J Korean Med Assoc.  2008 Jan;51(1):53-64.

The Management of Chronic Pelvic Pain

• Oh ST

Abstract

Chronic pelvic pain (CPP) is defined as lower abdominal pain lasting for at least 6 months. There are two forms of CPP: cyclic or continuous. The usual cyclic pain is dysmenorrhea. Dysmenorrhea is classified into primary and secondary. The primary dysmenorrhea is painful menstruation without any other pelvic disease. It can be treated by fat-free or omega-3-rich diet, quitting of smoking, nonsteroidal antiinflammatory drugs (NSAIDs), oral contraceptive pills, and long-acting injectable progestins. The most common origin of secondary dysmenorrhea and CPP is endometriosis. The management of pain of endometriosis can be controlled with stepby-step management of the original lesion by medical and surgical treatment, postoperative medical treatment, trigger point injection, NSAIDs, and immune therapy. Other etiologies of CPP are adenomyosis, pelvic congestion syndrome, abnormalities of uterus and ovary, psychological problems, gastrointestinal diseases (e.g. irritable bowel syndrome), urinary diseases (e.g. interstitial cystitis or chronic urethral syndrome), and musculoskeletal diseases. They can be treated by the management of the underlying diseases. The special form of CPP is chronic myofacial syndrome of the abdominal wall, which can be treated by trigger point injection. The other supportive treatments for CPP are laparoscopic adhesiolysis, uterine suspension, laparoscopic uterosacral nerve ablation (LUNA), presacral neurectomy, and hysterectomy. The treatment of CPP is very difficult. Therefore the exact diagnosis of its origin is necessary, and the combination treatment in various aspects is needed.

Keyword

Dysmenorrhea; Chronic pelvic pain; Endoemetriosis

MeSH Terms

Abdominal Pain
Abdominal Wall
Adenomyosis
Anti-Inflammatory Agents, Non-Steroidal
Cystitis, Interstitial
Diet
Dysmenorrhea
Endometriosis
Estrogens, Conjugated (USP)
Female
Gastrointestinal Diseases
Hysterectomy
Musculoskeletal Diseases
Ovary
Pelvic Pain
Piperazines
Progestins
Smoke
Smoking
Trigger Points
Uterus
Anti-Inflammatory Agents, Non-Steroidal
Estrogens, Conjugated (USP)
Piperazines
Progestins
Smoke

Reference

References

1. Chan WY, Hill JC, Determination of menstrual prostaglandin levels in nondysmenorrheic and dysmenorrheic subjects. Prostaglandins. 1978; 15:365–375.

2. Rees MC, Anderson AB, Demers LM, Turnbull AC. Prostaglandins in menstrual fluid in menorrhagia and dysmenorrhea. Br J Obstet Gynaecol. 1984; 91:673–680.

3. Lundstrom V, Green K. Endogenous levels of prostaglandin F2? and its main metabolites in plasma and endometrium of normal and dysmenorrheic women. Am J Obstet Gynecol. 1978; 130:640–646.

4. Rees MC, Di Marzo V, Tippins JR, Turnbull AC. Leukotriene release by endometrium and myometrium throughout the menstrual cycle in dysmenorrhea and menorrhagia, J Endocrinol. 1987; 113:291–295.

5. Levinson SL. Peptidoleukotriene binding in guinea pig uterine membrane preparations. Prostaglandins. 1984; 28:229–240.

6. Nigam S, Benedetto C, Zonca M, Leo?Rosberg I, Lubbert H. Increased concentrations of eicosanoids and platelet?acti-vating factor in menstrual blood from women with primary dysmenorrhea. Eicosanoids. 1991; 4:137–141.

7. Harel Z, Lilly C, Riggs S, Drazen J. Urinary leukotriene (LT)?E4 in adolescents with dysmenorrhea. J Adolesc Health. 2000; 27:151–154.

8. Balbi C, Musone R, Menditto A, Di Prisco L, Cassese E, D'Ajello M, Ambrosio D, Cardonel A. Influence of menstrual factors and dietary habits on menstrual pain in adolescence age. Eur J Obstet Gynecol Reprod Biol. 2000; 91:143–148.

9. Deutch B. Menstrual pain in Danish women correlated with low n?3 polyunsaturated fatty acid intake. Eur J Clin Nutr. 1995; 49:508–516.

10. Hornsby PP, Wilcox AJ, Weinber CR. Cigarette smoking and disturbance of menstrual function. Epidemiology. 1998; 9:193–198.

11. Barnard ND, Scialli AR, Hurlock D, Bertron P. Diet and sex-hormone binding globulin, dysmenorrhea, and premenstrual symptoms. Obstet Gynecol. 2000; 95:245–250.

12. Harel Z, Biro FM, Kotenhahn RK, Rosenthal SL. Supplementation with omega?3 fatty acids in the management of dysmenorrhea in adolescents. Am J Obstet Gynecol. 1996; 174:1335–1338.

13. Chan WY, Dawood MY. Prostaglandin levels in menstrual fluid of nondysmenorrheic and of dysmenorrheic subjects with and without oral contraceptive or ibuprofen therapy. Adv Prostaglandin Thromboxane Res. 1980; 8:1443–1447.

14. Hanson FW, Izu A, Henzyl MR. Naproxen sodium in dysmenorrhea: its influence in allowing work/school activities. Obstet Gynecol. 1978; 52:583–587.

15. Budoff PW. Zomepirac sodium in the treatment of primary dysmenorrhea syndrome. N Engl J Med. 1982; 307:714–719.

16. Smith RP, Powell JR. Intrauterine pressure changes during dysmenorrhea therapy. Am J Obstet Gynecol. 1982; 143:286–292.

17. Mehlisch DR. Ketoprofen, ibuprofen, and placebo in the treatment of primary dysmenorrhea: a double?blind crossover comparison. J Clin Pharmacol. 1988; 28:S29–33.

18. Mehlisch DR. Double?blind crossover comparison of ketoprofen, naproxen, and placebo in patients with primary dysmenorrhea. Clin Ther. 1990; 12:398–409.

19. Marchini M, Tozzi L, Bakshi R, Pistal R, Fedele L. Comparative efficacy of diclofenac dispersible 50 mg and ibuprofen 400 mg in patients with primary dysmenorrhea. A randomized, double blind, within?patient, placebo?controlled study. Int J Clin Pharmacol Ther. 1995; 33:491–497.

20. Owen PR. Prostaglandin synthetase inhibitors in the treatment of primary dysmenorrhea. Am J Obstet Gynecol. 1984; 148:96–103.

21. Roy S. A double?blind comparison of a propionic acid derivative (ibuprofen) and a fenamate (mefenamic acid) in the treatment of dysmenorrhea. Obstet Gynecol. 1983; 61:628–632.

22. DuRant RH, Jay MS, Shofitt T, Lider CW, Taylor W. Factors influencing adolescents' responses to regimens of naproxen for dysmenorrhea. Am J Dis Child. 1985; 139:489–493.

23. Harel Z, Riggs S, Vaz R, Flanagan P, Harel D. The use of the leukotriene receptor antagonist montelukast (Singulair) in the management of dysmenorrhea in adolescents. J Pediatr Adolesc Gynecol. 2004; 17:183–186.

24. Hauksson A, Akerlund M, Forsling ML, Kindahl H. Plasma concentrations of vasopressin and a prostaglandin F2α metabolite in women with primary dysmenorrhea before and during treatment with a combined oral contraceptive. J Endocrinol. 1987; 115:355–361.

25. Creatsas G, Deligeoroglou E, Zachari A, Loutradis D, Papadimitriou T, Miras K, Aravantinos D. Prostaglandins: PGFα, PGE2, 6?keto?PGF1α and TXB serum levels in dysmenorrheic adolescents before, during and after treatment with oral contraceptives. Eur J Obstet Gynecol Reprod Biol. 1990; 36:292–298.

26. Ekstrom P, Juchnicka E, Laudanski T, Akerlund M. Effect of an oral contraceptive in primary dysmenorrhea?changes in uterine activity and reactivity to agonists. Contraception. 1989; 40:39–47.

27. Ekstrom P, Akerlund M, Forsling M, Kindahl H, Laudanski T, Mrugacz G. Stimulation of vasopressin release in women with primary dysmenorrhea and after oral contraceptive treatment ? effect on uterine contractility. Br J Obstet Gynaecol. 1992; 99:680–684.

28. Milsom I, Andersch B. Effect of various oral contraceptive combinations on dysmenorrhea. Gynecol Obstet Invest. 1984; 17:284–292.

29. Larsson G, Milsom I, Lindstedt G, Rybo G. The influence of a low-dose combined oral contraceptive on menstrual blood loss and iron status. Contraception. 1992; 46:327–334.

30. Robinson JC, Plichata S, Weisman CS, Nathanson CA, Ens-minger M. Dysmenorrhea and use of oral contraceptives in adolescent women attending a family planning clinic. Am J Obstet Gynecol. 1992; 166:578–583.

31. Dmowski WP, Cohen MR. Treatment of endometriosis with an antigonadotrophin, danazol: a laparoscopic and histological education. Obstet Gynecol. 1975; 46:147–154.

32. Biberoglu KO, Behrman SJ. Dosage aspects of danazol therapy in endometriosis: short term and long term effectiveness. Am J Obstet Gynecol. 1981; 139:645–654.

33. Vercellini P, Bocciolone L, Vendola. N, Colombo A, Rognoni MT, Fedele L. Peritoneal endomeriosis: morphologic appearance in women with chronic pelvic pain. J Reprod Med. 1991; 36:533–536.

34. Moghissi KS, Boyce CR. Management fo endometriosis with oral medroxyprogestrone acetate. Obstet Gynecol. 1976; 47:265–267.

35. Johnston WI. Dydorgesterone and endometriosis. Br J Obstet Gynecol. 1976; 83:77–80.

36. Telimaa S. Puolakka J, Ronuberg L, Kauppila A. Placebo controlled comparison of danazol and high dose meroxy?pro-gestrone acetate in the treatment of endometriosis. Gynecol Endometrinol. 1987; 1:13–23.

37. Azadien?Boulanger G, Secchi J, Tournemine C. Hormonal activity profiles of drugs for endometriosis therapy. Raynoud JP, Ojassoo T, Martini L, editors. Medical Management fo Endomtriosis. 2nd ed.New York: Raven Press;2006. p. 125–129.

38. Couthinho EM, Husson JM, Azadieu?Boulanger G. Treatment of endometriosis with gestrinone?five year's experience. Raynoud JP, Ojasso T, Martini L, editors. Medical Management of Endometriosis. 2nd ed.New York: Raven Press;2006. p. 249–253.

39. Meldrum DR, Chang RJ, Lu J, Vale W, Rivier J, Judd HL. Medical oophorectomy using a long?acting GnRH agonsit: a possible new approach for the treatment of endotmetrisis. J Clin Endocrinol Metab. 1982; 54:1081–1083.

40. Reichel RP, Schweppe KW, Zoladex Endomtriosis Study Group. Goserelin (Zoladex) depot in the treatment of endometriosis. Fertil Steril. 1992; 57:1197–1202.

41. Hardt W, Schmidt?Gollwitzer M, Schmidt?Gollwitzer K, Genz T, Nevinny?Stickel J. Erste Ergebnisse beil der Behandlung der Endometriose mit dem LH?RH Analogen Buserelin. Geburtshilfe Frauenheikunder. 1986; 46:483–489.

42. Tokushige M, Suginami H, Taniguchi F, Kitaoka Y. Laparoscopic surgery for endometriosis: a long?term follow?up. J Obstet Gynecol Res. 2000; 26:409–416.

43. Sutton CJ, Ewen SP, Jacobs SA, Whitelaw NL. Laser laparoscopic surgery in the treatment of ovarian endometriomas. J Am Assoc Gynecol Laparosc. 1997; 4:319–323.

44. Daniell JF, Kurtz BR, Gurley LD. Laser laparoscopic management of large endometriomas. Fertil Steril. 1991; 55:692–695.

45. Donnez J, Squifflet J, Pirard C, Jadoul P, Wyns C, Smets M. The efficacy of medical and surgical treatment of endometriosis? associated infertility and pelvic pain. Gynecol Obstet Invest. 2002; 54:2–7.

46. Chapron C, Vercellini P, Barakat H, Vieira M, Dubuisson JB. Management of ovarian endometriomas. Hum Reprod Update. 2002; 8:591–597.

47. Jones KD, Sutton C. Patient satisfaction and changes in pain scores after ablative laparoscopic surgery for stage endometriosis and endometriotic cysts. Fertil Steril. 2003; 79:1086–1090.

48. Reiter RC. A profile of women with chronic pelvic pain. Clin Obstet Gyenecol. 1990; 33:130–136.

49. Fall M, Johannson SL, Aldenberg F. Chronic interstitial cystitis: A heterogeneous syndrome. J Urol. 1987; 137:35–38.

50. Holm?Bentzen M, Jacobsen F, Nerstrom B, Lose G, Kristensen JK, Pedersen RH, Krarup T, Feggetter J, Bates P, Barnard R. Painful bladder disease: Clinical and pathoanatomical differences in 115 patients. J Urol. 1987; 138:500–502.

51. Larsen S, Thompson SA, Hald T, Barnard RJ, Gilpin CJ, Dixon JS, Gosling JA. Mast cells in interstitial cystitis. Br J Urol. 1982; 54:283–286.

52. Travell J, Rinzler SH. The myofascial genesis of pain. Postgrad Med. 1952; 11:425–434.

53. Slocumb JC. Neurological factors in chronic pelvic pain: trigger point and the abdominal pelvic pain syndrome. Am J Obstet Gynecol. 1984; 149:536–543.

54. Carter JE. Surgical treatment for chronic pelvic pain. J Soc Laparoendosc Surg. 1998; 2:129–139.

55. Simons DG. Diagnostic criteria of myofascial pain caused by trigger points. J Musculoskel Pain. 1999; 7:111–113.

56. Chan CL, Wood C. Pelvic adhesiolysis?the assessment of symptom relief by 100 patients. Aust N Z J obstet Gynaecol. 1985; 25:295–298.

57. Nezhat FR, Crystal FR, Nezhat CH, Nezhat CR. Laparoscopic adhesiolysis and relief of chronic pelvic pain. JSLS. 2000; 4:281–285.

58. Sutton C, McDonald R. Laser laparoscopic adhesiolysis. J Gynecol Surg. 1990; 6:155–159.

59. Sutton C, Hill D. Laser laparoscopy in the treatment of endometriosis. Br J Obstet Gynecol. 1990; 97:181–185.

60. Lichten EM, Bombard J. Surgical treatment of primary dysmenorrhoea with laparoscopic uterosacral nerve ablation. J Reprod Med. 1987; 32:37–41.

61. Parsons LH, Stovall TG. Surgical management of chronic pelvic pain. Obstet Gynecol Clin North Am. 1993; 20:765–778.