Master Class

A Two-Pronged Approach


This combination of disease-specific and pain-specific therapies reflects the complexity of chronic pelvic pain and the fact that there most often will be more than one diagnosis, as well as the fact that pain itself will more often than not be one of the diagnoses and not only a symptom.

Just as we should be guided in our differential diagnosis by seeking diagnoses for which we have the best evidence of casual or associative roles in chronic pelvic pain, we should begin with treatments for which there is good level I evidence of efficacy.

Surgery will help a subgroup of women with chronic pelvic pain, especially those with endometriosis and other reproductive tract disorders, but the majority of women with chronic pelvic pain will benefit most from medical, psychological, and physical therapy.

There are strong data from studies of the treatment of irritable bowel syndrome (IBS) and pelvic congestion syndrome that show that adding psychological treatment to medical treatment is more effective than providing either by itself. Physical therapy, moreover, can be helpful for the secondary pelvic floor muscle pain that many women develop regardless of what problems were pain generators in the first place.

Disease-Specific Therapy

In trying to help women with chronic pelvic pain, we will most often find ourselves treating the common diagnoses that have level A evidence of association with the pain: IBS, endometriosis, interstitial cystitis, myofascial trigger points, depression, and chronic pain syndrome.

Endometriosis and interstitial cystitis are particularly common in women with chronic pelvic pain, and there is good evidence that the disorders not only cause the pain but also tend to occur together. The literature suggests that 30%–80% of women with endometriosis also have interstitial cystitis, and we know that treating one but not the other will significantly lessen our chances of success in treating pelvic pain.

For endometriosis, there is good level I evidence of efficacy for the use of hormonal treatments like GnRH agonists, progestins, and continuous oral contraceptives. Additionally, two randomized trials have confirmed that conservative—or organ-sparing—surgical removal of endometriosis lesions is effective in decreasing pain.

Combining surgery and medical treatment for endometriosis may be more efficacious than providing either by itself. We don't yet have level I evidence to support this approach—just as we don't yet have any published studies directly comparing medical and surgical treatments—but some of the completed clinical studies suggest that we should consider a combined approach in patients who are not trying to conceive.

For interstitial cystitis, randomized trials have demonstrated the efficacy of intravesical dimethyl sulfoxide and of oral pentosan polysulfate sodium.

Symptoms of IBS are present in a majority of women with chronic pelvic pain, and treatment tends to be based on which symptoms are predominant. For example, a number of good randomized trials have shown efficacy for the use of antispasmodics in patients whose symptomatology is predominantly abdominal pain, and for loperamide (Imodium) in patients with diarrhea-predominant symptomatology. Interestingly, tricyclic antidepressants, which often are prescribed to control chronic pelvic pain, can be useful for diarrhea-predominant IBS because constipation tends to be a side effect of the drugs. For constipation-predominant IBS, the newer drug tegaserod (Zelnorm) is frequently used.

In general, for our patients clearly troubled by IBS, evaluation and treatment with a gastroenterologist who is well versed in IBS are definitely worthwhile.

When it comes to myofascial and musculoskeletal pain, we don't have as much good data from randomized clinical trials to help direct our treatment decisions, but it certainly appears, based on clinical experience, that physical therapy—and, when indicated, trigger-point injections—is effective.

It is important to realize that physical therapy is often an important adjunct to the treatment of chronic pelvic pain, as well as a specific treatment. Regardless of what the pain generators or specific diagnoses are, many of these women develop secondary pelvic floor muscle pain, or pelvic floor tension myalgia.

Secondary pelvic floor muscle pain often does not respond to treatments for the specific diagnoses we make in women with chronic pelvic pain, and evaluation and treatment by a women's health physical therapist can thus be most useful. For this, contact the women's health section of the American Physical Therapy Association.

When it comes to the issue of surgery for chronic pelvic pain, endometriosis is one of the few diagnoses for which surgery has a clear role.

The treatment of adhesions, which are diagnosed in about one-quarter of women with chronic pelvic pain, is still controversial. It is not clear whether lysis of adhesions is effective in reducing pelvic pain, and it appears that the majority of adhesions that are surgically lysed do reform. The role of adhesions as a cause of pelvic pain, of course, is also controversial.

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