Chronic Pelvic Pain

Chronic pelvic pain is one of the underestimated and underattended problems in modern society. How often did you hear or read about chronic back pain or, let’s say, asthma? These are pretty common issues. I am sure you saw multiple back clinics as you commute through your city and, of course, who did not hear about or know somebody with asthma? These are pretty common! But did you know that the prevalence of chronic pelvic pain is similar to those of back pain and asthma? Did you know that 38 out of 1000 women ages 15-73 suffer from chronic pelvic pain?[1]

 

Another problem with chronic pelvic pain (CPP), besides its being often overlooked or minimized in women, that it is often completely neglected in men. Pain in the pelvic region in men has traditionally been regarded both as common and as an indication of prostatitis. A 2006 systematic review estimated the worldwide prevalence of CPP in men between 2 and 10% [2]. It is the most is the most common urologic disease in men below 50 years old and its prevalence is comparable to ischemic heart disease and diabetes mellitus. [3]

What is Chronic Pelvic Pain?

Chronic pelvic pain is not a disease; rather, it is a condition associated with dysfunction in one or usually more of the following body systems: gynecological, urological, gastrointestinal, musculoskeletal, and neurological. So what is the definition of chronic pelvic pain? European According to the Association of Urology Guidelines in Chronic Pain:

“Chronic pelvic pain syndrome as a persistent pain in structures related to the pelvis, in either men or women, is often associated with negative cognitive, behavioral, sexual and emotional consequences, as well as with symptoms and signs related to lower urinary tract, sexual, bowel, pelvic floor or gynecological dysfunction.”

 

Traditionally, pelvic pain was considered to become chronic once it has lasted for 6 months. However, the new ICD‐11 (adopted by the World Health Organization in May 2019) considers all pains to be chronic after 3 months [4]. What makes chronic pelvic pain even more challenging condition to manage that CPP is not only a debilitating physical condition, but also a source of significant emotional and psychological distress.

For example, women with CPP are likely to report depression, anxiety, and sleep disturbances, in addition to limitations in sexual activity and mobility [5]. Male patients with CPP have an increased risk of suffering from erectile dysfunction [6]. Despite it prevalence and significant impact on quality of life, symptoms of CPP are often overlooked or dismissed:

“Difficulties getting their symptoms taken seriously and accessing secondary/tertiary care is a common story heard from women with chronic pelvic pain and diagnostic (and therefore treatment) delay is seen worldwide … “ [7]

Unfortunately, the etiology of this condition is multifactorial and poorly understood, although it was suggested that central neurologic mechanisms might play a significant role [8]. Chronic pain is associated with changes in the central nervous system (CNS) that may maintain the perception of pain in the absence of acute injury.

These changes may also magnify perception so that nonpainful stimuli are perceived as painful (allodynia) and painful stimuli are perceived as more painful than expected (hyperalgesia). Pelvic muscles may become hyperalgesic with multiple trigger points. Other organs may also become sensitive (e.g., the uterus with dyspareunia (painful intercourse) and dysmenorrhea (painful periods) or the bowel with irritable bowel symptoms).

Another major problem is that the etiology of CPP remains unclear and there is no clear common symptoms or clear universal underlying mechanism for this condition:

Researchers and clinicians in the field generally agree that patients with CPPS are not a homogeneous group presenting with pain arising in pelvic organs but rather are individuals with widely different clinical phenotypes. It is likely that different mechanisms and dynamics are the basis for the highly individual courses of these conditions. 

If we don’t know exactly what causes CPP, at least what do we know about some predisposing/contributing factors?

 

Chronic Pelvic Pain – Contributing Factors

Several gynaecological and psychosocial factors are strongly associated with chronic pelvic pain. A recent Canadian large-scale study [9] identified the following factors independently associated with higher severity of chronic pelvic pain in women: abdominal wall pain, pelvic floor tenderness, painful bladder syndrome, higher pain catastrophizing, (i.e., negative cognitive and emotional coping response including amplification of pain and feeling of helplessness), adult sexual assault, higher body-mass index, current smoking, and family history of chronic pain. 

“Progress in the science of pain has led pain specialists to move away from an organ-centered understanding of pain located in the pelvis to an understanding based on the mechanism of pain and integrating, as far as possible, psychological, social, and sexual dimensions of the problem” [10].

In addition to the interplay among the immune, endocrine, and nervous systems, psychological factors may also play important roles in producing CP/CPPS symptoms. An accumulating body of research in recent years suggests an association between anxiety/panic symptoms and CPP. For example, a large-scale case-control study in Taiwan [11] compared 8,000 men with CPP and 24,000 randomly matched controls. They found that subjects with CPP had a significantly higher prevalence of prior Anxiety Disorders than the matched controls (11.5% vs 5.7%). 

Psychological factors also might affect the development and maintenance of persistent pelvic pain, adjustment to pain, and the outcome of treatments. It is not simply pain that causes distress and loss of valued activities that are attributable to pain; it is also worries about damage, disease, and prolonged suffering, particularly when there is no clear diagnosis. There is strong evidence for the involvement of cognitive and emotional processes in pain processing.

A prospective study of 115 women with endometriosis-associated CPP showed that catastrophizing had a significant impact on the experience of pain [12]. Similarly, post-traumatic stress disorder has been found to be related to poor health status in women with CPP [13]. However, not only psychological factors might contribute to the development or the severity of CPP, living with chronic pelvic pain also creates its own significant emotional distress and suffering.

There is even an evidence that anxiety and depression associated with living with CPP affect functioning and quality of life even more than pain itself [14].

 

Chronic Pelvic Pain and Psychological Treatment

Unfortunately, there is no high quality evidence that specific psychological interventions are effective for treatment of CPP. Partially, it is not so surprising considering the multifactorial nature of CPP. However, although CPP is specific to the pelvic area, its mechanism is largely has the nature of any chronic pain, which is characterized by maintenance of pain sensations in the absence of acute injury or clear pathology. Psychological factors such as anxiety, mood, beliefs about pain and coping style have been found to play an important role in adjustment and maintenance of persistent pain.

In addition, as it was mentioned above, people suffering with CPP often develop significant anxiety and depression as a result of the experience of living with CPP and psychological treatment can be very helpful in addressing and managing them. Indeed, there are several effective and evidence-based psychological treatments for chronic pain. For example, cognitive-behavioral therapy (CBT) has become a first-line psychosocial treatment for individuals with chronic pain. There is  a strong evidence for its efficacy in improving pain and pain-related problems across a wide spectrum of chronic pain syndromes [15]. However, it should be indicated that although the research shows benefit of CBT for pain, disability, and distress, overall effect is rather small [16].

Cognitive behavioral therapy (CBT) works with the fear-avoidance model, where fear and anxiety responses to pain lead to more fear and consequent avoidance of that pain and fear. This is functional and normal for acute pain, but for chronic pain it can lead to more pain, disability, catastrophizing and worse mental health outcomes. CBT works by targeting each aspect of this cycle, by providing accurate information, building awareness of this cycle, challenging dysfunctional beliefs and thinking patterns, and adjusting unhelpful behaviors.

Acceptance and commitment therapy (ACT) also shows good but small effect on improvement in pain, but less effect in improvement in pain-related disability and distress [16]. ACT in works on increasing each of the six domains of psychological flexibility in order to facilitate aspects such as mindfulness, increased pain tolerance, and values-based activities in order to improve functioning.

Short-term psychodynamic therapies, although have less published research, also show positive outcomes in treatment of different chronic pain conditions [17]. Interestingly, there is even one specifically CPP-related study [18]. In this randomized controlled study intensive short-term dynamic therapy (ISTDP) had significantly better outcome as compared to medical treatment as usual and maintained the benefits in long term. Significant improvement in urinary symptoms and pelvic pain was seen in those who received ISTDP, with 70% of participants in remission at four-year follow-up. ISTDP brought significant improvement at termination and outperformed the control group on target-symptom rating and measures of anxiety, depression, and hostility. At four-year follow-up, however, only the latter two associations were maintained [18].

References:

1. Zondervan et al. Prevalence and incidence of chronic pelvic pain in primary care: evidence from a national general practice database. Br J Obstet Gynaecol 1999;106: 1149–55.
2. Luzzi GA, Law LA. The male sexual pain syndromes. Int J STD AIDS 2006; 17: 720– 6. [PubMed]
3. Krieger JN, Nyberg L, Jr, Nickel JC. NIH consensus definition and classification of prostatitis. JAMA. 1999;282:236–7 [PubMed]
4. Treede RD, Rief W, Barke A, et al. Chronic pain as a symptom or a disease: the IASP Classification of Chronic Pain for the International Classification of Diseases (ICD‐11). Pain 2019; 160: 19–27.
5. Grace VM, Zondervan KT. Chronic pelvic pain in women in New Zealand: comparative well-being, comorbidity, and impact on work and other activities. Health Care Women Int. 2006; 27:585–599. [PubMed]
6. Chen, Xiang, et al. “The effect of chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) on erectile function: a systematic review and meta-analysis.” PLoS One 10.10 (2015): e0141447.
7. Vincent, K., and E. Evans. “An update on the management of chronic pelvic pain in women.” Anaesthesia 76 (2021): 96-107. https://doi.org/10.1111/anae.15421
8. Fall M., et al. EAU Guidelines on Chronic Pelvic Pain, European Urology, Volume 57, Issue 1, 2010, 35-48. [ScienceDirect]
9. Yosef, Ali, et al. “Multifactorial contributors to the severity of chronic pelvic pain in women.” American journal of obstetrics and gynecology 215.6 (2016): 760-e1.
10. Engeler DS, et al. The 2013 EAU Guidelines on Chronic Pelvic Pain: Is Management of Chronic Pelvic Pain a Habit, a Philosophy, or a Science? 10 Years of Development, European Urology, Volume 64, Issue 3, 2013, 431-439.
11. Chung, Shiu-Dong, and Herng-Ching Lin. “Association between chronic prostatitis/chronic pelvic pain syndrome and anxiety disorder: a population-based study.” PLoS One 8.5 (2013): e64630.
12. Martin CE, Johnson E, Wechter ME, Leserman J, Zolnoun DA. Catastrophizing: a predictor of persistent pain among women with endometriosis at 1 year. Hum. Reprod. 2011; 26(11), 3078–3084. 
13. Meltzer-Brody S, et al. Trauma and posttraumatic stress disorder in women with chronic pelvic pain. Obstet. Gynecol. 2007; 109(4), 902–908.
14. Miller-Matero, L.R., Saulino, C., Clark, S. et al. When treating the pain is not enough: a multidisciplinary approach for chronic pelvic pain. Arch Womens Ment Health 19, 349–354 (2016). https://doi.org/10.1007/s00737-015-0537-9
15. Ehde, D. M., Dillworth, T. M., & Turner, J. A. (2014). Cognitive-behavioral therapy for individuals with chronic pain: Efficacy, innovations, and directions for research. American Psychologist, 69(2), 153–166. https://doi.org/10.1037/a0035747
16. de C Williams, Amanda C., et al. “Psychological therapies for the management of chronic pain (excluding headache) in adults.” Cochrane database of systematic reviews 8 (2020).
17. Abbass, Allan. “Re: Short-term psychodynamic psychotherapies for chronic pain.” The Canadian Journal of Psychiatry 53.10 (2008): 710-710.
18. Baldoni F, Baldaro B, Trombini G. Psychotherapeutic perspectives in urethral syndrome. Stress Med. 1995;11:79–84.