Multifaceted approach to pelvic pain treatment

By Kimberly Swan, MD, FACOG, gynecologist and obstetrician

Kimberly SwanMore than 15% of women in the U.S. suffer from pelvic pain each year, requiring nearly $2 billion in medical care.1 This pain can be challenging to accurately diagnose and successfully resolve due to patients’ unique individual circumstances and goals combined with numerous potential causes. Fellowship-trained specialists at The University of Kansas Hospital offer the experience required to effectively treat this potentially debilitating condition.

First steps toward resolution

Primary care physicians can employ a number of measures to investigate the source and help patients reduce or eliminate the pain. A referral may be necessary for high-risk patients or when initial efforts prove ineffective. But to begin the journey toward resolution, general practitioners are encouraged to:

  • Take a detailed history. Inquire as to the duration of the pain, the quality of the pain, the alleviating and aggravating factors, and any methods of relief that have been attempted, as well as their impact. Obtain detail on any recent surgeries and related complications. Determine whether the pain is cyclical or noncyclical, potentially correlating with the patient’s menstrual periods.
  • Rule out acute conditions. Could it be a urinary tract infection? Is an ectopic pregnancy a possibility? Begin with a diagnosis of exclusion.
  • Perform a detailed physical exam, including the lower back, hips and abdomen. The reproductive system, gastrointestinal system and state of the pelvic floor muscles are just a few potential causes to consider. One or multiple systems may be involved. Proceed with a pelvic exam, using a Q-tip, single digit and speculum to evaluate the opening of the vagina, pelvic floor muscles and uterus.

To evaluate the pain, the physician will essentially attempt to reproduce it via examination. A pelvic ultrasound is also a safe, inexpensive test to aid in diagnosis.

Determining treatment

Dependent upon findings, primary care physicians may explore a number of noninvasive treatment courses. For example, if the pelvic floor response is in question, dietary and lifestyle changes combined with physical therapy may prove effective against the pain. If endometriosis is suspected, a trial of oral contraceptives is a suitable approach. A bland diet to remove foods causing irritation may lead to relief, as might improved sleep patterns to reduce depression or anxiety that could be playing a role. A menstrual calendar can shed light on pain patterns.

Generally, a three-month trial of any of the above measures should be sufficient to allow possible improvement to emerge. If this time period fails to bring about positive change, we recommend referral to a specialist. We suggest referrals in several additional cases, including:

  • When the patient is experiencing pain, inflammation or skin disorder of the vulva
  • When the patient is experiencing pain solely in conjunction with sexual intercourse
  • When the patient exhibits high-risk factors, such as obesity, multiple past Caesarian sections, other prior abdominal surgeries or advanced benign disease

Benefits of referral

In the cases outlined previously, or when initial treatment measures have not yielded the desired results, our team at The University of Kansas Hospital offers expertise to help evaluate the condition and pursue the right treatment path. Our experience and specialty focus guide us in diagnosing and treating the pathology within the context of the chronic pain.

In addition to further exploration of the treatment methods discussed, we can and will assess surgical options. Our experienced surgeons pursue the most effective patient outcomes with the least amount of risk.

In cases of female pelvic pain, a surgical approach may prove to be the right course of action when:

  • The patient is a high-risk referral.
  • The patient seeks a minimally invasive approach toward removal of uterine fibroids.
  • The patient requires treatment for extensive endometriosis, particularly in adolescence and when fertility preservation is desired.
  • The patient requires a multidisciplinary approach.

Of note in any discussion of pelvic pain treatment is morcellation, a procedure in which tissues are cut into smaller pieces to allow the removal of the uterus (hysterectomy) or fibroids (myomectomy) through a small, laparoscopic incision. The approach allows removal to occur in a minimally invasive manner when the tissues are too large for vaginal removal. Risks are fewer, scarring is reduced and recovery time is shorter than when invasive abdominal incisions are performed.

The procedure does warrant careful scrutiny, as in rare cases in which undiagnosed cancerous tissue is present, the cut tissues can spread within the abdominal cavity and potentially worsen the patient’s prognosis. However, the minimally invasive procedure still presents significant advantages for many patients, and advanced techniques minimize this specific worry. Cautious and evidence-based use of morcellation with sophisticated techniques that eliminate tissue dissemination remains an option we provide and often recommend when carefully explored on a patient-by-patient basis.

As a high-volume gynecologic surgery group with fellowship-trained, minimally invasive gynecologic surgeons, we offer excellent outcomes with laparoscopic and robotic surgeries and low complication rates. Our experience and focus help many patients resolve pelvic pain in minimally invasive manners, while our commitment to evidence-based practice and ongoing research continue to improve outcomes.

Dr. Swan practices minimally invasive gynecology at The University of Kansas Hospital and serves as assistant professor at the University of Kansas Medical Center. Her clinical practice focuses on pelvic pain, endometriosis and benign gynecologic surgery for fibroids.

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