Our expert is Colleen Fitzgerald, MD, MS, Medical Director for the Chronic Pelvic Pain Program at Loyola University Health System and an associate professor in the Department of Obstetrics & Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery at Loyola University Chicago Stritch School of Medicine.
PELVIC PAIN IS COMMON AND CAN BE DEBILITATING
At any one time, as many as 20 percent of reproductive-age women may be experiencing pelvic pain. This can range from a mild ache that comes and goes to steady and severe pain. Chronic Pelvic Pain (CCP), which is defined as pelvic pain that lasts for more than six months, can interfere with every aspect of life, including work, family, and the ability to exercise. In addition, ninety percent of women with CCP have pain associated with intercourse, which in turn can have a devastating impact on their intimate relationships.
WOMEN WITH CHRONIC PELVIC PAIN HAVE A “HIDDEN DISABILITY”
Their pain is real, but to the rest of the world, these individuals look normal. The problems associated with CCP include not only the pain, but also constipation and urinary incontinence. These are not visible, and on top of this, the usual tests for such possible causes as ovarian cysts, GI issues, endometriosis, bladder or colon problem may all be negative. A patient might hear, “No, you don’t have an ovarian cyst, and your colonoscopy is negative.” At the end of a long series of tests, she not only doesn’t have a diagnosis and treatment plan, she may become anxious and depressed. Her real problem is that even though her pain is real and physical, we don’t yet have tests to detect all the causes of CPP. I have found that by the time a patient comes to me, she will typically have already seen 10 other doctors who have told her, “Nothing is wrong.”
CONSIDER MUSCULOSKELATAL PROBLEMS WHEN DIAGNOSING PELVIC PAIN.
Traditionally, we have looked at an organ-based etiology for pelvic pain. We may be looking for a GI or gynecological explanation, but we’re now learning that upwards of 50% of pelvic pain cases come from muscle or nerve pain. Women with pelvic pain may have musculoskeletal problems such as low back or hip issues, and then the muscles and nerves associated with these issues become the drivers of the pain. These can cause a cascade of other problems in addition to pain, such as urinary incontinence or profound constipation.
TO TREAT PELVIC PAIN, IN MANY CASES WE FIRST HAVE TO TACKLE AN UNDERLYING MUSCULOSKELATAL PROBLEM
Addressing the underlying musculoskeletal or neurological problems can include seeing physical therapists specifically trained in treating the pelvic floor muscles. Think of pelvic floor physical therapy as first-line treatment in these cases, and refer patients to a provider who specializes in this treatment. The American Physical Therapy Association’s Section on Women’s Health offers a physical therapist locator to find qualified specialists. We use myofascial release vaginally to stretch the muscles and then we teach the patients how to relax the muscles. Interestingly, Kegel exercises are often the exact wrong approach since a patient’s problems may be that she can’t relax her muscles, not that the muscles aren’t strong enough.
PAIN MEDICATIONS AND MUSCLE RELAXANTS MAY BE APPROPRIATE, BUT AVOID OPIOIDS
Neuromodulator treatments (e.g., gabapentin [Neurontin, Gralise, others], pregabalin [Lyrica], amitriptyline [Elavil], and nortriptyline [Pamelor, others]) as well as muscle relaxants can be effective. We generally do not use opioids for chronic pelvic pain: in our experience, they have not been helpful. In addition, opioids can be constipating, which may lead to more pelvic pain. Many of the patients who enter our chronic pelvic pain program have been on opioids for years, and still report experiencing a pain level of 8 out of 10. I think many of these patients develop a tolerance to opioids as well as opioid-induced hyperalgesia hypersensitivity.