Chronic Pelvic Pain
Chronic Pelvic Pain
What is chronic pelvic pain?
Chronic pelvic pain is chronic or persistent pain in the pelvic region lasting for at least six months that can be cyclical or non-cyclical in nature. Chronic pelvic pain (CPP) is relatively common, with 4-16% of women being diagnosed with CPP over their lifetime. However, many women have symptoms of CPP for over two years before seeking medical care.
What causes chronic pelvic pain?
There are many potential causes of chronic pelvic pain, but typically patients have a combination of psychological and physical factors that contribute to their chronic pain. Pelvic floor dysfunction, which is impaired relaxation of the muscles in the pelvic area that provide support to the pelvic organs, is a very common cause of pain in CPP. Along with pelvic floor dysfunction, causes of CPP can include endometriosis, chronic bladder infection, pelvic adhesions, and musculoskeletal injury. Over time, pain caused by these conditions causes the body to experience constant high levels of pain, and can make the brain react to normal stimuli as though it were painful, increasing the amount of pain experienced. These physical factors are often coupled with psychological conditions that can predispose a patient to CPP, including generalized anxiety disorder, major depressive disorder, and posttraumatic stress disorder.
What other conditions can be associated with chronic pelvic pain?
- Chronic Fatigue Syndrome
- Sjogren’s Syndrome
- Interstitial cystitis
- Chronic prostatitis
- Irritable Bowel Syndrome
- Pelvic Floor Muscle Pain Syndrome
- Pelvic adhesions
- Mood disorders
What are treatment options for chronic pelvic pain?
Medical Therapies for Chronic Pelvic Pain
|First Line Options||
Non-steroidal anti-inflammatory drugs (NSAIDS)
Non-cyclical pain or neuropathic pain
|Selective serotonin reuptake inhibitors (SSRIs)|
|Tricyclic antidepressants (TCAs), pregabalin, gabapentin, serotonin-norepinephrine reuptake inhibitors (SNRIs)|
|Pelvic floor muscle spasm||Cyclobenzaprine|
|Compounded diazepam and/or baclofen vaginal suppositories or creams|
|Non-cyclical pelvic pain||Botulinum toxin injection|
|Suspected sacral nerve injury||
Local corticosteroid injection
|Severe uncontrolled pelvic pain||Referral to pain medicine specialist, consider opioids|
Non-Pharmacologic Therapies for Chronic Pelvic Pain
- Pelvic floor physical therapy
- Cognitive behavioral therapy
- Generally considered to be a last option
- Trigger point injections for short-term pain relief as an adjunctive treatment only
Compounded Medications for Chronic Pelvic Pain
In a prospective study of 21 women with pain due to pelvic floor dysfunction, 62% of women had moderately or markedly reduced pain with intravaginal diazepam use
In a retrospective study of 26 women with pelvic floor dysfunction and sexual pain, 25 women reported subjective improvement with intravaginal diazepam use
Topical gabapentin use has shown effectiveness in treating pain with reduced side effects compared with oral forms
In a prospective study of 118 patients with neuralgia, about 50% of patients reported improved pain relief with the use of a combination of amitriptyline and ketamine cream
In a retrospective study of 38 patients with provoked vestibulodynia, improved pain relief was noted in over 50% of patients with the use of a combination of amitriptyline and baclofen cream
In a retrospective study of 61 women with vulvodynia, 5% lidocaine ointment was associated with a significant decrease in intercourse-related pain
|Baclofen / diazepam||Vaginal suppository or cream|
|Baclofen / diazepam / gabapentin||Vaginal suppository or cream|
|Baclofen / gabapentin||Vaginal cream|
|Amitriptyline / ketamine||Vaginal cream|
|Amitriptyline / baclofen||Vaginal cream|
Compounded medications can be great options for patients who have specific medical needs unmet by commercial medications. All of the medications in the table above are not available at traditional pharmacies, and would need to be compounded to a patient’s specifications. Contact your healthcare provider for more information about specially compounded medications and to see if they may be right for you.
- Dydyk AM, Gupta N. Chronic Pelvic Pain. [Updated 2020 Jun 23]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK554585/
- Rogalski MJ, Kellogg-Spadt S, Hoffmann AR, Fariello JY, Whitmore KE. Retrospective chart review of vaginal diazepam suppository use in high-tone pelvic floor dysfunction. Int Urogynecol J. 2010 Jul;21(7):895-9.
- Passavanti MB, Pota V, Sansone P, Aurilio C, De Nardis L, Pace MC. Chronic Pelvic Pain: Assessment, Evaluation, and Objectivation. Pain Res Treat. 2017;2017:9472925.
- Hwang SK. Advances in the Treatment of Chronic Pelvic Pain: A Multidisciplinary Approach to Treatment. Mo Med. 2017;114(1):47-51.
- Faubion SS, Shuster LT, Bharucha AE. Recognition and management of nonrelaxing pelvic floor dysfunction. Mayo Clin Proc. 2012;87(2):187-193.
- Carrico DJ, Peters KM. Vaginal diazepam use with urogenital pain/pelvic floor dysfunction: serum diazepam levels and efficacy data. Urol Nurs. 2011 Sep-Oct;31(5):279-84, 299.
- Johns Hopkins Health. Solving the Pelvic Pain Puzzle. Johns Hopkins Health: Insight and News from Johns Hopkins Medicine. 2014;(2):4. Available at: https://www.hopkinsmedicine.org/news/publications/johns_hopkins_health/spring_2014/solving_the_pelvic_pain_puzzle.
- Boardman LA, Cooper AS, Blais LR, Raker CA. Topical gabapentin in the treatment of localized and generalized vulvodynia. Obstet Gynecol. 2008 Sep;112(3):579-85.
- Martin CJ, Alcock N, Hiom S, Birchall JC. Development and Evaluation of Topical Gabapentin Formulations. Pharmaceutics. 2017;9(3):31. Published 2017 Aug 30.
- Zolnoun DA, Hartmann KE, Steege JF. Overnight 5% lidocaine ointment for treatment of vulvar vestibulitis. Obstet Gynecol. 2003 Jul;102(1):84-7. doi: 10.1016/s0029-7844(03)00368-5. PMID: 12850611.
- Nyirjesy P, Lev-Sagie A, Mathew L, Culhane J. Topical Amitriptyline-Baclofen Cream for the Treatment of Provoked Vestibulodynia. J Low Genit Tract Dis. 2009;13(4):230-236.
- Lynch ME, Clark AJ, Sawynok J, Sullivan ML. Topical 2% Amitriptyline and 1% Ketamine in Neuropathic Pain Syndromes: A Randomized, Double-blind, Placebo-controlled Trial. Anesthesiology. 2005;103:140–146