Chronic Pelvic Pain in Women: Practical Guideline on Diagnostic and Treatment

Chronic pelvic pain syndrome (CPPS) is a debilitating condition, but its pathophysiology is not fully understood. It is not possible to cure CPPS, but treatment should aim to alleviate symptoms and to improve quality of life. CPPS management should be multimodal and, if necessary, multidisciplinary.

Before any medications are prescribed or any procedures are attempted to treat CPPS, a detailed medical work-up must be performed to exclude other differential diagnoses. It is essential to first establish a good doctor-patient relationship because many CPPS patients have difficult-to-manage symptoms. The patient must realise that CPPS is not a traditionally treatable disease, but rather a chronic condition that can be controlled. Managing patient’s expectation is as important in managing the various symptoms of CPPS.

The goal of the diagnostic evaluation for interstitial cystitis/bladder pain syndrome (IC/BPS) is to identify characteristic features and exclude other conditions. The evaluation includes eliciting a history of symptoms and associated conditions, physical examination, and laboratory testing.

The characteristics of the bladder pain or discomfort in patients with CPPS/IC/BPS are variable, but the most consistent feature is an increase in discomfort with bladder filling and a relief with voiding.

Common physical examination findings include tenderness in many areas of the abdominal wall, hip girdle, buttocks, thighs, and pelvic floor, as well as tenderness of the bladder base and/or urethra.

Urinalysis should be performed in all patients to exclude significant hematuria and infection. Urine culture can be obtained if the urinalysis results show pyuria suggestive of infection. Post-void residual urine measurement may also be useful to look for other conditions.

There are no characteristic findings for CPPS/IC/BPS on imaging studies. Cystoscopy is not required to make the diagnosis, but may be used for some patients to exclude other etiologies or identify bladder lesions associated with IC/BPS. Other tests include: Hydrodistention, bladder biopsy, and potassium sensitivity testing, but these are not routinely necessary for diagnosis of IC/BPS.

In general, therefore, cystoscopy and/or urodynamic studies should be considered as an aid to diagnosis only for complex presentations; these tests are not necessary for making the diagnosis in uncomplicated presentations. Although there are no existing cystoscopic or urodynamic findings specific for IC/BPS, guidelines state that these tests can be valuable in identifying lesions or alterations (Hunner's ulcers) in the bladder in patients with symptoms, and in ruling out other entities such as bladder cancer or urethral diverticula. When more major interventions are being considered a histological diagnosis obtained by cystoscopic Biopsy is important to justify the procedure. Special Stains are mandatory which light up the Mast Cells of IC.

First line medications for CPPS include alpha-1 antagonists, antimicrobial agents, and 5 alpha reductase inhibitors. Second line medications include anti-inflammatory agents, pentosan polysulfate, and tri-cyclic antidepressants. It is likely that a CPPS patient will require a combination of several medications to control his symptoms.

Many additional treatment options also play a role in CPPS management. These include biofeedback, acupuncture, prostatic massage, myofascial or trigger point release, and patient support groups. If the latter options fails, Pelvic Shock Wave Therapy or Botox Type A injections can be offered to the patient. The latest upcoming solution is the Microsphere injection of Professor Marshall - can be considered as a last resort. This technique is predicated on the following:
it has been proposed that a dysfunctional epithelium allow the transepithelial migration of solutes, such as potassium, which can depolarize subepithelial afferent nerves and provoke sensory symptoms.

Liposome (LP) are vesicles, composed of concentric phospholipid bilayers separated by aqueous compartments. Because liposomes adsorb to cell surfaces and fuse with cells, they are being used as vehicles for drug delivery and gene therapy. In addition, they create a molecular film on cell surfaces and therefore are being tested as possible therapeutic agents to promote wound healing. LP-based drug products provide a moisture film onto the wound and raise outstanding wound healing without chronic inflammatory-reaction in the neodermal layer. Other investigators suggest that LP could interact with cells by stable absorption, endocytosis, lipid transfer and fusion.

Intravesical administration of liposomes into the wounded uroepithelium, may improve the dysfunctional uroepithelium and provide an alternative treatment for IC. We have proved these concepts in rat models of hypersensitive bladder, which showed that intravesical instillation of LP could reduce the bladder hypersensitivity induced by intravesical potassium chloride or acetic acid.

Furthermore, we found that intravecial LP as a bladder lotion can ease the IC symptoms without notable side effects in a phase 2 study conducted at Chang Gung Memorial Hospital Kaohsiung which was the Asian Investigatory Centre for Prof Marshall who has his headquarters based in the USA.

Other Aspects
Role of Pain Centres:
Referral to a pain specialist is a tertiary referral. Hence patients with bladder or pelvic pain seen by the pain specialist would have been seen and managed by a urologist up to the extent that relevant investigations, procedures, diagnosis and treatment would have been carried out. The pain specialist does not work alone. Managing pain requires a holistic approach as pain is a perception and is difficult to measure objectively; the degree of pain is what the patient feels. The pain specialist coordinates the management of the pain together with the urologist, physiotherapist, psychologist etc. as needed. 

The pain specialist starts by reviewing the diagnosis, optimizing the patient’s medications, referring to other members of the team if necessary or adding on non invasive treatment methods such as TENS (Transcutaneous Electrical Nerve Stimulation). The forte of the pain specialist is really the specialised pain procedures such as nerve blocks, neurolysis of nerves or ganglions (chemical neurolysis or radiofrequency), neuromodulation with implantation of devices such as nerve or spinal cord stimulators or intrathecal morphine pumps when all the other treatment methods have been tried and failed. Neurolysis involves destruction of ganglions or plexuses such as the ganglion impar, superior or inferior hypogastric plexuses; these serve as the sensory innervations of the pelvis. Neuromodulation involves implanting impulse generators, which look much like cardiac pacemakers, subcutaneously, so that it will stimulate leads implanted in the spine or the sacral nerves. These electrical impulses neuromodulate the nerves or spinal cord so that the pain is reduced and the autonomic nerve balance is improved resulting in improved bladder function. Intrathecal pumps involve inserting a catheter into the intrathecal space in the spine and then infusing morphine or other drugs into the spine through an implanted pump. The pump will require medication refill every three months. These drugs work at the level of the spinal cord receptors, increasing efficacy and reducing systemic effects. Presently there is a growing body of evidence that sacral nerves neuromodulation is the treatment of choice for interstitial cystitis/chronic bladder pain syndrome when all other modalities of treatment has failed.  

Psychological Management
Bladder Pain can be quite challenging to manage. It can bring much stress and adjustments to patients and family members. A bio-psychosocial, multidisciplinary approach often requires psychological interventions when patients are desperate, distressed, or suffer from Anxiety and Depression. Patients often find that this condition takes a heavy toll on the loss of their physical health, mental well being, activities of daily living and even livelihood and financial independence.

Psychological well-being and self-esteem are particularly important in the recovery process. This can be achieved gradually with symptom improvement and   functional restoration.  Patients need to work closely with their doctors to achieve this in an atmosphere of openness, trust and compliance. 

Various medications can be prescribed for the treatment of psychological distress and symptoms. In addition, educational and cognitive behavioral interventions can be tailored to help individual patients cope better. Continued empathy to the suffering patient, engagement and sensitive communication by the doctor with patient and close family members are important to enhance recovery.  Various strategies can help patients defocus on their pain, manage their anxiety/depression and make adaptive changes to their lifestyle. These include the use of pain diary, bladder re-training, diet, exercise and appropriate recreational activities. It is also crucial to help patients take personal responsibility to manage their expectations while fostering hope. Patients need to understand that research is continuing to find innovative ways to treat this challenging condition and improve the lives of many sufferers and their families.