Guideline No. 445: Management of Chronic Pelvic Pain

Objective To provide evidence-based recommendations for the management of chronic pelvic pain in females. Target Population This guideline is specific to pelvic pain in adolescent and adult females and excluded literature that looked at pelvic pain in males. It also did not address genital pain. Benefits, Harms, and Costs The intent is to benefit patients with chronic pelvic pain by providing an evidence-based approach to management. Access to certain interventions such as physiotherapy and psychological treatments, and to interdisciplinary care overall, may be limited by costs and service availability. Evidence Medline and the Cochrane Database from 1990 to 2020 were searched for articles in English on subjects related to chronic pelvic pain, including diagnosis, overlapping pain conditions, central sensitization, management, medications, surgery, physiotherapy, psychological therapies, alternative and complementary therapies, and multidisciplinary and interdisciplinary care. The committee reviewed the literature and available data and used a consensus approach to develop recommendations. Only articles in English and pertaining to female subjects were included. Validation Methods The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations). Intended Audience Family physicians, gynaecologists, urologists, pain specialists, physiotherapists, and mental health professionals. Tweetable Abstract Management of chronic pelvic pain should consider multifactorial contributors, including underlying central sensitization/nociplastic pain, and employ an interdisciplinary biopsychosocial approach that includes pain education, physiotherapy, and psychological & medical treatments. SUMMARY STATEMENTS 1.Chronic pelvic pain is a common condition that can cause severe distress and considerable burden on the person affected as well as the health care system (high). 2.Etiology of chronic pelvic pain can be multifactorial and involve gynaecologic, urologic, gastrointestinal, myofascial/musculoskeletal, neuropathic, and psychosocial contributors as well as alterations in the central nervous system (high). 3.When pain becomes persistent and unresponsive to standard treatments, there is likely altered pain processing at the level of the central nervous system called central sensitization/nociplastic pain (moderate). 4.The therapeutic relationship between pain patients and their health care providers can impact their satisfaction with care and health outcomes (moderate). 5.Possible gynaecologic contributors to chronic pelvic pain include dysmenorrhea, endometriosis, adenomyosis, vulvodynia, and pelvic venous disorders (moderate). 6.Painful bladder syndrome and irritable bowel syndrome are chronic overlapping pain conditions that are common in the pelvic pain population and can be diagnosed based on clinical history (high). 7.Pelvic floor myofascial dysfunction is a frequent source of pain in women with chronic pelvic pain (high). 8.Myofascial abdominal pain, pelvic girdle pain, low back pain, referred hip pain, joint hypermobility, and postural imbalances may contribute to chronic pelvic pain (Moderate). 9.Pain, tingling, numbness following a dermatome may be suggestive of entrapment neuropathy (moderate). 10.Pain-specific psychosocial factors, such as pain catastrophizing and fear avoidance, and mental health conditions, including depression, anxiety, insomnia, and active trauma symptoms, contribute to perpetuating and intensifying chronic pelvic pain (moderate). 11.The presence of cutaneous allodynia, hyperalgesia, pelvic floor tenderness, and/or chronic overlapping pain conditions are suggestive of central sensitization/nociplastic pain (moderate). 12.Interdisciplinary management that includes psychological, physiotherapy, and medical treatment and is based on a biopsychosocial model offers more comprehensive and effective care than stand-alone treatments for individuals with chronic pelvic pain (moderate). RECOMMENDATIONS 1.Health care providers should have a systematic approach to identify and address nociceptive stimuli initiating and perpetuating pain, as well as clinical findings suggestive of central sensitization/nociplastic pain (strong, moderate). 2.Pelvic ultrasound should be offered as a low-cost investigation to identify some pelvic pathologies that may contribute to chronic pelvic pain (strong, moderate). 3.In the absence of studies specific to chronic pelvic pain, management interventions deemed effective for generalized chronic pain may be used for chronic pelvic pain when a centralized process is suspected (conditional, low). 4.Pain neuroscience education should be included as an important component of chronic pain management (strong, moderate). 5.Lifestyle changes including dietary modifications, exercise, and smoking cessation may be offered as part of chronic pain management (conditional, low). 6.Physiotherapy assessment and treatment should be offered for chronic pelvic pain management (strong, high). 7.Psychological treatments that should be included in management of chronic pain are cognitive behavioural therapy (strong, high), acceptance and commitment therapy (strong, high), and mindfulness meditation (conditional, moderate). 8.For insomnia symptoms, cognitive behavioural therapy for insomnia is the initial treatment of choice and is safer than prolonged use of sleeping medications (strong, high). 9.Nonsteroidal anti-inflammatory drugs should be recommended for the treatment of dysmenorrhea (strong, moderate), but are of unclear effectiveness for non-menstrual chronic pelvic pain (conditional, low). 10.Opioid medications are not recommended for long-term management of chronic pelvic pain (strong, moderate). 11.Tricyclic antidepressants should be considered for neuropathic pelvic pain (moderate, strong), painful bladder syndrome (conditional, moderate), and irritable bowel syndrome (strong, moderate). 12.Serotonin and norepinephrine reuptake inhibitors such as duloxetine (conditional, moderate) and venlafaxine (conditional, low) may be considered in chronic pain management. 13.Clinicians should consider alternative treatment options to gabapentin for the management of chronic pelvic pain without gynaecologic pathology; however, gabapentin may be an option in cases of neuropathic pain (strong, moderate). 14.There is currently insufficient evidence to recommend cannabinoids for chronic pelvic pain management (conditional, low). 15.Progestogens and gonadotropin-releasing hormone agonists or antagonists should be considered in the management of chronic pelvic pain, especially in the presence of cyclical exacerbation or endometriosis (strong, moderate). 16.Surgery for chronic pelvic pain may be offered after pain beliefs and treatment expectations are explored and with counselling about the rationale for surgery, the uncertainty of the evidence surrounding outcomes, and the possibility that pain could be unchanged or worse post-operatively (strong, moderate). 17.Targeted therapies such as trigger point injections and nerve blocks can be considered in specific clinical circumstances, if there is no response to modalities with higher evidence (good practice point, low). 18.Botox injection of the pelvic floor muscles may be considered in the presence of persistent spasm that has not responded to pelvic physiotherapy interventions (conditional, low). 19.Acupuncture may be considered as a complementary modality for chronic pelvic pain (conditional, low). 20.There is a need in Canada for more publicly funded programs where health care providers work together in an interdisciplinary approach to treat chronic pelvic pain (strong, moderate).