Chronic Pelvic Pain from All Angles

Incorporating an Integrative Approach

Courtney Lim, MD

Department of OBGYN

Jill Schneiderhan

Department of Family Medicine

Objectives:

1. To be able to articulate the most common factors at play in

multifactorial chronic pelvic pain (CPP)

2. To learn the components to a comprehensive exam for workup

of pelvic pain

3. Identify and initiate treatment for the most common

gynecological approaches for chronic pelvic pain

4. Be able to articulate the most common integrative approaches

for chronic pelvic pain

2

CASE

• Ms. AB is a 43 y/o G0 who presents to the University of Michigan Chronic Pelvic Pain Clinic and Endometriosis Center for management of her chronic pelvic pain

Pain History:

• She has a history of pelvic pain for 6 months prior to undergoing an abdominal myomectomy for heavy menstrual bleeding and fibroids

• Procedure was uncomplicated and no endometriosis was identified

• Pain improved for 2 months and then returned

• Pain described as a dull throbbing pain in lower abdomen, worse during/after menses, and has gotten worse

3

CASE

• Past Medical History: Recent diagnosis of fibromyalgia, hypothyroid, chronic low back pain, depression and anxiety, irritable bowel syndrome, history of sexual abuse

• Past Surgical History: Abdominal Myomectomy

• OBGYN History: G0, no history of abnormal paps or STI. Regular menses q 28 days, lasting 6-7 days, soaking a pad every 2-3 hours

• Medications: Cymbalta XR 30mg daily, synthroid 75mcg

• Allergies: None

• Family History: Mother with depression, alcohol abuse, Father with alcohol abuse, stroke and depression

• Social History: Never smoked, rare alcohol use, no illicit drug use

4

Essential Elements of the CPP History and Exam

• Pre-appointment Evaluation

• Pelvic Pain Questionnaire

- Pain mapping

- Validated questionnaires

- Pain, Urgency and Frequency Questionnaire

- Rome criteria

• Allows for collection of further data (prior imaging, operative reports, pathology reports

5

Essential Elements of the CPP History and Exam

6

• History

– Pain History (use pain scale)

– Interference with activities

– Time of day

– Stressors

– Psychiatric history

– GI and GU ROS

– Prior evaluation, treatments and outcomes

Essential Elements of the CPP History and Exam

7

• Systematic evaluation to reproduce pain

• Focal vs diffuse tenderness

• Patient control- May have to interrupt exam or

defer portions of exam

• Constant feedback to patient after palpation of

structures

• Used to confirm suspected diagnosis based on

history

Steege, JF., et al.(2014). “Chronic Pelvic Pain.” Obstetrics and Gynecology 124(3):616-629

Essential Elements of the CPP History and Exam

• Back

– Paraspinal, iliac crest, coccygeal palpation

– Evaluation of iliac crests

– Observe sitting position, gait to table

• Abdominal

– Superficial abdominal examination, consider use with light touch, pinprick

– Evaluation of incisions from prior abdominal surgeries

– Single digit exam of abdominal wall

– Identification of trigger points (focal hypersensitive area within muscles)

– Deep palpation for masses, hernias

– Carnett’s sign

8

Essential Elements of the CPP History and Exam

• Pelvic

– External inspection

– Sensory testing

– Single digit exam

– Pelvic floor palpation

– Bimanual exam

– Speculum exam

– +/- Rectal exam

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CASE

• Appears uncomfortable in chair

• Back: Paraspinal tenderness 4/10 in low back, SI joint palpation 5/10 bilaterally, coccyx 4/10

• Abdomen: 5/10 diffusely over entire abdomen, 4/10 pain with cotton swab in LLQ superior to low transverse incision, + carnets

• Pelvic:

- Qtip exam with 7/10 pain at posterior fourchette.

- Bladder non-tender

- Pelvic floor tenderness bilaterally, 3-6/10 reproducing pelvic pain and dyspareunia, with associated spasticity

- Nontender uterus and bilateral adnexa on single digit exam. Cervix with normal appearance on speculum exam

- No rectovaginal masses or nodularity

10

Chronic Pelvic Pain

• Pain in the pelvic region lasting 3-6 months or longer

– And not associated with pregnancy

– Non-cyclic pain

• Chronic Pelvic Pain accounts for 15-20% of gynecology visits

• Accounts for approximately $2.8 billion in healthcare costs

annually

• Catch all name for a diverse bucket of etiologies

– Chronic Pelvic Pain with probably etiology

– Chronic Pelvic Pain without an obvious etiology

• When an etiology can be identified much more likely to see

improvement

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Chronic Pelvic Pain is often Multifactorial

• Results from a complex interaction between pathology in peripheral tissues, peripheral nervous system,

and central nervous system, each with variable contribution in any given patient

• Need to treat various components of multifactorial pain in order to improve overall pain12

Peripheral Tissue

Peripheral nervous

system

Central nervous system

Social/Environmental Affective/Comorbid

symptoms

Cognitive/Behavioral

Integrative Management of Chronic Pelvic Pain:

Putting it all together

13

• Listen to the story

• Identify obvious causes

that have solid

treatment options

• Develop a multi-model

treatment plan

Improved

Function

Step One: Hear the Story (Always matters)

• Therapeutic Alliance

– Important regardless of where you meet a woman on her journey

– Hear her story of her pain from beginning to end

• No matter what you suggest next if there is no therapeutic

alliance it will be met with skepticism

• In the case of CPP

– High rate of trauma

– High rate of concurrent psychological overlay

14

Step One: Hear the Story (Always matters)

• Mixed method study of 80 patients living with chronic pain

(variety of conditions from fibromyalgia, arthritis, chronic back

pain and post surgical pain)

• Asked about what helped, what hindered, advice for other

patients etc

• Patients were found to be following behavior change model with

regards to self-care

• Those living well with pain:

– Action/maintenance phase

– Attributes of good coping

– Specifically employed exercise, persistence, cognitive control, relaxation,

pacing, assertive communication, and proper body mechanics

15

Owens, J. E., et al. (2016). "Stories of Growth and Wisdom: A Mixed-Methods Study of People Living Well With

Pain." Glob Adv Health Med 5(1): 16-28.

Stories of growth and wisdom: Stories of people

living well with chronic pain

• Those living less well with pain:

– Pre-contemplative/contemplative with regard to self-care

– They describe difficulty calming their minds, not paying positive attention

to their bodies, and not committing time for self-care, citing cost as an

issue in therapies such as massage.

• Authors suggest use of Positive Approach Model (PAM) where

the negative pain cycle is interrupted by persistent positive

approaches leading to psychological maturity

16

Owens, J. E., et al. (2016). "Stories of Growth and Wisdom: A Mixed-Methods Study of People Living Well With

Pain." Glob Adv Health Med 5(1): 16-28.

Step Two: Treat Identifiable Etiologies

(Low Hanging Fruit)

• Determine an etiology if able and trial of treatment

– Imaging (pelvic US, can consider MR Pelvis with endometriosis,

adenomyosis or fibroids)

– Labs

– Physical therapy

– Referral to gynecology, urology, or gastroenterology

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Management of Common GYN causes of CPP

Endometriosis:

• Diagnosed surgically with pathology

• Chronic condition, fluctuates during lifetime

- 1/3 have improvement, 1/3 worsening disease, 1/3 stable1

• Medical management with hormonal suppression, goal of amenorrhea if possible

- Cyclic vs continuous, combined, progestins, GNRH agonists/antagonists

- Based on patient side effects, risk factors

• Surgical management

- Laparoscopic excision or ablation of endometriosis

- Ovarian cystectomy or oophorectomy

- Hysterectomy

Approximately 25% of women with CPP have persistent pain after hysterectomy, 5% with new or worsening pain2

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1. Falcone T et al (2018). “Clinical management of Endometriosis” Obstetrics and Gynecology. 131(3):557-571

2. Brandsborg B. (2012). “Pain following hysterectomy: epidemiological and clinical aspects.” Dan Med J 59(1)

B4374.

Management of Common GYN causes of CPP

Dysmenorrhea/Adenomyosis

• Medical management with hormonal suppression, goal of amenorrhea

- Cyclic vs continuous, combined, progestins

- Based on patient side effects, risk factors

• Surgical management with hysterectomy

- Would not recommend endometrial ablation

Recurrent Ovarian Cysts

• Can cause acute pain, often identified incidentally on workup of CPP

• Hormonal suppression with systemic hormones

• Repeat ultrasound in 2-3 months

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Management of Common GYN causes of CPP

Vulvodynia

• Medical management with hormonal suppression

- Topical lidocaine

- Compounded neuropathic medications and muscle relaxants

- Oral neuropathic medications

• Surgical management as last resort with vestibulectomy

Fibroids

• If small, unlikely to cause pelvic pain

• Medical management of bleeding symptoms

• Procedural management with uterine artery embolization

• Surgical management with myomectomy, hysterectomy

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CASE

Gynecologic recommendations:

• Pelvic ultrasound ordered, no evidence of remaining

fibroids

• Recommended hormonal suppression with

norethindrone (Aygestin 5mg daily) for treatment of

dysmenorrhea

• Treatment of vulvodynia with topical lidocaine ointment

5% QHS

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Step Three: When no Etiology is Found

• In chronic pelvic pain, as with other chronic pain conditions,

there is frequently incomplete resolution of pain even with

known etiology and appropriate management

• Framework for approaching integratively:

– Continue with building common story as to cause of pain with your patient

– Pathology in somatic (muscles/bones) or visceral structures

(uterus/ovaries/bladder)

– Central sensitization of chronic pain

– Assess for history of trauma

– Support foundational aspects of care – ie. Move them along the behavior

change model

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Myofascial Pelvic Pain

• Refers to pain in the pelvic floor musculature and fascia

• 13-15% of patients with CPP screened positive for myofascial

pelvic pain

• Often overlooked because internal pelvic exams to evaluate

internal pelvic floor muscles are not routinely taught

• Can be a common cause of bladder and bowel dysfunction

• Can arise from any type of trauma (infection, surgery, childbirth)

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Bonder, J. H., et al. (2017). "Myofascial Pelvic Pain and Related Disorders." Phys Med Rehabil Clin N Am 28(3):

501-515.

Myofascial Pelvic Pain: Treatment Strategy

• Manual Therapies

1. Osteopathic Manipulation

2. Pelvic Floor PT

- Typically focuses on pelvic floor, hip, back and abdominal wall muscles,

including transvaginal manipulation of the pelvic floor muscles and

fascia

- May include manual therapy, mobilization, acupressure and

biofeedback

- Therapists often integrate pain education, mindfulness strategies,

cognitive-behavior techniques and motivational interviewing

- Evidence is limited despite wide utilization and anecdotal success

- Important to counsel patient on expectations prior to starting PT

24

Till, S. R., et al. (2017). "The role of nonpharmacologic therapies in management of chronic pelvic pain: what to do

when surgery fails." Curr Opin Obstet Gynecol 29(4): 231-239.

Myofascial Pelvic Pain: Treatment Strategy

• Muscle Relaxers

– Cyclobenzaprine(Flexeril) 5mg at night before bed, take 2-3 hours prior to

bedtime to decrease daytime drowsiness. Flexeril also has TCA-like effect

with daily use and can be titrated. Maximum dose is 30mg/daily

– Other options: metaxalone (skelaxin), methocarbamol (robaxin), tizanidine

(zanaflex)

– Use carisoprodol (soma) with caution as it gets metabolized to

meprobamate, which is a benzodiazepine

– Vaginal diazepam used off label for pelvic floor myofascial pain

o Data regarding efficacy is limited

o Systemically absorbed, so increased risks of CNS depression with

narcotic use, as well as risk of dependency and abuse

o Can give regular tablets vs compounded suppositories

o If choose to prescribe, recommend short term use and adjunct to PT

25Carey ET, et al. (2017). “Pharmacological management of Chronic Pelvic Pain in Women." Drugs 77:285-301.

Myofascial Pelvic Pain: Treatment Strategy

• Trigger Point injections

- Local anesthetics can be injected, with improvement lasting

longer than anesthetic duration of action

- Mechanism is unknown, possible explanations include dry

needling, hydrodissection of tight tissue bands

- Likely benefit if focal area of pain that reproduces symptoms

26

Till, S. R., et al. (2017). "The role of nonpharmacologic therapies in management of chronic pelvic pain: what to do

when surgery fails." Curr Opin Obstet Gynecol 29(4): 231-239.

Myofascial Pelvic Pain: Treatment Strategy

• Botox

- Small studies demonstrating improvement in dyspareunia and resting pressure

of the pelvic floor1

- Onset 72 hours after injection, lasts around 16 weeks

- Risk of bowel/bladder dysfunction (constipation/urinary retention, incontinence)

- Hard to get covered by insurance

• Acupuncture

– Pilot study on patients with CPP not responsive to trigger point injections showed

decreased pain after 10 weeks2

– Small meta-analysis of 4 RCT studies (474 participants) showed small

improvement with acupuncture as compared to regular care3

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1. Jarvis SK et al (2004) “Pilot study of botulinum toxin type A in the treatment of chronic pelvic pain associated

with spasm of the levator ani muscles” Aust N A J Obstet Gynaecol 44:46-50

2. Mitidieri, A. M. S., et al. (2017). "Effect of Acupuncture on Chronic Pelvic Pain Secondary to Abdominal

Myofascial Syndrome Not Responsive to Local Anesthetic Block: A Pilot Study." Med Acupunct 29(6): 397-404.

3. Sung, S. H., et al. Acupuncture Treatment for Chronic Pelvic Pain in Women: A Systematic Review and Meta-

Analysis of Randomized Controlled Trials. Evid Based Complement Alternat Med 2018.

Central Pain Sensitization

• Generally accepted notion – when CPP is unresponsive to

interventions there is likely a component of CNS sensitization

• Screen for sensitization with Fibromyalgia Screening

Questionnaire

– Are there other function syndromes present (fibro, IC, IBS, functional

dyspepsia, chronic headaches etc)?

– Is there increased or chronic fatigue?

– Is there increased sensitivity to other painful stimuli ie light, sound,

temperature etc?

• If yes then nervous system needs to be treated

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Fibromyalgia Screening Tool

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Scoring information is shown in blue. The possible score ranges from 0 to 31 points. A score equal to or greater than 13 points is

consistent with a diagnosis of fibromyalgia. In addition to a cutpoint of 13 points, diagnostic criteria in the 2011 Modification of the ACR

preliminary diagnostic criteria for fibromyalgiaa specify the presence of the following 3 conditions: [1] Widespread Pain Index .7 and

Symptom Severity .5 or Widespread Pain Index between 3 and 6 and Symptom Severity .9; [2] Presence of symptoms at a similar level

for at least 3 months; [3] The patient has no other disorder to explain the pain.

It’s not all in your head

• Make a clear distinction between central nervous system sensitization/amplification and psychological cause of pain

• Phrases I use:

– There are two components to every type of pain – the component where something in the body is inflamed/injured (ie the nociceptive component) and the component that involves the wiring sending that signal of damage up to the brain. We wouldn’t feel pain if we didn’t have that wiring and a brain to receive it. Sometimes the wiring gets over stimulated and the signal are going too fast and too loud – and sometimes continue after the initial damage has healed.

– Imagine your body is like a guitar and your nervous system is the amplifier. If your nervous system is NOT sensitive –like an amp turned way down you can strum the guitar really hard and not hear very much. If your amp is turned all the way up (ie CNS sensitization/amplification) you will feel even the lightest strum of the guitar

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Central Pain Sensitization: Treatment

• Medications

– TCAs (amitriptyline/nortriptyline), SNRIs (duloxetine, venlafaxine),

anticonvulsants (gabapentin/pregabalin)

• Exercise/Movement

– Physical therapy – little evidence other then small RCT’s but lots of opinion

and anecdotal benefit for CPP specifically (strong evidence for fibromyalgia)

• Even in setting of no obvious myofascial component

– Lots of evidence for increasing activity decreasing symptoms when central

amplification is involved

– Any movement can be successful so build on a patients current base

• Yoga

– Several small RCTs showed improvement in symptoms (one compared to

usual care and one to massage)1

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1. Till, S. R., et al. (2017). "The role of nonpharmacologic therapies in management of chronic pelvic pain: what to

do when surgery fails." Curr Opin Obstet Gynecol 29(4): 231-239.

Central Pain Sensitization: Treatment

• Cognitive Behavioral Therapies

– Targeted at maladaptive coping behaviors that arise in setting of

longstanding chronic pain

– Small RCT level evidence showing improved pain scores and improved

sexual function in setting of CPP1

• Mindfulness Strategies

– Evidence for improvement in fibromyalgia in FM symptoms, pain

perception, sleep quality, psychological distress, non-attachment (to self,

symptoms and environment), civic engagement2

– One small pilot showed improvement in pain and functionality in patients

with CPP3

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1. Till, S. R., et al. (2017). "The role of nonpharmacologic therapies in management of chronic pelvic pain: what to

do when surgery fails." Curr Opin Obstet Gynecol 29(4): 231-239. 2. Van Gordon, W., et al. (2017). "Meditation

awareness training for the treatment of fibromyalgia syndrome: A randomized controlled trial." Br J Health Psychol

22(1): 186-206. 3. Fox, S. D., et al. (2011). "Mindfulness meditation for women with chronic pelvic pain: a pilot

study." J Reprod Med 56(3-4): 158-162.

www.fibroguide.com

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Williams DA, Kuper D, Segar M, Mohan N, Sheth M, Clauw DJ. Internet-enhanced management of

fibromyalgia: a randomized controlled trial. Pain. 2010;151(3):694-702.

www.fibroguide.com

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Sleep

• Pain and sleep are reciprocally related

• Sleep deprivation is a stronger predictor of worsening

and recurrent chronic pain episodes

• Sleep disorders proven to exists in centralized pain

disorders

• Frequent pain behavior is to cope in ways that get in

the way of good sleep hygiene

35

Finan, P. H., Goodin, B. R., & Smith, M. T. (2013). The association of sleep and pain: an update and a path

forward. J Pain, 14(12), 1539-1552.

Diet

36

• Studies are limited

• Small RCT – 300 women with known endometriosis causing CPP

– Randomized to two arms – both had hormone therapy, one followed a gluten free diet

– Followed for 6 months – gluten free arm showed statistically significant improvement in pain

• Elimination diets (remove certain nutrients – ie gluten, dairy, corn, animal protein, sugar)

– Small limited data for individual level improvement with variety of removals

• Rat models showing linkage between sugar and increased pain

• Co-occurance between IBS and CPP – trial of FODMAPs reasonable

Marziali, M. and T. Capozzolo (2015). "Role of Gluten-Free Diet in the Management of Chronic Pelvic Pain of

Deep Infiltranting Endometriosis." J Minim Invasive Gynecol 22(6s): S51-s52.

Role of Trauma

37

• Long standing linkage between Adverse Childhood Events (ACEs) and chronic pain

• Specifically in CPP – rates of sexual trauma are nearly three times that of controls

– Unclear relationship

– Biological Embedding – developmental trajectories change in response to trauma due to alterations in pro-inflammatory cytokines

– ACEs consistently linked to increased levels of negative emotionality which in turn has been independently linked to increased painful symptoms and increased rates of chronic pain conditions

• Most studies have looked at the static relationship between ACEs and chronic pain

The Multidisciplinary Approach to the Study of

Chronic Pelvic Pain (MAPP)

38

• Results showed that cumulative severity of ACEs is associated with substantially worse pain scores at one year

• Individuals with worse perceived well-being were less likely to engage in healthy behaviors

• Higher ACE scores:

– less likely to engage in healthy behaviors

– reported lower levels of physical well-being

– higher levels of symptoms related to CNS sensitization/amplification

– higher levels of depression, catastrophizing, anxiety, and perceived stress.

• Individuals with a history of ACEs show of fMRI imaging studies:

– limbic hyper-responsiveness to threat, hippocampal hyper-responsiveness to sad subliminal images, and overall reduced limbic-prefrontal connectivity

Schrepf, A., et al. (2018). "Adverse Childhood Experiences and Symptoms of Urologic Chronic Pelvic Pain

Syndrome: A Multidisciplinary Approach to the Study of Chronic Pelvic Pain Research Network Study." Ann

Behav Med 52(10): 865-877.

MAPP: Treatment Implications

39

• ACE history will lead to higher likelihood of CNS sensitization

• Trauma based therapies should be offered/suggested with emphasis on communicating how/why these experiences are contributing to the current state of pain

• Must be addressed in the setting of a strong therapeutic alliance

• Psychotherapy, trauma based counseling, EMDR, somatic experiencing, cranial sacral therapy – all modalities with some evidence in trauma based care

• Shift the focus to self-care – high ACE scores associated with increased guilt, shame and affective disorders that need to be addressed

Schrepf, A., et al. (2018). "Adverse Childhood Experiences and Symptoms of Urologic Chronic Pelvic Pain

Syndrome: A Multidisciplinary Approach to the Study of Chronic Pelvic Pain Research Network Study." Ann

Behav Med 52(10): 865-877.

Putting It All Together

40

Myofascial

Components

Adverse

Childhood

Events

Central

Sensitizatio

n

CPP

CASE

41

Integrative treatment approach:

• Re-engaged with patient around cause of her pain

– Ie. Improved the therapeutic alliance

• Physical therapy for pelvic floor dysfunction and levator spasms

• Neurontin for centralized pain/fibromyalgia

• Acupucture

• CBT

• Reviewed role of trauma history and suggested ongoing work on therapy around what triggers her central nervous system

• Future topics of diet and activity are slowly being introduced

Take Home Points

42

• Develop a therapeutic alliance

– Come to shared story about cause

– Let them know you believe their pain

– Set common goal for improved function

• Do a good work up

– If there are identifiable causes that can be targeted – find them and treat and refer as needed (GYN, Urology, GI, neurology)

• Screen for myofascial/somatic component

– Pelvic floor PT never a wrong choice if not already tried

– Consider other manual modalities – acupuncture, cranial sacral therapy

• Screen for central sensitization

– Treat entire nervous system if present – medications, elimination diet, mindfulness, CBT

• Screen for trauma

Resources

• International Pelvic Pain Society (www.pelvicpain.org)

- Includes physicians, midlevel providers,

physical therapists, psychologists

- Annual meeting includes clinical foundations course

- Website (under construction) has downloadable assessment

forms, patient handouts, search for providers

• American Physical Therapy Association

Section on Women’s Health(www.womenshealthapta.org)

- PT locator for therapists that perform women’s pelvic PT43

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Questions?