Taking an integrative approach to treating pelvic pain
Estimates of up to 30 million women and an unknown number of men suffer from chronic pelvic pain in the U.S & UK. There are many conditions that overlap in the pelvis and the entire body, so we need to look at the whole person and be able to “connect the dots” in pelvic pain management.
Overlapping pelvic pain conditions
My own experience, and much of the literature, has shown that bladder pain syndromes are at least part of the picture of chronic pelvic, sexual and genital pain about 80% to 85% of the time. Interstitial cystitis, also known as painful bladder syndrome, is one of the most common triggers of pelvic pain, and I believe it is largely underdiagnosed. Interstitial cystitis is more common in women, but anyone can have the condition. Some of the more common symptoms of interstitial cystitis may include urinary frequency, urgency and otherwise unexplained pain located anywhere in the pelvic region. Painful symptoms usually occur upon “holding one’s bladder” for any length of time and urine cultures are negative or sterile. Inflammation without infection leads to many incorrect diagnoses of “UTIs.” Pain during intercourse is also another very common symptom. An interstitial cystitis “flare” is a period of extreme pain or increased intensity of symptoms across several hours, days or weeks, and is not the same for everyone.
Along with interstitial cystitis, endometriosis and IBS are also common generators of pelvic pain. Additionally, there are many other pain and inflammatory syndromes that are associated with chronic pelvic pain, including all the autoimmune disorders, migraines, fibromyalgia, TMJ, multiple chemical sensitivity syndrome, and others. Patients with pelvic pain often suffer from fatigue, sleep disorders, allergies and other slowly disabling illnesses. We also need to think about the muscular and nervous systems of the body that typically contribute to the pain.
Challenges of overlapping pelvic pain conditions
The pelvic region is the busiest region of the body, both functionally and mechanically. We constantly use our pelvic region with nearly every activity and for all of the obvious bodily functions of elimination, reproduction and sexual pleasure. The pelvis is divided into six or seven different medical specialties, and unfortunately very few of those specialty training programs are currently teaching 21st century pain science. Meanwhile, even those trained in pain management commonly fall short in their training of any of the pelvic organ “triggers.” Patients often face their biggest challenge when seeking practitioners who recognize that so many of these overlapping illnesses are really connected.
The integrative approach
As primary care physicians, we need to have knowledge in diagnosing and treating interstitial cystitis, irritable bowel syndrome, pelvic floor dysfunction, peripheral neuropathies, and other conditions of the pelvic region. We also need to know when to refer to the urologist or uro-gynecologist, rheumatologist, sleep specialist, psychiatrist, physical therapist, acupuncturist and other mind/body practitioners.
Initial approach to treating pelvic pain
There are guidelines for interstitial cystitis and chronic pelvic pain from prominent organizations, such as the American Urological Association and the International Pelvic Pain Society. First- and second-line treatments can easily be incorporated into the general practitioner's protocol. These include behavior modifications (ie, avoiding dietary triggers), stress management and pain control, including medications and physical therapy.
At a patient's initial visit, after obtaining their in-depth pain history, I perform a pelvic exam that includes musculoskeletal and neurological assessment between the mid-abdomen and mid-thighs. Almost always, the pelvic floor muscles are tight. If palpating the underside of the bladder demonstrates pain and the patient's history indicates that interstitial cystitis is a trigger, I often will do a bladder instillation of a proprietary compounded heparin-lidocaine formulation that provides immediate relief. Sometimes I will do variable peripheral nerve blocks in the pelvic region, inject Botox into the pelvic floor when necessary, and may incorporate the appropriate use of medications to control the pain.
These early treatments and referrals to specialized pelvic floor physical therapists are all simple, quick, safe, and go a long way in demonstrating that it is the bladder and nerves and muscle clenching that have been the source of much of the pain. It shows the patient that their pain level can go down significantly with proper treatment and management.
Look at the whole picture
Doctors shouldn't feel they have to learn all the overlapping conditions inside and out to be comfortable in managing pelvic pain. We just have to be good listeners, believe and understand the patient and educate them and ourselves.
Doctors or anyone licensed to do the simple office procedures mentioned are able to learn the techniques very easily. Additionally, it becomes important to be familiar with adjunctive practitioners to whom you can refer when necessary.
Disclosure: Echenberg reports no relevant financial disclosures.