Pelvic Pain Treatment in Modern Medicine: A Nightmare for Clinicians, Everyone Is Struggling Like A Blind Man Groping Elephant

Chronic pelvic pain (CPP) is defined as pain in the lower abdomen or pelvis lasting a minimum of 6 months and not associated exclusively with menstruation or related to pregnancy (Royal College of Obstetricians and Gynaecologists. 2012). CPP affects 25% of women and 2 to 10% of men (Bradley MH et al, 2017). In the United States, CPP accounts for about 10% of the admissions to urogynecologists with a varying prevalence of 5.7 to 26.6% (Ahangari A, 2014).

“No one, even OBGYNs, seems to want to take on chronic pelvic pain cases. Few physicians, including gynecologists, are interested in managing the complex area of pelvic pain.”

Says Kathryn Witzeman, MD, an Associate Professor in the Department of Obstetrics and Gynecology at the University of Colorado School of Medicine (Witzeman K, 2022).

Blind Men And The Elephant

Regarding the treatment of pelvic pain, Dr Witzeman says:

“You may have heard the parable of the blind men and the elephant, which is analogous to how pelvic pain has been treated in the US for the past 50 to 100 years. Each healthcare provider, no matter their specialty, focuses their evaluation and treatments from their own perspective. A urologist may look at the bladder and urinary system; a gastroenterologist may focus on digestion and the GI system; a gynecologist will examine the reproductive system; and a psychiatrist or psychologist will assess mental health. Clinicians in some specialties believe pelvic pain is “some other HCP’s problem” and always refer onward.

“As a result, the person with pelvic pain is left in a horrible quandary, going from provider to provider, seeking help from their suffering. They undergo multiple evaluations, invasive tests, and try several treatments, including surgery that may go as far as removal of reproductive organs. All of this occurs with little to no coordination of their care or communication among healthcare providers. And in many cases, these individuals do not get complete – or any – resolution of their painful symptoms.”

A Nightmare Frustrating All Specialists

Dr Witzeman's specialty is OBGYN. She noted that the specialists who are “responsible” for treating pelvic pain are not limited to OBGYNs. A variety of other specialists are involved incuding family medicine/primary care physicians, minimally invasive gynecologic surgeons (MIGS), pain specialists, PM&R physicians or physiatrists, physical therapists, behavioral health specialists, emergency physicians, gastroenterologists, urologists, and general surgeons.

Inclusive Diagnosis

CPP is poorly understood (Hunter , C W ? et al, 2021). Diagnosis of CPP remain challenging (Kloz SGR et al, 2019). Imaging and laboratory findings are often inconclusive in making the diagnosis of CPP (Alexandr MD et al, 2023).

Around 60% of these women never receive an exact diagnosis and approximately 20% are not even submitted to any investigation to explore the cause of their pain (Siqueira-Campos , VM et al, 2022).

In females, common diagnoses that contribute to chronic pelvic pain include endometriosis, interstitial cystitis/painful bladder syndrome, and vulvodynia .

Shared between males and females, there are other disorders such as irritable bowel syndrome, colitis, pelvic floor dysfunction, and neuropathy (Siqueira-Campos, VM et al, 2022).

The possible causes of CPP may be urological, gastrointestinal, gynaecological and / or sexual (Fulvio DF et al, 2022). In over half of cases of CPP, there are comorbid endometriosis, pelvic adhesions, irritable bowel, or interstitial cystitis (Williams RE et al, 2004; Haggerty CL et al, 2005). It was reported that 70% of patients with a previous diagnosis of endometriosis are diagnosed with CPP (Laufer MR, 1997; Mowers EL et al, 2016).

The following conditions are most often cited as etiologies of CPP (Alexandr M.D et al, 2023):

1. Irritable bowel syndrome (IBS),
2. Musculoskeletal pelvic floor pain,
3. Painful Bladder Syndrome,
4. Peripheral Neuropathy (such as pudental neuragia), and
5. Chronic Uterine Pain Disorders .

Poor Prognosis

Prognosis is often poor in patients with chronic pelvic pain, similar to other chronic pain syndromes. After hysterectomy surgery, up to 40% of patients with CPP, the pain will continue, and 5% of CPP patients will complain of worsening pain (Lamvu G 2011). According to American pain medicine specialists Alexander M.D et al (2023), the management of CPP can be a lifelong condition requiring continuous treatment.

Treatment of CPP: A Formidable Challenge

Treatment of CPP is very challenging (Hunter C W ? et al, 2021). The evidence-based literature for the treatment of CPP is limited (Alexandr M.D et al, 2023). Although there is no strong evidence to support, the following modalities are commonly used for treatment of CPP:

• NSAIDs
• Pelvic floor physical therapy
• Cognitive-behavioral therapy
• Neuromodulation
• Hysterectomy (uterus removal).

But how effective and reliable are these modalitites? Let's take a look into the most up-to-date literature reviews.

NSAIDs

There have been no evidence showing their effectiveness. A 2017 Cochrane Review (Julie Brown et al, 2017) found that comparison of NSAIDs (naproxen) versus placebo revealed no evidence of a positive effect on pain relief.

A 2020 Cochrane review by British researchers Allen C et al (2020) conclueded:

• There is inconclusive evidence to show whether or not NSAIDs (naproxen) are effective in managing pain caused by endometriosis.
• There is no evidence on whether any individual NSAID is more effective than another.
• As shown in other Cochrane reviews, women using NSAIDs need to be aware of the possibility that these drugs may cause unintended effects.

Pelvic Floor Physical Therapy (PFPT)

Musculoskeletal dysfunction is frequently cited as a possible aetiology. Physical therapy (or physiotherapy) is therefore often recommended as one treatment modality for CPP (Loving S et al, 2012). However, currently there is no distinct evidence to support its effectiveness.

A 2012 systematic review (Loving S et al, 2012) involving 10 studies found:

• The 'stand-alone' value of physiotherapy could not be determined, because in all studies reviewed, physiotherapy treatments were always provided in combination with psychotherapeutic modalities and medications.
• Heterogeneity across the studies prevented meta-analysis.
• There seems to be some evidence to support the use of a multidisciplinary intervention for CPP (but not physical therapy alone).
• Current recommendations for physical therapy in CPP clinical guidelines and textbooks should be interpreted with caution due to the lack of a sufficient evidence base.
• High quality randomised clinical trials are urgently needed.

Ten years later in 2023, the situation did not change very much. A most recent systematic review (Bittelbrunn CC et al, 2023) including 7 trials indicated that there are still no trials conducted which investigated the efficacy of “stand-alone” phyical therapy for CPP. All of the 7 trials included in this review applied a combination of pelvic floor physical therapy ( PFPT) and psychotherapy (mindfulness) to treat CPP.

The authors of the review concluded: A multidisciplinary approach is required to treat women with CPP (in other words, either physical therapy alone or psychotherapy alone would not work).

In medical research field, methodological flaws and high risk of bias is a prevailing phenomenon. Musculosckeletal medicine research is no exception. A 2019 systematic review by Germany researchers (Kloz SGR et al, 2019) on physiotherapy management of CPP including 8 studies concluded:

• The evidence currently available is sparse with methodological flaws, making it difficult to recommend a specific physiotherapy option. There is an urgent need for high-quality randomized controlled trials to identify the most effective physiotherapy management strategy for patients with CPP.

A 2022 review (Fulvio DF et al, 2022) published in Int. Urogynecol J. assessed the effectiveness of myofascial manual therapies (MMT) for CPP . Seven studies were included. The review found:

• All of the 7 studies had high risk of bias.
• The quality of evidence showing MMT's positive effect was "very low".
• MMT is not superior to standard care for pain reduction and symptom impact improvements.
• Further high-quality, double-blinded, sham-controlled RCTs are needed.

Another 2022 systematic review (Dani?lle A. R-B et al, 2022) on pelvic floor physical therapy (PFPT) including 10 trials brough us some encouraging findings:

• PFPT seems to be efficacious for chronic prostatitis , chronic pelvic pain syndrome , vulvodynia , and dyspareunia .
• Smallest effects were seen in patients with interstitial cystitis and painful bladder syndrome.

At the same time, the authors of the review also pointed out:

• Most studies had a high risk of bias.
• More than half of the studies were of low quality.
• Further high-quality RCTs are needed.

Neuromodulation

Among a variety of treatment options for CPP, neuromodulation remains a centerpiece which can include sacral stimulation, spinal cord stimulation (SCS), dorsal root ganglion (DRG) stimulation, and PNS (Hunter, CW et al, 2021) .

A 2020 systematic review (Cottrell Angela M et al , 2020) on the efficacy of neuromodulation for CPP including 36 studies with 1099 participants found that:

• Treatments generally improved quality of life but with variable reporting of adverse events.
• However, many studies showed high risks of bias and confounding.
• Further work is needed with high-quality studies to confirm it.

A 2023 systematic review (Greig, J et al, 2023) on the efficacy of sacral neuromodulation for CPP involving 26 studies with 856 patients found the similar results:

• The improvement in pain score (0 to 10) ranged between 1.9 and 6.5 with a weigted mean difference of -4.64 (in a pooled data with 460 patients acrsoss 20 studies) at 6 months after intervention.
• The success rate is heterogeneious, ranging bwtween 20% to 60 %. The best report was 64.3%. This means for every 100 patients, at least 35 patients do not response to neuromodulation therapy.
• Complication rate is as high as 12% (189 cases / 1555 patients).
• All 26 studies have risk of bias ranging from low to high.
• All of the 26 studies were case series but not randomly controlled (with no control groups to compare).

Since no control groups set in these studies, we do not know how much of the pain reduction and success rate was actually produced by neuromodulation interventions and how much by natural healing.

Hysterectomy

Hysterectomy for chronic pelvic pain (CPP) is likely effective when symptoms are linked to menstrual pain, menstrual activity, and a reproducibly tender uterus on examination (Cochrum R et al, 2022).

Although hysterectomy is often touted as definitive treatment for CPP, prior studies suggest that one in four women undergo the discomfort and morbidity of hysterectomy without adequate relief of pelvic pain (As-Sanie S et al, 2021).

A few studies of hysterectomy report favorable outcomes for pelvic pain in well selected patients, with only 5% to 26% of cases failing to result in significant or complete improvement. However, 38% of patients without pathologic abnormalities reported persistent pelvic pain after 12 months in one study (Cochhrum R et al, 2022).

Although more than 200,000 hysterectomies are performed annually for the treatment of chronic pelvic pain, previous studies indicate that 1 in 4 women undergo the discomfort and morbidity of hysterectomy without the relief of pain (As-Sanie S et al, 2021). The factors that predict treatment failure remain poorly characterized.

A Way to Get out of This Never-Ending Nightmare?

CPP is a never-ending nightmare for all clinicians. Is there a way to get out? The answer is definitely YES, if only we have a magic bullet medicine.

Where we can find the magic bullet medicine? It is under everyone's nose.

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