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Pain Management Options
Besides medication and surgery, there are many other methods to help you treat your pain. Pain often comes from more than one source, so it is important to look at several different possibilities that could be contributing to your pain. (see “Related Conditions“) Often a pain management specialist can help you navigate the variety of options to help you feel better.
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“Nerve Blocks: Neurolytic blocks of ganglion can be used effectively in some cases. The ganglion impar, or ganglion of Walther, is found on the ventral surface of the coccyx where it forms the caudal origin of the bilateral sympathetic chain. It has sympathetic innervation to the perineal and anal regions and block of this innervation can disrupt afferent sympathetic and nociceptive signals from that area.13 Superior hypogastric plexus blocks (SHPB) with fluoroscopy or computed tomography (CT) guidance also have been used in malignant and non-oncological chronic pelvic pain.14 The superior hypogastric plexus is a retroperitoneal structure extending below the aortic bifurcation in association with the common and internal iliac vessels. It innervates much of the pelvic viscera including the bladder, urethra, uterus, vagina, vulva, perineum, prostate, penis, testes, rectum and descending colon.
“Pelvic Floor Trigger Point Injections: Trigger point injections have been described in myofascial pain, including CPP.15 These injections can be beneficial when a patient presents with pelvic pain and is found to have one or more myofascial trigger points in the pelvic floor muscles. Trigger point injections are generally not used as a first line treatment or monotherapy but are generally more beneficial when used alongside physical therapy, medication management and behavioral therapy.15
“Pelvic Floor Botulinum Toxin Injections: For patients with refractory pelvic floor muscle spasm, botulinum toxin has been utilized to decrease spasm, therefore reducing pelvic pain. Botulinum toxin type A blocks the cholinergic transmission at the neuromuscular junction. Abbott et al.16 performed a double-blinded randomized, placebo-controlled trial in patients with CPP and demonstrated a significant decrease in dyspareunia and non-menstrual pain in the botulinum toxin group. In addition, they reported a significant reduction in pelvic floor pressure in the botulinum toxin group when compared to the pre-injection values. It is important to note that there were no statistically significant differences demonstrated between the groups in any of the previously mentioned parameters.
“Neuromodulation: Neuromodulation has also used as a treatment for CPP. Neuromodulation is a nondestructive, neuromodulory technique that delivers electrical stimulation to the spinal cord or peripheral nerves for the treatment of chronic pain. Patients with CPP may benefit from spinal cord stimulation, sacral stimulation or peripheral nerve stimulation. In particular, tibial nerve stimulation, which is an in-office weekly procedure, has shown some promise in the treatment of pelvic pain, fecal incontinence and overactive bladder.”
“Pain management should be individualized. The goal of medical therapy is to reduce pain by decreasing inflammation as well as ovarian and local hormone production (Table 1). Complete estrogen suppression may not be necessary to relieve endometriosis-associated pain.11 Medical treatment is usually not curative but suppressive, and symptoms will often recur after therapy discontinuation. The recurrence rate of endometriosis is highly variable, ranging from 4–74%.2,3 Initial treatment is typically use of combined oral contraceptive pills, which are effective in decreasing pain as well as in preventing postoperative recurrence.12 For those who cannot tolerate or have contraindications to estrogen, progestins such as medroxyprogesterone acetate, norethindrone acetate, or levonorgestrel are indicated. However, there are patients who have decreased receptor sensitivity as a result of aberrant gene expression in the eutopic endometrium that leads to progesterone resistance.13 For those unable to tolerate oral medications, the levonorgestrel-releasing intrauterine system can reduce pain and recurrence.4,14 However, the levonorgestrel-releasing intrauterine system does not inhibit ovulation and the recurrence of endometriomas. For those patients for whom the previous options have failed, we recommend using a gonadotropin-releasing hormone (GnRH) agonist with add-back therapy to prevent bone loss and to ease side effects. Patients taking GnRH agonists for endometriosis may develop resistance, because endometrial-like tissue expresses aromatase and produces its own estradiol.
“Our experience is mixed with GnRH antagonists, aromatase inhibitors, and bazedoxifene along with conjugated estrogens. Some patients obtain pain relief from these medications, but others discontinue them prematurely owing to high expectations of fast mitigation of symptoms.
“Since use was legalized in California, tetrahydrocannabinol and cannabidiol, either separately or in combination, present an alternative option. Patients frequently prefer these compounds over opioids, and their use is associated with less nausea and constipation. The use of tetrahydrocannabinol or cannabidiol is especially beneficial for managing postoperative pain, and their use does not have the addictive concerns associated with opioid use. We use an enhanced recovery after surgery protocol and highly discourage opioid use.
“Acupuncture is another potentially useful adjunct in treating the pain. It has been proposed to work by activating descending inhibitory pain pathways while centrally deactivating pain signals. Acupuncture also increases the pain threshold and leads to production of neurohumoral factors such as dopamine, nitric oxide, noradrenaline, acetylcholine, and others.15 In addition, it increases natural killer cells, thereby modifying immune function and decreasing estrogen production.15
“Pelvic physical therapy has been shown in a retrospective study to improve endometrial pain in 63% of patients after at least six sessions.4 Deep pressure massage, stretching pelvic floor muscles, joint mobilization, foam rollers with breathing, and relaxation techniques are the integral elements.
“Surgery remains the mainstay in definitive diagnosis. High-definition video laparoscopy with or without robotic assistance is the standard initial approach. In our extensive experience, laparotomy is seldom necessary. Excellent illumination with enhanced video magnification enables better recognition of subtle lesions as well as the depth of infiltrative lesions. Depending on the patient’s desire, location of lesion, availability of proper instrumentation, as well as the experience and skill of the surgeon, eradication of endometriosis can be achieved with surgical management techniques that include excision, vaporization, and ablation. The nonsurgical options discussed above can be used to supplement surgical treatment for long-term results.4
“Laparoscopic uterosacral nerve ablation to disrupt efferent nerve fibers has been tested. However, multiple large randomized controlled trials did not find it to be beneficial in reducing endometriosis-associated pain. Complications of subsequent uterine prolapse and intraoperative ureteral transection have been reported with this procedure.16 In contrast, laparoscopic presacral neurectomy was 87% efficacious in reducing severe midline pelvic pain.2,4–6 We find this procedure especially effective in patients with mild or no endometriosis.17 The adverse effects associated with presacral neurectomy are constipation and bladder and urinary symptoms.17 We perform presacral neurectomy in only about 1% of our patients.
“A prospective, multicenter cohort study of 981 women with varying degrees of disease showed significant postsurgical symptom improvement over 36 months in patients who underwent laparoscopic excision of endometriosis. The most notable improvement was seen in dysmenorrhea, with a 57% reduction in symptoms; chronic pelvic pain and dyspareunia were reduced by 30%. Owing to recurrent pain, a second-look surgery was performed in 9% of patients, and histologically confirmed endometriosis recurrence was documented in 5%. Of these patients, 7% benefited from medical therapy.18 Abbott et al demonstrated significant pain relief (80%) after surgery compared with a placebo group (32%). They report progression of disease with second-look laparoscopy in 45%, no change in 33%, and improvement in 22% of patients. Twenty percent of cases were not responsive to surgery.18”