Chronic pelvic pain may have a strong neuropathic
element, as mentioned before in this manuscript. Pain outflow from
different pelvic viscera and somatic areas converge into the dorsal horn,
spinal cord and brain centres. Prolonged stimulation of pain receptors in these
organs can lead to peripheral nerve sensitisation and upregulation of dorsal
horn receptors, resulting in primary and secondary hyperalgesia respectively.
Accordingly, efferent nerve impulses from the central nervous system can cause pain in different organs, not affected by the initial injury or disease.
Such phenomenon can also follow actual nerve injury, inflammation, ischaemia
or dysfunction resulting in wrong messages being sent to higher pain centres.
The end result will be a lower pain threshold and pain out of proportion to
nociceptive and non-nociceptive stimuli. Practical examples of visceral
hyperalgesia include irritable bowel syndrome and interstitial cystitis. The
presence of both problems in the same individual may represent viscero-visceral
conversion. As well, viscerosomatic hyperalgesia may occur in cases of
interstitial cystitis or dysmenorrhoea leading to pelvic muscles trigger points
and levator ani syndrome.
Management of chronic pelvic pain will not be
successful without proper attention to neuropathic pain. It can be the most
important factor causing treatment failure, despite proper surgical
interventions to deal with the primary pathology.
Management of neuropathic pain
Both medical and surgical means are used to deal with
neuropathic pain but psychological support is equally important to improve the
chances of success.
Neuropathic pain is usually not responsive to
standard or over the counter simple analgesics. Certain drugs are now available
for that purpose, but may not be equally effective in different cases.
Furthermore, they may need several weeks before having a real impact on the
patient’s symptoms. This information should be conveyed to all patients with
this type of pain to help them readjust their expectations to this fact, and not
to get disheartened in few days because of ‘failure of medication’.
antidepressants (amitriptyline) in small incremental doses [10 - 30 mg] every
night are known to reduce the intensity of neuropathic pain. However, there is
usual resentment by some patients to take antidepressants as it carries certain
stigma, in their views. Gentle persuasion and explanation goes a long way in
convincing the majority of patients.
[neurotin] which is GABA analogue, and other anti convulsant drugs can be
useful especially for patients with burning pain sensation. It is usually used
as part of a polypharmacy including NSAID and amitriptyline. Accordingly, a
smaller starting dose [100 mg] should be used before being increased slowly
depending on the patients’ response. The dose can be reduced down to the
lowest possible, once pain has been controlled. Patients should be monitored for
side effects as it can cause dizziness, ataxia, confusion and vertigo.
norepinephrine reuptake inhibitors have also proved useful in the treatment of
neuropathic pain, but are not first line management drugs.
injections of trigger points with local anaesthetics to desensitise the nerve
receptors are useful for anterior abdominal wall and pelvic muscles tender
points. This can lead to initial worsening of the pain before significant
improvement is felt. Targeting the pudendal nerve near the ischeal spine has
been mentioned before for the management of the levator ani syndrome.
reduce muscles spasm and tenderness and to reduce nerve outflow should be done
under the supervision of a trained physiotherapist.
Surgical nerve ablation has been used for a long
time in the treatment of chronic pain in general. The three techniques used in
the management of chronic pelvic pain are laparoscopic uterosacral nerve
ablation [LUNA] and excision [LUNE], and laparoscopic presacral neurectomy
[LPSN]. All these techniques have been described in detail before in this
Despite all the good intentions and great efforts
made by the medical profession, many patients still suffer from chronic pelvic
pain without having the chance to get specialists care. Furthermore, many
conditions are regularly missed in busy gynaecology, urology and
gastroenterology clinics, because of the nature of the problem itself. Chronic
pelvic pain is a disease and not a symptom. Many causes may be involved in
the same patient to different degrees. Furthermore, gynaecological problems
may cause urological or intestinal symptoms, and with the later two may cause muscular pelvic pain through viscerosomatic conversion. Examples of the
commonly under diagnosed problems are:
- Interstitial cystitis
- Levator ani syndrome
- Vulvodynia and vestibulitis
- Pelvic congestion syndrome
- Myofascial anterior abdominal wall problems
This can only emphasise the need for a dedicated management team with structured proactive protocols and follow up procedures
with regular auditing of management outcome. Hopefully, with better resources
and understanding, such teams will be the norm rather than an exception in
most hospitals with full communication with primary care providers.