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Chronic pelvic pain syndrome
Pain is defined as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage”.
We define chronic pelvic pain as non-cyclic pain lasting at least six months, located in the pelvis, lumbosacral area, buttocks or anterior abdominal wall below the naval, which is severe enough to cause the patient functional impairment or to seek medical care
(American College of Obstetricians and Gynecologists – ACOG).
Chronic pelvic pain can by presented with a wide range of forms, locations, intensities, psychological effects and progression times. The condition is a difficult challenge for healthcare professionals, given the complexity in making the correct diagnosis and determining the appropriate treatment.
The syndrome can affect both men and women, regardless of their age.
The type of pain, whether inflammatory, neuropathic or nociceptive, must be established. We must then try to determine the cause of the pain, which may be gynaecological, urological, gastrointestinal or a musculoskeletal disorder.
There are many diagnoses included in CPPS. Here we will focus of the most common and well-known ones.
The pudendal nerve is a mixed nerve that originates in the sacral nerve roots, and when it reaches the pelvis, it its three terminal branches innervate the perineal area.
Pudendal nerve neuralgia mainly occurs in women between the ages of 50 and 70. The topography of the pain is perineal, from the penis or clitoris to the anus, although it may radiate to the vulva or scrotum. It may occur in one side only or in both. Its onset may be sudden and constant or it may have remission periods.
With regard to the type of pain, it is neuropathic pain with the characteristics defined in DN4. There is resistance to classic painkillers, although it responds to tricyclic antidepressants and antiepileptic drugs.
The pain is continuous, of varying intensity, and posture is a determining factor for its onset.
It is important to diagnose pudendal nerve neuralgia due to compression and, therefore, those which can benefit from surgical treatment.
We can use the Nantes criteria to help make the diagnosis:
- Pain in the anatomical territory of the pudendal nerve.
- The pain is worsened by sitting.
- The patient is not woken at night by the pain.
- No objective sensory loss on clinical examination.
- Positive anaesthetic pudendal nerve block.
With regard to treatment of pudendal nerve neuralgia due to compression, we always begin with conservative treatment with drugs and physiotherapy. If this treatment is not effective, we will indicate surgical decompression of the nerve. There are three techniques for performing pudendal nerve decompression: trans-ischiorectal, transgluteal and laparoscopy.
Vulvar pain is a highly common reason for consultation among women, with an estimated frequency of 10%.
We use the term vulvodynia to refer to vulvar pain or discomfort present for over six months, with no obvious cause, whether organic or neurological. It may be localised or generalised and can be provoked, e.g. if the patient only experiences the pain on contact, such as during sexual intercourse, or it may be spontaneous or mixed.
In order to diagnose vulvodynia, we must always rule out the most common causes of vulvar pain, such as infection (candidiasis or herpes), inflammation (lichen planus), neoplasm (Paget’s disease, squamous carcinoma), neurological changes (herpetic or pudendal neuralgia) or a muscular or psychological disorder (vaginismus).
Various aetiologies have been suggested as possible causes of vulvodynia, such as embryonic changes, genetic or hormonal factors, neurological changes, etc.
Diagnosis is based on the patient’s medical history and physical examination and its treatment is complex. We can use a range of approaches, from specific drugs for chronic pain or creams with local anaesthetics, to performing infiltrations with botulinum toxin or even surgery.
Myofascial syndrome is a condition induced by a muscle or muscle group which causes local or referred pain. It is characterised by a motor disorder in the muscle itself, consisting of a taut band, of increased consistency, which is painful, can be identified by palpation and in which the trigger point is located, and by a sensitive disorder that causes pain on palpation.
It is classified as musculoskeletal pain that may be chronic or acute, and regional or generalised. It may be primary or secondary to another condition, such as pudendal nerve neuralgia.
It is important to obtain the patient’s medical history and a thorough examination of all muscle groups and innervations.
Treatment is multidisciplinary, and physiotherapy and even osteopathy are an essential part of this. In more complex cases, infiltrations may be performed in these muscles with local anaesthesia or botulinum toxin.
We define painful bladder syndrome as chronic pelvic pain present for over six months, which is perceived as pressure or discomfort related to the urinary bladder accompanied by at least one of the following symptoms: frequent, urgent need to urinate and/or pollakiuria (extraordinary daytime urinary frequency).
It is important to obtain a good medical history of the pain reported by the patient for diagnosis, as well as a physical examination. It may even be necessary to perform a cystoscopy to view the appearance of the bladder. As with all chronic pain, we must first rule out an organic cause, such as an infection.