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Interventional Treatment Options for Women with Pelvic Pain

  • Women’s Health Rehabilitation (S Bennis and C Fitzgerald, Section Editors)
  • Published:
Current Physical Medicine and Rehabilitation Reports Aims and scope Submit manuscript

Abstract

Purpose of Review

To provide an overview of current interventional treatment options for women with chronic pelvic pain (CPP).

Recent Findings

Accessibility of CT imaging, ultrasound, and fluoroscopy has assisted the development of novel interventional techniques. Similarly, neuromodulation techniques have improved with the development of novel stimulation patterns and device implants.

Summary

Numerous small-scale studies report high success rates with injection intervention therapies in CPP, but there are limited well-designed large-scale studies that demonstrate the superiority of treatment. Female pelvic pain is difficult to diagnose due to the multifactorial etiology and the variable presentation causing delay in accurate diagnosis and lack of response to conventional medical and initial interventional therapies. Despite the shortfalls of current studies, collectively, our understanding of chronic pain conditions and helpful injection interventions are improving. Undoubtedly, the breadth of current research will provide a rich foundation for future large-scale well-designed studies involving multiple disciplines with more uniform methods and criteria to produce reliable and reproducible results.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Baranowski AP, Lee J, Price C, Hughes J. Pelvic pain: a pathway for care developed for both men and women by the British Pain Society. Br J Anaesth. 2014;112(3):452–9.

    PubMed  CAS  Google Scholar 

  2. Nicholas MK. When to refer to a pain clinic. Best Pract Res Clin Rheumatol. 2004;18:613–29.

    PubMed  Google Scholar 

  3. Atkinson L, Sundaraj SR, Brooker C, O’Callaghan J, Teddy P, Salmon J, et al. Recommendations for patient selection in spinal cord stimulation. J Clin Neurosci. 2011;18(10):1295–302.

    PubMed  CAS  Google Scholar 

  4. Willard FH, Schuenke MD. The neuroanatomy of female pelvic pain. In: Bailey A, Bernstein C, editors. Pain in women: a clinical guide. New York: Springer Science 1 Business Media; 2013. p. 17–55.

    Google Scholar 

  5. de Leon-Casasola OA, Kent E, Lema MJ. Neurolytic superior hypogastric plexus block for chronic pelvic pain associated with cancer. Pain. 1993;54(2):145–51.

    PubMed  Google Scholar 

  6. Plancarte R, de Leon-Casasola OA, El-Helaly M, Allende S, Lema MJ. Neurolytic superior hypogastric plexus block for chronic pelvic pain associated with cancer. Reg Anesth. 1997;22(6):562–8.

    PubMed  CAS  Google Scholar 

  7. Plancarte R, Amescua C, Patt RB, Aldrete JA. Superior hypogastric plexus block for pelvic cancer pain. Anesthesiology. 1990;73(2):236–9.

    PubMed  CAS  Google Scholar 

  8. Wechsler RJ, Maurer PM, Halpern EJ, Frank ED. Superior hypogastric plexus block for chronic pelvic pain in the presence of endometriosis: CT techniques and results. Radiology. 1995;196(1):103–6.

    PubMed  CAS  Google Scholar 

  9. Kim JH, Kim E, Kim BI. Pulsed radiofrequency treatment of the superior hypogastric plexus in an interstitial cystitis patient with chronic pain and symptoms refractory to oral and intravesical medications and bladder hydrodistension: a case report. Medicine. 2016;95(49):e5549.

    PubMed  PubMed Central  Google Scholar 

  10. • Nagpal AS, Moody EL. Interventional management for pelvic pain. Phys Med Rehabil Clin N Am. 2017;28(3):621–46 This review article describes the various interventional options for pelvic pain.

    PubMed  Google Scholar 

  11. Schultz DM. Inferior hypogastric plexus blockade: a trans sacral approach. Pain Physician. 2007;10(6):757–63.

    PubMed  Google Scholar 

  12. Hunter CW, Stovall B, Chen G, Carlson J, Levy R. Anatomy, pathophysiology and interventional therapies for chronic pelvic pain: a review. Pain Physician. 2018;21(2):147–67.

    PubMed  Google Scholar 

  13. • Amin MM, Ait-Allah AS, Ali AE-SA, Salem RA, Ahmed SR, Alsammani MA. Inferior hypogastric plexus blockade versus acupuncture for the management of idiopathic chronic pelvic pain: a randomized clinical trial. Biomed J. 2015;38(4):317–22 RCT involving 117 patients with CPP compared the inferior hypogastric block with Acupuncture and showed 72.6% success rate and significantly reduced pain intensity in the IHPB group.

    PubMed  Google Scholar 

  14. •• Le Clerc Q-C, Riant T, Levesque A, Labat J-J, Ploteau S, Robert R, et al. Repeated ganglion impar block in a cohort of 83 patients with chronic pelvic and perineal pain. Pain Physician. 2017;20(6):E823–8 This retrospective review of 3 repeated ganglion impar blocks with chronic pelvic and perineal pain showed complete but temporary pain relief in 119 of the 220 blocks performed concluding that repeated blocks results in short term reduction in pain intensity with a moderate intermediate term effect.

    PubMed  Google Scholar 

  15. Oh C-S, Chung I-H, Ji H-J, Yoon D-M. Clinical implications of topographic anatomy on the ganglion impar. Anesthesiology. 2004;101(1):249–50.

    PubMed  Google Scholar 

  16. Scott-Warren JT, Hill V, Rajasekaran A. Ganglion impar blockade: a review. Curr Pain Headache Rep. 2013;17(1):306.

    PubMed  Google Scholar 

  17. Benzon HT, Rathmell JP, Wu CL, Turk DC, Argoff CE, Hurley RW. Practical management of pain. 5th ed. Philadelphia: Elsevier Mosby; 2014. p. 683–800.

    Google Scholar 

  18. Plancarte D, Amescua C, Patt R, Allende S. A751 presacral blockade of the ganglion of Walther (GANGLION IMPAR). Anesthesiology. 1990;73:3A.

    Google Scholar 

  19. • Sousa Correia J, Silva M, Castro C, Miranda L, Agrelo A. The efficacy of the ganglion impar block in perineal and pelvic cancer pain. Support Care Cancer. 2019;27(11):4327–30 This retrospective single center study showed significant pain reduction in oncological pelvic pain with ganglion impar injection under fluoroscopic guidance.

    PubMed  Google Scholar 

  20. •• Gunduz OH, Sencan S, Kenis-Coskun O. Pain relief due to trans sacrococcygeal ganglion impar block in chronic coccygodynia: a pilot study: ganglion impar block in chronic coccygodynia. Pain Med. 2015;16(7):1278–81 This retrospective study on 22 patients with chronic coccydynia showed that 82% of patients received >50% pain reduction and the remaining patients had complete relief after second injection for median duration of 17 months.

    PubMed  Google Scholar 

  21. Malec-Milewska M, Horosz B, Kolęda I, Sękowska A, Kucia H, Kosson D, et al. Neurolytic block of ganglion of Walther for the management of chronic pelvic pain. Wideochir Inne Tech Maloinwazyjne. 2014;3:458–62.

    Google Scholar 

  22. Labat J-J, Riant T, Robert R, Amarenco G, Lefaucheur J-P, Rigaud J. Diagnostic criteria for pudendal neuralgia by pudendal nerve entrapment (Nantes criteria). Neurourol Urodyn. 2008;27(4):306–10.

    PubMed  Google Scholar 

  23. Hibner M, Desai N, Robertson LJ, Nour M. Pudendal neuralgia. J Minim Invasive Gynecol. 2010;17(2):148–53.

    PubMed  Google Scholar 

  24. Stav K, Dwyer PL, Roberts L. Pudendal neuralgia: fact or fiction? Obstet Gynecol Surv. 2009;64(3):190–9.

    PubMed  Google Scholar 

  25. Abdi S, Shenouda P, Patel N, Saini B, Bharat Y, Calvillo O. A novel technique for pudendal nerve block. 2004;7(3):4.

  26. McDonald JS, Spigos DG. Computed tomography-guided pudendal block for treatment of pelvic pain due to pudendal neuropathy. Obstet Gynecol. 2000;95(2):306–9.

    PubMed  CAS  Google Scholar 

  27. Cok OY, Eker HE, Cok T, Akin S, Aribogan A, Arslan G. Transsacral S2-S4 nerve block for vaginal pain due to pudendal neuralgia. J Minim Invasive Gynecol. 2011;18(3):401–4.

    PubMed  Google Scholar 

  28. Fang H, Zhang J, Yang Y, Ye L, Wang X. Clinical effect and safety of pulsed radiofrequency treatment for pudendal neuralgia: a prospective, randomized controlled clinical trial. J Pain Res. 2018;11:2367–74.

    PubMed  PubMed Central  CAS  Google Scholar 

  29. Rhame EE, Levey KA, Gharibo CG. Successful treatment of refractory pudendal neuralgia with pulsed radiofrequency. Pain Physician. 2009;12(3):633–8.

    PubMed  Google Scholar 

  30. Ozkan D, Akkaya T, Yildiz S, Comert A. Ultrasound-guided pulsed radiofrequency treatment of the pudendal nerve in chronic pelvic pain. Anaesthesist. 2016;65(2):134–6.

    PubMed  CAS  Google Scholar 

  31. Vleeming A, Schuenke MD, Masi AT, Carreiro JE, Danneels L, Willard FH. The sacroiliac joint: an overview of its anatomy, function and potential clinical implications. J Anat. 2012;221(6):537–67.

    PubMed  PubMed Central  CAS  Google Scholar 

  32. Roberts SL, Burnham RS, Ravichandiran K, Agur AM, Loh EY. Cadaveric study of sacroiliac joint innervation: implications for diagnostic blocks and radiofrequency ablation. Reg Anesth Pain Med. 2014;39(6):456–64.

    PubMed  Google Scholar 

  33. Laslett M, Aprill CN, McDonald B, Young SB. Diagnosis of sacroiliac joint pain: validity of individual provocation tests and composites of tests. ManTher. 2005;10:207–18.

    Google Scholar 

  34. Kennedy DJ, Engel A, Kreiner DS, Nampiaparampil D, Duszynski B, MacVicar J. Fluoroscopically guided diagnostic and therapeutic intra-articular sacroiliac joint injections: a systematic review. Pain Med. 2015;16(8):1500–18. https://doi.org/10.1111/pme.12833 Epub 2015 Jul 14.

    Article  PubMed  Google Scholar 

  35. • Dutta K, Dey S, Bhattacharyya P, Agarwal S, Dev P. Comparison of Efficacy of Lateral Branch Pulsed Radiofrequency Denervation and Intraarticular Depot Methylprednisolone Injection for Sacroiliac Joint Pain. Pain Physician. 2018;21(5):489–96 This randomized control study on 30 patients who were L4 medial branch, L5 DR and S1-3 lateral branch block positive and underwent radiofrequency ablation showed significant reduction in pain and global perceived effect at 6 months compared to intra-articular steroid group.

    PubMed  Google Scholar 

  36. • Stout A, Dreyfuss P, Swain N, Roberts S, Loh E, Agur A. Proposed optimal fluoroscopic targets for cooled radiofrequency neurotomy of the sacral lateral branches to improve clinical outcomes: an anatomical study. Pain Med. 2018;19(10):1916–23 This anatomical study used fluoroscopy to compare current targets for lateral branch blocks for SIJ denervation using radiofrequency ablation and identified new targets that decreased miss rates and improved SIJ denervation success rated from 60% to 95%.

    PubMed  Google Scholar 

  37. Shah JP, Thaker N, Heimur J, Aredo JV, Sikdar S, Gerber LH. Myofascial trigger points then and now: a historical and scientific perspective. PM R. 2015 Jul;7(7):746–61.

    PubMed  PubMed Central  Google Scholar 

  38. Meister MR, Sutcliffe S, Ghetti C, Chu CM, Spitznagle T, Warren DK, et al. Development of a standardized, reproducible screening examination for assessment of pelvic floor myofascial pain. Am J Obstet Gynecol. 2019;220(3):255.e1–9.

    Google Scholar 

  39. Sikdar S, Shah JP, Gebreab T, Yen R-H, Gilliams E, Danoff J, et al. Novel applications of ultrasound technology to visualize and characterize myofascial trigger points and surrounding soft tissue. Arch Phys Med Rehabil. 2009;90(11):1829–38.

    PubMed  PubMed Central  Google Scholar 

  40. Kim DS, Jeong TY, Kim Y-K, Chang WH, Yoon J-G, Lee SC. Usefulness of a myofascial trigger point injection for groin pain in patients with chronic prostatitis/chronic pelvic pain syndrome: a pilot Study. Arch Phys Med Rehabil. 2013;94(5):930–6.

    PubMed  Google Scholar 

  41. Albayrak A, Ozcafer R, Balioglu MB, Kargin D, Atici Y, Ermis MN. Piriformis syndrome: treatment of a rare cause of posterior hip pain with fluoroscopic-guided injection. Hip Int. 2015;25(2):172–5. https://doi.org/10.5301/hipint.5000219.

    Article  PubMed  Google Scholar 

  42. Bartley J, Han E, Gupta P, Gaines N, Killinger KA, Boura JA, et al. Transvaginal trigger point injections improve pain scores in women with pelvic floor hypertonicity and pelvic pain conditions. Female Pelvic Med Reconstr Surg. 2019;25(5):392–6.

    PubMed  Google Scholar 

  43. • Morrissey D, El-Khawand D, Ginzburg N, Wehbe S, O’Hare P, Whitmore K. Botulinum toxin A injections into pelvic floor muscles under electromyographic guidance for women with refractory high-tone pelvic floor dysfunction: a 6-month prospective pilot study. Female Pelvic Med Reconstr Surg. 2015;21(5):277–82 This prospective open-label study on 21 women with high-tone pelvic floor dysfunction who had Botox as intervention using EMG guidance showed significant improvement in global perceived effect, reduction in dyspareunia, decreased resting pressure and pelvic floor tenderness and less sexual dysfunction.

    PubMed  Google Scholar 

  44. •• Jarvis SK, Abbott JA, Lenart MB, Steensma A, Vancaillie TG. Pilot study of botulinum toxin type A in the treatment of chronic pelvic pain associated with spasm of the levator ani muscles. Aust N Z J Obstet Gynaecol. 2004;44(1):46–50 A prospective cohort study using Botox on 12 women with pelvic floor muscle spasm and hypertonicity showed improvement in manometry pressures and pelvic pain at 12week follow-up. These findings were further confirmed by an RCT by the same authors in 2006.

    PubMed  Google Scholar 

  45. Levesque A, Ploteau S, Michel F, Siproudhis L, et al. Botulinum toxin infiltrations versus local anaesthetic infiltrations in pelvic floor myofascial pain: multicentre, randomized, double-blind study. Ann Phys Rehabil Med. 2020. https://doi.org/10.1016/j.rehab.2019.12.009.

  46. Melzack R, Wall PD. Pain mechanisms: a new theory. Science. 1965;150(3699):971–9.

    PubMed  CAS  Google Scholar 

  47. Rushton DN. Electrical stimulation in the treatment of pain. Disabil Rehabil. 2002;24(8):407–15.

    PubMed  Google Scholar 

  48. Miller JP, Eldabe S, Buchser E, Johanek LM, Guan Y, Linderoth B. Parameters of spinal cord stimulation and their role in electrical charge delivery: a review. Neuromodulation. 2016;19(4):373–84.

    PubMed  Google Scholar 

  49. British Pain Society. Spinal cord stimulation for the management of pain: recommendations or best clinical practice. 2009.

  50. Raff M, Melvill R, Coetzee G, Smuts J. Spinal cord stimulation for the management of pain: recommendations for best clinical practice. S Afr Med J. 2013;103(6):423.

    PubMed  CAS  Google Scholar 

  51. • Kapural L, Narouze SN, Janicki TI, Mekhail N. Spinal cord stimulation is an effective treatment for the chronic intractable visceral pelvic pain. Pain Med. 2006;7(5):440–3 In this small case series report of 6 patients who had visceral pain and previous treatment with hypogastric blocks received SCS and had significant improvement with >50% pain reduction at 30 months and improved disability index and reduction in opioid usage.

    PubMed  Google Scholar 

  52. Hunter C, Davé N, Diwan S, Deer T. Neuromodulation of pelvic visceral pain: review of the literature and case series of potential novel targets for treatment. Pain Pract. 2013;13(1):3–17.

    PubMed  Google Scholar 

  53. •• Deer T, Slavin KV, Amirdelfan K, North RB, Burton AW, Yearwood TL, et al. Success Using Neuromodulation with BURST (SUNBURST) Study: results from a prospective, randomized controlled trial using a Novel Burst Waveform. Neuromodulation. 2018;21(1):56–66 This study was conducted on 100 patients randomized and crossed over to receive burst stimulation and conventional tonic stimulation to determine the efficacy and showed that burst stimulation was not only noninferior to tonic stimulation but was also superior and 70.8% patients preferred burst stimulation.

    PubMed  Google Scholar 

  54. Simopoulos T, Yong RJ, Gill JS. Treatment of chronic refractory neuropathic pelvic pain with high-frequency 10-kilohertz spinal cord stimulation. Pain Pract. 2018;18(6):805–9.

    PubMed  Google Scholar 

  55. Levine AB, Parrent AG, MacDougall KW. Stimulation of the spinal cord and dorsal nerve roots for chronic groin, pelvic, and abdominal pain. Pain Phys. 2016;19(6):405–12.

    Google Scholar 

  56. Krames ES. The dorsal root ganglion in chronic pain and as a target for neuromodulation: a review. Neuromodulation. 2015;18(1):24–32.

    PubMed  Google Scholar 

  57. •• Deer TR, Levy RM, Kramer J, Poree L, Amirdelfan K, Grigsby E, et al. Dorsal root ganglion stimulation yielded higher treatment success rate for complex regional pain syndrome and causalgia at 3 and 12 months: a randomized comparative trial. Pain. 2017;158(4):669–81 152 patients were studied in this prospective multicenter randomized comparative effectiveness trial and showed DRG stimulation was safe and effective and >50% pain relief was seen in 81% the DRG patients versus 55% of dorsal column SCS stimulation. DRG also provided improved psychological disposition and less unpleasant paresthesia.

    PubMed  Google Scholar 

  58. Janicki TI. Chronic pelvic pain as a form of complex regional pain syndrome. Clin Obstet Gynecol. 2003;46(4):797–803.

    PubMed  Google Scholar 

  59. Hunter CW, Sayed D, Lubenow T, Davis T, Carlson J, Rowe J, et al. DRG FOCUS: a multicenter study evaluating dorsal root ganglion stimulation and predictors for trial success. Neuromodulation. 2019;22(1):61–79.

    PubMed  Google Scholar 

  60. Hunter CW, Yang A. Dorsal root ganglion stimulation for chronic pelvic pain: a case series and technical report on a novel lead configuration. Neuromodulation. 2019;22(1):87–95.

    PubMed  Google Scholar 

  61. Tam J, Loeb C, Grajower D, Kim J, Weissbart S. Neuromodulation for chronic pelvic pain. Curr Urol Rep. 2018;19(5):32.

    PubMed  Google Scholar 

  62. Steven S, Karen N, Jeffrey M, Jason B, Griebling TL, Sutherland SE, et al. Five-year follow up results of a prospective, multicenter study of patients with overactive bladder treated with sacral neuromodulation. J Urol. 2018;199(1):229–36.

    Google Scholar 

  63. Gajewski JB, Al-Zahrani AA. The long-term efficacy of sacral neuromodulation in the management of intractable cases of bladder pain syndrome: 14 years of experience in one centre. BJU Int. 2011;107(8):1258–64.

    PubMed  Google Scholar 

  64. •• Cottrell AM, Schneider MP, Goonewardene S, Yuan Y, Baranowski AP, Engeler DS, et al. Benefits and harms of electrical neuromodulation for chronic pelvic pain: a systematic review. Eur Urol Focus. 2019;a. This large systematic review aimed at identifying evidence for neuromodulation and studied 1099 patients who underwent electrical stimulation for chronic pelvic pain in various forms, 8 studies were RCT’s. This study found evidence in favor of percutaneous tibial nerve stimulation and transcutaneous electric nerve stimulation. However, only narrative synthesis was available for SCS, pudendal and sacral neuromodulation and studies had various confounding and bias concluding that neuromodulation may be useful in reducing pain and improving quality of life but larger controlled studies are needed.

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Funding

Donald McGeary, PhD, ABPP, received funding from the NCCIH; PI: McGeary: R01 AT008422

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Authors and Affiliations

  1. Department of Anesthesiology, UT Health San Antonio, 7703 Floyd Curl Drive MC 7838, San Antonio, TX, 78229, USA

    Joseph E. Torres, Ameet S. Nagpal & Alice Iya

  2. Rehabilitation Medicine, Psychiatry, UT Health San Antonio, San Antonio, TX, USA

    Donald McGeary

  3. Rothman Orthopedics Institute, Philadelphia, PA, USA

    Malathy Srinivasan

  4. Department of Physical Medicine and Rehabilitation, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA

    Malathy Srinivasan

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  1. Joseph E. Torres
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  2. Ameet S. Nagpal
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  3. Alice Iya
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  4. Donald McGeary
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Correspondence to Ameet S. Nagpal.

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Conflict of Interest

Donald McGreary reports grants from the National Center for Complementary and Integrative Health during the conduct of the study. Joseph Torres, Ameet Nagpal, Alice Iya, and Malathy Srinivasan declare no conflicts of interest relevant to this manuscript.

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Torres, J.E., Nagpal, A.S., Iya, A. et al. Interventional Treatment Options for Women with Pelvic Pain. Curr Phys Med Rehabil Rep 8, 229–239 (2020). https://doi.org/10.1007/s40141-020-00265-5

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