Primary care management of chronic pelvic pain in women

Primary care management of chronic pelvic pain in women CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 85 • NUMBER 3 MARCH 2018 215 C hronic pelvic pain is a common clinical problem in women, as prevalent in pri- mary care as asthma or back pain.1,2 It is often associated with lost work days and decreased productivity, increased healthcare spending, mood disorders, and negative effects on per - sonal relationships. 1–3 While specialty care referral may eventual- ly be indicated, primary care doctors can take steps to diagnose and effectively manage the condition. ■ COMPREHENSIVE MANA GEMENT LED BY PRIMARY CARE Chronic pelvic pain is defined as pain in the lower abdomen persisting for 3 to 6 months and of sufficient severity to require medical care or cause a functional disability. 3 It is of- ten detrimental to a woman’s personal life and overall health, making a comprehensive assessment and multidisciplinary approach to management especially important. The ideal care-delivery mo del is the patient- centered medical home, whereby a primary care physician coordinates comprehensive care with the help of an interdisciplinary team. 4,5 For complex cases, referral may be needed to other specialties (eg, obstetrics and gynecology, pain medicine) to help manage care. ■ T ARGETED EVALUATION Chronic pelvic pain often coexists with other systemic pain syndromes or psychiatric condi- tions common in primary care. Table 1 lists common causes and associated findings. Detailed history is critical The history is of utmost importance. Clini- cians should query patients about the char - REVIEW doi:10.3949/ccjm.85a.16038 ABSTRACT Chronic pelvic pain in women can arise from many causes and often results in significant declines in function and quality of life. A systematic approach for evaluating patients and initiating a management plan are recom- mended in the primary care setting. Comprehensive management strategies may include medication, pelvic physical therapy, and behavioral interventions. KEY POINTS Diagnosing and managing chronic pelvic pain may be difficult, but patients are often best served when their primary care provider directs a team-based approach to their care. A detailed history, thorough abdominal and pelvic exami- nations, and targeted testing facilitate the diagnosis. As in other chronic pain syndromes, the goals of therapy should be incremental and meaningful improvements in pain, function, and overall well-being. RACHEL BONNEMA, MD, MS Associate Professor of Medicine, Division of General Internal Medicine, University of Nebraska Medical Center, Omaha MEGAN McNAMARA, MD, MSc Associate Professor of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH; Louis Stokes Cleveland VA Medical Center JENNIFER HARSH, PhD, LMFT Assistant Professor, Division of General Inter- nal Medicine, University of Nebraska Medical Center, Omaha CREDIT CME ELIZABETH HOPKINS, PT, DPT The Nebraska Medical Center, Omaha on June 10, 2026. For personal use only. All other uses require permission.www.ccjm.orgDownloaded from 216 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 85 • NUMBER 3 MARCH 2018 PELVIC PAIN TABLE 1 Common causes of chronic pelvic pain and associated findings Differential diagnosis Associated historical feature Physical examination Musculoskeletal P elvic floor dysfunction Complicated delivery, dyspareunia Vaginismus, point tenderness, or high tone of pelvic floor Myofascial pain or fibromyalgia Tender points, chronic somatic pain Tender points Stress fractures Pain with repetitive movements, improved with rest Degenerative disk disease Burning, paresthesias Radicular signs, muscle weakness Gastrointestinal Constipation Inflammatory bowel disease Bowel urgency, hematochezia Irritable bowel syndrome Bowel symptoms; may increase premenstrually Gynecologic (often cyclic with menses) Adhesions Surgical history Immobile uterus, nodularity Adenomyosis Menorrhagia, dysmenorrhea Enlarged, irregular tender uterus on bimanual examination Adnexal mass Localized to 1 area Localized adnexal mass Chronic pelvic inflammatory disease Dysmenorrhea Uterine cramping with menses Endometrial or cervical polyp Intermenstrual or postcoital bleeding Visual inspection Endometritis Uterine tenderness on bimanual examination Endometriosis Diffuse pelvic pain with menses, deep dyspareunia Fixed or immobile uterus, nodularity Leiomyomata Menorrhagia, pressure or heaviness Uterine nodularity, enlargement Pelvic congestion syndrome Multigravid patient; deep dyspareunia, post- coital pain, worse after prolonged standing Varicosity of labia, uterine tenderness on bimanual examination Vulvar vestibulitis Vulvodynia, dyspareunia Exquisite localized tenderness Urologic Interstitial cystitis Urgency, increased frequency of urination Urinary tract infection Dysuria Urolithiasis Localized sharp pain Radiation cystitis History of radiation Other Psychiatric (depression, somatization) Concurrent mood disorder Neurologic (herpes zoster, nerve entrapment) Hot, burning, electric shock-like pain; shingles on June 10, 2026. For personal use only. All other uses require permission.www.ccjm.orgDownloaded from CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 85 • NUMBER 3 MARCH 2018 217 BONNEMA AND COLLEAGUES acteristics of the pain as well as their medical and surgical history. Particular attention should be given to obtaining a complete gynecologic history, including pregnancy, delivery complica- tions, dyspareunia, sexual assault, and trauma. A detailed review of systems should focus on the reproductive, gastroenterologic, musculoskel- etal, urologic, and neuropsychiatric systems. As with many pain syndromes, allowing the patient to “tell her story” helps to establish rap- port and obtain a more complete assessment. Chronic pelvic pain has been associated with physical or sexual abuse as a child or adult, so is essential to foster the doctor-patient relation- ship and create a safe and open space for dis- closure. 3,6 It is important to screen women for safety at home as well as for satisfaction or dis- satisfaction with their relationships with their spouse or partner and family. Physical examination The physical examination should be directed by the history but should always include ab- dominal and pelvic examinations. These should be conducted slowly and gently, assess- ing for areas of tenderness, masses, and other abnormalities. Clinicians should aim to pin- point the exact anatomic locations of tender- ness if possible. Ongoing dialogue facilitates this process by inquiring about pain at each point of the examination. The pelvic examination should begin with visual inspection for redness, discharge, le- sions, fissures, excoriations, and other abnor - malities. A moistened cotton swab may be used to evaluate the vulva and vestibule for localized tenderness. The manual portion of the pelvic examination should begin with a single digit, noting any introital tenderness or spasm. Next, the levator ani muscles should be directly palpated for tone and tenderness. The pelvic floor should be evaluated with at- tention to tenderness of the bladder or muscu- loskeletal structures (Figure 1). A bimanual examination assessing uterine size and tender- ness, nodularity, or a fixed, immobile uterus should be conducted. Diagnostic workup Because the differential diagnosis of chronic pelvic pain is broad, the diagnostic workup and testing should be based on findings of the Chronic pelvic pain has been associated with physical or sexual abuse Figure 1. Pelvic floor anatomy. During the pelvic examination, the levator ani muscles should be directly palpated for tone and tenderness, and the pelvic floor should be evalu- ated with attention to any tenderness of the bladder and musculoskeletal structures. Ischiocavernosus muscle Perineal membrane External anal sphincter Levator ani muscles Gluteus maximus muscle Bulbocavernosus muscle Ischiopubic ramus Superficial transverse perineus muscle Ischial tuberosity Internal pudendal artery Perineal body on June 10, 2026. For personal use only. All other uses require permission.www.ccjm.orgDownloaded from 218 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 85 • NUMBER 3 MARCH 2018 PELVIC PAIN history and physical examination. In general, extensive laboratory testing is of limited use for evaluating women with chronic pelvic pain. 3,7 Urinalysis should be obtained for symp- toms suggesting bladder involvement such as interstitial cystitis. Pelvic ultrasonography can help identify pelvic  masses palpated during the physical examination, but routine use of imaging is not recommended. 3,7 If pelvic congestion syn- drome is suspected, starting with pelvic ultra- sonography is reasonable before incurring the risk or cost of computed tomography or mag- netic resonance imaging. 8 ■ GENERAL TREA TMENT A holistic approach ensures that the treatment plan adequately addresses the physical, social, and psychological aspects of chronic pelvic pain. 9 Treatments may include medication, pelvic physical therapy, and behavioral thera- pies (Table 2). As with other chronic pain syndromes commonly seen in primary care, the treatment plan may develop over multiple vis- its as the patient-provider relationship grows and as treatment response is evaluated. Medical therapy The main goals of medical therapy are to im- prove function and quality of life while mini- mizing adverse effects. General treatments in- clude the following: Analgesics. Nonsteroidal anti-inflamma- tory drugs and acetaminophen may provide pain relief, although there is weak evidence for their efficacy in treating chronic pelvic pain. 9 Neuropathic agents. One of several avail- able neuropathic agents commonly used in the treatment of chronic pain can be tried on patients who fail to respond to analgesics. Tricyclic antidepressants such as amitripty- line and imipramine decrease pain, reduce symptoms of depression, and improve sleep. 10 The results of a small randomized controlled trial suggest that gabapentin is more effective than amitriptyline for reducing chronic pelvic pain. 11,12 Published guidelines currently list both amitriptyline and gabapentin as first-line agents; nortriptyline and pregabalin are con- sidered acceptable initial alternatives. 9 V enlafaxine and duloxetine may help chronic pelvic pain, although specific evi- dence is lacking. Duloxetine may be an appro- priate choice for women with chronic pelvic pain who also experience depression and uri- nary stress incontinence. 9 Opioids. Opioid therapy should be consid- ered only when all other reasonable therapies have failed. 10 Patients may develop tolerance or dependence, as well as opioid-induced ad- verse effects such as hyperalgesia. 9,10 Guide- lines recommend that primary care providers consult with a pain management specialist be- fore prescribing opioids, and that patients be thoroughly counseled about the risks and side effects. 9 Nerve block and neuromodulation. There is weak evidence for the use of these modalities for treating chronic pelvic pain. 9 If used, they should be part of a broader treatment plan and should be performed by providers who special- ize in management of chronic pain. ■ DISEASE-SPECIFIC TREA TMENT Endometriosis: Hormonal therapy Pelvic pain that significantly fluctuates with the menstrual cycle may be caused by endome- triosis, the most common gynecologic cause of chronic pelvic pain. Women with cyclic chronic pelvic pain should be empirically treated with hormonal therapy for at least 3 to 6 months be- fore diagnostic laparoscopy is performed. 13 Oral contraceptives, gonadotropin-releas - ing hormone (GnRH) analogues, progesto- gens, and danazol have proven efficacy, al- though side-effect profiles differ significantly. In a comparative trial, patients treated with GnRH analogues had more improvement in pain scores compared with those treated with oral contraceptives, but they experienced a significant decrease in bone mineral density. 11 The effects on bone mineral density associ- ated with GnRH analogue therapy can be mitigated by “add-back” low-dose hormonal therapy (norethindrone, low-dose estrogen, or a combination of estrogen and progesterone), which may also provide symptomatic relief for associated hot flashes and vaginal symptoms. 11 Interstitial cystitis often accompanies endometriosis Recognizing that chronic pelvic pain may have more than one cause is important when developing a comprehensive care plan. In- Extensive laboratory testing and imaging are of limited value on June 10, 2026. For personal use only. All other uses require permission.www.ccjm.orgDownloaded from CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 85 • NUMBER 3 MARCH 2018 219 BONNEMA AND COLLEAGUES terstitial cystitis coexists with endometriosis in up to 60% of patients. 14 Initial treatment is pentosan polysulfate sodium, an oral treat- ment approved by the US Food and Drug Ad- ministration for interstitial cystitis that works by restoring the protective glycosaminoglycan layer in the bladder. 14,15 Amitriptyline may also be used to treat interstitial cystitis-asso- ciated nocturia. Myofascial pain: Neuromuscular blockers According to a recent systematic review of therapies for chronic pelvic pain, patients TABLE 2 Treatment options for chronic pelvic pain in primary care Type of therapy Examples or description Comments Medications Simple analgesics Acetaminophen, nonsteroidal anti- inflammatory drugs (NSAIDs) Avoid prolonged use of NSAIDs due to potential toxicities Neuropathics Amitriptyline, gabapentin Gabapentin may be more efficacious than amitriptyline Hormonal therapies Oral contraceptives, gonadotropin- releasing hormone (GnRH) analogues, progestogens, danazol GnRH analogues are more effective for pain relief than oral contraceptive pills Antispasmodics Dicyclomine May worsen constipation Neuromodulators Botulinum toxin A Very effective for pelvic floor spasm Other Pentosan polysulfate sodium First-line therapy for interstitial cystitis Pelvic physical therapy Strengthening (up-training) Contracting the pelvic floor in isolation Improves symptoms of pelvic heaviness and discomfort Relaxation (down-training) Stretching, meditation, internal and external manual release of involved muscle groups Improves symptoms of chronic pelvic pain due to overactive pelvic muscles Biofeedback Surface electromyography in conjunction with strengthening and relaxation Allows visual feedback on muscle control; useful for strengthening or relaxation and treatment of reflexive pelvic floor spasm Vaginal dilators Tool for stretching, pain-free vaginal insertion Restores flexibility and coordination of pelvic floor Psychosocial interventions Collaborative goal-setting Identify what has improved patients’ current symptoms to develop goals Very individualized and specific Short-term goals Assess progress during each visit and modify goals as needed Progressive muscle relaxation Systematic tensing and relaxing of each large muscle group progressing from toes to head Establish a practice goal (number of practices per week) Allows for partner participation Can be done with other relaxation techniques (eg, visualization, deep breathing) on June 10, 2026. For personal use only. All other uses require permission.www.ccjm.orgDownloaded from 220 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 85 • NUMBER 3 MARCH 2018 PELVIC PAIN Recognizing a possible multifactorial etiology to chronic pelvic pain is important with symptoms related to myofascial pain may benefit from neuromuscular blockade. 12 One randomized controlled trial of the effective- ness of botulinum toxin A vs saline for the treatment of chronic pelvic pain secondary to pelvic floor spasm found that after 6 months of observation, women who received botulinum toxin had significantly lower pain scores than those who received saline. 12 Pelvic congestion syndrome: Multiple options Pelvic congestion syndrome may be treated with hormonal, radiologic, or surgical thera- py. 16 A randomized controlled trial involving patients with chronic pelvic pain secondary to pelvic congestion demonstrated that treat- ment with medroxyprogesterone acetate or a GnRH agonist (goserelin) improved pelvic symptoms. 17 A Cochrane review of nonsurgical inter - ventions for chronic pelvic pain included women with a diagnosis of pelvic congestion syndrome or adhesions. It found that patients treated with medroxyprogesterone acetate were more likely to have 50% pain reduction lasting up to 9 months compared with patients taking placebo. 12 In comparative studies, GnRH analogues were more effective in re- lieving pelvic pain than progestogen therapy. Radiologic embolization therapy is as ef - fective as hysterectomy for the relief of chron- ic pelvic pain related to pelvic congestion syndrome, and it can be performed in the out- patient setting. Irritable bowel syndrome: Try dietary changes Symptoms of chronic pelvic pain that are as- sociated with changes in stool consistency and frequency suggest irritable bowel syndrome. Symptoms may improve with dietary changes and fiber supplementation. Antispasmodic agents are frequently used but their anticho- linergic effects may worsen constipation. 14 ■ PEL VIC PHYSICAL THERAPY Pelvic physical therapy targets the musculo- skeletal components of bowel, bladder, and sexual function to restore strength, flexibility, balance, and coordination to the pelvic floor and surrounding lumbopelvic muscles. Pa- tients with dyspareunia, pain with activity, or a significant musculoskeletal abnormality (eg, vaginismus or point tenderness on examina- tion) are particularly good candidates for this therapy. It is done by a physical therapist with special training in techniques to manipulate the pelvic floor to address pelvic pain. Educating the patient Informing the patient before the initial physi- cal therapy visit is essential for success. Refer- ring clinicians should emphasize to patients that treatment response can help to guide fur- ther physician intervention. Patients should be counseled that pelvic physical therapy includes a pelvic examination and an expec- tation to participate in a home program. Al- though noticeable improvement takes time, encouragement provided by the entire team, including medical providers, can help a pa- tient maintain her care plan. Therapists typically see a patient once a week for 8 to 12 visits initially. Insurance usu- ally covers pelvic physical therapy through the same policy as routine physical therapy. During the initial evaluation, the patient receives an external and internal pelvic ex - amination assessing muscle length, strength, and coordination of the back, hip, and inter - nal pelvic floor. Internal evaluation can be done vaginally or rectally, with one gloved finger, without the need for speculum or stir - rups. Biofeedback and surface electromyog- raphy (using either perianal or internal elec- trode placement) are used to evaluate muscle activity and to assist the patient in developing appropriate motor control during strengthen- ing or relaxation. 18 Up-training (or strengthening) aims to im- prove pelvic floor endurance. It can improve pelvic instability and symptoms of heaviness and discomfort from prolapse. Patients learn to appropriately utilize the pelvic floor in iso- lation. If a patient is too weak to contract on her own, neuromuscular electrical stimulation is used with an internal electrode to provide an assisted contraction. Down-training (or relaxation) focuses on reducing tone in overactive pelvic muscles. It can improve symptoms of chronic pelvic pain, sexual pain, vulvodynia, and pudendal neuralgias. Patients are made aware of chron- on June 10, 2026. For personal use only. All other uses require permission.www.ccjm.orgDownloaded from CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 85 • NUMBER 3 MARCH 2018 221 BONNEMA AND COLLEAGUES ic holding patterns that lead to excess tone in the pelvic floor and learn how to release them through stretching, cardiovascular ac- tivity, meditation, and manual release of the involved muscle groups internally and exter - nally. Internal musculature can be manipu- lated by a therapist in clinic or by the patient’s trained partner; the patient can also reach necessary areas with a vaginal dilator. Functional coordination of the pelvic floor is needed for comfortable vaginal penetration and defecation. Training with biofeedback improves a patient’s ability to relax and open the pelvic floor. 18 Vaginal dilators with surface electromyography are used to treat vaginismus to eliminate reflexive pelvic floor spasm during penetration. Perineal and vaginal compliance can be improved through manual release tech- niques with hands or vaginal dilators to restore normal mobility of tissues. This can reduce pain from postsurgical changes, postpartum sequelae, atrophic vaginal changes, shortened muscles from chronic holding, and adhesions. ■ PSYCHOSOCIAL INTER VENTIONS Pelvic pain is not only a biomedical difficulty; psychosocial factors can contribute to and be affected by pelvic pain. Patients with pelvic pain often experience lower quality of life, higher rates of anxiety and depression, and increased stress compared with others. 19,20 People with pain also have more relationship stress, and patients’ partners often experience emotional distress, isolation, and feelings of powerlessness in the relationship. 21 Psychosocial interventions, provided along with biomedical treatment, can help to reduce pain, anxiety, and depression and improve re- lational well-being. 22,23 In addition to attend- ing to pain-related symptoms, comprehensive care involves recognizing and treating coexist- ing anxiety, depression, stress, and relationship conflict. Interventions for these difficulties are many, and a comprehensive list of interven- tions is beyond the focus of this section. 19 Cognitive behavioral therapy Cognitive behavioral therapy is based on the idea that maladaptive cognitions can lead to problematic behaviors and emo- tional distress. 24 Interventions are carried out by a provider with specialized training in its use (eg, therapist, pain psychologist, psychiatrist). Meta-analyses of studies that investigated the efficacy of cognitive behavioral therapy for chronic pain found consistent small to medi- um improvement in pain-related symptoms. 24 Studies that used cognitive behavioral therapy for pelvic pain found reduced overall pain se- verity and pain during intercourse, increased sexual satisfaction, enhanced sexual function, and less-exaggerated responses to pain. 25–27 Although cognitive behavioral therapy and mindfulness-based interventions produce positive outcomes, research on these inter - ventions typically includes treatment carried out over a span of weeks. Common barriers to such care include lack of patient motivation, financial limitations, transportation problems, and time constraints. The following psychosocial interventions have been chosen because they can be deliv- ered in a short amount of time and integrated into a patient’s medical care by a medical or behavioral health provider. Because of the brevity and simplicity of these interventions, more patients with pelvic pain can receive psychosocial care as part of their usual medi- cal encounters. Behavioral activation People experiencing depressive symptoms tend to isolate themselves and stop participat- ing in activities they enjoy, including spend- ing time with family and friends. Behavioral activation interventions that address such isolating behaviors have been shown to be ef- fective in improving depressive symptoms. 28–30 A simple, brief intervention can be admin - istered during routine medical care, 28 involv- ing the following steps: • Determine activities that the patient might implement that would decrease depressive symptoms. Questions such as, “When do you feel less depressed?” or “What brings you some happiness in your life?” can gen- erate possible activities. • Ask the patient to identify people in her life who have been supportive and with whom she could engage. • Create with the patient a list of possible activities and social interactions that may enhance well-being. Patients with dyspareunia are good candidates for pelvic physical therapy on June 10, 2026. For personal use only. All other uses require permission.www.ccjm.orgDownloaded from 222 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 85 • NUMBER 3 MARCH 2018 PELVIC PAIN • Make a schedule for participating in activ - ities, possibly with rewards for completing them. Patients should be encouraged to follow the prescribed schedule of activities rather than make decisions based on mood or other factors.  Relaxation strategies Relaxation can help patients reduce stress and anxiety, and can also help reduce pain. 31–33 Diaphragmatic or “belly breathing” is a deep-breathing technique in which partici- pants are asked to take in air through the nose and fully fill the lungs and lower belly. This technique allows the body to take in more oxygen, helping to lower blood pressure and slow the heartbeat. In addition to physiologic benefits, concentrating on deep breathing can help slow down or stop intrusive thoughts and distressing physical sensations. 34 Progressive muscle relaxation involves the systematic tensing and relaxing of each large muscle group in the body. 35 The goal is to eliminate physical and emotional stress through focusing on the sensations of tension and relaxation. Scripts and audio and video resources for bel - ly breathing and progressive muscle relaxation can be found on the Internet. The techniques can be taught during the medical appointment or offered as resources for home practice. Couple-based care T argeting couples is more effective for im- proving well-being than focusing solely on a patient’s psychosocial difficulties, so each of the above interventions may be more effec- tive if tailored to include the patient’s part- ner. 36 If the partner is with the patient dur - ing medical visits or is included in long-term psychosocial treatment, he or she can be directly involved in learning and practicing interventions with the patient. If the partner is not present, the patient can be asked to practice newly learned well-being-enhanc- ing strategies with her partner outside the appointment time. Couples therapy can im- prove psychosocial well-being for both part- ners. Setting goals For all interventions, setting goals is impor - tant. Using collaborative goal-setting, pa- tients and providers together should develop goals that specifically attend to reducing pain-related difficulties and comorbid anxi- ety, stress, and depression. 22 For example, if a patient has found that belly breathing helps reduce anxiety, a goal may be for the patient to practice belly breathing with her partner 3 times per week for 10 minutes, until her next medical appointment in 1 month. After the patient and provider have codeveloped goals for improving psychosocial well-being, pro- vider and patient can discuss progress made toward goals during each subsequent visit. De- pending on progress, providers can highlight patient success and modify goals as needed. Table 3 provides an example outline of col- laborative goal-setting. ■ ■ REFERENCES 1. Zondervan KT , Yudkin PL, Vessey MP , et al. The community preva- lence of chronic pelvic pain in women and associated illness behav- ior. Br J Gen Pract 2001; 51:541–547. 2. 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Relaxation techniques: breath control helps quell errant stress response. www. health.harvard.edu/mind-and-mood/relaxation-techniques-breath- control-helps-quell-errant-stress-response. Accessed February 2, 2018. 35. Bernstein DA, Borkovec TD . Progressive relaxation training: a manual for the helping professions. Champaign, IL: Research Press; 1973. 36. Whisman MA, Baucom DH. Intimate relationships and psychopa - thology. Clin Child Fam Psychol Rev 2012; 15:4–13. ADDRESS: Rachel Bonnema, MD, MS, Division of General Internal Medi- cine, University of Nebraska Medical Center, 983331 Nebraska Medical Center, Omaha, NE 68198-3331; [email protected] on June 10, 2026. For personal use only. All other uses require permission.www.ccjm.orgDownloaded from