Anatomy, Pathophysiology and Interventional Therapies for Chronic Pelvic Pain: A Review

Abstract

Background: Chronic pelvic pain (CPP) represents a group of poorly understood disorders that are often refractory to conventional treatment. Referral to pain management typically occurs later in the continuum of care; as such, many of the injections and nerve blocks commonly prescribed for such patients are potentially limited in efficacy. While neuromodulation is conventionally considered the next algorithmic step in the treatment of chronic pain after injections fail, there is a common perception that neuromodulation is largely ineffective for CPP conditions. However, there is evidence that suggests neuromodulation may in fact be a viable treatment option for this particular patient population when utilized properly. Objectives: To provide a basic overview of the pathophysiology of CPP and the relevant neuroanatomy as it pertains to various available treatment options, as well as the techniques and potential targets for neuromodulation. Study Design: Literature review. Setting: Private practice, academic and hospital setting. Methods: A comprehensive review of the available literature was performed targeting publications focused on CPP and various techniques for utilizing neuromodulation to treat it. Results: Neuromodulation is an established treatment modalities, however its usefulness as it relates to treating CPP has typically been drawn into question. In this literature review, we discuss the efficacy of various techniques for treating CPP with neuromodulation. Limitations: Evidence to support the various treatments, while encouraging, is based on small studies and case series. Large-scale randomized, placebo-controlled clinical trials are warranted to evaluate the clinical efficacy and safety of the different treatments described, particularly neuromodulation. Conclusions: In addition to the percutaneous, injection-based treatments described herein, neuromodulation remains a plausible option for recalcitrant cases that fail to respond to more conventional means. Key words: Chronic pelvic pain, neuromodulation, spinal cord stimulation, CRPS, complex regional pain syndrome, neuropathic pain.

Neuromodulation of the Dorsal Root Ganglion for Chronic Postsurgical Pain

“…Long-term follow-up demonstrated an average 52% decrease in pain, with the average VAS decreasing from 83.5 +/− 10.5 to 38.9 +/− 27.1 [10]. Hunter, et al [41] successfully demonstrated that radiofrequency stimulation can be used to predict the optimal DRG target in a series of four PLP patients, eventually demonstrating 60–90% pain relief after implant. This valuable technique may help clarify the optimal target DRG(s) to stimulate in cases of PLP where the affected or painful dermatomes are surgically absent and neuroplastic changes may create overlap or shifts from expected coverage regions.…”

“…Chronic pelvic pain (CPP) is a debilitating, highly prevalent, and costly condition that affects up to 25–40% of both men and women all over the world [42]. Although this condition includes a variety of diagnoses such as pudendal neuralgia, interstitial cystitis, and endometriosis, common themes with CPP include a cumbersome and often lengthy diagnostic process with limited therapeutic options [41]. Strong links can be found between CPP and CRPS, the primary indication for DRG stimulation.…”

A novel, nonopiod‐based treatment approach to men with urologic chronic pelvic pain syndrome using ultrasound‐guided nerve hydrodissection and pelvic floor musculature trigger point injections

“…The protocol we propose uses a peripheral nerve hydrodissection technique, which is a type of procedure that removes adhesiolysis by introducing anesthetic or saline under pressure into planes of dissection. 11 The technique uses an anesthetic solution to separate the nerve from its adjacent fascia or muscle to decrease nerve hypersensitivity and create space and ultimately improve blood flow around the nerve which will secondarily decrease neurogenic inflammation. Our protocol addresses neural sensitization as this is considered a central event in the pathogenesis of CPPS.…”

Multimodal treatment of myophasal chronic pelvic pain in women: institutional experience

“…7 There are several modalities of treatments, which must be staggered according to the recommendations of the American pain association, often poor clinical responses are obtained, so the management must be multidisciplinary. 8 The present study was conducted in order to report our results of multimodal management in patients with chronic pelvic pain secondary to myofascial syndrome, in the Clinic of Gynecological Urology of the "Centro Médico Nacional 20 de Noviembre, ISSSTE, Mexico".…”