THERAPY
Patients
with chronic pelvic pain offer a therapeutic challenge. If possible,
care should be directed at a specific cause. The use of analgesics should be on
a fixed time schedule that is independent of symptoms.
Suppression of ovulation may be
useful as either a ther-apeutic modality or as a diagnostic tool to assist in
ruling out ovarian or cyclic processes. Gonadotropin-releasing hor-mone (GnRH) agonists cause a central
down-regulation of the ovarian hormones and have been used in the treatment of
endometriosis. These agents may also help relieve some of the symptoms of IBS,
interstitial cystitis, and pelvic congestion syndrome (in which engorged pelvic
blood vessels are purported to cause pelvic aching and pain).
Patients with symptoms
characteristic of IBS or infec-tion should be referred to a gastroenterologist
for further evaluation. Use of a food diary to identify and eliminate foods
that are associated with symptoms, combined with the nurturing
physician–patient relationship to avoid “doctor shopping” and episodic care,
are the mainstays of treatment. The limiting of caffeine, alcohol, fatty foods,
and gas-producing vegetables is often helpful. Lactose or wheat gluten
intolerance may be identified by the diary. If constipation is a major symptom,
the consumption of 20 to 30 g of fiber or the use of osmotic laxatives such as
lactulose is often useful. When diarrhea is a major symp-tom, antidiarrheals
can be useful. Gas pain and cramping may be treated with antispasmodics such as
dicyclomine and hyoscyamine.
Treatments for interstitial
cystitis include dietary modification, intravesical agents, and oral agents
aimed at decreasing inflammation and pain signals. As with IBS, caffeine,
alcohol, artificial sweeteners, and acidic foods should be eliminated. Dimethyl sulfoxide (DMSO) is the only
drug approved for direct bladder instillation to treat interstitial cystitis,
although many physicians treat with a “cocktail” of anti-inflammatory and
analgesic medications. Oral agents include antihistamines, tricyclic
antidepres-sants, and pentosan
polysulfate, a glycosaminoglycan analogue that may help reestablish the
disrupted mucosa of the bladder.
Surgical therapies, such as hysterectomy, should be performed only
after nongynecologic causes have been ruled out. Hysterectomy is very effective
is relieving pain arising from the uterus and may also improve symptoms in
women without identifiable uterine pathology. Alternate treatment modalities,
such as transcutaneous electrical nerve stimulation (TENS), biofeedback, nerve
blocks, laser ablation of the uterosacral ligaments, and presacral neurec-tomy
may be used, as appropriate. Adding psychotherapy to medical treatment of
chronic pelvic pain appears to improve response over that of medical treatment
alone and should be considered. In some cases, the goal in treatment may not be
a cure, that is, elimination of the chronic pain, but rather successful
management of the symptoms to allow maximal function and quality of life.
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