Doctor Armando Librino M.D.— Photo courtesy of Hanoi French Hospital
by Doctor Armando Librino M.D.*
(Continued from February 10)
Diagnosis of the cause of chronic pelvic pain
Because a number of different conditions can cause chronic pelvic pain, it is sometimes difficult for doctors to pinpoint the specific cause.
History and physical examination – Your health care provider will talk to you about your history (including past health problems and any symptoms you are having) and examine your abdomen, lower back, hips, and pelvis. This should include an internal pelvic examination.
Your provider might order laboratory tests, including a white blood cell count, urinalysis, tests for sexually transmitted infections, and a pregnancy test.
Pelvic ultrasound – A pelvic ultrasound can help your provider look for certain causes of pelvic pain, including ovarian cysts (sometimes caused by ovarian endometriosis) and uterine fibroids. However, an ultrasound is not helpful in the diagnosis of irritable bowel syndrome, diverticulitis, or painful bladder syndrome.
Laparoscopy – A surgical procedure called a laparoscopy may help diagnose some causes of chronic pelvic pain such as endometriosis and chronic pelvic inflammatory disease. A laparoscopy is a procedure that is often done as a day surgery under general anaesthesia. A thin telescope with a camera is inserted through a small incision just below the navel. This allows the surgeon to see inside your abdomen and look at your reproductive organs. If the laparoscopy is normal, your provider can then focus on non-gynecologic causes of pelvic pain.
If the laparoscopy is abnormal (for example showing areas of endometriosis or abnormal tissue), these areas may be treated or biopsied during the procedure.
Chronic pelvic pain treatment
Chronic pelvic pain has multiple possible treatments that can be combined if needed.
Managing pain – Initially, your health care provider might suggest treating your pain with medications such as:
●Nonsteroidal anti-inflammatory drugs (NSAIDs), which include ibuprofen and naproxen
In general, most providers try to avoid or limit the use of opioids in treating chronic pain. These drugs have been found to be of limited benefit in the long term, and are associated with a risk of misuse or addiction.
Treating the underlying cause – In addition to relieving your pain, your health care provider will also try to treat whatever condition is causing your pain:
● If diagnostic testing such as ultrasound or laparoscopy has suggested a specific cause for your symptoms, your provider will plan for treatment accordingly. While it is ideal to be able to accurately diagnose and treat the underlying cause, this is not always possible.
● One approach is to prescribe sequential drug treatments for disorders that are the most likely causes of your pelvic pain. As an example, endometriosis is the most common gynecologic cause of chronic pelvic pain. If your provider thinks you might have endometriosis, they might start you on treatment for this condition for a trial. If your pain does not improve, your provider will try a different treatment. If one of these treatments relieves the pelvic pain, then the likelihood that endometriosis is causing your pain increases. However, it is important to note that improvement in symptoms is not an absolute confirmation of diagnosis since treatment effects are often not specific.
● Another approach involves directing treatment at the nervous system pathways responsible for processing pain as a response to triggers. Nonsteroidal anti-inflammatory drugs, antidepressants, and anticonvulsive medications are often used to modulate the activity of nerve pathways.
Physical therapy – Pelvic floor physical therapy (PT) is often helpful for women with abdominal myofascial pain or with pelvic floor pain. This type of PT aims to release the tightness in these muscles by manually "releasing" the tightness; treatment is directed to the muscles in the abdomen, vagina, hips, thighs, and lower back. Physical therapists who perform this type of PT must be specially trained.
Surgical treatment – A few gynecologic causes of pelvic pain can be treated with surgery. For example, some women benefit from surgical removal of endometriosis tissue, ovarian cysts, or fibroids.
Hysterectomy (surgery to remove the uterus) may alleviate chronic pelvic pain, especially when it is due to uterine disorders such as adenomyosis or fibroids. However, pain can persist even after hysterectomy, particularly in younger women (under 30) and in women with a history of chronic pelvic inflammatory disease or pelvic floor dysfunction. Hysterectomy is not a good choice for women who want to get pregnant in the future.
Surgery to cut some of the nerves in the pelvis (presacral neurectomy) has also been studied as a treatment for chronic pelvic pain. However, this approach has shown effectiveness mostly for cyclical midline pelvic pain and has additional surgical risks, so it is not recommended for most women.
Multidisciplinary pain management clinics – if the above approaches are not effective in treating your pain, you may be referred to a medical practice specialising in pain management. Pain services utilise multiple treatment modalities including:
●Biofeedback and relaxation therapies
●Nerve stimulation devices
●Injection of tender sites with a local anesthetic (eg, lidocaine) to numb the area. — Hanoi French Hospital
*Doctor Armando Librino is a Specialist in Obstetrics & Gynecology at Hanoi French Hospital.
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