Urogenital and pelvic pain is defined as pain originating in the pelvis or lower abdominal organs. These pains may be further described as acute or chronic depending on presentation. Acute urogenital and pelvic pain may be due to infectious and inflammatory pain states (such as pelvic inflammatory disease, sexually transmitted disease, or infectious cystitis) as well as cancer, trauma, or injury to external genitalia. Chronic urogenital and pelvic pain is pain in the aforementioned area that has been present for at least 3 months duration. When these pains don’t have a clear etiology and other more common diagnoses have been ruled out, patients are given a diagnosis of chronic pelvic pain (CPP) (females) or prostatodynia/chronic prostatitis (males).
Clinical Features and Diagnosis
Patient presentation and symptomatology vary and often involve more than one organ system. As such, a comprehensive and chronological history and physical exam (including thorough neurological exam and psychosocial assessment) are essential for accurate diagnosis as well as to establish rapport with the patient. While there is increased incidence of depression, anxiety, and a history of physical or sexual abuse in patients with chronic urogenital and pelvic pain, it is important to understand that there is not a proven cause and effect relationship. Additionally, the practitioner must bear in mind that the sites of exam are private and associated with bodily functions (i.e., sexual function, defecation, urination) that elicit strong emotions in patients. The patient should be asked about onset of pain, its location, associated symptoms, exacerbating or remitting factors, whether the pain is cyclic or present at all times, dyspareunia, increase in symptoms with valsalva maneuvers, history of abdominal surgeries, and other pertinent information as guided by their presenting symptoms . The physical exam should be conducted in as gentle a manner as possible, recognizing that it is often a painful experience for the patient. A methodical approach to the physical examination is recommended in an attempt to duplicate the pain either by palpation or by positioning. One way to approach this often challenging task is to divide the exam by systems (i.e., neurologic, gynecologic, and gastrointestinal) or by postural components (i.e., standing, sitting, supine, and lithotomy). In addition to a thorough history and physical exam, careful utilization of laboratory and imaging studies to aid diagnosis may include modalities such as ultrasonography, magnetic resonance imaging (MRI), urodynamic testing, urethral cultures, and CA-125. In some cases, surgery (e.g., diagnostic laparoscopy) is necessary for a proper diagnosis as well as to relieve pain.
Common Causes of Urogenital and Pelvic Pain in Males and Females
IC/BPS is one of the most common causes of pelvic pain in both sexes. IC/BPS is likely not a single disease entity but rather a complex of urological complains including pain that may have a common, but as yet undetermined, etiology. IC/ BPS has a female-to-male ratio of 10:1, with an estimated prevalence of 2 in 10000 patients, primarily in young to middle-aged females. It is regularly implicated as a reason for continued pelvic pain after hysterectomy. Diagnosis of IC/ BPS in the past was based on criteria that mandated the presence of glomerulations or a Hunner’s ulcer on cystoscopic examination as well as bladder pain and urinary urgency or frequency. More recent definitions are surely symptom- based. Urodynamic testing and intravesical potassium sensitivity testing have also been used to support the diagnosis. Therapies unique to the management of IC/BPS include oral pentosan polysulfate, hydrodistention (using dimethyl sulfoxide, heparin, steroids, etc.), and immunosuppressive agents. In general, the least invasive therapies are attempted first prior to trial of more invasive treatment modalities. The prognosis of IC/BPS is mildly favorable with reports that up to 50% of patients experience spontaneous remission within 5–7 years.
Endometriosis is a gynecologic condition whereby endometrial glandular tissue is found in other areas of the body (i.e., ovaries, bladder, and peritoneal cavity). Pain secondary to endometriosis is often cyclic in nature, worsening during the hormonal cycling associated with menstruation. Pathophysiology of endometriosis is unconfirmed but postulated to be retrograde menstruation from the fallopian tubes into the pelvis and adjacent structures leading to implantation of viable endometrial tissue at these sites. The presentation of endometriosis varies and includes urinary urgency, back pain, leg pain, bladder pain, and dyspareunia. The gold standard of diagnosis is visualization and histologic confirmation of endometrial tissue outside the uterus at the time of laparoscopy. Initial therapy of endometriosis is fairly well defined utilizing hormonal therapy with OCPs or GNRH agonists as well as surgical excision of endometriomas.
Vulvodynia differs from other chronic urogenital and pelvic pains due to the fact that pain is clearly located outside of the pelvis and in the external genitalia. This disorder is more prevalent in women who are in their reproductive years and is characterized by a stinging, burning discomfort in their vulva. Research has identified at least six subgroups of this disorder. In general, therapeutic intervention begins with a cream or ointment containing local anesthetics before progressing to more systemic and invasive treatment options. For long-term therapy, there is some evidence that surgical excision or pelvic floor muscle training as well as cognitive behavioral therapies are beneficial.
Male Chronic Pelvic Pain Syndrome (mCPPS)
This disease entity is the equivalent of chronic pelvic pain in females, but there appear to be some unique qualities that differentiate it from the female variety. Despite the numerous urogenital structures that are unique to men, the prostate has been assumed to be the organ generating mCPPS. Diagnosis of mCPPS can be aided by the use of the Chronic Prostatitis Symptom Index (CPSI), a nine-point questionnaire that inquires about the patient’s quality of life, pain, as well as the presence of urinary symptoms. Patient presentation is characterized by urinary urgency, poor flow, and perineal discomfort. A complete history and physical exam that includes examination of the external genitalia should be completed. For males with chronic urogenital and pelvic pain, a urine culture should be sent to rule out bacterial prostatitis or a urinary tract infection as a reversible etiology of the patient’s pain. If the clinical situation warrants, a PSA may also be checked to rule out prostate cancer. There is some thought that alpha blockers play a unique role in managing pain in patients with chronic prostatitis due to the abundance of alpha receptors in the bladder neck and prostate despite the lack of conclusive clinical evidence of this effect. Anti-inflammatory agents, immunosuppressants, and skeletal muscle relaxants have all been evaluated for management with inconsistent results. Surgery is generally reserved for patients with proven etiology/obstructive symptoms (i.e., bladder neck obstruction). The UPOINT system also provides a practical approach to the management of this patient population. Prognosis is similar to that of chronic urogenital and pelvic pain.
Orchialgia is defined as pain located in the male testes. Pain secondary to orchialgia can be acute or chronic in nature. Etiology of this disorder includes prior surgeries, trauma, chronic inflammation, infection, and neuropathology associated with the lower thoracic spine (e.g., can be a form of T10 radiculopathy). Management is procedural when thoracic pathology is identified, but otherwise is pharmacologic or minimally invasive procedures.
Treatment
There are few monotherapies with proven clinical efficacy for this disorder, mandating a multi-disciplinary, multimodal approach to management. Unfortunately, the diagnosis assigned to this painful condition has often depended on the initial specialist who evaluated the patient and not on the underlying pathophysi-ology. In general, if the underlying cause of pain is defined, then treatment is focused on that par-ticular etiology; otherwise, a more empiric approach is taken. The UPOINT system is a phe-notypic approach to therapy consisting of six components: urinary, psychosocial, organ- specific, infection, neurologic/systemic, and muscle tenderness. This system was originally designed for male urogenital pain; however, it has been extended and modified to include uro-genital and pelvic pain in females as well. Physicians utilizing the UPOINT system first classify or assign patients to a specific phenotype based on clinical symptoms and presentation; this phenotypic characteristic is then used to guide therapy.A trial of oral medication is the most common first step in management. Drugs from multiple classes (i.e., muscle relaxants, NSAIDS, antidepressants, anticonvulsants, opioids) have all been used with varying efficacy. The following is a list of the most commonly used drug classes as well as examples of medications in each class:
Nonsteroidal anti-inflammatory drugs (NSAIDS): Suggested treatments include meloxicam 7.5–15 mg daily or ibuprofen 800 mg Q8 hours for short-term management. Celecoxib, a selective COX2 inhibitor (200–400 mg/ day), is also an option due to decreased risk of gastrointestinal issues.
Oral contraceptives (OCPs): OCPs are used to treat female pelvic pain related to ovulation or mittelschmerz and endometriosis. OCPs are often combined with NSAIDS to increase efficacy.
Gonadotropin-releasing hormone analogues (GNRH analogues): These are used to treat patients with cyclic pain symptoms usually due to endometriosis. Examples include leuprolide and goserelin
Antidepressants: The most commonly used medications in this class are agents that decrease the reuptake of norepinephrine, serotonin, or both. Duloxetine and amitriptyline are common choices in this class
Anticonvulsants: These agents are utilized for neuropathic pelvic pain. Gabapentin and pregabalin are common choices, but others such as carbamazepine, lamotrigine, and topiramate have anecdotal support for use
Topical formulation: Local anesthetics and capsaicin are commonly employed to help manage allodynia and hyperalgesia. Initial application of capsaicin can be very painful and so may need to be preceded by use of local anesthetics.
Opioids: They are used to decrease overall pain levels, irrespective of etiology. Regimens include combinations of hydrocodone or oxycodone with or without acetaminophen, fentanyl patches, methadone, or extended release formulations of oxymorphone, hydromorphone, morphine, and oxycodone. Interventional management of chronic pelvic pain should include consideration of the following:
Fluoroscopically guided pain procedures: This includes epidural injections, pudendal nerve block, genitofemoral nerve block, lumbar sympathetic, ganglion of impar, anhypogastric plexus blockade. In some patients, radiofrequency thermocoagulation or neurolysis with alcohol or phenol is an option after repeated successful blocks, but normally this modality is reserved for the most severe cases such as those associated with cancer.
Neuromodulation: Spinal cord stimulation targeting the S2-S4 nerve roots has been well described in this population. Other, less traditional approaches may include lead placement as high as the T6/7 level or as low as the conus medullaris. Peripheral lead placement including percutaneous posterior tibial nerve stimulation and lead placement in the subcutaneous tissues of the lower abdomen have been described.
Other procedures: Botulinum toxin injections or trigger point injections are used to manage chronic symptoms or to treat acute flares. Some complementary and alternative medicine (CAM) approaches to consider are:
Transcutaneous electrical nerve stimulation (TENS) unit
Acupuncture
Physical therapy (including pelvic physical therapy where available)
Biofeedback
Dietary therapy
Read More: Expert Solutions for Neck Pain: Insights from Dr. Manas Manohar, Consultant Pain Physician in Shivajinagar, Pune
Disclaimer: The information provided here should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. The information is provided solely for educational purpose and should not be considered a substitute for medical advice.
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