Introduction

As discussed in Chapter 8.1, historically, medical management of chronic pelvic pain (CPP) has frustrated both patients and providers, leading to the evolution of multimodal therapeutic strategies. Specialists are now viewing CPP as a polymorphic syndrome that may include organic pathology, musculoskeletal dysfunction, neuropathology and psychosocial impairments. Medical practice utilizing interdisciplinary, co-ordinated interventions is resulting in more successful treatment outcomes (Montenegro 2008).

Patients with pelvic pain seek help from multiple medical disciplines due to the wide variations in symptoms:

Due to the varied symptoms, patients may seek the help of primary care physicians, gynaecologists, urologists, colorectal surgeons, orthopedists, neurologists and/or psychiatrists. It is reported that 85–90% of patients with CPP have musculoskeletal dysfunction (Tu et al. 2006, Butrick 2009) that has been identified as either a primary cause of pain and dysfunction or a secondary consequence of vulvodynia, painful bladder syndrome/interstitial cystitis, chronic pelvic pain syndrome/non-bacterial chronic prostatitis, irritable bowel syndrome, pudendal neuralgia and endometriosis (Tu et al. 2006, Butrick 2009).

Furthermore, 30% of patients seen in primary care settings, and 85% in dedicated pain centres, are diagnosed with myofascial pain syndrome, demonstrating the importance of including musculoskeletal investigation early in the assessment of a patient with CPP (Butrick 2009). Ideally such investigation would be undertaken as part of a team approach to the condition.

Team management

As in the UK, physicians, physical therapists and mental health providers in the US commonly form interdisciplinary teams working with chronic pain in general and CPP in particular (see Figure 8.2.1). Surgical interventions and invasive procedures run the risk of symptom exacerbation in patients with CPP, therefore conservative therapies such as manual physical therapy techniques, psychotherapies and pharmaceuticals are often utilized first to modulate pain. Simultaneously, organic pathology needs to be addressed if identified. Interventional medicine strategies have shown efficacy in treatment of CPP and should be utilized if conservative measures fail (Simons et al. 1999, Zhang et al. 2004, Maria et al. 2005, Amir et al. 2006). Numerous treatment options exist, and more than one medical professional may be able to treat particular pathophysiological features, whereas certain treatments may only be available from one team member. Treatment of CPP should be considered as a dynamic process with many possible effective treatment combinations. Certain treatments will be more or less important than others as a patient’s presentation changes.

Figure 8.2.1 • Multimodal treatment algorithm, ψ; PT, physical therapy; IPM, interventional pain management; RF, radiofrequency; ANS, autonomic nervous system. See text for further abbreviations

As CPP is a syndrome associated with numerous pathophysiological features (see Box 8.2.1), extensive patient education and excellent interdisciplinary communication is imperative. Commonly, the treatment of a single impairment does not translate into the dramatic change the patient may expect. For example, if a patient with a 5-year history of severe vaginal burning is given an anticonvulsant and the pain is reduced, but not eradicated, the patient reports ‘disappointment’, and may think ‘it is not working’. In actuality, studies cited later in this chapter show anticonvulsants are effective for treating the central processing dysfunction this patient likely has. However, this patient may also present with pelvic floor myofascial trigger points and pudendal nerve inflammation, and until these impairments are also addressed, the overall syndrome is likely to persist. Through examinations, re-examinations, differential diagnoses and communication, the team can manage patient expectations more effectively.

The interventions listed in this text are effective treatments for the pathophysiological features listed in Box 8.2.1. The multimodal algorithm (see Figure 8.2.1) helps explain how to turn the complex problem of CPP into a sum of more manageable parts, expanding on the decision-making process to determine when and how to use different modalities. Clinical examples will be used to demonstrate the utility of the interdisciplinary approach.

Organic pathology intervention

Organic pathologies associated with CPP may include: yeast and bacterial infections, urinary tract, bladder and prostate infections, irritable bowel syndrome, endometriosis, colitis, Crohn’s disease, gastritis and sexually transmitted diseases. Symptoms of these pathologies mimic the symptoms of CPP and appropriate treatment protocols for the pathology should be followed (Butrick 2009).

Cognitive behavioural therapy

Cognitive behavioural therapy (CBT) should be considered an important component in a comprehensive treatment plan for patients with CPP. Behavioural interventions for chronic pain have become commonly available alternatives to medical and rehabilitative therapies (Campbell & Mitchell 1996, Gatchel & Turk 1996). CBT has been shown to be an effective treatment for chronic pain patients, by helping to develop self-management skills to improve their personal control of their condition, reduce pain, distress, and pain behaviour, and improve daily functioning (Turk et al. 1983, Eccleston et al. 2009). Treatment that focuses on decreasing negative thinking, emotional responses to pain, and perceptions of disability, while increasing orientation toward self-management, are predictive of favourable treatment outcomes (Morely et al. 1999, McCracken & Turk 2002).

CBT has been shown to be efficacious for the treatment of vulvodynia in two uncontrolled studies (Abramov et al. 1994, Weijmar et al. 1996) and in one well-controlled, randomized study (Bergeron et al. 2008). Masheb et al. conducted a randomized trial to test the relative efficacy of CBT and supportive psychotherapy (SPT) in women with vulvodynia. The results suggest that psychosocial treatments for vulvodynia are well tolerated and produce clinically meaningful improvements in pain. They observed that CBT, relative to SPT, resulted in significantly greater improvements in pain severity and sexual function. Additionally, participants in the CBT condition reported significantly greater treatment improvement, satisfaction and credibility than in the SPT condition (Masheb et al. 2009).

Manual physical therapy intervention

The musculoskeletal impairments that may cause pelvic pain and dysfunction are connective tissue restrictions, muscle hypertonus with or without myofascial trigger points (including muscles of the pelvic floor, trunk and lower extremities), altered neurodynamics of peripheral nerves and pelvic girdle and biomechanical abnormalities. After a thorough history, an extensive physical examination is performed. The entire surface areas of the abdomen, trunk, thighs, pelvis (up to the base of the clitoris and penis including the labia and scrotum) should be examined for connective tissue restrictions (Fitzgerald 2009).

Conservative medical management starts with manual therapy to eradicate or modify the impairments, which may in turn, decrease pain. In 2009, the Urological Pelvic Pain Collaborative Research Network (UPPCRN) concluded that somatic abnormalities, including myofascial trigger points and connective tissue restrictions, were found to be very common in women and men with IC/PBS and chronic prostatitis/chronic pelvic pain syndrome, respectively (Fitzgerald et al. 2009).

Somatic abnormalities may be the primary abnormality in at least some patients and secondary in others, but in either situation they should be identified and treated. The UPPCRN also published the outcomes of their feasibility trial comparing connective tissue manipulation (CTM) and myofascial physical therapy, versus global therapeutic massage, in patients with CPP. The group receiving skilled CTM and myofascial therapy had a significantly higher response rate than the group receiving massage alone (Fitzgerald et al. 2009). See Chapter 11.2 for a summary of CTM methodology.

Lifestyle modifications and home exercise programmes

All members of the interdisciplinary team can help the patient make temporary lifestyle modifications to improve function while the patient is being treated. Techniques to promote autonomic nervous system quieting, improve sleep hygiene, decrease stress, and improve diet and nutrition are all helpful, if not imperative, to the treatment process. Examples include the use of cushions, posture and/or breathing education, workstation, home and car modifications, clothing and footwear recommendations, and advice on exercise programme development (Prendergast & Rummer 2008).

Pharmacological therapy

The approach to pharmacological therapy for CPP in the USA is very similar to that in the UK. See Chapter 8.1.

Trigger point injection therapy

As described in Chapters 11 and 15, myofascial trigger points (MTrPs) are a nodular and hyperirritable area within a taut band of skeletal muscle. They can cause characteristic referred pain, local tenderness, autonomic phenomena, motor dysfunction and/or weakness and proprioceptive disturbances (Simons et al. 1999). Trigger points can be successfully treated with several approaches, one of which is trigger point injections. The most accepted theory hypothesizes that the mechanical disruption of the skeletal muscle fibres by an anaesthetic injection inactivates the trigger point (Simons 1999). Another possible mechanism is that the fluid injection may dilute nerve-sensitive substances that are present. Therefore, the injection may cause muscle fibre trauma releasing intracellular potassium, which can cause depolarization and block nerve fibres. A study looked at 18 women with pelvic pain for at least 6 months. All the women were found to have three to five trigger points in the pelvic floor muscles upon vaginal examination. Post trigger point injections, there was a significant decrease in a visual analogue scale, and improved patient global satisfaction and patient global cure visual scales (Langford et al. 2007). Trigger point injection therapy appears to be a viable treatment option for MTrPs in patients with CPP and should be considered when developing a comprehensive treatment plan.

Nerve blocks

Nerve blocks can be utilized for therapeutic and/or diagnostic purposes, however, interpreting a diagnostic block can be challenging given the many mechanisms by which a block acts. These mechanisms must be thoroughly understood as local anaesthetic agents are often utilized in nerve blocks. They primarily act by blocking sodium channels and can be effectively used for pain modulation at low doses that do not completely block nerve impulse propagation (Zhang et al. 2004, Amir et al. 2006). When managing neuropathic pain, sodium channels accumulate in the area of neural damage and develop abnormal discharge patterns at the periphery, and in the region of the dorsal root ganglia. Both the periphery and the dorsal root ganglia are sensitive to lidocaine (Ramer et al. 1999, Zhang et al. 2004, Amir et al. 2006). When neuropathic pain has become chronic, the mechanisms change over time resulting in several central and peripheral neural changes (Zhang et al. 2004). The reversal of these peripheral and central sensitizations or up-regulations would require the central nervous system to return to a more normal state, thus reducing pain (Abdi et al. 1998). It has been hypothesized that sodium channel blockade over an extended period can achieve this (Abdi et al. 1998). In addition to local anaesthetic, corticosteroids have also been used in the symptomatic relief of CPP (Antolak & Antolak 2009). The specifics on the techniques used, risks associated with, and the individual specialists performing neural blockades are available in various texts and will not be described here. The effectiveness of neural blockades for the treatment of the CPP population will be reviewed.

Botulinum toxin therapy

Botulinum toxin A (BTX/A) has been successfully used with myofascial pain and pain associated with chronic muscle spasm (Acquardo & Borodic 1994, Cheshire et al. 1994, Yue 1995, Porta et al. 1997). Initially it was thought that the mechanism of pain relief involved muscle relaxation induced by blockade of the release of acetylcholine at the neuromuscular junction. Now it is also thought to involve the direct antinociceptive activity of blocking the release of local neurotransmitters involved in pain signalling as well as maintaining stimulation of local inflammatory mediators. This decrease in peripheral sensitization results in a secondary decrease in central sensitization by a direct reduction in neurotransmitter release in the dorsal horn (Aoki 2003). Additionally, there is a reduction in the release of substance P and glutamate within the dorsal horn (Porta 2000). It has been postulated that the relaxation of affected muscles by BTX/A should decompress entrapped nerves in patients with myofascial pain syndrome or pain from chronic muscle spasm and should facilitate physical therapy (Filippi et al. 1993, Rosalis et al. 1996). Physical therapy is imperative if maximum benefits are to be achieved with BTX/A. The effects of BTX/A are typically evident within 3–10 days and last for approximately 3 months (Porta 2000). The potential use of BTX/A in the treatment of CPP has been recognized for more than 10 years (Brin & Vapnek 1997). The literature presents recent evidence for utilizing BTX/A in successfully treating CPP conditions:

Pulsed radiofrequency

There are two types of radiofrequency used clinically: continuous radiofrequency (CRF) and pulsed radiofrequency (PRF). CRF ablation has been in use for over 25 years. It uses a constant output of high-frequency current and produces temperatures greater than 45°C, which is neuroablative (Racz & Ruiz-Lopez 2006). PRF, on the other hand, uses brief pulses of high-voltage electric current which pauses between pulses to allow heat to dissipate. This causes less nerve destruction since the temperature does not usually exceed 42°C (Racz & Ruiz-Lopez 2006). The exact mechanism of PRF is unknown (Sluijter et al. 1998), but the current hypothesis proposes that PRF acts by modulating pain perception rather than directly destroying neural tissue (Cahana et al. 2006). Current evidence suggests that PRF may be useful in treating refractory neuropathic conditions (Hammer & Menesse 1998, Robert et al. 1998, Munglani 1999, Mikeladeze et al. 2003, Shah & Racz 2003, Van Zundert et al. 2003a,b, 2007, Cahana et al. 2006, Abejon et al. 2007, Martin et al. 2007, Wu & Groner 2007). There has been one reported case study of successfully using PRF on the pudendal nerve for CPP (Rhame et al. 2009). See Chapter 16.

Neuromodulation

Neuromodulation is technology that acts directly upon nerves by altering, or modulating, nerve activity by delivering electrical or pharmaceutical agents directly to a target area.

Multimodal treatment algorithm (Figure 8.2.1)

Patients with CPP present with a wide range of symptoms, impairments, disability and syndrome chronicity. Unfortunately, in many cases the patient is also suffering from the neuropathological and psychological consequences of having chronic pain. Thorough evaluations will lead to the initiation of appropriate, individualized treatments. This collection of individual, impairment-based treatments will comprehensively form an effective treatment plan. Once a pelvic pain syndrome has been diagnosed, a multimodal treatment algorithm can be a useful tool to organize the different therapies, re-formulate treatments after re-evaluations, and provide alternatives for ineffectual or intolerable therapies (Figure 8.2.1).

The process starts with the identification of CPP, treating organ pathologies (if present), and introducing the patient to the interdisciplinary team concept. (Fig 8.2.1: top two boxes). The interdisciplinary team (Fig 8.2.1: centre circles) may consist of many providers in four general therapeutic domains: physical therapy, interventional pain management, pharmaceuticals and psychosocial services. As the relevant literature and this chapter describe, the patient will benefit from a physical therapy evaluation to identify somatic dysfunction. The severity and chronicity of the patient’s case will dictate which other therapies are initiated. If a provider suspects central sensitization, anxiety, depression, nutritional, diet and/or sleep issues, simultaneous referrals to the psychosocial domain and for pharmacotherapy management may be indicated and beneficial. Patients are often evaluated over several appointments to identify all pain generators, dysfunction and limiting factors to treatment plans.

The multidirectional arrows of the algorithm stress the interdependent relationships between the providers, treatments and desired therapeutic outcomes. Once a treatment plan has been initiated, each provider needs to think critically about the efficacy of the intended individual treatment for the impairment in question (Fig 8.2.1: upper boxes). When two patients have the same diagnosis under the umbrella of pelvic pain (i.e. vulvodynia, painful bladder syndrome, etc.), it is almost certain their objective findings and treatment plans will be quite different. For example, as mentioned in this text, BTX/A has shown efficacy for decreasing pelvic floor hypertonus, which is known to cause pelvic pain. Often ineffectually, practitioners have administered BOX/A to treat ‘CPP’. However, a patient may have pelvic pain and not necessarily pelvic floor hypertonus. Therefore, BTX/A is likely ineffectual for this patient. Conversely, myofascial trigger points in the adductors, rectus abdominis and gluteal muscles can also cause CPP. The introduction of manual therapy, dry needling or trigger point injections, to the involved muscles, is reasonable and may be helpful. BTX/A may decrease hypertonus and MTrP therapy may eradicate MTrPs. Since the diagnosis of ‘pelvic pain’ does not explain the source of the problem it is more practical to think of interventions as tools for impairments rather than treatments for ‘pelvic pain’. In other areas of medicine, batteries of tests and a history and physical lead to a diagnosis. The diagnosis then dictates treatment. As Figure 8.2.1 depicts, multiple impairments are causal of CPP. The algorithm demonstrates that it is not appropriate to apply a linear therapeutic approach to complex syndromes such as CPP.

The overall treatment plan comprises the sum of individual therapeutic modalities as seen in the algorithm. Providers need to think globally about the function of the patient, but also locally about the intended intervention. Examples of individual treatments include connective tissue manipulation to restricted tissues, manual trigger point therapy to myofascial trigger points, prescribing of a sleep aid, talk therapy for a patient to decrease anxiety or use of hypnosis for pain management (Fig 8.2.1: upper boxes).

Once a treatment is initiated, patients will either respond, not tolerate the intervention, tolerate the intervention but have no response (i.e. a decrease in or elimination of the impairments, not necessarily an immediate change in the pain and/or functional status of the patient), or they may tolerate the treatment but generally not comply with the treatment plan (missed appointments, failure to take or tolerate medications, non-compliance with necessary lifestyle modifications, etc.) (Fig 8.2.1: lowest circles).

Reasons for poor treatment tolerance

There are numerous reasons why patients do not tolerate certain treatments. Patients may not tolerate medications because of side effects. Other drugs or another class of drugs could be tried. As the algorithm shows, other treatments in different domains could be substituted or employed in concert. Pharmaceuticals may help neuropathic components of pain; however, eradicating somatic dysfunction can also provide pain relief if medications are not tolerated. Manual therapy techniques and interventional medicine may also be used to eliminate primary or secondary sources of pain if medication is not tolerated.

Conversely, painful manual therapy techniques may be augmented by pain medications. CBT therapies may be used to help patients cope with the pain while they are being treated. If a patient with a hypertonic pelvic floor has a history of sexual abuse, he or she may not be able to tolerate internal manual pelvic floor therapy until psychosocial services are effectively utilized. Even then, this method of therapy may not be appropriate for this particular patient and perhaps BTX/A injections to the pelvic floor muscles under anaesthesia should be considered. In general, the individual treatments may need to be modified due to pain from the treatment, side effects, psychosocial distress with the treatment, belonephobia or personal choices and/or religious beliefs regarding particular therapies. The team has the ability to present the patient with choices so that collectively a tolerable and effective treatment plan can be developed.

Modifying manual treatment

Commonly, manual therapy techniques to impaired tissues cause pain both during and after treatment. For example, a patient with an obturator internus myofascial trigger point may also have pudendal nerve irritation if the trigger point is close to Alcock’s canal. Internal manual therapy to the trigger point may further aggravate the nerve and the patient may not be able to tolerate internal trigger point work due to hyperpathic reactions. This is another example where a patient could perceive the plan as ‘not working’. In actuality, the patient is not tolerating a single treatment and is experiencing a transient increase in pain. Even though it is certainly less than ideal, the reality of treating chronic pain is that certain treatments may temporarily create more pain before relief is achieved. The therapist could change the plan and attempt to externally release the trigger point or utilize dry needling. It may also be reasonable to consider a pudendal nerve block, which may decrease neural irritation and pain and allow the patient to tolerate internal trigger point therapy. Numerous therapeutic strategies, combined with interdisciplinary communication and patient education will help move patients out of treatments they cannot tolerate and into plans they can.

Non-responding symptoms

It is also possible that patients can, in fact, tolerate a treatment; however, they are ‘not responding’. It is crucial to differentiate between an impairment not changing versus the patient’s overall functional status not changing as a result of a sole treatment. Rarely does a sole intervention translate into what a patient desires and deems as ‘success’. For example, a patient is tolerating neural mobilizations to the pudendal nerve; however, the nerve continues to be exquisitely tender to palpation and their pain levels are not changing. If the neural mobility is not improving and pain persists it is advisable to change the technique or progress to more invasive procedures to facilitate impairment improvement. If the neural mobility is improving objectively but the subjective complaints persist, it is advisable to continue the current plan as well as re-evaluate to determine what other impairments are pain generators and implement treatment. Trigger point treatment can be used as a second example. Consider an accurate trigger point injection to a coccygeus trigger point. After the injection, the patient reports no change in their coccygeal pain. Upon examination, the trigger point is gone. The treatment was successful, now the team needs to address other impairments such as the sacrococcygeal joint, sacroiliac joint or pelvic floor muscles could be contributing to the coccygeal pain. It appears that the coccygeal trigger point was not relevant to the syndrome, though a reasonable thought, and now the team can move on to other treatments in the algorithm.

In the past, linear treatment approaches for CPP have yielded limited success. Current views of CPP as a multipathological syndrome have led to comprehensive interdisciplinary treatment strategies that recognize management of provider and patient expectations, while modulating pain and dysfunction, as hallmarks of the syndrome and its solution. With an evidenced-based team approach, excellent interdisciplinary communication, and appropriate patient education, providers and patients are progressing towards greater treatment efficacy and achieving desired therapeutic outcomes.