Management of CPP

Medical Management - Treatment of chronic pelvic pain (CPP) is complex in patients with multiple problems.

  • Initially, pain may respond to simple over-the-counter (OTC) analgesics such as paracetamol, ibuprofen, aspirin, or naproxen. If treatment results are unsatisfactory, the addition of other modalities or the use of prescription drugs is recommended.

  • If possible, avoid the use of barbiturate or opiate agonists. Also discourage long-term use and overuse of all symptomatic analgesics because of the risk of dependence and abuse.

  • Tizanidine may improve the inhibitory function in the central nervous system and can provide pain relief. Therapy with tizanidine is not considered the standard of care

  • Amitriptyline (Elavil) and nortriptyline (Pamelor) are the tricyclic antidepressants (TCAs) used most frequently for chronic pain.

  • The selective serotonin reuptake inhibitors (SSRIs) fluoxetine (Prozac), paroxetine (Paxil), and sertraline (Zoloft) also are commonly prescribed. Other antidepressants such as doxepin, desipramine protriptyline, and buspirone also can be used.

Physical Therapy Management - The optimal treatment of CPP is based on a biopscychosocial model delivered by a multidisciplinary approach. This multidisciplinary treatment concludes oral analgesics and other medications, pain management, pelvic floor rehabilitation, nerve stimulation therapies, teaching cognitive coping strategies, educate about the importance of planning and pacing exercise and activities.

Pelvic Floor Rehabillitation - In women with multiple CPP conditions and in women who were healthy. This suggests a relationship between the presence of an organic pain condition and PFM pain. A recent (2010) systematic review concluded that myofascial pain in the PFMs is associated with several different CPP conditions that occur in women.

Therefore pelvic floor rehabilitation is a part of the treatment. Treatment interventions which are applied are:

  • manual therapy of the pelvic floor muscles
  • electromyographic biofeedback
  • electrical stimulation
  • myofascial release of painful trigger points of the pelvic floor
  • Thiele massage techniques
  • relaxation
  • PFM exercises
  • specific stretches; although this may take in excess of six months to show any benefit

Pain physiotherapy / management - Pain management and cognitive coping strategies should include education about how psychological factors, such as catastrophizing, pain related fear and anxiety, may affect sexual function and the perception of pain during intercourse and other activities for which patients may report pain.)

Pain management should also include educating patients about the importance of planning and pacing exercise and activities. The goal is to enable patients to pace their activity to achieve a similar amount each day. Overactive patients may experience constant pain with exacerbations called flare-ups, while others may have constant pain with flare-ups associated with minimal activity.

In addition, therapy can include education about vulvodynia, dyspareunia (painful intercourse), muscle relaxation, Kegel exercises, and vaginal dilation. The goals of the therapy are reducing the fear of pain and other pain-related cognitions associated with intercourse, increase sexual activity level, and decrease pain.