Identifying the Causes and Managing Chronic Pelvic Pain in Women

Avani Patel is a rising fourth-year medical student at Loyola University Chicago Stritch School of Medicine, in Maywood. Originally from Schaumburg, Ill., she is a proud alumna of University of Illinois at Urbana-Champaign. Patel is interested in pursuing a career in physical medicine and rehabilitation, with current interests including pelvic pain. 

Chronic pelvic pain is an underdiagnosed yet highly common and challenging condition that affects an estimated 26% of the world’s female population.¹ Chronic pelvic pain is defined as abdominal pain below the umbilicus for at least six months.² The pain can stem from various systems, including urogynecologic, gastrointestinal, musculoskeletal and nervous systems.³ Despite its multifactorial nature, specific etiologies are often unidentified in patients with chronic pelvic pain.

The diagnosis of chronic pelvic pain is primarily clinical and requires a comprehensive assessment of a patient’s medical history and physical examination. Healthcare professionals should also inquire about other functional somatic pain syndromes and mental health disorders, as they often coexist with chronic pelvic pain.⁴ Treatment is best when the patient can be treated at multiple angles due to the complexity of this disease. Chronic pelvic pain is a diagnosis of exclusion; therefore, it is important to rule out red flags in patients. Lab studies should be ordered broadly to evaluate for sexually transmitted infections, urinary tract infections and more. In some cases, imaging such as ultrasound may be warranted to exclude other potential disorders.

Treatment of chronic pelvic pain is not straightforward and usually requires tailoring to each presenting patient. For reasons mentioned above, the etiology of chronic pelvic pain makes it difficult to target treatment. One of the largest contributors to chronic pelvic pain is myofascial pain. Despite the fact that myofascial pain affects such a large proportion of people with pelvic pain, it is one of the most overlooked diagnoses in this population.⁵ Pelvic myofascial pain is typically diagnosed based on pain with palpation of pelvic floor muscles, requiring a physical pelvic exam by a professional who is able to localize the pelvic muscles.

There are several studies examining the effect of myofascial physical therapy, including a longitudinal study looking at the effects of a myofascial physical therapy intervention on chronic pelvic pain syndrome. 

The study included 39 women with chronic pelvic pain syndrome who were evaluated before and after receiving manual physical therapy. These evaluations included the Urgency Severity and Life Impact Questionnaire, the morphological assessment of the levator ani, psychological evaluation, and psychophysical assessments of pain.

 Of note, this study found significant improvement in self-reports of pelvic pain intensity three and nine months after myofascial therapy compared with baseline pain intensity, with no significant change in pelvic pain observed in the group that did not undergo therapy. An interesting finding includes that myofascial physical therapy improved all pain-related psychological parameters including anxiety levels, somatization and depression.⁶

This study suggests that myofascial physical therapy may be beneficial in the treatment of chronic pelvic pain, including a multisystemic benefit. However, the small sample size of this research study should be noted. While other systematic reviews have looked at myofascial therapy for treatment of chronic pelvic pain, most have inconclusive data; larger studies are needed on this topic.⁷

The psychological results in the previous study point to an important aspect of treating chronic pelvic pain syndrome. Chronic pelvic pain has a huge impact on patients’ emotional well-being and ability to function, which is why it is particularly essential to consider psychotherapy for pelvic pain. Among patients with chronic pelvic pain, the prevalence of depression ranges from 26% to 52% compared with 5% to 10% in the general population.5 Cognitive behavioral therapy (CBT) has been explored heavily in chronic pain conditions. CBT aims to educate patients about their pain and teach coping techniques to manage their pain, with techniques including bladder training, deep breathing and learning techniques to control the pelvic muscles.⁸

Although many interventions for chronic pelvic pain are not robustly researched, CBT seems to have a positive effect on women with chronic pelvic pain. In a study analyzing 28 selected studies, they found that CBT and interpersonal therapy were associated with improved mental health and pain outcomes including decreased medication use and morning cortisol levels. Long-term follow-up studies showed sustained or improved mental health and pain outcomes.⁹

In conclusion, the management of women with chronic pelvic pain requires a patient-centered approach that integrates evidence-based interventions. Psychological strategies, such as CBT, play a significant role in improving pain outcomes, enhancing coping strategies and promoting overall well-being. Further research is needed to explore additional treatment options and expand knowledge in this field. Increased education for healthcare professionals and trainees will facilitate optimal care for this vulnerable population.

References
1. Lamvu G, Carrillo J, Ouyang C, et al. Chronic pelvic pain in women: a review. JAMA. 2021;325(23):2381-2391. 
2. Berghmans B. Physiotherapy for pelvic pain and female sexual dysfunction: an untapped resource. Int Urogynecol J. 2018;29(5):631-638. 
3. Grinberg K, Sela Y, Nissanholtz-Gannot R. New insights about chronic pelvic pain syndrome (CPPS). Int J Environ Res Public Health. 2020;17(9):3005. 
4. Speer LM, Mushkbar S, Erbele T. Chronic pelvic pain in women. Am Fam Physician. 2016;93(5):380-387.
5. Till SR, Nakamura R, Schrepf A, et al. Approach to diagnosis and management of chronic pelvic pain in women: incorporating chronic overlapping pain conditions in assessment and management. Obstet Gynecol Clin North Am. 2022;49(2):219-239. 
6. Grinberg K, Weissman-Fogel I, Lowenstein L, et al. How does myofascial physical therapy attenuate pain in chronic pelvic pain syndrome? Pain Res Manag. 2019;2019:6091257. 
7. Dal Farra F, Aquino A, Tarantino AG, et al. Effectiveness of myofascial manual therapies in chronic pelvic pain syndrome: a systematic review and meta-analysis. Int Urogynecol J. 2022;33(11):2963-2976. 
8. Urits I, Callan J, Warner C, et al. Cognitive behavioral therapy for the treatment of chronic pelvic pain. Best Pract Res Clin Anaesthesiol. 2020;34(3):409-426.
9. Brooks T, Sharp R, Evans S, et al. Predictors of psychological outcomes and the effectiveness and experience of psychological interventions for adult women with chronic pelvic pain: a scoping review. J Pain Res. 2020;13:1081-1102.