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