Chronic Pelvic Pain

Today we welcome Dr. Eva Reina, who is a current PGY-3 at Brown/Women and Infants. Eva shares with us some information on one of the most clinically challenging topics in office gynecology: chronic pelvic pain.

In terms of the initial evaluation, using the PPUBS framework can be useful:

• Pain: typical “can you describe your pain?”

• Periods: a thorough menstrual history, which should always be part of your GYN history taking.

• Urinary symptoms: timeline of symptoms with respect to urination, as well as triggers for any symptoms related to urination.

• Bowels: constipation and diarrhea, depending on pattern, can relay problems such as IBS, IBD, or other functional GI disorders.

• Sexual function: describing not only the nature of dyspareunia, but the timing and length of pain symptoms.

After history taking, a physical examination is the next important step. Particularly with the pelvic exam, starting with a single digit may be revelatory. Deep infiltrating endometriosis may be suggested by particular point tenderness. Bimanual examination can help to assess uterine size or concerns for adenomyosis. Speculum exam may not reveal much in the way of pain, but allows for testing for infectious etiologies.

We then discuss some of the mechanisms of chronic pelvic pain development:

Central Sensitization: Most patients with chronic pelvic pain do have multiple pain generators and may even be centrally sensitized: that is, amping up of a stimulus leading to a state of constant reactivity. This lowers the threshold of a stimulus to cause pain and also may maintain pain even after the initial insult has been removed. For instance, in population-based studies vulvodynia, IC, endo, IBS, migraines are commonly found together.

Cross-Talk:

• The top-down phenomenon. The patient who has low back pain, migraines, fibromyalgia, and has now been referred to your office with chronic pelvic pain. 

• The bottom-up phenomenon. 30 year old female who has “always had painful periods.” Stopped OCPs 5 years ago in order to achieve pregnancy. Presenting to your office for urinary symptoms (pain with bladder filling, urgency, frequency). 

• Pelvic Organ Cross-Sensitization: Convergence of sensory input from the pelvic viscera, their associated striated sphincters, muscular components of the pelvic floor, lower abdominal wall, the muscular perineum and its corresponding cutaneous components. 

Afferent information from the major pelvic organs (e.g. bladder, bowels, and uterus) is conducted through the hypogastric, splanchnic, pelvic, and pudendal nerves to cell bodies in thoracolumbar and lumbosacral dorsal root ganglia. At first, these signals go up to the brain (central nervous system), and an efferent signal comes back down (e.g. reflexically removing your hand from a hot stove). 

Over time, if one doesn’t remove the noxious stimulus, the body thinks there must be nobody home to hear the fire alarm, let’s try the neighbor’s house. So, long-term, noxious afferent stimulation from an irritated pelvic organ (peripheral to central) leads to that sensory input traveling back down to the peripheral nervous system to pass the message along to a nearby pelvic organ that was not previously affected. This neurogenic “inflammation” via the central to peripheral pathway may even produce functional changes in the uninsulted organ with little evidence of an organic etiology (e.g. IBS, IC/PBS, vulvodynia). 

Where do the muscles come in? 

• It is helpful to think of muscular spasm as a reactive phenomenon. If you uncover pelvic or abdominal wall myalgia, be sure to treat other primary pain generators BEFORE pelvic floor PT. If you don’t remove the stimulus, the patient is unlikely to make sustained forward progress in PT. 

• Pelvic floor PT is hard to come by (shortage of well-trained providers) and it is uncomfortable both physically and mentally for patients. Thus it is difficult to motivate patients to return to pelvic floor PT after a previous failure of therapy.