management of chronic pelvic pain

Lauren Hill

DRA. The goal of DRA rehabilitation has shifted due of modifiable risk factors, exercise in the form of
to literature supporting the space between the rectus physical activity is negatively correlated with dysmen-
muscle bellies is less important than the ability to orrhea [45].
generate tension through the fascia connecting the
muscles, which can provide stability in the spine and Smoking cessation is another common educa-
pelvis despite a continued DRA or actual separation tional topic discussed with patients in relation to
[43]. their pain as well as other symptoms. A systematic
review found no studies to demonstrate that smoking
Patient Education and Lifestyle Changes in cessation resolves or reduces urinary incontinence
Pelvic Health Physical Therapy although urinary urgency and frequency have been
shown to be up to three times more common among
The foregoing information and description of treat- current than never smokers and this association
ments for pelvic pain and dysfunction are meant seems to be a dose–response relationship. Current
primarily to help the clinician understand the vari- data suggest that smoking increases the risk of more
ous evidence-based options to help this patient severe urinary incontinence [46].
population, understanding that is it likely not within
the scope of practice, nor is it possible within the Dietary factors have shown to play a role in pelvic
limited timeframe provided, for clinicians to per- floor symptoms through their impact on the bladder
form or progress the various conservative treatment and/or bowel. Avoiding bladder irritants has been
modalities. The foregoing information can be help- a typical recommendation to patients, particularly
ful knowledge to the clinician when the decision is those reporting symptoms consistent with IC/BPS or
made to refer the patient for treatment with another functional complaints of urinary frequency and
clinician such as a pelvic health physical therapist, as urgency. Studies on counseling to reduce caffeine are
the patient will likely want information regarding more impactful in conditions with urge, not stress,
what to expect from such a referral. The largest primary incontinence symptoms. Fluid intake has not
aspect in the initiation of treatment that the clinician been supported by research as a method to help
does participate in, other than surgical and interven- improve urinary incontinence due to the minor
tion techniques obviously, is education. There are impact decreased fluid intake would have compared
numerous education topics that the clinician can to the risk of limited intake including dehydration,
provide regarding anatomy of the pelvic floor and urinary tract infections and constipation [4, 47].
pelvic girdle, diagnosis, and interrelated symptoms Dietary changes have also been found to impact the
as well as modifiable lifestyle choices and habits that incidence of stress urinary incontinence (SUI), with
can impact the success of the clinician-driven treat- studies demonstrating the incidence of SUI is
ment plan. increased in women who consumed more total fat,
saturated fatty acids, and monosaturated fatty acids as
There are many lifestyle modifications that the well as increased carbonated beverages, zinc, or B12.
patient may be educated about because of their impact This was compared to the reduced incidence of SUI in
and relationship to pelvic floor dysfunction. Obesity women who ate more vegetables and chicken at base-
has been shown to have a multitude of impacts on the line. A high intake of vitamin D, protein, and potas-
patient’s health and well-being, and in regard to pelvic sium has also been associated with decreased onset of
floor dysfunction, has been shown to have an impact overactive bladder in women [4, 47].
on urinary incontinence. A systematic review per-
formed by Hunskaar found evidence to support Education on bowel and bladder habits can also be
waist–hip ratio and thus abdominal obesity may be initiated during clinic visits and can be invaluable
independent risk factors for incontinence and that information to patients with constipation and/or
moderate weight loss should be seen as an adequate voiding difficulties associated with their chronic pain
first-line therapy for urinary incontinence in women symptoms. Associations have been shown between
[44]. Women may be hesitant to initiate physical constipation and urinary incontinence likely due to
activity in the form of exercise if recommended to the chronic straining required for evacuation and
do so for fear that it may impact or worsen their associated pelvic floor dysfunction. Medical relief of
incontinence. Studies have also found that in terms constipation has been shown to significantly reduce
lower urinary tract symptoms in the elderly although
there has been no evidence to show that interventions

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Physical Therapy for Musculoskeletal Impairments

targeted as reducing constipation in incontinent understanding her perceived importance of the
patients decreases urinary incontinence [48]. behavior change, providing information if necessary,
Education about bowel care including positioning and exploring her level of perceived self-efficacy to
with the knees elevated while on the toilet to decrease make a change [49].
the anorectal angle, avoidance of straining, slight bul-
ging of the pelvic floor on inhalation to encourage Concurrent Medical Interventions with
emptying, and consistency in meal amounts and times Musculoskeletal Impairments
and other dietary changes can be beneficial informa-
tion to this patient population. Patients may present with muscle dysfunction or joint
or connective tissue conditions and even with appro-
In patients with chronic pelvic pain, instructions priate physical therapy their current state may war-
in pacing themselves to learn how to operate in the rant additional supportive medical treatments.
“safe zone” helps them to gain confidence in their
body again, and not overdo their capability until Often patients who have long history of pelvic
they have built up the capacity with aerobic endur- pain from muscle spasm may trial oral or local
ance, strength, neuromotor resilience, and reduced antispasmodics to reduce the muscle tension gener-
fear of movement. ated at rest that may also be too great to start to
reduce with the correct physical therapy interven-
Education provided by the clinician can help to tions. This pharmacological option may create
initiate the treatment process for the patient; however, a break in the spasm cycle that allows for progress
simply telling the patient about her condition and to normalization of muscle tone and balance to be
contributing behaviors is likely insufficient to motiv- gained. In addition, if there is progress made but it is
ate patients toward changing these behaviors. Various temporary, it may be beneficial to do a local trigger
behavior modification theories and strategies have point injection (TPI) with analgesics to evaluate the
been studied and some consistencies are present. It effect on the local muscle immediately after to see if
is important when educating patients to individualize it was helpful to reset the muscle bias and continue
and personalize the information, focusing on how the to improve the muscle group relaxation with physical
change could impact the goals and activities they feel therapy techniques. For longer lasting effects, some
they are not currently able to tolerate or perform. physicians use steroid in the TPI, or they can opt to
Asking the patient about her belief in her ability to use Botox injections and send the patient back to
make the changes being asked and the feasibility of pelvic health physical therapist to keep working on
implementing the changes is also important. The clin- balancing the muscular system centrally and locally.
ician must understand what the patient perceives as
“normal” in terms of her behaviors which will be Another common pharmacological aid is the use
influenced by her social group, with clinicians helping of topical analgesic ointment, cream, or gel. This can
to modify misperceptions through evidence-based improve the tolerance for palpation, release, and
information. The clinician must stay aware that stretch and progressive desensitization of the vaginal
a patient’s progress toward change will not be linear introitus. At times it is valuable for initiating the
and she will move forward and backward along mobility and flexibility back in an area that has been
a continuum that will likely be affected by changes hypersensitive and presents with reactive muscle
in her beliefs, perceptions of the impact of the spasm and guarding.
changes, and input from her social circles and
environment. Pelvic health physical therapists also count on
their medical counterparts to adequately assess and
A patient’s readiness and decision to change will manage the patient’s hormonal status, as imbalance of
shift forward and backward with time, and this is one estrogen or testosterone can set up painful mucosal
of the main reasons advice-giving has limited effect- conditions that impact function of the perineal and
iveness. Patients will accept advice and act upon it pelvic floor.
only when they are ready. The ambivalence toward
behavioral changes can be met with motivational All pharmacological adjuncts must be screened for
interviewing techniques that allow for reflective lis- allergy, interaction, and appropriateness through the
tening and open-ended questioning. This style offers patients referring provider. Pelvic health physical
the opportunity to build rapport with the patient, therapists can report response or adverse reactions if
noted on their visits.
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219

Lauren Hill

Conclusion hypersensitive situations and/or help continue
progress the patient has made. This is often a two-
Pelvic health physical therapists have a wide range of way street, with medical interventions and pelvic
interventions that have been demonstrated as highly health physical therapy helping to potentiate the
effective and low risk in addressing the primary effects of the other.
muscle, joint, and soft tissue dysfunctions associated
with pelvic pain conditions. References

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10. FitzGerald MP, Payne CK, Lukacz ES, et al.
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Chapter If Everything Else Fails

21 Michael Hibner and Elizabeth Banks

Editor’s Introduction may become spastic and tender as the painful stimulus
from the visceral organ travels. This is demonstrated by
Pelvic pain is one of the most difficult human the high incidence of pelvic floor dysfunction and
conditions to diagnose and treat. The pelvis is muscle spasm in women with endometriosis. In
composed of a complicated network of somatic and a similar vein, via the mechanism of viscerovisceral
visceral nerves; connective tissues; as well as convergence, patients with one source of visceral pain
reproductive, urinary, and gastrointestinal organs. Pain may develop pain in another visceral organ, as seen in
in the pelvis can thus be from any of these areas. In women with endometriosis and other coexisting pain
order to diagnose and treat patient correctly it is very syndromes such as interstitial cystitis/bladder pain syn-
important to have a knowledge of all nongynecologic drome (IC/BPS) or irritable bowel syndrome (IBS).
and gynecologic conditions leading to pelvic pain.
Despite this knowledge, diagnosis may still be very Another difficulty in treating pelvic pain is that there
difficult. Very often reexamining history and medical is no single medical specialty that routinely treats the
records may be helpful. In many patients pelvic floor is condition. The majority of women with chronic pelvic
a main contributing factor to the pelvic pain. pain see their primary gynecologist as the first provider
for their complaint. Unfortunately, specialists in general
The pelvis has multiple functions such as providing obstetrics and gynecology receive minimal education
support to the upper body, locomotion, evacuation of in residency regarding pelvic pain. Thus, the majority
waste, childbirth, and sexual pleasure (from stimulation of general gynecologists are most comfortable with
of both external and deep structures). The nerves medical management and simple surgery for endomet-
innervating the pelvis and lower extremity often origin- riosis. Some may attempt to treat IC/BPS, but most
ate in the same segments of the spinal cord, such as in rarely treat lesser known but common conditions such
the case of pudendal and sciatic nerves; thus, by the as pelvic floor dysfunction, intraabdominal adhesions,
mechanism of crosstalk, pain originating in one nerve or pelvic congestion syndrome. Urologists are well
may subsequently lead to pain in a neighboring nerve trained to treat IC/BPS but very rarely address any
Additionally, muscles of the lower back and anterior and other pain-causing conditions. Other physicians such
posterior thighs attach to the pelvis and often become as gastroenterologists, neurologists, general surgeons,
affected themselves in patients with pelvic pain. and orthopedists rarely address pelvic pain at all.
Physiatrists (physical medicine and rehabilitation
Coexistence and opposing functions (such as con- physicians) and pelvic floor physical therapists with
tinence and evacuation) of the pelvic organs often make special training in the pelvic floor may in fact be the
the diagnosis and treatment of pelvic pain difficult. For best equipped to address the needs of pelvic pain
instance, patients often complain of pain related to their patients, as pelvic floor muscle spasm is the main
bladder; however, there is a big difference if pain is at the cause of pain for the majority of these patients.
beginning of urination, during urination, or at the end.
Each one of these is caused by a different condition. Despite best efforts, it has been shown that approxi-
mately 60% of women with chronic pelvic pain seen in
Unlike in other parts of the body, coexistence of pain a general Obstetrics and Gynecology practice do not
conditions in the pelvis is well described. In the mech- receive a proper diagnosis and therefore cannot get
anism of viscerosomatic convergence when a patient has proper treatment [1]. This percentage is possibly less
a visceral source of pelvic pain, such as endometriosis for patients seen in a specialized pelvic pain practice or
implants on the pelvic organs, the surrounding muscles

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Michael Hibner and Elizabeth Banks

in a multidisciplinary practice; however, this number is Table 21.1 (cont.) Possible mechanism
unknown. Unfortunately, there are still some patients Causes of pelvic
who will not receive the correct diagnosis even when floor muscle Increased laxity of pelvic joints may
seen at the most specialized practices. This chapter aims spasm lead to overactivity and spasm of
to provide guidance and suggestions on how to proceed Laxity of pelvic pelvic muscles to stabilize the joint.
when this occurs. In these cases, there is little scientific
evidence on how to proceed and many statements in this ligaments/joints Certain physical activity
chapter are from very extensive personal experience Physical activity (gymnastics, ballet) may lead to
treating many patients with pelvic pain over several overgrowth and increased tone
years. Nerve compression of pelvic floor muscles.

Multiple Sources of Pain Unknown Nerve compression leads to
significant pain that then causes
Most patients with chronic pelvic pain have multiple reflex muscle spasm in the area
sources of pain [2]. There are frequently coexisting close to the injured nerve
conditions such as endometriosis with IC/BPS, IBS, (somatosomatic reflex).
and spastic pelvic floor syndrome or pudendal nerve
injury with spastic pelvic floor syndrome. Ideally all Possible genetic or anatomical
sources of pain should be identified and treated in predisposition to muscle spasm
order to improve a patient’s pain. If all coexisting condi-
tions are not addressed the patient will not be helped. Table 21.2 Symptoms indicative of pelvic floor muscle spasm

Think Pelvic Floor Symptom Comment

The majority of physicians who see women for pelvic Urinary hesitancy Possibly the most sensitive
pain (gynecologists, urologists, gastroenterologists) symptom. Women without
are not familiar with pelvic floor muscle spasm, muscle spasm should be able
which is often a source or a contributing factor to to urinate immediately after
pelvic pain [3]. Often patients with chronic pelvic sitting down on the toilet. Any
pain undergo multiple laparoscopies and even hyster- delay is abnormal. Pelvic floor
ectomy, but their pain persists. More often than not muscle spasm puts pressure
they have spasm of the levator ani, obturator internus, around the urethra, causing
and superficial pelvic muscles that is unrecognized hesitancy. This also explains
and thus has never been addressed. Unfortunately, why some patients have
physicians don’t know what questions to ask, nor are difficulty emptying their
bladder after pelvic surgery. In
extreme cases patients may
have to self-catheterize.

Constipation In a mechanism similar to urinary
hesitancy, patients with pelvic
Table 21.1 Causes of pelvic floor muscle spasm floor muscle spasm often
develop constipation. Patients
Causes of pelvic Possible mechanism will often complain of thin
floor muscle pencil-shaped stool. In some
spasm Viscerosomatic conversion. Visceral cases patients may also
Endometriosis organs with implants of complain of severe bloating.
endometriosis are innervated This may be due to difficulty in
Pelvic trauma/surgery/ through the same segment of passing gas.
mesh implantation the spinal cord as the pelvic
muscles. If the viscera is irritated, Pain after intercourse The majority of patients with
Sexual and the pelvic muscle may develop Pain with physical activity pelvic pain have pain with
psychological a spasm in response. intercourse. Patients with pelvic
trauma floor muscle spasm also have
Direct trauma and irritation of the pain after intercourse. Some
muscles. patients will complain of pain
after intercourse lasting for 1–2
Protective mechanism against days.
penetration/rape.
Patients with pelvic floor muscle
spasm often have more pain
after physical activity.

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If Everything Else Fails

Table 21.2 (cont.) Comment Questions regarding the events that lead to the onset of
pain are central to the diagnosis. Often, at the patient’s
Symptom Patients with pelvic floor muscle initial visit, when the history is taken for the first time,
Increased pain in the spasm usually have less pain she may not remember all the events leading up to the
when they wake up and pain start of her pain (Figure 21.2). Thus, it may be very
evening (at the end of increases as the day goes by. beneficial to retake the history from the very beginning.
the day) Patients who complain of pain since menarche are more
Pain improved with the likely to have endometriosis. On the other hand, if their
Pain improved with application of heat is almost pain started with pregnancy, delivery, surgery, athletic
heating pad always indicative of pelvic activity, or trauma they most likely have another eti-
floor muscle spasm. ology causing their pain. Many patients with complex
pain conditions have several reasons to have pain, and it
they taught to properly examine for pelvic floor is very important to identify all the sources of pain.
muscle spasm. If there is any doubt if the patient has Often pain from different sources may begin at different
pelvic floor muscle spasm she should be referred to chronological points; thus obtaining a detailed history
a pelvic floor physical therapist. with a precise timeline is crucial. For example, pain
caused by endometriosis, which often starts with onset
Repeat History of menstrual periods, with time may become related to
physical and sexual activity. This usually signifies
The most important component of diagnosis and evalu- involvement of pelvic floor muscles. As time progresses
ation of chronic pelvic pain is the history (Figure 21.1).

Pelvic pain

Continuous Activity related
(day and night) (day only)

Noncyclical Cyclical Sitting
PNE
Nocturia Localized
IC/BPS Standing
ovarian PCS
remnant

No nocturia Diffused Exercise
adhesions intercourse
endometriosis
adenomyosis SPFS

Figure 21.1 Simplified diagnosis of pelvic pain based on the initial incident. IC/BPS, interstitial cystitis/bladder pain syndrome; PCFN,
posterior cutaneous femoral nerve; PCS, pelvic congestion syndrome; PFTM, pelvic floor tension myalgia; PNE, pudendal nerve entrapment.

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Michael Hibner and Elizabeth Banks

Table 21.3 Review of patient’s history

Onset of pain Pain beginning with menarche – endometriosis
Location Pain after pelvic trauma, surgery, vaginal delivery – musculoskeletal/nerve pain
Aggravating factors Pain after pregnancy – pelvic congestion
Pain after abdominal/pelvic surgery – adhesions
Alleviating factors
Sexual symptoms Localized pain – nerve pain, ovarian remnant
Urinary symptoms Diffuse pain – muscular pain, visceral pain, endometriosis

Physical activity – musculoskeletal/nerve pain, adhesions
Upright position – pelvic congestion syndrome
Pain with sitting – pudendal neuralgia
Pain with full bladder – IC/BPS
Pain at the end of urination/bowel movement – pelvic floor muscle spasm
Pain worse in the evening – musculoskeletal pain, pelvic congestion syndrome
Pain at night when turning in bed – adhesions
Pain with menstrual periods – endometriosis, adenomyosis
Pain with ovulation – mittelschmerz, ovarian entrapment/remnant

Pain decreased with heating pad – musculoskeletal pain
Pain decreased after urination – interstitial cystitis

Pain during intercourse – any pelvic pain condition
Pain lasting after intercourse – pelvic floor muscle spasm, pelvic congestion syndrome
Pain with sexual arousal without penetration – pudendal neuralgia, pelvic congestion syndrome
Persistent sexual arousal – pudendal neuralgia
Pain with intercourse in quadripedic (“doggy”) position – IC/BPS

Urinary hesitancy – pelvic floor muscle spasm
Nocturia – IC/BPS
Pain with full bladder – IC/BPS
Pain at the end of urination – pelvic floor muscle spasm

IC/BPS, interstitial cystitis/bladder pain syndrome.

Onset of pelvic pain

Incident No incident

Menarche Pregnancy Trauma Infection Vulvodynia
Psychological
Endometriosis Pelvic Vaginal delivery Bladder Adenomyosis
Primary dysmenorrhea congestion Athletic sudden IC/BPS
syndrome unilateral Athletic repetitive bilateral
Müllerian anomaly Abdomen
Surgery Adhesions

Nerve injury mesh

SPFS

iIlioinguinal pudendal
genitofemoral

PCFN
obturator

Figure 21.2 Simplified diagnosis of pelvic pain based on the nature of pain and additional symptoms. Abbreviations as for Figure 21.1.

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If Everything Else Fails

the bladder may become affected and patients may In the process of working up their pain condition
begin complaining of nocturia and pain with a full patients often undergo multiple tests, consultations,
bladder. In addition to taking a repeat history from the and procedures. Often, at the time of the first visit,
patient it is sometimes very helpful, with the patient’s patients will provide hundreds of pages of records
permission, to talk to family members, especially par- from other providers and it is almost impossible to
ents or partners. People close to the patient may notice review those records in the allocated time for their
patterns that the patient herself may be unaware of. visit. It is thus important to choose which records
Another good technique, especially if the patient is should be reviewed first, and those that may need to
referred from another physician, is to “start clean.” It be reviewed at a later time.
may be more helpful to first obtain a full history directly
from the patient before reviewing notes from another Operative Reports
provider. This may allow the clinician a broader per-
spective and may prevent the clinician from coming to In patients in whom pain began after a surgical pro-
the same conclusion as prior providers. cedure the most important record to review is the
report of that surgery or surgeries. It is crucial to
Determine if Pain Is Somatic or Visceral determine what was the indication for the procedure,
if there was any pain present prior to the procedure,
If the etiology of the pain cannot be determined, it and if the pain that patient has now is the same pain
may be helpful to determine if pain is somatic or but worse or if this this a new onset of pain.
visceral. This may help later on to narrow down the Additionally, it is important to note how the patient
pain to a specific location. was positioned for surgery and if there’s any possibil-
ity of compression of the pelvic nerves from position-
Pelvic pain may be nociceptive somatic, nocicep- ing. Location of the incision(s) should also be
tive visceral, or peripheral neuropathic. Often if pain determined to assess the possibility of injury to the
has persisted for a long period of time through previ- abdominal wall nerves secondary to the surgical
ously described mechanisms of viscerosomatic and incision(s). This may be especially important in lap-
viscerovisceral convergence, patients may have a mix aroscopic surgery, since incisions are placed close to
of all of the above. the anterior superior iliac spine and consequently may
injure the iliohypogastric or ilioinguinal nerve. In
Reexamine Medical Records open abdominal or vaginal surgery it is important to
determine which retractors were used, where the
Pelvic pain patients are usually seen by many pro-
viders before being seen by a pelvic pain specialist.

Table 21.4 Types of pain

Location Nociceptive Nociceptive visceral Peripheral neuropathic
Characteristics somatic
Localized Diffuse Radiating
Mechanism Pinprick, stabbing, Ache, pressure or sharp Burning, shooting, tingling, numb,

Examples of sharp C fiber electric shock-like, or lancing
medical A-delta fiber located in Dermatomal innervation
treatment Opioids and NSAIDs
the periphery Antidepressants, anticonvulsants, local
Examples of Opioids and NSAIDs Resection of endometriosis, anesthetics
surgical adhesiolysis
treatment Trigger point Neurolysis neurectomy
injections Endometriosis, IC/BPS, IBS,
Examples in the abdominal/pelvic adhesions Pudendal nerve entrapment
pelvis Spastic pelvic floor
syndrome

IBS, irritable bowel syndrome; IC/BPS, interstitial cystitis/bladder pain syndrome; NSAIDs, nonsteroidal antiinflammatory drugs.

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Michael Hibner and Elizabeth Banks

blades were positioned, and how deeply they were Other Specialty Consultations
placed. Equally important is the physical exam. The
purpose of the exam is to determine which structures One needs to be careful in reviewing the notes of other
may have possibly been affected by the surgical pro- providers, as providers of other specialties may not be
cedure. This is particularly important in surgeries experts in pelvic pain; thus the results of these con-
where sutures or any other surgical material may sultations should be interpreted with caution. On the
have been placed deep into the muscles or close to other hand, reports from pelvic floor physical therap-
the nerves. Permanent sutures or permanent surgical ists are very important and often have invaluable
material such as mesh may cause irritation to the insight to the patient’s pain.
muscles or nerves. Direct nerve injury, although
rare, also needs to be anticipated. Furthermore, it Laboratory Tests
needs to be determined if this surgical material
needs to be removed, and if yes what is the best Blood and urine test results are rarely helpful. One of
route to remove it. The surgical report should also the exceptions is in the case of ovarian remnant syn-
be scrutinized to identify if there are any descriptions drome in a premenopausal patient who has had the
of difficulties or complications encountered during contralateral ovary removed. In this case serum hor-
the procedure. mone levels (follicle-stimulating hormone, estradiol)
may reveal premenopausal levels.
Pathology Reports
By far the most important case in which to review
Examining the pathology report may be especially medical records, as previously mentioned, is in
important in cases of endometriosis. Too often patients with pain that originated after placement of
patients have multiple surgeries for presumed endo- pelvic mesh. These patients often have more than one
metriosis, but there are no pathology reports present type of mesh kit placed either for prolapse or incon-
that corroborate the diagnosis of endometriosis. tinence. Additionally, it is important to determine if
Pathology reports are also very important in patients these patients have already had parts of the mesh
with pain caused by pelvic mesh placement who had removed. One needs to be familiar with all types of
mesh removal surgery. The pathology report will spe- meshes used in pelvic surgery, points of attachments,
cify the size of the removed piece and therefore will technique of placement, and anatomical correlations
allow the treating physician to determine whether the of mesh and pelvic nerves/muscles. As mesh is very
entire piece was removed or if there is any mesh left difficult to identify on radiological tests, a surgeon
behind. who is planning to remove the patient’s mesh must
have a clear understanding of how much mesh is left
Radiology Reports in situ and where it is located.

Other medical records that are important to review Pelvic MRI
may include radiological reports. Pelvic MRI may be
helpful in diagnosing conditions such as pelvic con- One of the most useful radiological tests in diagnosing
gestion, pelvic masses, deep infiltrating endometri- causes of pelvic pain is pelvic MRI. It has the potential
osis, abdominal wall endometriosis, hernias, ovarian of demonstrating pelvic congestion, deep infiltrating
remnant, and nerve compression. Radiological endometriosis in the rectovaginal septum, endomet-
imaging is not very accurate for determining the riosis in the adnominal wall layers, pelvic and abdom-
presence of permanent sutures and mesh. Pelvic inal masses, spinal abnormalities, and nerve
and abdominal ultrasound may also be useful in compression. Routine MRI on every patient with pel-
ruling out conditions such as abdominal and pelvic vic pain may not be warranted, but if the patient has
masses, ovarian remnant, as well as pelvic conges- no diagnosis despite workup this test should be
tion. Both MRI and ultrasound require experienced ordered. It is important, though, to communicate
radiologists and sometimes it may be useful to have with the radiologist regarding the presumed path-
the existing study be reviewed by another radiologist ology before ordering the study, as multiple protocols
with excellent knowledge of pelvic pain and pelvic exist for MRI and the correct test must be ordered.
pathology.
From the author’s experience there have been
e Cambridge Core terms of use, available at multiple cases where diagnosis was very difficult to
.022 establish. After discussing the case with a radiologist

If Everything Else Fails

Table 21.5 Medical records to review Table 21.6 MRI protocols for various pain causing conditions

Operative reports Indications for surgery Condition Protocol Comments
Positioning Pelvic
Pathology reports Location of incisions Dedicated pelvic Assessment of
Radiology reports Retractors used congestion time resolving early arterial
Other specialty Structures operated syndrome MRA angiogram enhancement
Surgical materials used w/wo contrast of dilated
consultations Mesh type, location, and amount Deep infiltrating gonadal veins
removed endometriosis Dedicated MRI and parauterine,
Laboratory tests female protocol paravaginal
Confirm endometriosis Endometriosis of w/wo, vaginal venous plexus
Confirm amount of mesh removed the abdominal and rectal
Confirm removal of ovarian wall contrast Evaluation of the
remnant enhancement uterus, adnexa,
Pelvic/ deep pelvic
MRI – pelvic congestion, deep abdominal Dedicated MRI spaces,
infiltrating endometriosis, pelvic masses female protocol ligaments,
masses, nerve compression w/wo, + vaginal rectovaginal
Spinal contrast to septum, and
Need to be carefully interpreted abnormalities include colonic wall for
since few providers have deep abdominal wall endometriosis
knowledge of pelvic pain Nerve in the FOV
Pelvic floor physical therapist compression Assessment of
reports may have important Dedicated MRI abdominal wall
insight to the patient’s pain female protocol endometriosis
w/wo, + vaginal
Rarely helpful with the exception contrast Assessment of
of premenopausal patients with uterine, cervical,
suspected ovarian remnant Dedicated MRI of ovarian, and
syndrome in whom the lumbosacral vaginal
contralateral ovary has been spine w/wo pathology
removed contrast
Evaluation of disk
well versed in pelvic pathology, specific protocol pel- Dedicated level, neural
vic MRI helped establish the underlying etiology of pudendal MRI foramen
the pelvic pain. w/wo contrast
High-resolution T2
Selective Nerve Blocks andT1 WI in
paraxial and
In some patients the diagnosis of pain has been nar- paracoronal
rowed to nerve injury. In these patients pain usually planes, dynamic
begins after some traumatic event such as sport trauma, axial contrast
accident, childbirth, or surgery. Pain is usually localized, enhanced
burning, and tingling in nature. Patients often have examination for
allodynia, which is pain in response to a stimulus that evaluation of
is normally not painful. If the nerve also has a motor neurovascular
component there may be motor deficit noted as well. bundle
Unfortunately, with the significant overlap of innerv- morphology,
ation in the pelvis it is at times difficult to determine course, and
which nerve is responsible for the patient’s pain. In these pathology
cases, selective pelvic nerve blocks may be very helpful.
These blocks must be completed with radiological guid- Autonomic Nerve Blocks
ance to ensure that the proper nerve is being blocked.
The majority of pelvic nerves can be blocked using When laparoscopic assessment and somatic nerve
ultrasound guidance, but some nerves are better blocked blocks have failed to provide the diagnosis for the
with CT guidance. Blocks done with local anesthetic and patient’s pain, it may be appropriate to offer patients
steroid serve mostly diagnostic purposes, but there may autonomic nerve blocks. For pelvic pain they include
also be therapeutic benefit, as the steroid can decrease the superior hypogastric plexus (SHP) block, inferior
inflammation around the nerve. hypogastric plexus block, and the ganglion impar
block. These blocks are usually performed by
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229

Michael Hibner and Elizabeth Banks

anesthesiologists specialized in the treatment of pain have been favorable for the treatment of the aforemen-
or interventional radiologists and are completed tioned conditions. SCS may be beneficial for treatment
under fluoroscopic or CT guidance. of select patients with neuropathic pelvic pain [12].

The superior hypogastric plexus is located anterior Hysterectomy for Chronic Pelvic Pain
to the bifurcation of the aorta. It receives sympathetic
contribution from L3–L4 lumbar splanchnic nerves and Preforming hysterectomy for chronic pelvic pain is one
parasympathetic contribution from S2–S4 pelvic of the most controversial issues in gynecology. Different
splanchnic nerves. Inferiorly the SHP forms the right providers have different conflicting options on the out-
and left hypogastric nerves, which continue into the comes of hysterectomy in patients with pelvic pain.
pelvis to form right and left inferior hypogastric plexi. Unfortunately, the research and literature are not helpful
In patients with genitourinary cancer who receive SHP either, as published results are conflicting. One of the
block, almost 80% have a positive response to first studies was published by Stovall in 1990. He
a diagnostic block and more than 70% have significant reported on long-term outcomes of hysterectomy pre-
reduction in pain following neurolytic block. This num- formed on 99 women for idiopathic chronic pelvic pain.
ber remains almost unchanged at 6 months follow-up. This study found that 78% of women had significant
improvement in pain 12–64 months after surgery [5].
The inferior hypogastric plexus (IHP) is paired Another study preformed 5 years later on 308 women by
and located on either side of the rectum and vagina. Hillis and colleagues found that 74% of women with
It is a continuation of the hypogastric nerves. IHP pelvic pain a year after hysterectomy had complete reso-
block has been shown to help in patients with endo- lution of pain, 21% of women had a decrease of pain, and
metriosis, bladder pain, and rectal pain. in 5% pain was unchanged or worsened [6]. In certain
subgroups – women who were younger than 30 years of
The ganglion impar is formed by the convergence of age, who were uninsured or on Medicaid, who did not
the right and left sympathetic trunks in front of the have identifiable pathology, and who had a history of
coccyx. It provides sympathetic innervation to the coc- pelvic inflammatory disease – 40% of patients continued
cygeal, perineal, and rectal area. Ganglion impar block to be in pain after hysterectomy. Both of those studies
has been shown to help with pain in the rectum, anus, proved that hysterectomy is more effective when hyster-
distal urethra, distal third of the vagina, and vulva. In one ectomy is done for identifiable disease that is causing
study patients with nonmalignant pelvic pain there was pelvic pain.
50% reduction in pain lasting on average 2.2 months [4].
A study of quality of life and sexual functioning in
Sacral Nerve Stimulation women with preoperative pain and depression was per-
formed in 1,200 women who underwent hysterectomy
Sacral neuromodulation is a well-established treat- [7]. They were monitored up to 24 months after surgery.
ment for patients with urinary dysfunction. The It was found that 78%–86% of women with preoperative
most commonly used device (InterStim) involves pain, depression, or both reported improvement in pain
insertion of electrodes in the third and/or fourth after surgery. Also 50%–52% of women reported
sacral foramen next to the nerve root. Sacral nerve improvement in mental, physical, and social function
stimulation is currently not FDA approved for treat- and 60% reported decrease in dyspareunia. It is also
ment of chronic pain; however, there are several stud- debated whether ovaries should be removed in patients
ies that have shown promising results [11]. with pelvic pain. This is discussed in chapter 7.

Spinal Cord Stimulation Centralized Pain and Complex
Regional Pain Syndrome
The use of spinal cord stimulation (SCS) is well estab-
lished in the treatment of neuropathic pain from vari- Central pain may be one of the most difficult pain
ous conditions such as complex regional pain conditions to treat. In patients with central pain and
syndrome, failed back surgery syndrome, and ischemic central sensitization the central nervous system ampli-
limb pain. SCS provides analgesia through electrical fies sensory inputs from many organ systems and treat-
stimulation of the dorsal column of the spinal cord via ment of peripheral organ only rarely leads to resolution
electrode leads placed into the epidural space. It is of pain. In those cases in which patients continue to be
currently FDA approved for the treatment of neuro-
pathic pain of the trunk and lower limbs. Outcomes

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If Everything Else Fails

in pain despite successful treatment of organic causes of Many patients arrive to their medical appoint-
pain the treating physician concludes that patient must ments already having researched their condition and
be fabricating pain. Some patients with pelvic pain their physician on the internet. Physicians themselves
demonstrate many features of complex regional pain are often discussed and ranked on these patient-
syndrome [8]. Those are pain in response to minor targeted discussion boards.
stimulus, pain exacerbated by movement, pain
improved by sympathetic block. Minor stimuli in pelvic Refer the Patient Out
pain may be ovulation, minimal adhesions, and minimal
endometriosis. Disruptions of sympathetic pathways If despite all the tests and treatments the patient still
that are helpful in patients with pelvic pain are presacral has no relief of her pain, the best course of action
neurectomy, superior and interior hypogastric plexus might be to refer the patient out to the specialized
block, and ganglion impar block. pelvic pain center. There are several renowned
practices in the United States and abroad who spe-
Ketamine infusions have been shown to be helpful cifically see patients for chronic pelvic pain, and the
in patients with centralized pain and complex knowledge and resources available to them allow for
regional pain syndrome [9]. much better care of patients with chronic pelvic
pain. One of the societies most involved in chronic
Psychosomatic Pain pelvic pain is International Pelvic Pain Society (pel
vicpain.org). Their website lists providers (phys-
Psychosomatic disorders are conditions in which icians and physical therapists) who have an interest
physical diseases have mental component derived in seeing patients with pelvic pain. Another good
from stresses of everyday living. Chronic pain is cer- resource is website of Women’s Section of
tainly one of the best described conditions that may be American Physical Therapy Association (women
caused by stressful and traumatic events of the past. It shealthapta.org).
has been estimated that 40%–60% of women with
chronic pain have a history of being abused during When referring a patient for psychiatric treat-
childhood or adulthood [10]. This is twice to four ment, it is important not to lead the patient to believe
times higher than in the general population. that the root cause of her pain is psychiatric. It very
rarely is. A patient who is told that the pain is “in her
Use Discussion Boards head” makes her feel as though medical providers
don’t believe that her pain is real. Moreover, when
Sometimes despite multiple diagnostic procedures a patient’s family member learns that the patient is
a diagnosis still cannot be reached. Fortunately, there being referred to a psychiatrist the family may blame
are several chronic pelvic pain discussion boards for the patient for “making her pain up.” A patient’s
providers where information and ideas can be partner, especially, may feel that the patient is using
exchanged. One of the best discussion boards is man- her pain to avoid sexual intimacy.
aged by the International Pelvic Pain Society (pelvic
pain.org). This society is composed of physicians from Offer Random Treatment
multiple medical fields as well as numerous pelvic floor
physical therapists; thus discussion board questions are Sometimes even if the patient does not have
answered by specialists from numerous medical fields. a diagnosis it is better to offer random treatment
Another frequently used discussion board is managed rather than doing nothing. If the treatment helps it
by AAGL (aagl.com). This society of minimally inva- may lead to the correct diagnosis. This diagnosis by
sive gynecological surgeons is composed of several treatment is called ex juvantibus in Latin. One of the
physicians who specialize in pelvic pain. more commonly used treatments without diagnosis is
gonadotropin-releasing hormone analogs for pre-
There are also numerous support groups and dis- sumed endometriosis. Other treatments may include
cussion boards for patients. These boards are usually doing pelvic nerve blocks or botulinum toxin
not monitored by healthcare professionals. Often, A injections to the pelvic floor. The data remain
information exchanged on these boards is inaccurate limited on these treatment modalities; however, our
and should not be used by physicians; however, phys- patients have had excellent success with both pelvic
icians should be aware that patients are reading them nerve blocks and botulinum toxin A injections into
and may be receiving incorrect information.

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Michael Hibner and Elizabeth Banks

the pelvic floor. Please refer to Chapters 15, 16, and 20 References
for additional information.
1. Mathias SD, Kuppermann M, Liberman RF,
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ling. The literature is very limited on the use of these
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ventions that patients may explore and find beneficial. and endometriosis in patients with chronic pelvic
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Psychological Treatments
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vention; however, in recent years mindfulness has nononcological pain. Pain Pract. 2005;5:103–10.
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• Most of the patients have more than one reason regional pain syndrome. Pain Med. 2004;5:263–275.
for pain and all the causes have to be identified. DOI: 10.1111/j.1526-4637.2004.04043.x.
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• One of the most important questions to ask is how 2005;98:1092–1099, 1138.
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13. Till SR, Wahl HN, As-Sanie S. The role of
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14. Dunkley CR, Brotto LA. Psychological treatment for
provoked vestibulodynia: integration of

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Index

AAPT system. See ACTTION-APS diagnosis of, 147 aromatase inhibitors, 91
Pain Taxonomy system dyspareunia, 146 artificial reproductive technology
etiology of, 145–6
abdominal examination formation of, 145 (ART), 92
for chronic pelvic pain, 19–21 pelvic pain, 145–6 autonomic nerve blocks, 229–30
Carnett’s test, 20 prevention strategies, 146
genitofemoral neuralgia, 20 risk factors for, 146 back examination, for chronic pelvic
ilioinguinal neuralgia, 20 symptoms, 146 pain, 19
obturator nerve, 20 treatment strategies, 147
rectus abdominis muscle, 41–2 baclofen, 58
myofascial trigger points, 41 adhesiolysis, 147–8 bacterial overgrowth, 121
transverse abdominis muscle, 39 surgical, 147 behavior modification, for bladder
allodynia. See vestibular allodynia
abdominal wall dysfunction, 216–18 alosetron, 126 pain syndrome, 103
ablation procedures altered microbiota, IBS and, 121 belladonna, 58–9
American College of Obstetricians and benzodiazepines, 58–9
laparoscopic uterine nerve ablation, bilateral salpingo-oophorectomy
78 Gynecologists (ACOG)
opinions, 4, 18 (BSO), 150
nerve ablation, for peripheral American Pain Society (APS), 23 bimanual physical examination, 21–2
neuropathic pain, 171 amitriptyline, 54–5, 56, 61, 103 biofeedback. See SEMG biofeedback
Analgesic, Anesthetic, and Addiction biosocial approach, in psychological
pain and endometrial ablation, 178 Clinical Trial Translations
acetaminophen/paracetamol, 52 Innovations Opportunities and assessment, of female patients,
ACOG. See American College of Networks (ACTTION), 23 24
anal/vaginal intercourse, dyspareunia bladder overdistension, 79
Obstetricians and with, 17 bladder pain syndrome (BPS), 1
Gynecologists antibiotic therapies, for bladder pain chronic pelvic pain and, 4
ACTTION. See Analgesic, Anesthetic, syndrome, 107 course of, 100
and Addiction Clinical Trial antidepressants definitional criteria, 98
Translations Innovations selective serotonin reuptake diagnosis of, 100–2
Opportunities and Networks inhibitors, 57 patient medical history in, 100–1
ACTTION-APS Pain Taxonomy serotonin and norepinephrine through physical examination,
(AAPT) system, 23 reuptake inhibitors, 54, 57 101
acupuncture therapy, 204 adverse effects, 57 through supplemental
acute pain, 1–2 description and properties, 57 questionnaires, 101
chronic pain compared to, 3 efficacy of, 57 symptoms in, 100–1
dopamine and, 9 tricyclic, 56–7 through testing, 101–2
norepinephrine and, 9 adverse side effects, 56–7 flares of, 109–11
physiology of, 8–9 contraindications, 56–7 glycosaminoglycan deficiency, 99
nociceptive activation from description and properties, 56 Hunner’s lesions and, 99
stimulation, 8 efficacy, 56 treatment strategies for, 105
noxious stimuli, 8–9 for vulvodynia, 139–40 irritable bowel syndrome
primary hyperalgesia, 8–9 antiepileptics, 54–5 and, 11
tissue damage, 8–9 gabapentanoids, 54–5 pathophysiology, 98–9
processing of, 8–9 antispasmodics, 126 central sensitization in, 99
emotions in, 9 anxiety, in psychological assessment, of glycosaminoglycan deficiency, 99
psychosocial attributes of, 11 female patients, 25, 27–8, 29 prevalence of, 99–100
catastrophizing, 11 appendectomy, 75 pudendal neuralgia and, 156
serotonin and, 9 appendiceal endometriosis, 94 quality of life impact, 100
adenomyosis externa, 87 APS. See American Pain Society treatment strategies, 102–7
adhesiolysis, for pelvic adhesive with cystoscopy, 105
disease, 147–8 experimental, 107
adhesive disease, pelvic fifth-line, 105–6
clinical presentation of, 145

at 20:21:51, .023 233

Index

bladder pain syndrome (BPS) (cont.) economic and social impact of, 3 safety guidelines in, 18
first-line, 102–3. See also first-line maladaptive plasticity and, 3 timeline of inciting events, 14,
treatment strategies physiology of
future, 107 15
high-risk, 106–7 brain volume, 10 trigger identification, 15–16
neuromodulation, 105 enteric nervous system changes, patient referrals, 231
second-line, 103–5. See also physical examination, 18–22
second-line treatment strategies 10 of abdomen, 19–21
sixth-line, 106 hypothalamic–pituitary–adrenal of back, 19
third-line, 105 bimanual, 21–2
axis, 10 of external genitals, 21
ulcerative, 99 visceral hypersensitivity, 10–11 general evaluation in, 19
vulvodynia and, 129 prescription drug abuse and. See manual, 21–2
body image issues, 197 of rectum, 22
Botox injection of pelvic floor muscles, prescription drug abuse in psychosomatic disorders, 231
prevalence of, 3 sacral nerve stimulation, 230
79 spinal cord stimulation, 230
botulinum toxin (Botox) in women, 3 summary of, 5
processing of, 9–11 symptoms of, 17, 18
injection in pelvic floor muscles, 79 treatment strategies, 231–2
intradetrusor, for bladder pain central sensitization, 9–10 cognitive behavioral
disinhibition phase, 10
syndrome, 105–6 psychosocial attributes of, 11 therapy, 232
for pudendal neuralgia, 164–5 catastrophizing, 11 psychological, 232
bowel endometriosis chronic pelvic pain, 3–5. See also random, 231–2
MRI imaging, 90 types of, 227
treatment strategies for, 93–4 specific topics chronic postsurgical pain (CPSP), after
bowel movement abnormalities, 124 bladder pain syndrome and. See
BPS. See bladder pain syndrome gynecological surgery
brain volume, chronic pain and, 10 bladder pain syndrome anatomy of, 176
Bristol Stool Form Scale, for IBS, 124 causes of, 4–5 assessment of, 177–8
BSO. See bilateral salpingo- centralized, 230–1
comorbidity syndromes associated after cesarean-section, 177–8
oophorectomy after global endometrial ablation,
with, 23
cannabidiol (CBD), 62 complex regional pain syndrome 178
cannabinoids, 62–3 after hysterectomy, 177
and, 230–1 causes of, 175–6
description and properties, 62 definition of, 9 cyclical incisional pain, 176
efficacy, 62–3 intraabdominal adhesions, 176
side effects, 63 by International Pelvic Pain musculoskeletal pain, 175
tetrahydrocannabinol, 62 Society, 3 nerve injury, 176
capsaicin, 59–60 definition of, 175
description and properties, 59 diagnostic challenges of, 3–4 etiology, 177
efficacy, 59 American College of Obstetricians incidence rates, 177–8
side effects, 60 and Gynecologists’ guidelines, 4 prevention strategies, 178–9
for vulvodynia, 138 endometriosis and, 3–4 chronic region pain syndrome (CRPS),
carisoprodol, 58 laboratory tests, 229
Carnett’s test, 20 lack of identifiable pathology, 4 62
catastrophizing, 11 MRI imaging, 228, 229 cimetidine, 103
in musculoskeletal assessment, 34 for musculoskeletal causes in, 4 circular female sexual response cycle,
in psychological assessment, of spasm of pelvic floor muscles and, 4
196
female patients, 24–5, 27–8, 29 discussion boards for, 231 clitoris, sexual dysfunction
CBD. See cannabidiol dyspareunia and, 17
CBT. See cognitive behavioral therapy from chronic pelvic pain
central sensitization with anal or vaginal intercourse, and, 200
17 clomiphene stimulation test, 152
in bladder pain syndrome coccyx, 38–9
pathophysiology, 99 differential diagnosis of, 17 codeine, 53
hysterectomy for, 230 cognitive behavioral therapy (CBT)
chronic pain and, 9–10 menstrual cycles and, 16–17 for chronic pelvic pain, 231–2
of pain, 3 multiple sources of, 224 for vulvodynia, 138
vulvodynia and, 131–2, 135 nerve blocks, 229–30 complex regional pain syndrome,
childbirth, spasm of pelvic floor 230–1
autonomic, 229–30 coping styles, in psychological
muscles and, 4 selective, 229 assessment, of female patients,
chocolate cysts, 86 patient evaluation, 13–18 25, 27–8, 29
chronic pain, 2 aggravating factors, 16
operative reports, 227–8
acute pain compared to, 3 pain mapping, 14–15
past medical history, 17, 225–7,

228
pathology reports, 228
patient history, 13–18
radiology reports, 228–9

e Cambridge Core terms of use, available at
.023

Index

COX-1 enzyme inhibitors. See treatment strategies, 92–4 embolization, for ovarian remnant
nonselective COX-1 enzyme surgical intervention, 92–3 syndrome, 154
inhibitors
ultrasound imaging for, diagnosis emotions, acute pain processing
COX-2 enzyme inhibitors. See through, 89–90 and, 9
nonselective COX-2 enzyme
inhibitors; selective COX-2 urinary bladder endometriosis, 94 endometriomas. See cystic
enzyme inhibitors MRI imaging, 94 endometriosis

CPSP. See chronic postsurgical; pain urinary tract, 75 endometriosis. See also cystic
CRPS. See chronic region pain uterosacral ligament endometriosis, endometriosis; deep infiltrating
endometriosis; pelvic
syndrome 93 congestion syndrome;
cyclical incisional pain, 176 deep nociceptive pain, 1 superficial endometriosis
cyclobenzaprine, 57–8
cyclosporin, 106 somatic, 1, 227 chronic pelvic pain and. See also
cystectomy visceral, 1, 227 laparoscopic surgery
deep somatic nociceptive pain, 1, 227
cystic endometriosis, 92 deep visceral nociceptive pain, 1, 227 diagnostic challenges of, 3–4
ovarian, 76 denervation procedures. See clinical presentation, 85–6
cystic endometriosis, 86–7 definition of, 85–6
chocolate cysts, 86 fertility-sparing pelvic diagnosis of, 87–8
diagnosis of, 88–9 denervation procedures
“kissing ovaries,” 86–7 depression, in psychological histological, 88
lesions, 85 assessment, of female patients, through physical examination, 88
MRI imaging, 89 25, 27–8, 29 dysmenorrhea and, 88
pathogenesis, 87 desipramine, 56 dyspareunia and, 88
recurrence rates, 92 desire, chronic pelvic pain as influence hysterectomy, 77–8
symptoms of, 89 on, 198 pelvic congestion syndrome, 77,
treatment strategies, 91–2 dextropropoxyphene, 53
diaphragmatic endometriosis, 94–5 117
cystectomy, 92 diastasis rectus abdominus (DRA), laparoscopic surgery for, 73–5
drainage, 92 217–18
hormone therapy, 92 diclofenac, 62 goal of, 73
surgical interventions, 92 DIE. See deep infiltrating hysterectomy, 77–8
ultrasound imaging, 89 endometriosis oophorectomy, 76–7
cystoscopy, 105 diet therapies large fibrous endometriosis nodules,
cysts. See chocolate cysts for irritable bowel syndrome, 123–4
FODMAPS, 124, 125 85
decompression, for peripheral food sensitivity, 121 MRI imaging, 90
neuropathic pain, 171 gluten-free, 125 prevalence of, 85
probiotics, 124–5 symptoms, 88
deep infiltrating endometriosis (DIE), for musculoskeletal impairments, endopelvic fascia, 40–1
87 218 enteric nervous system (ENS), 10
dimethyl sulfoxide, 103–4 erythema, with vulvodynia, 132–3
adenomyosis externa, 87 disability, in psychological assessment, estrogen therapy
appendiceal endometriosis, 94 of female patients, 24, 27–8, 29 for ovarian remnant syndrome, 151
bowel endometriosis, 90 discussion boards, for chronic pelvic for superficial endometriosis, 91
pain, 231 vulvodynia, 139
treatment strategies for, 93–4 disinhibition phase, of chronic European Urological Association
Cesarean section, scar pain, 10
dopamine, 9 (EUA) guidelines, 45
endometriosis, 95 doxepin, 61 external genital exam, for chronic
diagnosis of, 89–90 DRA. See diastasis rectus abdominus
drug abuse. See prescription drug pelvic pain, 21
MRI imaging in, 89–90 abuse
ultrasound imaging in, 89–90 duloxetine, 57 FDA. See Food and Drug
diaphragmatic endometriosis, 94–5 dysmenorrhea, 88 Administration
iatrogenic endometriosis, 95 dyspareunia (sexual pain), 17
MRI imaging, 95 with anal or vaginal intercourse, 17 female orgasmic disorder, 195–6
intestinal, 74 differential diagnosis of, 17 Female Sexual Dysfunction Index
laparoscopic surgery for, 74 endometriosis and, 88
intestinal, 74 pelvic adhesive disease and, 146 (FSDI), 198
nodulectomy, 74 dyssynergia, interventions for, 214–15 Female Sexual Function Index (FSFI),
urinary tract, 75
MRI imaging for eluxadoline, 126 134, 198
diagnosis, 89–90 female sexual interest/arousal disorder
iatrogenic endometriosis, 95
urinary bladder endometriosis, 94 (FSIAD), 195–6
rectal nodule, 87 female sexual response cycle, 196–7

circular, 196
fermentable oligosaccharides,

disaccharides, monosaccharides
and polyols (FODMAPS), 124,
125

at 20:21:51, .023 235

Index

fertility issues, with PCS embolization, global endometrial ablation, 178 ICS. See International Continence
114 glucocorticoid administration, for Society

fertility-sparing pelvic denervation bladder pain syndrome, 107 iliohypogastric nerve
procedures, 78 gluten-free diets, 125 peripheral neuropathic pain and,
glycosaminoglycan (GAG) deficiency, 171–2
laparoscopic uterine nerve ablation, somatic pain and, 7
78 99
GnRH analog stimulation test, 152–3 ilioinguinal nerve
presacral neurectomy, 78 goserelin acetate, 115–16 abdominal examination, for chronic
fibromyalgia, pharmacological pelvic pain, 20
heparin for treatment of bladder pain peripheral neuropathic pain and,
management, 51 syndrome (BPS), 103–4 171–2
fifth-line treatment strategies, for somatic pain and, 7
high-pressure long-duration
bladder pain syndrome (BPS), hydrodistension, for bladder imaging modalities. See magnetic
105–6 pain syndrome, 107 resonance imaging; ultrasound
cyclosporin, 106 imaging
intradetrusor botulinum toxin A, hip joint, musculoskeletal assessment
105–6 of, 40 impaired pelvic girdle form/force
first-line treatment strategies, for closure, 216
bladder pain syndrome (BPS), labral tears, 40
102–3 hormone therapy. See also specific inflammatory bowel disease (IBD), 25
through behavior modification, 103 Integrative Pelvic Exam Protocol
through patient education, 102 hormones
through relaxation/stress cystic endometriosis, 92 (IPEP), 202–4
management, 102 GnRH analog stimulation test, alternative methods, 204
flares, with bladder pain syndrome 4-D Wheel of Sexual Experience,
(BPS), 109–11 152–3
FODMAPS. See fermentable for pelvic congestion syndrome, 202–3
oligosaccharides, disaccharides, procedures for, 203–4
monosaccharides and polyols 115–16 International Association for the Study
Food and Drug Administration (FDA) superficial endometriosis, 90–1
taxonomy, 23 for vulvodynia, 139 of Pain (IASP), 1, 9
food sensitivities, 121 Howard, Fred, 3–4 International Continence Society
4-D Wheel of Sexual Experience, 202–3 HPA axis. See
FSDI. See Female Sexual Dysfunction (ICS), 42
Index hypothalamic–pituitary– International Pelvic Pain Society, 3
FSFI. See Female Sexual Function adrenal axis International Society for the Study of
Index Hunner’s lesions, 99
FSIAD. See female sexual interest/ treatment strategies for, 105 Vulvovaginal Diseases (ISSVD),
arousal disorder hydroxyzine, 103 129
hyperalgesia, 135 interstitial cystitis. See bladder pain
gabapentanoids, 54–5 primary, 8–9 syndrome
adverse side effects, 55 hypersensitive bladder syndrome. See intestinal deep infiltrating
amitriptyline, 54–5 bladder pain syndrome endometriosis, 74
contraindications, 55 hypersensitivity of vulvar vestibule, intestinal inflammation, 121
description and properties, 54 131–2 intraabdominal adhesions, 176
efficacy of, 54–5 hypnotherapy, 204 intradetrusor botulinum toxin A,
gabapentin, 54–5 hypothalamic–pituitary–adrenal 105–6
pregabalin, 54 (HPA) axis, 10 intravesical Bacillus Calmette-Guerin,
hysterectomy, 77–8 107
gabapentin, 54–5, 178–9 for chronic pelvic pain, 230 IPEP. See Integrative Pelvic Exam
GAG deficiency. See chronic postsurgical pain after, 177 Protocol
for pelvic congestion syndrome, 77, irritable bowel syndrome (IBS)
glycosaminoglycan deficiency 117 bladder pain syndrome and, 11
gastrointestinal dysmotility, 120 diagnosis, 121–3
Gastrointestinal Symptom Rating IASP. See International Association for with bowel movement
the Study of Pain abnormalities, 124
Scale, 35 Bristol School Form Scale, 124
genitofemoral nerve iatrogenic endometriosis, 95 Rome IV criteria, 122, 123
MRI imaging, 95 IBS-C, 125–6
abdominal examination, for chronic IBS-D, 126
pelvic pain, 20 IBD. See inflammatory bowel pathophysiology, 120–1, 122
disease altered microbiota, 121
peripheral neuropathic pain, 172 bacterial overgrowth, 121
somatic pain and, 7 IBS. See irritable bowel syndrome food sensitivity, 121
genito-pelvic pain/penetration IBS-C. See irritable bowel gastrointestinal dysmotility, 120
intestinal inflammation, 121
disorder, 195–6 syndrome-constipation visceral hypersensitivity, 120–1
gestrinone, 91 IBS-D. See irritable bowel

syndrome-with diarrhea
IBS-PI. See postinfectious IBS

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Index

postinfectious, 121 for vulvodynia, 138 myofascial trigger points, 41
prevalence of, 120 limbic brain, sexual dysfunction and, sacroiliac joint, 37–8
pudendal neuralgia and, 156 standardized tools for, 35
subtypes, 123 200–1
treatment therapies for, 123–6, 127 loperamide, 126 screening questions, 36
lumbar spine, 39 subjective intake, 34–5
through diet. See diet therapies LUNA. See laparoscopic uterine nerve
vulvodynia and, 129 central sensitization screening, 34
in women, 120 ablation kinesiophobia screening, 34
irritable bowel syndrome-constipation pain catastrophizing screening, 34
magnetic resonance imaging (MRI) patient medical history collection
(IBS-C), 125–6 bowel endometriosis, 90
irritable bowel syndrome-with chronic pelvic pain, 228, 229 in, 34
for cystic endometriosis, 89 transverse abdominis muscle, 39
diarrhea (IBS-D), 126 for deep infiltrating endometriosis, vaginal assessment, 43–5
ISSVD. See International Society for 89–90
iatrogenic endometriosis, 95 Modified Oxford Scale, 43
the Study of Vulvovaginal for pudendal neuralgia, 162 of muscle function, 43
Diseases urinary bladder endometriosis, 94 of pelvic floor structures, 43–5
PERFECT scheme, 43
ketorolac, 62 manual exam, 21–2 musculoskeletal impairments, in pelvic
kinesiophobia screening, 34 Marinoff Scale, 35
“kissing ovaries,” 86–7 Marshall–Marchetti–Kranz procedure, pain. See also myofascial
dysfunction
labral tears, 40 182 dyssynergia, interventions for,
laparoscopic surgery May-Thurner syndrome, 113, 117 214–15
McGill Pain Questionnaire, 26–9, 35, goal setting, 207–9
appendectomy, 75 lifestyle changes, 218–19
for endometriosis, 73–5 134 dietary factors, 218
menopause. See premature surgical smoking cessation, 218
deep infiltrating endometriosis, patient education, 218–19
74, 75 menopause pelvic floor incoordination,
menstruation, chronic pelvic pain and, interventions for, 214–15
goal of, 73 physical impairment-based
hysterectomy, 77–8 16–17 interventions, 209–10. See also
oophorectomy, 76–7 mesh implants. See pelvic mesh overactive pelvic floor muscles;
fertility-sparing pelvic denervation specific interventions
implants concurrent interventions, 219
procedures, 78 mesh removal, 79–80 treatment planning, 207–9
laparoscopic uterine nerve midurethral sling systems, pelvic mesh physical therapy, 208
underactive pelvic floor muscles,
ablation, 78 implants, 183–4 interventions for, 213–14
presacral neurectomy, 78 mind–body techniques, 212–13 electrical stimulation, 214
ovarian cystectomy, 76 mindfulness, 204 SEMG biofeedback, 213–14
laparoscopic uterine nerve ablation Modified Oxford Scale, 43 therapeutic devices and
mood, sexual dysfunction and, 197 modalities, 213–14
(LUNA), 78 morphine, 53 myofascial dysfunction, 210, 215–18
laparoscopy, evaluation through MRI. See magnetic resonance imaging abdominal wall dysfunction, 216–18
muscle relaxers, 57–8. See also specific diastasis rectus abdominis, 217–18
for acute pelvic pain, 71–2. See also impaired pelvic girdle form/force
specific surgical procedures drugs closure, 216
musculoskeletal assessment painful or restricted scar tissue,
for adhesiolysis, 75–6 215–16
for chronic pelvic pain, 72–3. See chronic postsurgical pain, 175 myofascial trigger points, 41
clinical anatomy overview, 35–7 myomectomy, 79
also specific surgical procedures coccyx, 38–9
negative, 73 endopelvic fascia, 40–1 Nantes Criteria, 162
for pain mapping, 73 function-based approach, 34 nerve ablation, for peripheral
large fibrous nodules, in hip joint, 40
neuropathic pain, 171
endometriosis, 85 labral tears, 40 nerve blocks
lateral femoral cutaneous nerve, 172–3 lumbar spine, 39
lateral femoral nerve, somatic pain of pelvic floor. See pelvic floor for chronic pelvic pain, 229–30
of pelvic girdle, 36–7. See also specific autonomic, 229–30
and, 7 selective, 229
lesions anatomy
pelvic muscle activity, observation for peripheral neuropathic pain
with cystic endometriosis, 85 as treatment strategy, 170–1
Hunner’s lesion with bladder pain of, 42–3
piriformis muscle, 39–40
syndrome, 99 psoas muscle, 41
treatment strategies for, 105 pubic symphysis, 38
leuprolide acetate, 91
lidocaine, 60–1, 104, 179 osteitis pubis, 38
adverse effects, 60 rectus abdominus, 41–2
description and properties, 60
efficacy, 60

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Index

nerve blocks (cont.) vaginal suppositories, 58–9 catastrophizing, 11
with ultrasound imaging, 169–70 adverse effects, 58 Pain Disability Index (PDI), 35
description and properties, 58 pain management
for pudendal nerve, 161, 164 efficacy of, 58
nerve injury, chronic postsurgical pain, for bladder pain syndrome, 104–5
oophorectomy, 76–7 pelvic mesh implants, 191–3
176 opioids, 52–4. See also specific opioids pain mapping, for chronic pelvic pain,
neurectomy, 171
neurological basis, of chronic pelvic with adjuvant mechanisms, 54 14–15
adverse side effects of, 53–4 painful bladder syndrome. See bladder
pain description and properties, 52–3
anatomy of, 6–8 efficacy of, 53 pain syndrome
ORS. See ovarian remnant syndrome paracetamol. See acetaminophen/
somatic pain, 6–7 osteitis pubis, 38
visceral pain, 8 ovarian cystectomy, 76 paracetamol
overview of, 6 ovarian remnant syndrome (ORS) PCS. See pelvic congestion syndrome
neuropathic pain, 1. See also specific bilateral salpingo-oophorectomy, 150 PDI. See Pain Disability Index
clinical presentation, 150, 151 pelvic adhesive disease. See adhesive
topics
nociceptive activation from estrogen replacement therapy disease
and, 151 pelvic congestion syndrome (PCS), 77,
stimulation, 8
nociceptive pain. See also specific topics definition of, 150 78–9
diagnosis, 152–3 anatomical considerations, 112
bladder pain syndrome, 1 clinical criteria, 112
deep, 1 clomiphene stimulation test, 152 complications from, 114
GnRH analog stimulation test, diagnostic considerations, 113–14
somatic, 1, 227
visceral, 1, 227 152–3 risk factors, 113–14
origins of, 1 through imaging, 152 symptoms as part of, 113
superficial, 1 through laboratory evaluation, fertility issues, 114
nodulectomy, 74 imaging for, 114, 115
nonopioid analgesics, 51–2. See also 152 ultrasound, 114
incidence rates, 150 May–Thurner syndrome, 113, 117
nonsteroidal anti-inflammatory management strategies, 153–4 Nutcracker syndrome, 113, 117
drugs overview of, 117–18
acetaminophen/paracetamol, 52 embolization, 154 pathophysiology, 113
nonselective COX-1 enzyme nonsurgical methods, 154 primary venous insufficiency, 113
inhibitors, 51–2 radical surgical methods, 151, 152, secondary pelvic vein
nonselective COX-2 enzyme
inhibitors, 51–2 153–4 incompetence, 113
nonsteroidal antiinflammatory drugs prevention strategies, 151 prevalence rates, 112
(NSAIDs), 51–2 residual ovarian syndrome and, 150 treatment strategies, 114–17
adverse side effects, 52 risk factors, 150–1
classification of, 51–2 hormone therapies, 115–16. See
contraindications, 52 cancer, 153 also specific hormones
efficacy of, 52 supernumerary ovary syndrome
nonselective COX-1 enzyme radiological interventions, 116
inhibitors, 51–2 and, 150 surgical procedures, 117
nonselective COX-2 enzyme overactive pelvic floor dysfunction, transcatheter embolotherapy, 116
inhibitors, 51–2 pelvic floor, assessment of, 36–7,
selective COX-2 enzyme inhibitors, 45–6
51–2 overactive pelvic floor muscles, 224–5. See also overactive pelvic
topical, 62 floor muscles; specific anatomy
chronic region pain syndrome, 62 interventions for, 210–13 deep layer of, 36, 44–5
side effects, 62 manual therapies, 210–11 dysfunction of
norepinephrine, 9 mind–body techniques, 212–13 classification of, 45–6
nortriptyline, 56 myofascial dysfunction, 210 overactive, 45–6
noxious stimuli, 8–9 SEMG biofeedback, 212 underactive, 46
NSAIDs. See nonsteroidal therapeutic devices and modalities, European Urological Association
antiinflammatory drugs guidelines, 45
Nutcracker syndrome, 113, 117 211–12 intermediate layer of, 36
vaginal dilators, 211–12 International Continence Society
obturator nerve overdistension. See bladder definition of, 42
abdominal examination, for chronic through palpation, 44, 45
pelvic pain, 20 overdistension pelvic mesh implants, disorders
peripheral neuropathic pain, 173 oxycodone, 53 registry for, 185–6
somatic pain and, 7 physical examination, 42
pain. See also specific topics superficial muscles of, 36
off-label medications, 58–9 central sensitization, 3 Botox injection of, 79
common terms, 2 vaginal assessment of, 43–5
definition of, 1
in psychological assessment, of
female patients, 24, 26–9
psychosocial attributes of, 11

e Cambridge Core terms of use, available at
.023

Index

vulvodynia and, 133 decompression, 171 prescription drug abuse
pelvic floor incoordination, nerve ablation, 171 of opioids, 53–4
nerve blocks, 170–1 in United States
interventions for, 214–15 neurectomy, 171 mortality rates in, 3
pelvic girdle, 36–7 vulvodynia and, 173–4 prevalence rates for, 3
persistent genital arousal disorder
impaired pelvic girdle form/force primary hyperalgesia, 8–9
closure, 216 (PGAD), 159 primary venous insufficiency, 113
PGAD. See persistent genital arousal probiotics, 124–5
pelvic inflammatory disease (PID), progestin therapy
spasm of pelvic floor muscles disorder
and, 4 pharmacological management. See also for pelvic congestion syndrome, 115
for superficial endometriosis, 91
pelvic mesh implants antidepressants; topical and prolapse repair, pelvic mesh implants
cure rates, 183 transdermal agents; specific
development of, 182–6 disorders for, 184–6
approaches in, 184 adverse side effects of, 51 propoxyphene, 53
future designs in, 186 antiepileptics, 54–5 PSN. See presacral neurectomy
manufacturers, 184, 188 gabapentanoids, 54–5 psoas muscle, 41
midurethral sling systems, 183–4 approaches to, 51 psychological assessment, of female
products, 188 targeted therapy, 51
for prolapse repair, 184–6 background of, 50–1 patients
timeline of pelvic floor disorders cannabinoids, 62–3 assessment methods for, 26–9
registry, 185–6 evidence-based limitations of, 50–1
history of, 182–6 muscle relaxers, 57–8 scales and tools, 26–9
legal issues, 186–7 nonhormonal therapies, 64–5 semistructured interviews, 26
Marshall–Marchetti–Kranz nonopioid analgesics, 51–2. See also functional consequences in, 24–6
procedure, 182 nonsteroidal anti-inflammatory anxiety, 25, 27–8, 29
pain management, 191–3 drugs depression, 25, 27–8, 29
from transvaginal mesh implants, acetaminophen/paracetamol, 52 quality of life, 24, 27–8, 29
190–1 off-label medications, 58–9 sexual functioning, 25–6, 27–8, 29
stress urinary incontinence, 182 vaginal suppositories, 58–9 social support, 25, 27–8, 29
success rates for, 182 opioids, 52–4. See also specific inflammatory bowel disease (IBD)
transvaginal, 187–91 opioids
complications with, 187–90 with adjuvant mechanisms, 54 in, 25
pain from, 190–1 adverse side effects of, 53–4 overview of, 29–30
description and properties, 52–3 risk factors in, 24–6
pelvic pain. See also chronic pelvic efficacy of, 53
pain; specific topics PHN. See postherpetic neuralgia catastrophizing, 24–5, 27–8, 29
physical therapy coping style, 25, 27–8, 29
coexistence of pain conditions, 223 for bladder pain syndrome, 103 depression, 25, 27–8, 29
lack of medical specialties for, 223 for musculoskeletal impairments, disability, 24, 27–8, 29
pelvic vein ligation, 78–9 208 pain levels, 24, 26–9
pentosan polysulfate, 103 for pudendal neuralgia, 163 quality of life as, 24, 27–8, 29
PERFECT scheme. See Power, for vulvodynia, 137 theoretical approach to, 23–4
PID. See pelvic inflammatory disease AAPT system, 23
Endurance, Repetitions, Fast piriformis muscle, 39–40 ACTTION, 23
contractions, Every- posterior femoral cutaneous nerve, 173 biosocial approach, 24
Contraction-Timed scheme postherpetic neuralgia (PHN), UPOINT system, 24
peripheral diabetic neuropathy, pharmacological management, psychosomatic disorders, 231
pharmacological management, 51 pubic symphysis, 38
51 postinfectious IBS (IBS-PI), 121 osteitis pubis, 38
peripheral neuropathic pain, 1 postinfectious irritable bowel pudendal nerve
diagnostic procedures, 169–70 syndrome, 121 anatomy of, 156–7
ultrasound nerve blocks, 169–70 postoperative pain, pharmacological implications of, 157
epidemiology, 168 management, 51 variations of, 157
etiology, 168 Power, Endurance, Repetitions, Fast motor terminal latency testing, 161–2
genitofemoral nerves, 172 contractions, Every- nerve blocks, 161, 164
iliohypogastric nerves, 171–2 Contraction-Timed somatic pain and, 7, 158
ilioinguinal nerves, 171–2 (PERFECT) scheme, 43 pudendal nerve entrapment, 156
lateral femoral cutaneous nerve, 172–3 pregabalin, 54, 178–9 anatomical considerations, 157–8
obturator nerve, 173 premature surgical menopause, 202 pudendal neuralgia
patient medical history, 168–9 presacral neurectomy (PSN), 78 bladder pain syndrome and, 156
physical examination for, 168–9 causes of, 156
posterior femoral cutaneous nerve, clinical presentation, 159
173 persistent genital arousal disorder,
treatment strategies, 170–1
159

at 20:21:51, .023 239

Index

pudendal neuralgia (cont.) pain management, 104–5 holistic approach, 195
diagnosis, 159–62 selective COX-2 enzyme inhibitors, well-being influenced by, 197–8
differential, 161
MRI, 162 51–2 body image issues, 197
with Nantes Criteria, 162 selective nerve blocks, 229 mood, 197
through other testing, 161–2 selective serotonin reuptake inhibitors relationship and intimacy issues,
through patient history, 159–60
through physical examination, (SSRIs), 57 197–8
160 SEMG biofeedback sexual functioning. See also sexual
through pudendal nerve block,
161 for overactive pelvic floor muscles, dysfunction
through pudendal nerve motor 212 female sexual response cycle, 196–7
terminal latency testing, 161–2
epidemiology, 158 for underactive pelvic floor muscles, circular, 196
etiology, 158 213–14 in psychological assessment, of
neuropathic causes, 158
somatic causes, 158 serotonin, 9 female patients, 25–6, 27–8, 29
traumatic events, 158 serotonin and norepinephrine sexual intercourse. See anal/vaginal
visceral origins, 158
irritable bowel syndrome and, 156 reuptake inhibitors (SNRIs), 54, intercourse
treatment strategies, 162–6 57. See also specific drugs sexual pain. See dyspareunia
behavior modification, 163 adverse effects, 57 SI joint. See sacroiliac joint
botulinum toxin injections, 164–5 description and properties, 57 single-digit manual examinations, 21
medications, 163 efficacy of, 57 Skene’s gland, 198–200, 201
nerve blocks, 164 sex hormones, suppressed or absent, smoking cessation, musculoskeletal
patient education, 162–3 201–2
physical therapy, 163 premature surgical menopause, 202 impairments and, 218
surgical procedures, 165–6 testosterone levels, 201 SNRI. See serotonin and
transgluteal decompression of the sexual dysfunction, from chronic
pudendal nerve, 165–6 pelvic pain norepinephrine reuptake
anatomical implications, for genital inhibitor
pudendal neurolysis, 80 structures, 198–200 social support, in psychological
clitoris, 200 assessment, of female patients,
quality of life, in psychological Skene’s gland, 198–200, 201 25, 27–8, 29
assessment, of female patients, biopsychosocial evaluation tools, social support strategies. See discussion
24, 27–8, 29 198 boards
Female Sexual Dysfunction Index, somatic pain, anatomy of, 6–7
rectal nodule, 87 198 genitofemoral nerve, 7
rectum, physical examination of, for Female Sexual Function Index, iliohypogastric nerve, 7
198 ilioinguinal nerve, 7
chronic pelvic pain, 22 brain–body connections, 200–1 lateral femoral nerve, 7
rectus abdominus, 41–2 classification of, 195–6 obturator nerve, 7
female orgasmic disorder, 195–6 pudendal nerve, 7, 158
myofascial trigger points, 41 female sexual interest/arousal spasm of pelvic floor muscles, 4
relationship and intimacy issues, 197–8 disorder, 195–6 causes of, 224
resected Cesarean section deep generalized versus situational childbirth and, 4
disorders, 196 pelvic inflammatory disease and, 4
infiltrating endometriosis, 95 genito-pelvic pain/penetration secondary, 4
residual ovarian syndrome (ROS), 150 disorder, 195–6 symptoms of, 224–5
Robert, Roger, 80 lifelong versus acquired disorders, spinal cord stimulation (SCS), 230
Rome IV criteria, for IBS, 122, 123 196 SSRIs. See selective serotonin reuptake
ROS. See residual ovarian syndrome desire influenced by, 198 inhibitors
Integrative Pelvic Exam Protocol, stress management, for bladder pain
sacral nerve stimulation, 230 202–4 syndrome, 102
sacroiliac (SI) joint, 37–8 alternative methods, 204 stress urinary incontinence
SCS. See spinal cord stimulation 4-D Wheel of Sexual Experience, (SUI), 182
secondary pelvic vein incompetence, 113 202–3 superficial endometriosis, 85, 86
second-line treatment strategies, for procedures for, 203–4 clinical presentation, 86
limbic brain, 200–1 diagnosis of, 88
BPS, 103–5 sex hormones and, suppressed or etiology, 86
intravesical medications, 103–4. absent, 201–2 treatment strategies for, 90–1
premature surgical menopause, hormone therapy, 90–1
See also specific drugs 202 surgical interventions, 91
manual physical therapy, 103 testosterone levels, 201 theoretical approach to, 90–1
oral medications, 103. See also theoretical approaches to, 195 superficial nociceptive pain, 1
biopsychosocial approach, 195 surgical procedures. See also specific
specific drugs topics
theoretical approach to, 71

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Index

tapentadol, 54 efficacy of, 61 dermatomes, 131, 132
TCAs. See tricyclic antidepressants trigeminal neuralgia, pharmacological neurological distribution in, 131,
TCE. See transcatheter embolotherapy
testosterone, 201 management, 51 132
bladder pain syndrome and, 129
tetrahydrocannabinol (THC), 62 ulcerative bladder pain syndrome, 99 burden of, 129–31
tizanidine, 58 ultrasound imaging
topical and transdermal agents, 59–62, on US healthcare system, 130
for cystic endometriosis, 89 classification of, 129
66–7 for deep infiltrating endometriosis, clinical evaluation, 134–6
analogues, 61–2
89–90 hyperalgesia, 135
adverse effects, 61 for pelvic congestion syndrome, 114 with physical examination, 135–6
efficacy of, 61 for peripheral neuropathic pain, vestibular allodynia, 135, 136
capsaicin, 59–60 clinical presentation, 133–4
description and properties, 59 nerve blocks and, 169–70 definitional criteria, 129
efficacy, 59 underactive pelvic floor muscles, in historical literature, 129
side effects, 60 diagnostic criteria for, 130
for vulvodynia, 138 interventions for, 213–14 epidemiology of, 129–31
electrical stimulation, 214 factors associated with, 130
description and properties, 59 SEMG biofeedback, 213–14 irritable bowel syndrome and, 129
lidocaine, 60–1 therapeutic devices and modalities, pathophysiology, 131–3
central sensitization, 131–2, 135
adverse effects, 60 213–14 erythema, 132–3
description and properties, 60 UPOINT system, 24 hypersensitivity of vulvar
efficacy, 60 ureteroneocystotomy, 75
urinary bladder endometriosis, 94 vestibule, 131–2
for vulvodynia, 138 pelvic floor muscle dysfunction,
nonsteroidal antiinflammatory MRI imaging, 94
urinary tract deep infiltrating 133
drugs, 62 peripheral neuropathic pain and,
chronic region pain syndrome, 62 endometriosis, 75
side effects, 62 uroguanylin, 125–6 173–4
tricyclics, 61–2 uterosacral ligament endometriosis, 93 subtypes of, 131
adverse effects, 61
efficacy of, 61 vaginal assessment, 43–5 generalized vulvodynia, 131
for vulvodynia, 138–9 Modified Oxford Scale, 43 localized pain in, 131
for inflammation, 138–9 of muscle function, 43 treatment strategies, 136–40
of pelvic floor structures, 43–5 education on, 137
peripheral nociceptors, targeting hormone therapy, 139
of, 138 vaginal cuff revision, 78 oral medications, 139–40
vaginal diazepam, 58 physical therapy, 137
tramadol, 53, 54 vaginal dilators, 211–12 psychological interventions,
vaginal suppositories, 58–9
transcatheter embolotherapy (TCE), 137–8
116 adverse effects, 58 surgical, 140
description and properties, 58 topical treatments, 138–9
transdermal agents. See topical and efficacy of, 58
transdermal agents venlafaxine, 57 well-being, sexual dysfunction and,
vestibular allodynia, 135, 136 197–8
transgluteal decompression of the vestibulectomy, 80
pudendal nerve, 165–6 visceral hypersensitivity, 10–11, 120–1 body image issues, 197
visceral pain mood, 197
transverse abdominis muscle, 39 anatomy of, 8 relationship and intimacy issues,
tricyclic analogues, 61–2 deep visceral nociceptive pain, 1, 227
viscerosomatic convergence, 169 197–8
adverse effects, 61 viscerosomatic convergence, in women. See also specific topics
efficacy of, 61
tricyclic antidepressants (TCAs), 56–7. peripheral neuropathic pain, female sexual response cycle, 196–7
169 circular, 196
See also specific drugs von Rokitansky, Karl, 87
adverse side effects, 56–7 Vulvar Questionnaire, 35 vaginal assessment, 43–5
contraindications, 56–7 vulvodynia, 59 Modified Oxford Scale, 43
anatomy of, 131 of muscle function, 43
description and properties, 56 of pelvic floor structures, 43–5
efficacy, 56
for vulvodynia, 139–40
tricyclics, as topic agents, 61–2
adverse effects, 61

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