EDITORIAL

Chronic Pelvic Pain:

Is It Time for an Algorithmic

Approach?

Chronic pelvic pain (CPP) is a ubiquitous, yet poorly

defined condition that is described in terms of the ana-

tomic area from which the presumed pathophysiologic

pain generator originates. However, the pelvis contains

multiple organ systems with complex overlapping

innervation and integrated function, so it is often diffi-

cult to identify a single contributor to the pathogenesis

or maintenance of CPP. The search for a specific etiol-

ogy leads the 15 million sufferers from CPP to seek

evaluation with multiple specialists over time, at signif-

icant cost to both the patient and the healthcare sys-

tem. In addition to this problem of misdiagnosis (or

lack of precise diagnosis), there are no clear treatment

strategies for the condition. Further, even when a diag-

nosis is suggested by characteristic pathologic features,

for example, interstitial cystitis, comparative effective-

ness trials of various pharmacologic or procedural

therapies are few.1

In this issue of Pain Practice, Apte et al.2 have per-

formed an extensive review of the condition known as

CPP. As described by the authors, the comprehensive

evaluation and diagnosis of CPP are time–consuming

and may involve invasive physical examination tech-

niques or biomechanical maneuvers not familiar to

many practitioners. Thus, in common practice,

patients receive treatments that vary by both geo-

graphic location as well as the specialty of origin of

the treating physicians. Similar to the recommenda-

tions of Nelson et al.,3 we agree the treatment of pelvic

pain should involve a multidisciplinary approach and

should ideally involve evaluation and treatment only

by physicians, physical therapists, and psychologists

well-versed in the complex biopsychosocial and patho-

physiologic contributors to the development and main-

tenance of CPP.

The available data suggest that a common feature

of CPP is primary biomechanical dysfunction in the

pelvic floor, pelvic ring, or associated stabilizing lum-

bar or abdominal structures. This can also be second-

ary to neuropathic pain generators and/or psychologic

factors. As described by Apte et al.,2 a thorough evalu-

ation and examination is key to determining the best

treatment strategy. However, many of the proposed

and potentially effective treatment modalities are

already inconsistently reimbursed (pelvic floor PT and

cognitive behavioral therapy), not traditionally reim-

bursed (peripheral nerve stimulation and pulsed radio-

frequency ablation), or currently in danger of lost

reimbursement (sacroiliac joint injections).4–7

In light of this, it is important to note that, even

given the preponderance of data supporting pharmaco-

logic, interventional, rehabilitative, and cognitive ther-

apies for CPP, no stepwise validated approach exists

for the management of CPP. In the absence of compel-

ling, robust, comparative effectiveness data with vali-

dated outcomes, reimbursements for logical and likely

effective therapies may continue to suffer, further com-

pounding the problem.

Subspecialty-specific algorithmic approaches to pel-

vic pain are already described in the gynecologic or

urologic literature, and advocate pharmacologic, hor-

monal, and surgical therapy of defined pain-generat-

ing disease processes.1,8–10 However, like many

chronic disabling pain syndromes, CPP may be the

result of an incompletely understood dysfunction in

peripheral and/or central neural processing. As our

understanding of neural plasticity and central sensiti-

zation evolves over time, CPP may become a disease

unto itself, with persistent pain even when the origi-

nal inciting pathophysiologic process is understood.11

Therefore, it is critical that timely interventions are

DOI. 10.1111/j.1533-2500.2011.00523.x

� 2012 The Authors

Pain Practice � 2012 World Institute of Pain, 1530-7085/12/$15.00

Pain Practice, Volume 12, Issue 2, 2012 85–87

rationally introduced when the process can be inter-

rupted or abated.

Algorithms have been published for evaluation and

treatment of headaches, fibromyalgia, and pain of

spinal origin, for example,12–16 yet multidisciplinary

approaches to the management of CPP by pain practi-

tioners has largely been limited to descriptive reports

of injections and neuromodulatory techniques.17–21

One of the few algorithms for the management of CPP

was published by De Andres in 2003,22 was specific to

coccydynia, and has yet to be validated. Others, like

Ducic et al.’s23 algorithm for the treatment of postsur-

gical incisional groin pain, are specific in scope and

discuss only medical and surgical options for manage-

ment. Nelson et al.’s article is an excellent comprehen-

sive summary of the available literature with regard to

the treatment of CPP in women, but does not propose

a stepwise treatment strategy for pain practitioners,

and does not address CPP in men.

What is critically needed, both from the standpoint

of the urgent public health and economic needs of the

nation, and our goal as physicians devoted to the elim-

ination of suffering, is to develop and implement evi-

dence-based multidisciplinary treatment algorithms for

both male and female patients with undifferentiated

CPP. Concomitant with these algorithms, we must

develop the means to critically assess clinical and func-

tional outcomes. The use of IMMPACT recommenda-

tions where several facets of disease (pain intensity,

functionality, depression, etc.) can be assessed longitu-

dinally may be a logical start.24 There is also a critical

need for ongoing comparative effectiveness research

and resource utilization assessments to ensure the

availability of clinically effective, systematically viable

options for patients with CPP.

Tracy Jackson, MD;

Marc Huntoon, MD

Department of Anesthesiology,

Vanderbilt University, Nashville,

Tennessee, U.S.A.

E-mail: tracy.jackson@vanderbilt.edu

REFERENCES

1. Hanno PM, Burks DA, Clemens JQ, et al. AUA

guideline for the diagnosis and treatment of interstitial cysti-

tis/bladder pain syndrome. J Urol. 2011;185:2162–2170.

2. Apte GNP, Brismee J-M, Dedrick G, Justiz R, Sizer P.

Chronic female pelvic pain – Part 1: clinical pathoanatomy

and examination of the pelvic region. Pain Pract.

2012;12:88–110.

3. Nelson PAG, Justiz R, Brismee J-M, Dedrick G, Sizer

P. Chronic female pelvic pain, Part 2: differential diagnosis

and management. Pain Pract. 2012;12:111–141.

4. Manchikanti L, Singh V, Caraway DL, Benyamin

RM, Hirsch JA. Medicare physician payment systems: impact

of 2011 schedule on interventional pain management. Pain

Physician. 2011;14:E5–E33.

5. Manchikanti L, Singh V, Boswell MV. Interventional

pain management at crossroads: the perfect storm brewing

for a new decade of challenges. Pain Physician.

2010;13:E111–E140.

6. Mekhail NA, Aeschbach A, Stanton-Hicks M. Cost

benefit analysis of neurostimulation for chronic pain. Clin J

Pain. 2004;20:462–468.

7. Manchikanti L, Giordano J. Physician payment 2008

for interventionalists: current state of health care policy. Pain

Physician. 2007;10:607–626.

8. Fall M, Baranowski AP, Elneil S, et al. EAU

guidelines on chronic pelvic pain. Eur Urol. 2010;57:

35–48.

9. Gambone JC, Mittman BS, Munro MG, Scialli AR,

Winkel CA. Consensus statement for the management of

chronic pelvic pain and endometriosis: proceedings of an

expert-panel consensus process. Fertil Steril. 2002;78:961–

972.

10. Heidelbaugh JJ, Llanes M, Weadock WJ. An algo-

rithm for the treatment of chronic testicular pain. J Fam

Pract. 2010;59:330–336.

11. National Research Council. ‘‘Front Matter.’’ Reliev-

ing pain in America: a blueprint for transforming prevention,

care, education, and research. Washington, DC: The

National Academic Press;2011.1. print.

12. Boomershine CS, Crofford LJ. A symptom-based

approach to pharmacologic management of fibromyalgia.

Nat Rev Rheumatol. 2009;5:191–199.

13. Wiesel SW. The multiply operated lumbar spine. Instr

Course Lect. 1985;34:68–77.

14. Van Zundert J, Huntoon M, Patijn J, Lataster A,

Mekhail N, van Kleef M. 4. Cervical radicular pain. Pain

Pract. 2010;10:1–17.

15. Biondi DM. Cervicogenic headache: diagnostic evalu-

ation and treatment strategies. Curr Pain Headache Rep.

2001;5:361–368.

16. Gilmore B, Michael M. Treatment of acute migraine

headache. Am Fam Physician. 2011;83:271–280.

17. Marcelissen T, Jacobs R, van Kerrebroeck P, de

Wachter S. Sacral neuromodulation as a treatment for

chronic pelvic pain. J Urol. 2011;186:387–393.

18. Fariello JY, Whitmore K. Sacral neuromodulation

stimulation for IC/PBS, chronic pelvic pain, and sexual dys-

function. Int Urogynecol J. 2010;21:1553–1558.

19. Misra S, Ward S, Coker C. Pulsed radiofrequency for

chronic testicular pain-a preliminary report. Pain Med.

2009;10:673–678.

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20. McJunkin TL, Wuollet AL, Lynch PJ. Sacral nerve

stimulation as a treatment modality for intractable neuro-

pathic testicular pain. Pain Physician. 2009;12:991–995.

21. Rhame EE, Levey KA, Gharibo CG. Successful

treatment of refractory pudendal neuralgia with pulsed

radiofrequency. Pain Physician. 2009;12:633–638.

22. De Andres J, Chaves S. Coccygodynia: a proposal for

an algorithm for treatment. J Pain. 2003;4:257–266.

23. Ducic I, Moxley M, Al-Attar A. Algorithm for

treatment of postoperative incisional groin pain after

cesarean delivery or hysterectomy. Obstet Gynecol.

2006;108:27–31.

24. Dworkin RH, Turk DC, Farrar JT, et al. Core out-

come measures for chronic pain clinical trials: IMMPACT

recommendations. Pain. 2005;113:9–19.

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