Managing the complexities of chronic pelvic pain - Medical Observer

GPs are well-placed to lead the treatment of women with persistent pelvic pain

Persistent pelvic pain, also known as chronic pelvic pain, is a common condition that affects around 15% of women worldwide.

Despite being poorly understood and underdiagnosed, persistent pelvic pain is the most common cause of days off work for women of child-bearing age and costs Australia around $6 billion annually.¹

Persistent pelvic pain occurs in the area below the navel and nguinal ligament for six months or more.

It is a complicated condition, and symptoms can present in the bowel, bladder, reproductive organs, muscles, bones and nerves.

There can be increased sensitivity in pain signals from the pelvis to the brain, which can make the pain more generalised.

Patients can become hard-wired to feel pain and the body may start to feel pain even without a trigger or cause. The pain can also spread to a larger area.

Jean Hailes for Women's Health has opened its first Persistent Pelvic Pain Service in Melbourne, adopting a multidisciplinary team approach for the management of the condition.

Similar health services operate elsewhere, such as Perth (see Resources below), but Jean Hailes's service is unique because women can self-refer.

Research shows persistent pelvic pain is best managed by a team of specialists tailored specifically to the patient and her symptoms.

The team may include a GP, pelvic physiotherapist, psychologist, gynaecologist, pain specialist, acupuncturist, naturopath and clinical nurse.

The aim is for the patient to be able to live with the condition in a manageable way and have a good quality of life.

GPs are well placed to initiate treatment for suspected persistent pelvic pain, referring the patient to a multidisciplinary team if, within six months, medical management fails to sufficiently control symptoms.

Signs and symptoms

The following signs and symptoms may suggest persistent pelvic pain:

• Pelvic pain that persists after the initial cause is gone;
• Pain experienced on most days for more than six months;
• Complicated pain symptoms and multiple pain issues, for example, IBS, painful bladder syndrome, non-specific symptoms, hyperalgesia/allodynia;
• Pain accompanied by fatigue, feeling unwell and/or headaches;
• Multiple tests all returning normal results; and
• Multiple treatments with limited success.

Consultation

Obtain history from the patient, including:

• Menstrual history, including menarche, cycle, timing and/or progression of dysmenorrhoea;
• Bowel/bladder symptoms;
• Dyspareunia;
• Patient's pain journey, including severity of symptoms and impact on quality of life;
• Treatments, both past and current, and including surgery and outcomes; and
• Mental and emotional health – patients with persistent pelvic pain are at increased risk of depression or anxiety.

Undertake general examination including:

• Vital signs and BMI;
• Abdominal palpation for any masses, tenderness, scars and, if appropriate, vaginal examination (including cervical screening and swabs if indicated); and
• Specific organ systems as clinically indicated.

Conduct investigations including:

• STI, MSU, beta HCG;
• Pelvic ultrasound, preferably transvaginal if appropriate, and preferably with an experienced gynaecological ultrasound provider holding a certificate of obstetric and gynaecological ultrasound qualification.

Management

Discuss and initiate management options including analgesia, menstrual suppression, initial pain education and medical options.

Simple analgesia options will include regular NSAID use with pain; add paracetamol if necessary.

Other analgesic options can include, but should not be limited to, heat packs, gentle activity and acupuncture.

Menstrual suppression options include hormonal menstrual suppression with the aim of amenorrhoea.

Provide patients with information about useful websites to help familiarise them with pain science, for example the Pelvic Pain Foundation of Australia and Tame the Beast (see Resources at the end of this article).

Medical options for consideration in managing persistent pelvic pain:

• Amitriptyline – about 50% of women will find it useful. It can help to relieve stabbing/burning pain, bladder pain, pelvic muscle tension, migraine, irritable bowel, poor sleep, vulvodynia and bloating.
• Serotonin and norepinephrine reuptake inhibitors (SNRIs). These increase the norepinephrine effect in the brain, which treats pain, while selective serotonin reuptake inhibitors (SSRIs) increase the serotonin effect in the brain, which treats anxiety. Duloxetine, venlafaxine and desvenlafaxine have both SNRI and SSRI effects;
• Pregabalin and gabapentin. Both are useful for sharp, stabbing or burning pain and are less sedating that amitriptyline;
• Opioids are useful for short-term pain relief/ flares (days rather than weeks).

Referral

Refer to a gynaecologist if the patient:

• Fails to respond adequately to six months of medical management; or
• Has previously been diagnosed with endometriosis, with return of symptoms unresponsive to medical management; or
• Is experiencing infertility.

Referral to the following practitioners may assist the patient:

• A gynaecologist treats patients with possible endometriosis, complicated menstrual issues and those needing laparoscopy.
• Get a physiotherapist involved if there is a musculoskeletal or pelvic muscle component, vulvodynia, or bladder/bowel dysfunction.
• A psychologist will treat pain behaviours such as distress and avoidance, and can assist patients in developing coping strategies.
• A naturopath or acupuncturist can help patient to explore alternative approaches to improving symptoms.
• Involve a pain physician with patients with complex condition who have not responded to other management.

Resources

• Royal Women's Hospital, Melbourne chronic pelvic pain clinic
• Women Centre, Perth
• Continence Foundation of Australia
• Pelvic Pain Foundation of Australia
• Health Professionals list
• Tame the Beast

Reference

1. The Pelvic Pain Report