by Charles W. Butrick, MD, The Urogynecology Center
Chronic pelvic pain affects 20% of all women in the United States. Often patients suffer in silence and continue to have pain despite multiple treatments and/or surgeries having been tried. In 1995, I and a handful of other providers in various fields of sub-specialization including gynecology, urology, physical therapy, anesthesiology and basic science got together to educate one another about our individual understandings of this common problem. A few of us felt it was time to aggressively pursue a better understanding of pelvic pain so that we could better help the many men and women who suffer with this problem. I and three other physicians started the International Pelvic Pain Society. That Society now has a membership of over 500 and it is growing every day. Our annual meeting is attended by hundreds of providers that represent a diverse multidisciplinary background that involves gynecologists, physical therapists, neurologists and basic scientists. It is always a wonderful exchange of ideas by the world leaders in pelvic pain. The website has evolved into a great teaching tool as well as a great way of finding providers that specialize in the evaluation and management of pelvic pain. In the last 20 years we have continued to expand our knowledge of what chronic pelvic pain really is and it is these new concepts that we educate the attendees of The International Pelvic Pain Society about annually.
There have been many advancements in our understanding of chronic pelvic pain. An important concept for all individuals with pain to understand is that chronic pain is totally different than acute pain. Chronic pain involves significant change not only in the organ involved in the original insult. It also results in an alteration in the way the central nervous system reacts and in the way neighboring organs and tissues perceive pain. This neuropathic up regulation can trigger new pain generators. The astute clinician must therefore identify every pain generator and attempt to treat each of these as well as the neural up regulation that is present in more than 90% of patients who have pain of more than six months duration. While patients often describe that their pain is caused by a single disorder, for example endometriosis, it is rare that the pain experience is actually originating only from the lesions that might be found on her ovary or uterus. The pain of endometriosis will result in changes within the central nervous system that secondarily cause pelvic floor muscles to tighten and soon the patient struggles with constipation as well as pain with intercourse and/or when her bladder becomes full. The generalized hypersensitivity and multiple pain generators all need to be targets for appropriate treatment of what might have started as localized endometriosis but has progressed into a multifocal pain disorder.
Now that we understand that chronic pelvic pain is being produced by multiple problems it makes sense that therapies must be directed towards each of these problems. Triggers or potentiators to the pain must also be identified. Often insomnia, stress, the wrong diet or even medications given to try to help the problems will actually worsen the symptoms. A multimodal approach has been repeatedly shown to provide benefit for the management of various chronic pain disorders and this certainly applies to pelvic pain as well. The challenge to the patient who suffers with chronic pelvic pain involves finding providers that are knowledgeable in the management of patients with pelvic pain. It is rare that pursuing a surgical approach to treat an individual pain generator makes a significant impact in the daily pain that the patient suffers with. We now understand that nonsurgical approaches often provide higher patient satisfaction and typically will not result in exacerbations of pain which is so often seen after surgery is attempted to correct a single pain generator.
I am excited when I looked towards the future because now that we understand the true pathology involved in chronic pain our therapies have become more targeted to the actual neuropathic change that occurs. There are medications that target specific neurotransmitters involved in this neuropathic up regulation that hold great promise for the future of pain management. There are nonsurgical interventions including low level lasers, platelet rich plasma injections and various techniques of neuromodulation that I believe will pave the way for a better life for patients suffering with chronic pelvic pain. In the meantime, I and many others will continue to work hard with current modalities to help our patients get better.
by Lesli Hill, Relieving Pain in Kansas City Citizen Leader
I am woman who was diagnosed with endometriosis in my thirties and had a hysterectomy to “cure” me. As I have aged, I realize that the solution to that problem brought on a host of other problems with pelvic organ prolapse, ongoing pelvic pain and multiple surgeries to address these comorbid issues. I was fortunate to find my way to Dr. Butrick’s care. At the beginning, I refused to acknowledge that muscle pain generated a great deal of my pain. However, I became a believer as I collected the tools I needed to manage this chronic condition. I encourage every woman who has pain “down there” to find a practitioner who will look at her in a holistic manner. I also strongly advise women to become diligent about learning how their body works, to be educated about the pelvic floor and to recognize how intricately connected the muscle groups are. This knowledge will serve a woman well as she moves through the decades of her life.