy, especially given the high prevalence of depression in chronic pelvic pain patients. Medications that are typically used are imipramine, amytriptiline, or doxepin. These medications have been shown to improve pain tolerance, restore normal sleep, and help reduce depression.⁴ Amytriptyline has been shown to be effective in increasing the patients’ activity level and reducing the intensity of pain.

Many doctors are combining the tricyclic anti-depressants with the newer anti-depressant medications, called selective serotonin reuptake inhibitors (SSRIs). The tricyclic medications are being used at smaller doses, helping relieve pain but limiting the side effects, while the SSRIs are helping with depression. This form of treatment has been seen to be extremely effective with patients with chronic pelvic pain and interstitial cystitis. Anti-depressants have been shown to be extremely effective in the treatment of patients who have psychogenic pain or somatoform pain disorder by reducing pain when compared with placebo.

Anti-convulsants
Anticonvulsants have proven effective in the treatment of post-herpetic or pudendal neuralgia. Gabapentin has proven to be beneficial for the use of relieving burning or lancing pain as seen with interstitial cystitis.⁷ Pregabalin is related to gabapentin and is approved to treat neuropathic pain, specifically diabetic peripheral neuropathy and postherpetic neuralgia. It may have potential for other chronic pain disorders.

Medications for Irritable Bowel Syndrome
Patients have seen improvement with tricyclic antidepressants, anti-cholinergics (dicyclomine hydrochloride, hyoscyamine sulfate) for irritable bowel syndrome.¹² Daily use of fiber — if used religiously — is effective in significantly relieving symptoms. It is effective in increasing stool bulk, and water content and decreases transit time, decreasing pain and constipation and providing for more formed, regular bowel movements.

Hormones
Controlling the menstrual cycle pain through the use of hormones, such as birth control pills, continuous progestogens, or a GnRH agonist, may help IC, endometriosis, and pelvic congestion syndrome. Hormones are usually chosen when NSAIDS (non-steroidal anti-inflammatory drugs) have failed in decreasing discomfort. The use of GnRH agonists is an effective approach to providing relief for patients with chronic pelvic pain and may be useful in clinical diagnosis of endometriosis.

Pelvic Pain Physical Therapy

Physical therapy has been shown to be effective in helping pelvic pain. Patients with chronic pelvic pain require intervention secondary to the myofascial (muscle) component. It has been shown that, with the use of internal manual massage, approximately 70% of patients will have a significant improvement of pain with physical therapy targeting the pelvic floor (pelvic floor hypertonus) specifically helpful in patients with urgency/frequency syndrome and interstitial cystitis.¹

Pelvic Pain Injections and Surgery

Injections

Trigger point injections with anesthetics (bupivacane 0.25%) have provided significant relief for patients with chronic pelvic pain. Response rates have been as high as 80% to 90% after repeated injections.¹ Recently, evidence has shown that injections with Botulinum Toxin A have decreased pain scores by producing local, temporary muscle paralysis and possibly reducing mediators of neurogenic inflammation.² Injecting Botulinum Toxin A into the genitofemoral and ilio-inguinal nerves or into spastic muscles with trigger points has been shown successful in patients with high tone pelvic floor dysfunction.

Surgery

Of all the treatment modalities for chronic pelvic pain, surgery is the most controversial. There have been many procedures that have arisen both for the diagnosis and treatment of chronic pelvic pain that have met with limited success.

Sacral neuromodulation of the third nerve root is a FDA-approved modality for the treatment of refractory interstitial cystitis patients and urgency incontinence. Because pain is a major component of interstitial cystitis, sacral neuromodulation has proven to be effective in decreasing pain.

With the widespread use of laparoscopy, many procedures have been proposed for helping chronic pelvic pain including cutting (lysis) adhesions, removing endometrial lining outside the uterus either through laser or electric current (ablation or fulguration), destruction of the uterosacral nerve ablation (burning the ligaments that attach the uterus to the sacrum, which is a part of the pelvic bone), and pelvic pain mapping.

Traditionally laparoscopy has been thought of as the gold standard for evaluation and treatment of chronic pelvic pain with the improvement rates reported as high as 65% to 84%. There has been success in the treatment of chronic pelvic pain associated with endometriosis in the short term with laparoscopy, with symptom relief gained by 62.5% of the patients and those who have laser treatment of their endometriosis showing a 70% improvement of pain. Of these patients undergoing ablative (destruction of abnormal areas) procedures, 44% will recur after one year.

Approximately 12% of hysterectomies in the United States (approximately 60,000 annually) are for chronic pelvic pain. Success rates, which some experts believe are exaggerated, range from 60% to 95%. Researchers have found that one in four women experienced some pain one year following hysterectomy. Another group of researchers demonstrated that 40% of patients who have had a hysterectomy will have continued chronic pain. Recurrence rates of 40% were also observed in women in whom hysterectomy was performed without identifiable disease. Another study showed that, in the United States, more than 60% of uteri removed from patients with chronic pelvic pain were pathologically normal.