Medical Care: Treatment of pelvic pain is complex in patients with multiple problems. It usually requires specific treatment and simultaneous psychological and physical therapy. A good relationship should be established between the physician and the patient. Treatment of chronic pelvic pain (CPP) must be tailored for the individual patient.
The goals of treatment must be realistic. They should be focused toward restoration of normal function (minimal disability), better quality of life, and prevention of relapse of chronic symptoms.
Pharmacotherapy
Pharmacotherapy consists of symptomatic abortive therapy to stop or reduce the severity of the acute exacerbations and long-term therapy for chronic pain.
Initially, pain may respond to simple over-the-counter (OTC) analgesics such as paracetamol, ibuprofen, aspirin, or naproxen. If treatment results are unsatisfactory, the addition of other modalities or the use of prescription drugs is recommended.
If possible, avoid use of barbiturate or opiate agonists. Also discourage long-term use and overuse of all symptomatic analgesics because of the risk of dependence and abuse.
Tizanidine may improve the inhibitory function in the central nervous system and can provide pain relief. Therapy with tizanidine is not considered the standard of care
Amitriptyline (Elavil) and nortriptyline (Pamelor) are the tricyclic antidepressants (TCAs) used most frequently for chronic pain.
The selective serotonin reuptake inhibitors (SSRIs) fluoxetine (Prozac), paroxetine (Paxil), and sertraline (Zoloft) also are prescribed commonly by many physicians. Other antidepressants such as doxepin, desipramine protriptyline, and buspirone also can be used.
Physical therapy
Physical therapy techniques include hot or cold applications, positioning, stretching exercises, traction, massage, ultrasound therapy, transcutaneous electrical nerve stimulation (TENS), and manipulations. Heat, massage, and stretching can be used to alleviate excess muscle contraction and pain.
Pelvic floor training also may be recommended.
Psychophysiological therapy
Psychophysiological therapy includes reassurance, counseling, relaxation therapy, a stress management program, and biofeedback techniques. With these modalities of treatment, both frequency and severity of chronic pain may be reduced.
Biofeedback may be helpful in some patients when combined with medications.
Surgical Care:
Various minimally invasive techniques may provide pain relief. These techniques include the following:
Trigger point injections: These injections are used mostly for localized trigger points (myofascial pain or neuroma).
Peripheral nerve blocks: Specific peripheral nerve block with local anesthetic and steroids may be helpful in selected cases.
Neuroablation of selected nerves can be performed by using different techniques, including thermocoagulation (radiofrequency ablation), cryoablation, or injection of chemical agents (alcohol, hypertonic saline, phenol).
An intrathecal morphine pump may be used, but careful selection for appropriate patients is very important.
Sacral nerve stimulation may be effective in the treatment of therapy-resistant pelvic pain syndromes linked to pelvic floor dysfunction (Everaert, 2001).
Various surgical procedures may be considered to treat CPP. Surgical procedures include presacral neurectomy (superior hypogastric plexus excision), paracervical denervation (laparoscopic uterine nerve ablation), and uterovaginal ganglion excision (inferior hypogastric plexus excision).
DRUG TREATMENT :
1. ANALGESICS :
- ACETAMINOPHEN
- IBUPROFEN
- NAPROXEN
2. OPIOIDS :
- FENTANYL
3. ANTICONVULSANTS : Certain antiepileptic drugs (eg, the GABA analogue gabapentin) have proven helpful in some cases of neuropathic pain. Other anticonvulsant agents (eg, pregabalin, clonazepam, topiramate, lamotrigine, zonisamide, tiagabine) have been tried in CPP.
- GABAPENTIN
- PREGABALIN
- CLONAZEPAM
- TOPIRAMATE
4. TRICYCLIC ANTIDEPRESSANTS
- NORTRIPTYLINE
- AMYTRIPTYLINE
5. SELECTIVE SEROTONIN REUPTAKE INHIBITORS :
- FLUOXETINE
- SERTRALINE
- PAROXETINE