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Pelvic Pain

Pelvic Pain Female Patient, Treating Pelvic Pain, Pelvic Pain Treatments, Pelvic Pain Treatment, Pelvic Pain Causes, Pelvic Pain NYC New York City, Manhattan New York, Pelvic Pain SpecialistPelvic pain is a complex disorder that affects both men and women.  If you are experiencing a piercing pain in the pelvis or genitals, or pain accompanying your everyday movements and activities that involve those areas, you may be suffering from pelvic pain. If this pain has continued unabated for six months or more, it could be an identifiable disorder called chronic pelvic pain (CPP). Pelvic Pain is a nebulous condition that is typically diagnosed only after excluding other things. It’s cause is unknown and it is notoriously difficult to treat.

Pelvic pain is considered a “diagnosis of exclusion” – only entertained after more obvious and testable pathologies are ruled out. Since there are a myriad of possible causes and contributing factors to this mysterious condition, it is crucial to understand them in order to initiate a correct treatment program that will yield results. Fortunately, at the Ainsworth Institute of Pain Management, our physicians are experts in treating pelvic pain, and can offer a variety of treatments, many of which are not available anywhere else in New York City.

People with pelvic pain say they begin to feel pain when engaging in ordinary, everyday non-painful activities. Activities like going to the bathroom, sexual contact, or ovulation. If you feel you fit this profile, schedule an appointment with the Ainsworth Institute of Pain Management today.

What is Chronic Pelvic Pain?

Pelvic Pain, Pelvic pain causes, pelvic pain treatment, Pelvic Pain NYC New York City, Manhattan New York, Pelvic Pain SpecialistPelvic pain is neuropathic in nature. That means it is pain caused as the result of nerve damage, in this case nerves associated with the pelvic area. As will be discussed in the causes section below, there are many different and divulgent factors that can lead to nerve injury or insult. Pelvic pain is a catch-all diagnosis that may contain other intersecting and overlapping pathologies.

While Pelvic Pain can affect both men and women, the greatest incidence is in women between the ages of 26 and 30.[1] It is estimated that 33-39% of woman will experience pelvic pain at least one point in their lives with as many as 20% of these cases progressing to Chronic Pelvic Pain (CPP). It is also estimated that up to 5% of the general population of women will experience CPP – that estimate rises to 20% in those with a previous diagnosis of pelvic inflammatory disease (PID). [2] A current estimate of those suffering from CPP in the United States is reported to be as high as 14.7%.[3],[4]

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Pelvic Pain - Lumbosacral PlexusPelvic Pain – A Closer Look

CPP is a complex, debilitating disorder defined as “a non-malignant pain perceived in the pelvis in either men or women.” In the case of documented nocioceptive pain that becomes chronic, the pain must have been continuous for at least 6 months, although this timeline has been debated.[5] If “non-acute” mechanisms of pain and/or central sensitization are noted, then the pain may be regarded as “chronic,” irrespective of the time period. More often than not, one will note the presence of behavioral, sexual and emotional sequelae.[6]

Pelvic Pain is a broad diagnosis of exclusion that likely encompasses other pathologic states, and even more likely encompasses an evolution of those states to a neuropathic state. Like all neuropathic pain, Pelvic Pain is a result of an insult or injury to the somatosensory nervous system (peripheral or central), whereby an insult to the nervous tissue leads a pain syndrome often characterized by disproportionate pain.[5]

What are the Symptoms?

Symptoms of a body area affected by Pelvic Pain include:

 Burning and/or lancinating pain in the pelvis, anus, and/or genitals
 Pain with sitting
 Pain with urinating and/or defecating
 Pain with intercourse or painful ejaculation
 Paresthesias (pins & needles sensation) and numbness

What are the Causes?

As mentioned above, the exact cause of Pelvic Pain is unknown. A number of inciting pathologies that render one susceptible to the signs and symptoms characteristic of Pelvic Pain, though, have been implicated. Among them are disease states, and causes specific to gender and organs.

Disease

There are several diseases and conditions that are thought may contribute to the development of Pelvic Pain. It has been postulated that particular disease states damage organs leading to somatic or visceral pain, which over time develops into neuropathic pain. Some such disease states include:
Pelvic Pain
Interstitial Cystitis
Prostatitis
PID
Vestibulitis
Ectopic Pregnancy
Varicocele

CPP is also inclusive of a variety of presentations many of which can be attributed to a local neuralgia:
Pudendal Neuralgia
Coccydynia
Penile Pain Syndrome
Meralgia Parenthetic

Gender-Specific Causes

CPP is typically more prevalent in the female population (affecting over 9 million women in the US), and has often initially been labeled as interstitial cystitis/painful bladder syndrome (IC/PBS). In as many as 61% of women, the cause of their CPP was unknown.[7] In men, CPP is typically referred to as chronic prostatitis (CP). Predisposing and/or associated factors in the female population include a history of multiple laparoscopies,[8] endometriosis, sexual or physical abuse,[9] vulvar vesitibulitis, fibromyalgia, and irritable bowel syndrome.[10],[11],[12] In men, CPP is thought to be either an inflammatory or non-inflammatory insult to the prostate, with the syndrome accounting for up to 90-95% of all cases of prostatitis.[3]

WOMENPelvic Pain
Infection

Endometriosis
Dysmenrrhea
Dysparenia
Myofascial Pain Syndrome
Vulvitis
Cystitis
Ovarian Remnant Congestion
Sympathetically Mediated Pain
Pelvic Congestion
Pelvic Fibrosis
Pelvis Neurodystonica
Irritable Bowel Syndrome
Sexual/Physical Abuse
Cancer Pain
Psychiatric Disorders
Surgical Procedures (adhesions)

MENPelvic Pain
Chronic Orchalgia

Prostatodynia
Prostatitis
Interstitial Cystitis
Ureteral Obstruction
Irritable Bowel Syndrome
Sexual/Physical Abuse
Cancer Pain
Psychiatric Disorders
Surgical Procedures (adhesions)

Organ-Specific Causes

Reproductive
 Visceral: uterus, ovaries, bladder, urethra
Somatic: skin, vulva, clitoris, vaginal canal
Adhesions, endometriosis, salpingo-oophoritis

Vascular
 Dilated pelvic vein/pelvic congestions theory

Musculocutaneous
Ligamentous structures, muscular (iliopsoas, piriformis, quadrates lumborum, sacroiliac joint, obturator internus, pubococcygeus)
Skeletal (referred pain)
Pelvic floor muscle tension/spasm

Spinal
 Degenerative joint disease, disc herniation, spondylosis, neoplasm of spinal cord/sacral nerve, coccydynia, degenerative disease

Neurologic
Neuralgia/cutaneous nerve entrapment (surgical scar in the lower part of the abdomen), iliohypogastric, ilioingiunal, genitofemoral, lateral femoral cutaneous nerve, shinges (herpes zoster infection), spine-related nerve compressions

Gastrointestinal
 Irritable bowel syndrome, abdominal epilepsy, abdominal migraine, recurrent small bowel obstruction, hernia

Urologic
 Bladder dysfunction, chronic (nonbacterial) prostatitis, chronic orchalgia, and prostatodynia

Psychological (Psychosocial/Sexual)
 Anxiety, depression, somatization, physical or sexual abuse, drug addiction, dependence, family problems, sexual dysfunction

What are my Treatment Options?

Pelvic Pain, Pelvic pain causes, pelvic pain treatment, Pelvic Pain NYC New York City, Manhattan New York, Pelvic Pain SpecialistIn most cases, those suffering from Pelvic Pain or Chronic Pelvic Pain are already under the care of either a OB/GYN or Urologist and only consult a Pain Management Physician afterward. Once they do it is imperative for the physician to obtain a thorough history and conduct a comprehensive physical (with a focuses abdominal examination) as many of the causes of Pelvic Pain can be reversible. Pelvic examination, lab testing, and ultrasounds or CT scans of the abdomen and pelvis are often utilized to rule out other more conventional causes.

Both diagnosis and management of patients with Pelvic Pain require good integration and knowledge of all pelvic organ systems and other systems including musculoskeletal, neurologic, and psychiatric. A significant number of patients with Pelvic Pain may have a variety of associated problems including bladder or bowel dysfunction, sexual dysfunction, and other systemic or constitutional symptoms. Other associated problems, such as depression, anxiety, and drug addiction, may also coexist.

Pelvic pain treatment requires a specialist with experience and precision.  At the Ainsworth Institute of Pain Management, we offer some of the most modern and cutting edge treatments for chronic pelvic pain. Some of which include:

Interventional Pain Management Treatments

Superior Hypogastric Block – This procedure is used as both a diagnostic and therapeutic tool. Under radiographic guidance, a thin needle is inserted through the skin and advanced toward the L5 vertebra – the location of the superior hypogastric plaexus. A blockade of the superior hypogastric plexus has been reported to decrease pelvic pain by 70%.[14]

Ganglion of Impar Block – Like the Superior Hypogastric Block, this procedure can also be used for both diagnostic and therapeutic purposes. This procedure is performed under radiographic guidance with the target being a small area directly in front of the coccyx (tailbone). This injection is extremely effective in treating pain originating from the cervix, colon, bladder, rectum and endometrium. Studies have reported 70-100% pain relief from this procedure.[13]

Peripheral Nerve Block – A peripheral nerve block can be extremely effective way of treating many types pain, including CPP. There are an abundance of nerves providing innervation to the pelvic region and its organs – any of which can be targeted and blocked with a small amount of local anesthetic to provide dramatic pain relief. Many of these injections can be performed under ultrasound guidance.Pelvic Pain, Pelvic pain causes, pelvic pain treatment, Pelvic Pain NYC New York City, Manhattan New York, Pelvic Pain Specialist

  • Pudendal Nerve Block
  • Genitofemoral Nerve Block
  • Ilioinguinal Nerve Block
  • Iliohypogastric Nerve Block
  • Lateral Femoral Cutaneous Nerve Block
  • Obterator Nerve Block
  • Subcostal Nerve Block

Neurolysis & Ablation – In many cases an injection will provide relief, but this is only a temporary solution. In cases such as these, neurolysis or neuroablation can be utilized to provide longer relief. There are several different techniques available:

  • Radiofrequency Ablation (RFA) – Radio waves are applied to a nerve, subsequently stunning it and preventing from transmitting pain.
  • Cryoablation – Similar to RFA; however, cold temperatures are applied to the nerve instead of radio waves.
  • Chemodenervation – Small amounts of either alcohol or phenol are injected, thus blocking the nerve’s ability to transmit a signal.

Epidural Steroid Injection – These injections are more commonly used for neck and low back pain, however they can also be used to provide local pain relief to a specific dermatome – in the case of pelvic pain, a dermatome overlying pain in the pelvic region.

IV Infusion Therapy – A simple procedure commonly performed in the office. Your doctor will administer a small IV catheter, and then infuse special medications intravenously in an attempt to halt the pain process. 

Spinal Cord Stimulation – This is a regularly performed procedure utilizing technology similar to that of cardiac pacemakers. This method involves placing small electrodes into the epidural space near the spinal cord. These electrodes produce a small electrical current over the spinal cord that your brain will interpret as a gentle massage or feeling of “champagne bubbles.” In the case of pelvic pain, the leads are placed over the sacral nerve roots, or in the thoracic region.[15]  Our doctors at the Ainsworth Institute have made unprecedented strides in the use of spinal cord stimulation for pelvic pain by using unique lead combinations that isolate discomfort in the pelvic region.

Intrathecal Pumps – This is a method whereby a small catheter is placed in the subarachnoid space and minuscule amounts of medication are delivered directly to the spinal cord and the rest of the CNS. This enables your physician to provide the same medications but at a fraction of the dose due to the proximity to the spinal cord.  More importantly, our doctors have been putting a revolutionary drug inside the pumps called ziconotide and are reported amazing successes!

Other Treatment Options

Medication Management & Pharmacologic Therapy – There are a wide-variety of medications found to be effective in treating CPP – these include non-steroidal anti-inflammatories (i.e. ibuprofen or naproxen), membrane stabilizers (Lyrica or gabapentin), antidepressants (Cymbalta or amitriptyline), anticonvulsants (Keppra) and opioids (oxycodone or hydrocodone).

Physical Therapy & Biofeedback – Exercises focusing on pelvic floor muscle relaxation, as well as ultrasounds and stretching have been shown to help relieve pelvic pain.

The Ainsworth Institute is Here to Help

Our doctors at the Ainsworth Institute of Pain Management are experiences in managing and treating pelvic pain. Dramatic improvements are possible with the right treatment. The sooner treatment is started, the better the chances of success. Call and schedule an appointment now with one of our board-certified pain management experts.

References

[1] Reiter RC: Chronic pelvic pain. Clin Obstet Gynecol. 1990; 33:130-136.

[2] Ryder RM: Chronic pelvic pain. Am Fam Physician. 196; 54:2225-2232.

[3] Zondervan KT, Yudkin PL, Vessey MP, et al. The community prevalence of chronic pelvic pain in women and associated illness behavior. Br J Gen Pract. 2001;51: 541-547.

[4] Fall M, Baranowski AP, Elneil S, et al. Guidelines on chronic pelvic pain. In: EAU Guidelines. Edition presented at the 23rd EAU Annual Congress, Milan, 2008.

[5] Kothari S. Neuromodulation approaches to chronic pelvic pain and coccydynia. Acta Neurochir Suppl. 2007;97: 365-371.

[6] Fall M, Baranowski AP, Fowler CJ, et al. EAU guidelines on chronic pelvic pain. Eur Urol 2004:46(6):681-689.

[7] Mathias SC, Kupperman M, Liberman RF, et al. Prevalence, health-related quality of life, and economic correlates. J Obstet Gynaecol. 1999;106:1149-55.

[8] Janicki, TI. Chronic pelvic pain as a form of complex regional pain syndrome. Clin Obstet Gynecol. 2003;46: 797-803.

[9] Heim C, Ehlert U, Hanker JP, et al. Abuserelated posttraumatic stress disorder and alterations of the hypothalamic-pituitaryadrenal axis in women with chronic pelvic pain. Psychosom Med. 1998;60:309–318.

[10] Aaron LA, Herrell R, Ashton S, et al. Co- morbid clinical conditions in chronic fatigue: a co-twin control study. J Gen Intern Med. 2001;16:24–31.

[11] Martinez-Lavin M. Is fibromyalgia a generalized reflex sympathetic dystrophy? Clin Exp Rheumatol. 2001;19:1–3.

[12] Longstreth GF. Irritable bowel syndrome and chronic pelvic pain. Obstet Gynecol Surv. 1994;49:505–507.

[13] Benzon, Honorio. Essentials of Pain Medicine. Philadelphia: Saunders Elsevier, 2011. Print

[14] De Leon Casasola OA, Kent E, Lema MJ: Neurolytic superior hypogastric plexus block for chronic pelvic pain associated with cancer. Pain. 1993; 54:145-151.

[15] Hunter C, Davé N, Diwan S, Deer T. Neuromodulation of Pelvic Visceral Pain: A Review of the Literature and Case Series of Potential Novel Targets for Treatment. Pain Practice 2013;13(1):3-17.

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