{"paper_id":"40611abd-0754-406b-ab1c-ffaf817a1299","body_text":"Primary care management \nof chronic pelvic pain in women\nCLEVELAND CLINIC JOURNAL OF MEDICINE   VOLUME 85   •  NUMBER 3   MARCH  2018  215\nC\nhronic pelvic pain is a common clinical \nproblem in women, as prevalent in pri-\nmary care as asthma or back pain.1,2 It is often \nassociated with lost work days and decreased \nproductivity, increased healthcare spending, \nmood disorders, and negative effects on per -\nsonal relationships.\n1–3\n While specialty care referral may eventual-\nly be indicated, primary care doctors can take \nsteps to diagnose and effectively manage the \ncondition. \n ■ COMPREHENSIVE MANA\nGEMENT  \nLED BY PRIMARY CARE\nChronic pelvic pain is defined as pain in the \nlower abdomen persisting for 3 to 6 months \nand of sufficient severity to require medical \ncare or cause a functional disability.\n3 It is of-\nten detrimental to a woman’s personal life \nand overall health, making a comprehensive \nassessment and multidisciplinary approach to \nmanagement especially important. \n The ideal care-delivery mo\ndel is the patient-\ncentered medical home, whereby a primary \ncare physician coordinates comprehensive care \nwith the help of an interdisciplinary team.\n4,5 \nFor complex cases, referral may be needed to \nother specialties (eg, obstetrics and gynecology, \npain medicine) to help manage care.\n ■ T\nARGETED EVALUATION\nChronic pelvic pain often coexists with other \nsystemic pain syndromes or psychiatric condi-\ntions common in primary care. Table 1 lists \ncommon causes and associated findings.\nDetailed history is critical\nThe history is of utmost importance. Clini-\ncians should query patients about the char -\nREVIEW\ndoi:10.3949/ccjm.85a.16038\nABSTRACT\nChronic pelvic pain in women can arise from many \ncauses and often results in significant declines in function \nand quality of life. A systematic approach for evaluating \npatients and initiating a management plan are recom-\nmended in the primary care setting. Comprehensive \nmanagement strategies may include medication, pelvic \nphysical therapy, and behavioral interventions. \nKEY POINTS\nDiagnosing and managing chronic pelvic pain may be \ndifficult, but patients are often best served when their \nprimary care provider directs a team-based approach to \ntheir care. \nA detailed history, thorough abdominal and pelvic exami-\nnations, and targeted testing facilitate the diagnosis.\nAs in other chronic pain syndromes, the goals of therapy \nshould be incremental and meaningful improvements in \npain, function, and overall well-being.\nRACHEL BONNEMA, MD, MS \nAssociate Professor of Medicine, Division \nof General Internal Medicine, University of \nNebraska Medical Center, Omaha\nMEGAN McNAMARA, MD, MSc\nAssociate Professor of Medicine, Case Western \nReserve University School of Medicine, Cleveland, \nOH; Louis Stokes Cleveland VA Medical Center \nJENNIFER HARSH, PhD, LMFT \nAssistant Professor, Division of General Inter-\nnal Medicine, University of Nebraska Medical \nCenter, Omaha\nCREDIT\nCME\nELIZABETH HOPKINS, PT, DPT \nThe Nebraska Medical Center, Omaha\n on June 10, 2026. For personal use only. All other uses require permission.www.ccjm.orgDownloaded from \n\n216 CLEVELAND CLINIC JOURNAL OF MEDICINE   VOLUME 85   •  NUMBER 3   MARCH  2018\nPELVIC PAIN\nTABLE 1\nCommon causes of chronic pelvic pain and associated findings\nDifferential diagnosis Associated historical feature Physical examination\nMusculoskeletal\n \nP\nelvic floor dysfunction Complicated delivery, dyspareunia Vaginismus, point tenderness, or high tone \nof pelvic floor\nMyofascial pain or fibromyalgia Tender points, chronic somatic pain Tender points \nStress fractures Pain with repetitive movements, improved with rest\nDegenerative disk disease Burning, paresthesias Radicular signs, muscle weakness\nGastrointestinal\nConstipation\nInflammatory bowel disease Bowel urgency, hematochezia\nIrritable bowel syndrome Bowel symptoms; may increase premenstrually\nGynecologic (often cyclic with menses)\nAdhesions Surgical history Immobile uterus, nodularity\nAdenomyosis Menorrhagia, dysmenorrhea Enlarged, irregular tender uterus \non bimanual examination\nAdnexal mass Localized to 1 area Localized adnexal mass\nChronic pelvic inflammatory \ndisease\nDysmenorrhea Uterine cramping with menses\nEndometrial or cervical polyp Intermenstrual or postcoital bleeding Visual inspection\nEndometritis Uterine tenderness on bimanual examination\nEndometriosis Diffuse pelvic pain with menses, deep dyspareunia Fixed or immobile uterus, nodularity\nLeiomyomata Menorrhagia, pressure or heaviness Uterine nodularity, enlargement\nPelvic congestion syndrome Multigravid patient; deep dyspareunia, post-\ncoital pain, worse after prolonged standing\nVaricosity of labia, uterine tenderness \non bimanual examination\nVulvar vestibulitis Vulvodynia, dyspareunia Exquisite localized tenderness\nUrologic\nInterstitial cystitis Urgency, increased frequency of urination\nUrinary tract infection Dysuria\nUrolithiasis Localized sharp pain\nRadiation cystitis History of radiation\nOther\nPsychiatric (depression, \nsomatization)\nConcurrent mood disorder\nNeurologic (herpes zoster, \nnerve entrapment)\nHot, burning, electric shock-like pain; shingles\n on June 10, 2026. For personal use only. All other uses require permission.www.ccjm.orgDownloaded from \n\nCLEVELAND CLINIC JOURNAL OF MEDICINE   VOLUME 85   •  NUMBER 3   MARCH  2018  217\nBONNEMA AND COLLEAGUES\nacteristics of the pain as well as their medical \nand surgical history. Particular attention should \nbe given to obtaining a complete gynecologic \nhistory, including pregnancy, delivery complica-\ntions, dyspareunia, sexual assault, and trauma. A \ndetailed review of systems should focus on the \nreproductive, gastroenterologic, musculoskel-\netal, urologic, and neuropsychiatric systems.\n As with many pain syndromes, allowing the\n \npatient to “tell her story” helps to establish rap-\nport and obtain a more complete assessment. \nChronic pelvic pain has been associated with \nphysical or sexual abuse as a child or adult, so is \nessential to foster the doctor-patient relation-\nship and create a safe and open space for dis-\nclosure.\n3,6 It is important to screen women for \nsafety at home as well as for satisfaction or dis-\nsatisfaction with their relationships with their \nspouse or partner and family.\nPhysical examination\nThe physical examination should be directed \nby the history but should always include ab-\ndominal and pelvic examinations. These \nshould be conducted slowly and gently, assess-\ning for areas of tenderness, masses, and other \nabnormalities. Clinicians should aim to pin-\npoint the exact anatomic locations of tender-\nness if possible. Ongoing dialogue facilitates \nthis process by inquiring about pain at each \npoint of the examination.\n The pelvic examination should begin with\n \nvisual inspection for redness, discharge, le-\nsions, fissures, excoriations, and other abnor -\nmalities. A moistened cotton swab may be \nused to evaluate the vulva and vestibule for \nlocalized tenderness. The manual portion of \nthe pelvic examination should begin with a \nsingle digit, noting any introital tenderness or \nspasm. Next, the levator ani muscles should \nbe directly palpated for tone and tenderness. \nThe pelvic floor should be evaluated with at-\ntention to tenderness of the bladder or muscu-\nloskeletal structures (Figure 1). A bimanual \nexamination assessing uterine size and tender-\nness, nodularity, or a fixed, immobile uterus \nshould be conducted.\nDiagnostic workup\nBecause the differential diagnosis of chronic \npelvic pain is broad, the diagnostic workup \nand testing should be based on findings of the \nChronic \npelvic pain has \nbeen associated\n \nwith physical \nor sexual abuse\nFigure 1. Pelvic floor anatomy. During the pelvic examination, the levator ani muscles \nshould be directly palpated for tone and tenderness, and the pelvic floor should be evalu-\nated with attention to any tenderness of the bladder and musculoskeletal structures.\nIschiocavernosus \nmuscle\nPerineal membrane\nExternal \nanal \nsphincter\nLevator ani \nmuscles\nGluteus maximus \nmuscle\nBulbocavernosus \nmuscle\nIschiopubic ramus\nSuperficial \ntransverse \nperineus \nmuscle\nIschial tuberosity\nInternal pudendal artery\nPerineal body\n on June 10, 2026. For personal use only. All other uses require permission.www.ccjm.orgDownloaded from \n\n218 CLEVELAND CLINIC JOURNAL OF MEDICINE   VOLUME 85   •  NUMBER 3   MARCH  2018\nPELVIC PAIN\nhistory and physical examination. In general, \nextensive laboratory testing is of limited use for \nevaluating women with chronic pelvic pain.\n3,7 \n Urinalysis\n should be obtained for symp-\ntoms suggesting bladder involvement such as \ninterstitial cystitis. \n Pelvic ultrasonography\n can help identify \npelvic  masses palpated during the physical \nexamination, but routine use of imaging is \nnot recommended.\n3,7 If pelvic congestion syn-\ndrome is suspected, starting with pelvic ultra-\nsonography is reasonable before incurring the \nrisk or cost of computed tomography or mag-\nnetic resonance imaging.\n8\n ■ GENERAL TREA TMENT\nA holistic approach ensures that the treatment \nplan adequately addresses the physical, social, \nand psychological aspects of chronic pelvic \npain.\n9 Treatments may include medication, \npelvic physical therapy, and behavioral thera-\npies (Table 2). As with other chronic pain \nsyndromes commonly seen in primary care, the \ntreatment plan may develop over multiple vis-\nits as the patient-provider relationship grows \nand as treatment response is evaluated.\nMedical therapy\nThe main goals of medical therapy are to im-\nprove function and quality of life while mini-\nmizing adverse effects. General treatments in-\nclude the following: \n Analgesics.\n Nonsteroidal anti-inflamma-\ntory drugs and acetaminophen may provide \npain relief, although there is weak evidence for \ntheir efficacy in treating chronic pelvic pain.\n9 \n Neuropathic agents. \nOne of several avail-\nable neuropathic agents commonly used in \nthe treatment of chronic pain can be tried \non patients who fail to respond to analgesics. \nTricyclic antidepressants such as amitripty-\nline and imipramine decrease pain, reduce \nsymptoms of depression, and improve sleep.\n10 \nThe results of a small randomized controlled \ntrial suggest that gabapentin is more effective \nthan amitriptyline for reducing chronic pelvic \npain.\n11,12 Published guidelines currently list \nboth amitriptyline and gabapentin as first-line \nagents; nortriptyline and pregabalin are con-\nsidered acceptable initial alternatives.\n9\n V enlafaxine and duloxetine may help \nchronic pelvic pain, although specific evi-\ndence is lacking. Duloxetine may be an appro-\npriate choice for women with chronic pelvic \npain who also experience depression and uri-\nnary stress incontinence.\n9\n Opioids.  Opioid therapy should be consid-\nered only when all other reasonable therapies \nhave failed.\n10 Patients may develop tolerance \nor dependence, as well as opioid-induced ad-\nverse effects such as hyperalgesia.\n9,10 Guide-\nlines recommend that primary care providers \nconsult with a pain management specialist be-\nfore prescribing opioids, and that patients be \nthoroughly counseled about the risks and side \neffects.\n9\n Nerve block and neuromodulation.  There \nis weak evidence for the use of these modalities \nfor treating chronic pelvic pain.\n9 If used, they \nshould be part of a broader treatment plan and \nshould be performed by providers who special-\nize in management of chronic pain.\n ■ DISEASE-SPECIFIC TREA\nTMENT\nEndometriosis: Hormonal therapy\nPelvic pain that significantly fluctuates with \nthe menstrual cycle may be caused by endome-\ntriosis, the most common gynecologic cause of \nchronic pelvic pain. Women with cyclic chronic \npelvic pain should be empirically treated with \nhormonal therapy for at least 3 to 6 months be-\nfore diagnostic laparoscopy is performed.\n13 \n Oral contraceptives, gonadotropin-releas\n-\ning hormone (GnRH) analogues, progesto-\ngens, and danazol have proven efficacy, al-\nthough side-effect profiles differ significantly. \nIn a comparative trial, patients treated with \nGnRH analogues had more improvement in \npain scores compared with those treated with \noral contraceptives, but they experienced a \nsignificant decrease in bone mineral density.\n11 \nThe effects on bone mineral density associ-\nated with GnRH analogue therapy can be \nmitigated by “add-back” low-dose hormonal \ntherapy (norethindrone, low-dose estrogen, or \na combination of estrogen and progesterone), \nwhich may also provide symptomatic relief for \nassociated hot flashes and vaginal symptoms.\n11\nInterstitial cystitis  \noften accompanies endometriosis \nRecognizing that chronic pelvic pain may \nhave more than one cause is important when \ndeveloping a comprehensive care plan. In-\nExtensive \nlaboratory \ntesting \nand imaging \nare of limited \nvalue\n on June 10, 2026. For personal use only. All other uses require permission.www.ccjm.orgDownloaded from \n\nCLEVELAND CLINIC JOURNAL OF MEDICINE   VOLUME 85   •  NUMBER 3   MARCH  2018  219\nBONNEMA AND COLLEAGUES\nterstitial cystitis coexists with endometriosis \nin up to 60% of patients. 14 Initial treatment \nis pentosan polysulfate sodium, an oral treat-\nment approved by the US Food and Drug Ad-\nministration for interstitial cystitis that works \nby restoring the protective glycosaminoglycan \nlayer in the bladder.\n14,15 Amitriptyline may \nalso be used to treat interstitial cystitis-asso-\nciated nocturia.\nMyofascial pain: Neuromuscular blockers\nAccording to a recent systematic review of \ntherapies for chronic pelvic pain, patients \nTABLE 2\nTreatment options for chronic pelvic pain in primary care\nType of therapy Examples or description Comments\nMedications\nSimple analgesics Acetaminophen, nonsteroidal anti-\ninflammatory drugs (NSAIDs)\nAvoid prolonged use of NSAIDs due to potential \ntoxicities\nNeuropathics Amitriptyline, gabapentin Gabapentin may be more efficacious than amitriptyline\nHormonal therapies Oral contraceptives, gonadotropin-\nreleasing hormone (GnRH) analogues, \nprogestogens, danazol\nGnRH analogues are more effective for pain relief \nthan oral contraceptive pills\nAntispasmodics Dicyclomine May worsen constipation\nNeuromodulators Botulinum toxin A Very effective for pelvic floor spasm\nOther Pentosan polysulfate sodium First-line therapy for interstitial cystitis\nPelvic physical therapy\nStrengthening (up-training) Contracting the pelvic floor in isolation Improves symptoms of pelvic heaviness and discomfort\nRelaxation (down-training) Stretching, meditation, internal and \nexternal manual release of involved \nmuscle groups\nImproves symptoms of chronic pelvic pain due to \noveractive pelvic muscles\nBiofeedback Surface electromyography in conjunction \nwith strengthening and relaxation\nAllows visual feedback on muscle control; useful \nfor strengthening or relaxation and treatment of \nreflexive pelvic floor spasm\nVaginal dilators Tool for stretching, pain-free vaginal \ninsertion\nRestores flexibility and coordination of pelvic floor\nPsychosocial interventions \nCollaborative goal-setting Identify what has improved patients’ \ncurrent symptoms to develop goals\nVery individualized and specific\nShort-term goals\nAssess progress during each visit and modify goals \nas needed\nProgressive muscle relaxation Systematic tensing and relaxing of each \nlarge muscle group progressing from \ntoes to head\nEstablish a practice goal (number of practices per week)\nAllows for partner participation\nCan be done with other relaxation techniques (eg, \nvisualization, deep breathing)\n on June 10, 2026. For personal use only. All other uses require permission.www.ccjm.orgDownloaded from \n\n220 CLEVELAND CLINIC JOURNAL OF MEDICINE   VOLUME 85   •  NUMBER 3   MARCH  2018\nPELVIC PAIN\nRecognizing  \na possible  \nmultifactorial  \netiology  \nto chronic  \npelvic pain  \nis important\nwith symptoms related to myofascial pain may \nbenefit from neuromuscular blockade. 12 One \nrandomized controlled trial of the effective-\nness of botulinum toxin A vs saline for the \ntreatment of chronic pelvic pain secondary to \npelvic floor spasm found that after 6 months of \nobservation, women who received botulinum \ntoxin had significantly lower pain scores than \nthose who received saline.\n12\nPelvic congestion syndrome:  \nMultiple options\nPelvic congestion syndrome may be treated \nwith hormonal, radiologic, or surgical thera-\npy.\n16 A randomized controlled trial involving \npatients with chronic pelvic pain secondary \nto pelvic congestion demonstrated that treat-\nment with medroxyprogesterone acetate or a \nGnRH agonist (goserelin) improved pelvic \nsymptoms.\n17 \n A Cochrane review of nonsurgical inter -\nventions for chronic pelvic pain included\n \nwomen with a diagnosis of pelvic congestion \nsyndrome or adhesions. It found that patients \ntreated with medroxyprogesterone acetate \nwere more likely to have 50% pain reduction \nlasting up to 9 months compared with patients \ntaking placebo.\n12 In comparative studies, \nGnRH analogues were more effective in re-\nlieving pelvic pain than progestogen therapy. \n Radiologic embolization therapy is as ef\n-\nfective as hysterectomy for the relief of chron-\nic pelvic pain related to pelvic congestion \nsyndrome, and it can be performed in the out-\npatient setting.\nIrritable bowel syndrome:  \nTry dietary changes \nSymptoms of chronic pelvic pain that are as-\nsociated with changes in stool consistency and \nfrequency suggest irritable bowel syndrome. \nSymptoms may improve with dietary changes \nand fiber supplementation. Antispasmodic \nagents are frequently used but their anticho-\nlinergic effects may worsen constipation.\n14 \n ■ PEL\nVIC PHYSICAL THERAPY\nPelvic physical therapy targets the musculo-\nskeletal components of bowel, bladder, and \nsexual function to restore strength, flexibility, \nbalance, and coordination to the pelvic floor \nand surrounding lumbopelvic muscles. Pa-\ntients with dyspareunia, pain with activity, or \na significant musculoskeletal abnormality (eg, \nvaginismus or point tenderness on examina-\ntion) are particularly good candidates for this \ntherapy. It is done by a physical therapist with \nspecial training in techniques to manipulate \nthe pelvic floor to address pelvic pain.\nEducating the patient\nInforming the patient before the initial physi-\ncal therapy visit is essential for success. Refer-\nring clinicians should emphasize to patients \nthat treatment response can help to guide fur-\nther physician intervention. Patients should \nbe counseled that pelvic physical therapy \nincludes a pelvic examination and an expec-\ntation to participate in a home program. Al-\nthough noticeable improvement takes time, \nencouragement provided by the entire team, \nincluding medical providers, can help a pa-\ntient maintain her care plan. \n Therapists typically see a patient once a\n \nweek for 8 to 12 visits initially. Insurance usu-\nally covers pelvic physical therapy through \nthe same policy as routine physical therapy. \n During the initial evaluation, the patient \nreceives an external and internal pelvic ex\n-\namination assessing muscle length, strength, \nand coordination of the back, hip, and inter -\nnal pelvic floor. Internal evaluation can be \ndone vaginally or rectally, with one gloved \nfinger, without the need for speculum or stir -\nrups. Biofeedback and surface electromyog-\nraphy (using either perianal or internal elec-\ntrode placement) are used to evaluate muscle \nactivity and to assist the patient in developing \nappropriate motor control during strengthen-\ning or relaxation.\n18\n Up-training  (or strengthening) aims to im-\nprove pelvic floor endurance. It can improve \npelvic instability and symptoms of heaviness \nand discomfort from prolapse. Patients learn \nto appropriately utilize the pelvic floor in iso-\nlation. If a patient is too weak to contract on \nher own, neuromuscular electrical stimulation \nis used with an internal electrode to provide \nan assisted contraction.\n Down-training\n (or relaxation) focuses on \nreducing tone in overactive pelvic muscles. \nIt can improve symptoms of chronic pelvic \npain, sexual pain, vulvodynia, and pudendal \nneuralgias. Patients are made aware of chron-\n on June 10, 2026. For personal use only. All other uses require permission.www.ccjm.orgDownloaded from \n\nCLEVELAND CLINIC JOURNAL OF MEDICINE   VOLUME 85   •  NUMBER 3   MARCH  2018  221\nBONNEMA AND COLLEAGUES\nic holding patterns that lead to excess tone \nin the pelvic floor and learn how to release \nthem through stretching, cardiovascular ac-\ntivity, meditation, and manual release of the \ninvolved muscle groups internally and exter -\nnally. Internal musculature can be manipu-\nlated by a therapist in clinic or by the patient’s \ntrained partner; the patient can also reach \nnecessary areas with a vaginal dilator.\n Functional coordination of the pelvic floor\n \nis needed for comfortable vaginal penetration \nand defecation. Training with biofeedback \nimproves a patient’s ability to relax and open \nthe pelvic floor.\n18 Vaginal dilators with surface \nelectromyography are used to treat vaginismus \nto eliminate reflexive pelvic floor spasm during \npenetration. Perineal and vaginal compliance \ncan be improved through manual release tech-\nniques with hands or vaginal dilators to restore \nnormal mobility of tissues. This can reduce \npain from postsurgical changes, postpartum \nsequelae, atrophic vaginal changes, shortened \nmuscles from chronic holding, and adhesions.\n ■ PSYCHOSOCIAL INTER\nVENTIONS \nPelvic pain is not only a biomedical difficulty; \npsychosocial factors can contribute to and be \naffected by pelvic pain. Patients with pelvic \npain often experience lower quality of life, \nhigher rates of anxiety and depression, and \nincreased stress compared with others.\n19,20 \nPeople with pain also have more relationship \nstress, and patients’ partners often experience \nemotional distress, isolation, and feelings of \npowerlessness in the relationship.\n21 \n Psychosocial \ninterventions, provided along \nwith biomedical treatment, can help to reduce \npain, anxiety, and depression and improve re-\nlational well-being.\n22,23 In addition to attend-\ning to pain-related symptoms, comprehensive \ncare involves recognizing and treating coexist-\ning anxiety, depression, stress, and relationship \nconflict. Interventions for these difficulties are \nmany, and a comprehensive list of interven-\ntions is beyond the focus of this section.\n19 \nCognitive behavioral therapy\nCognitive behavioral therapy is based on \nthe idea that maladaptive cognitions can \nlead to problematic behaviors and emo-\ntional distress.\n24 Interventions are carried \nout by a provider with specialized training \nin its use (eg, therapist, pain psychologist, \npsychiatrist).\n Meta-analyses of studies that investigated\n \nthe efficacy of cognitive behavioral therapy for \nchronic pain found consistent small to medi-\num improvement in pain-related symptoms.\n24 \nStudies that used cognitive behavioral therapy \nfor pelvic pain found reduced overall pain se-\nverity and pain during intercourse, increased \nsexual satisfaction, enhanced sexual function, \nand less-exaggerated responses to pain.\n25–27 \n Although cognitive behavioral therapy\n \nand mindfulness-based interventions produce \npositive outcomes, research on these inter -\nventions typically includes treatment carried \nout over a span of weeks. Common barriers to \nsuch care include lack of patient motivation, \nfinancial limitations, transportation problems, \nand time constraints. \n The following psychosocial interventions\n \nhave been chosen because they can be deliv-\nered in a short amount of time and integrated \ninto a patient’s medical care by a medical or \nbehavioral health provider. Because of the \nbrevity and simplicity of these interventions, \nmore patients with pelvic pain can receive \npsychosocial care as part of their usual medi-\ncal encounters. \nBehavioral activation\nPeople experiencing depressive symptoms \ntend to isolate themselves and stop participat-\ning in activities they enjoy, including spend-\ning time with family and friends. Behavioral \nactivation interventions that address such \nisolating behaviors have been shown to be ef-\nfective in improving depressive symptoms.\n28–30\n A simple, brief intervention can be admin -\nistered during routine medical care, 28 involv-\ning the following steps:\n•\n Determine activities that the patient might\n \nimplement that would decrease depressive \nsymptoms. Questions such as, “When do \nyou feel less depressed?” or “What brings \nyou some happiness in your life?” can gen-\nerate possible activities.\n•\n Ask \nthe patient to identify people in her \nlife who have been supportive and with \nwhom she could engage.\n•\n Create with the patient a list of possible\n \nactivities and social interactions that may \nenhance well-being.\nPatients with \ndyspareunia  \nare good  \ncandidates for \npelvic physical\n \ntherapy\n on June 10, 2026. For personal use only. All other uses require permission.www.ccjm.orgDownloaded from \n\n222 CLEVELAND CLINIC JOURNAL OF MEDICINE   VOLUME 85   •  NUMBER 3   MARCH  2018\nPELVIC PAIN\n• Make a schedule for participating in activ -\nities, possibly with rewards for completing \nthem. Patients should be encouraged to \nfollow the prescribed schedule of activities \nrather than make decisions based on mood \nor other factors. \nRelaxation strategies \nRelaxation can help patients reduce stress and \nanxiety, and can also help reduce pain.\n31–33 \n Diaphragmatic or \n“belly breathing” is a \ndeep-breathing technique in which partici-\npants are asked to take in air through the nose \nand fully fill the lungs and lower belly. This \ntechnique allows the body to take in more \noxygen, helping to lower blood pressure and \nslow the heartbeat. In addition to physiologic \nbenefits, concentrating on deep breathing can \nhelp slow down or stop intrusive thoughts and \ndistressing physical sensations.\n34\n Progressive muscle relaxation  involves \nthe systematic tensing and relaxing of each \nlarge muscle group in the body.\n35 The goal \nis to eliminate physical and emotional stress \nthrough focusing on the sensations of tension \nand relaxation. \n Scripts and audio and video resources for bel\n-\nly breathing and progressive muscle relaxation \ncan be found on the Internet. The techniques \ncan be taught during the medical appointment \nor offered as resources for home practice.\nCouple-based care\nT argeting couples is more effective for im-\nproving well-being than focusing solely on a \npatient’s psychosocial difficulties, so each of \nthe above interventions may be more effec-\ntive if tailored to include the patient’s part-\nner.\n36 If the partner is with the patient dur -\ning medical visits or is included in long-term \npsychosocial treatment, he or she can be \ndirectly involved in learning and practicing \ninterventions with the patient. If the partner \nis not present, the patient can be asked to \npractice newly learned well-being-enhanc-\ning strategies with her partner outside the \nappointment time. Couples therapy can im-\nprove psychosocial well-being for both part-\nners.\nSetting goals\nFor all interventions, setting goals is impor -\ntant. Using collaborative goal-setting, pa-\ntients and providers together should develop \ngoals that specifically attend to reducing \npain-related difficulties and comorbid anxi-\nety, stress, and depression.\n22 For example, if a \npatient has found that belly breathing helps \nreduce anxiety, a goal may be for the patient \nto practice belly breathing with her partner 3 \ntimes per week for 10 minutes, until her next \nmedical appointment in 1 month. After the \npatient and provider have codeveloped goals \nfor improving psychosocial well-being, pro-\nvider and patient can discuss progress made \ntoward goals during each subsequent visit. De-\npending on progress, providers can highlight \npatient success and modify goals as needed. \nTable 3 provides an example outline of col-\nlaborative goal-setting.\n ■\n ■ REFERENCES\n 1. Zondervan KT , Yudkin PL, Vessey MP , et al. The community preva-\nlence of chronic pelvic pain in women and associated illness behav-\nior. Br J Gen Pract 2001; 51:541–547.\n \n2.\n Mathias SD, Kuppermann M, Liberman RF\n, Lipschutz RC, Steege JF. \nChronic pelvic pain: prevalence, health-related quality of life, and \neconomic correlates. Obstet Gynecol 1996; 81:321–327.\n \n3.\n Howar\nd FM. Chronic pelvic pain. Obstet Gynecol 2003; 101:594–611.\n \n4.\n AHRQ PCMH Resour\nce Center. Transforming the organization and \ndelivery of primary care. www.pcmh.ahrq.gov/. Accessed February 2, \n2018.\n \n5.\n Pryzbylkowski P\n, Ashburn MA. The pain medical home: a patient-\ncentered medical home model of care for patients with chronic \npain. Anesthesiol Clin 2015; 33:785–793.\n \n6.\n Jamieson DJ, Steege JF\n. The association of sexual abuse with pelvic \npain complaints in a primary care population. Am J Obstet Gynecol \n1997; 177:1408–1412.\nFor all  \ninterventions, \nsetting goals  \nis important\nTABLE 3\nCollaborative goal-setting\nIndividual Couple\nMy goal is: Our goal is:\nI will: We will:\nWhen: When:\nI will do this first: We will do this first:\nChallenges that may arise: Challenges that may arise:\nI will handle them by: We will handle them by:\nI will reward myself when: We will reward ourselves when:\nMy reward will be: Our reward will be:\n on June 10, 2026. For personal use only. All other uses require permission.www.ccjm.orgDownloaded from \n\nCLEVELAND CLINIC JOURNAL OF MEDICINE   VOLUME 85   •  NUMBER 3   MARCH  2018 223\nBONNEMA AND COLLEAGUES\n7. Gambone JC, Mittman BS, Munro MG, Scialli AR, Winkel CA; Chr onic\nPelvic Pain/Endometriosis Working Group. Consensus statement \nfor the management of chronic pelvic pain and endometriosis: \nproceedings of an expert-panel consensus process. Fertil Steril 2002; \n78:961–972.\n8. Ganeshan A, Upponi S, Hon LQ, Uthappa MC, Warakaulle DR,\n \nUberoi R. Chronic pelvic pain due to pelvic congestion syndrome: \nthe role of diagnostic and interventional radiology. Cardiovasc Inter-\nvent Radiol 2007; 30:1105–1111.\n9. Engeler D, Baranowski AP , Elneil S, et al; Eur\nopean Association \nof Urology. Guidelines on chronic pelvic pain. http://uroweb.org/\nwp-content/uploads/EAU-Guidelines-Chronic-Pelvic-Pain-2015.pdf.\nAccessed February 5, 2018.\n10. Ver\ncellini P , Vigano P , Somigliana E, Abbiati A, Barbara G, Fedele L. \nMedical, surgical and alternative treatments for chronic pelvic pain\nin women: a descriptive review. Gynecol Endocrinol 2009; 25:208–\n221.\n11. Rafique S, DeCherney AH\n. Medical management of endometriosis.\nClin Obstet Gynecol 2017; 60:485–496. \n12. Cheong YC, Smotra G, Williams AC. Non-surgical interventions for\n \nthe management of chronic pelvic pain. Cochrane Database Syst Rev\n2014; 3:CD008797.\n13. 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Behavioral activation \ntreatments of depression: a meta-analysis. Clin Psychol Rev 2007; \n27:318–326.\n29. Mazzucchelli T, Kane R, Rees C\n. Behavioral activation treatments \nfor depression in adults: a meta-analysis and review. Clin Psychol Sci\nPractice 2009; 16:383–411.\n30. Riebe G, Fan MY, Unützer J, V\nannoy S. Activity scheduling as a core\ncomponent of effective care management for late-life depression. \nInt J Geriatr Psychiatry 2012; 27:1298–1304.\n31. Chen YF, Huang XY\n, Chien CH, Cheng JF. The effectiveness of \ndiaphragmatic breathing relaxation training for reducing anxiety.\nPerspect Psychiatr Care 2017; 53:329–336.\n32. Klainin-Yobas P\n, Oo WN, Yew PYS, Lau Y. Effects of relaxation \ninterventions on depression and anxiety among older adults: a\nsystematic review. Aging Ment Health 2015; 19:1043–1055.\n33. Finlay KA, Rogers J. Maximizing self-care through familiarity: the\n \nrole of practice effects in enhancing music listening and progressive\nmuscle relaxation for pain management. Psychology of Music 2015; \n43:511–529.\n34. Harvard Health Publications; Harvar\nd Medical School. Relaxation \ntechniques: breath control helps quell errant stress response. www.\nhealth.harvard.edu/mind-and-mood/relaxation-techniques-breath-\ncontrol-helps-quell-errant-stress-response. Accessed February 2, \n2018.\n35. Bernstein DA, Borkovec TD\n. Progressive relaxation training: a \nmanual for the helping professions. Champaign, IL: Research Press;\n1973.\n36. Whisman MA, Baucom DH. Intimate relationships and psychopa\n-\nthology. Clin Child Fam Psychol Rev 2012; 15:4–13.\nADDRESS: Rachel Bonnema, MD, MS, Division of General Internal Medi-\ncine, University of Nebraska Medical Center, 983331 Nebraska Medical \nCenter, Omaha, NE 68198-3331; rbonnema@unmc.edu\n on June 10, 2026. For personal use only. All other uses require permission.www.ccjm.orgDownloaded from","source_license":"CC0","license_restricted":false}