Chronic Pelvic Pain
This Is A Pain In My Pelvis
The American Board of Obstetrics and Gynecology defines chronic pelvic pain (CPPG) as pain in the pelvic area lasting six months of longer. Pelvic pain is a common disorder representing up to 10% of all referrals to general gynecologists. Possible causes of chronic pelvic pain include endometriosis, scar tissue, pelvic infections, musculoskeletal disorders resulting in pelvic floor dysfunction, interstitial cystisis, and vaginal mesh reactions. These last three causes of pelvic pain are treated by specialists in Female Pelvic Medicine and Reconstructive Surgery (FPMRS). Dr. Zipper and Dr. Raders are both board certified in FPMR.
Dr. Zipper Explains Chronic Pelvic Pain
Do I Have Chronic Pelvic Pain?
If you are experiencing pelvic pain that has lasted greater than six months, you meet the ACOG definition of chronic pelvic pain.
How Did I Get Pelvic Pain?
We believe that the most common cause for CPP leading to specialist referral today is Vaginal Mesh. If you did not have CPP, underwent transvaginal mesh surgery and now have CPP, this is most likely the cause of your CPP. Each week we treat muliple patients who have undergone transvaginal mesh surgery and suffer from CPP. As specialists in Female Pelvic Medicine, we also treat CPP caused by Interstitial Cystitis (IC) and Pelvic Floor Dysfunction. IC is a poorly understood disorder of the bladder associated with urgency of urination, frequency of urination, and bladder discomfort. When there is less bladder symptoms and more pain, it is sometimes referred to as Painful Bladder Syndrome (PBS). IC/PBS are not contracted nor inherited. Although postulated to be secondary to defects in the lining of the bladder wall, the mechanism by which this develops is not understood.
Pelvic Floor Dysfunction (PFD) is typically associated with spasm of the pelvic muscles and resultant bladder symptoms, bowel symptoms, and or pain. PFD may be caused by movement of the SI joint and or increased tone of the piriformis muscle. High impact activities, exercise, and pelvic trauma may all contribute to the development of PFD. Other causes of CPP such as endometriosis are evaluated and treated by general gynecologists.
SI Joint Dysfuntion: The SI joint joins your sacrum and your ileums. Unlike other joints, it is designed to be relatively motionless, moving less than 2 mm with normal activity. Multiple factors including childbirth and a vigorous, active lifestyle can lead to increased mobility, arthritis, and misalignment of the SI joint. The SI joint is extremely pain sensitive and is supplied by spinal nerves (L2-S3). These nerves include nerves responsible muscles of the pelvis, pelvic sensation, and even bowel and bladder control. When the SI Joint becomes dysfunctional so does the pelvis. As most physicians are not familiar with SI Joint Dysfunction, it has become one of the most underdiagnosed and treated causes of pelvic pain and pelvic floor disorder.
Chronic Pelvic Pain (CPP) can be very difficult to diagnose and treat. However, what is even more difficult is living with CPP. We understand this and we are here for you. We ask that you be patient and give us a chance to make you better. Although we are typically successful in decreasing CPP, complete resolution is difficult but not impossible to achieve. We are specialists in FPMRS and are not pain management specialists. Should your pain require narcotics, we will ask a pain management specialist to manage this aspect of your care. We will work diligently to get you to a point where you no longer need such medication.
After properly identifying the root cause of your Chronic Pelvic Pain, the next step will be to select the appropriate treatment. Our goal is to get you back to feeling like yourself and we offer highly effective treatment methods that do just that. Specific treatment options will depend on the origin of your Chronic Pelvic Pain.
Treatment for CPP secondary to Vaginal Mesh
Zipper Urogynecology is a national referral center for the treatment of vaginal mesh related complications. Secondary to the exceedingly high incidence of mesh complications in Brevard county, we gained early experience with the management of these difficult to treat and debilitating complications. Each week we see and treat patients from across the United States. Chronic Pelvic Pain is the most debilitating and most difficult to treat of the mesh complications. Nonetheless, we continue to help the majority of patients sent to us with CPP following transvaginal mesh complications. We utilize a combination of robotic surgery, vaginal surgery, and physiotherapy to deal with the inflammation, scaring and contraction associated with vaginal mesh. It is important to remember that, secondary to the material properties of mesh, complications can develop many years after implantation. Please see our web pages dedicated to vaginal mesh for further education and treatment options.
Treatment for CPP secondary to PFD
The most important modality of treatment is manual therapy. Sherri Lorraine, PhD, DPT, is the director of pelvic floor physiotherapy at Zipper Urogynecology. Dr. Lorraine and her team utilize a multimodality approach to treat SI Joint Dysfuntion. You will receive manual therapy to pelvic and abdominal muscular trigger points and therapy to lengthen muscle contractures, release scars and thickened connective tissue. Your gait and posture will be assessed and bad habit contributing to PFD will be corrected. You will be trained in excercises and home therapies that may stabalize the SI joint and restore the pelvic floor to a healthy state. Unfortunately, the physiotherapy needed to achieve a good result is not readily available at most centers. Although there are many physical therapists that dabble in pelvic floor physiotherapy, you are best treated by a doctor of physical therapy who specializes in the pelvic floor. If you are unable to travel to one of our centers, we may be able to assist you in finding a specialist closer to your home.
In rare cases, when SID symptoms cannot be improved by our PT team, we work closely with carefully selected radiolists and pain management physicians who offer treatments including SI Joint Injections and Radioablation.
Treatment for CPP secondary to IC
If you are visiting with us for the evaluation and treatment of IC, the first thing we are going to do is prove that you don’t have it. IC is a diagnosis of exclusion. According to the most formalized diagnosis criteria, IC is only diagnosed after other caused of urgency, frequency, and pain are ruled out. There are many conditions that mimic the symptoms of IC. You will be thoroughly evaluated for disorders such as detrusor overactivity, pelvic floor dysfunction, chronic urinary tract infection, and inflammatory conditions such as IBS and diverticulitis. If this evaluation is negative, we may begin treatment for IC.
Although we offer many treatments for many disorders found few places in the known, we continue to require our patients to be evaluated and treated within accepted guidelines and standards. We hence comply with the AUA guidelines for the evaluation and treatment of IC. If you do not respond to a first or second line treatment for IC, you may have the opportunity to be treated with novel and or investigational therapies such as Low Level Laser Therapy.
First Line And Second Line Treatments For IC
First and foremost we will educate you about normal bladder function and provide you with information about IC. We will discuss stress management and coping techniques. Thereafter, a combination of therapies are typically initiated.
Medications including Elmiron, Vistaril, and Amitriptyline are often used in combination.
DMSO, heparin, and lidocaine may be instilled into the bladder, either alone or in combination. These are typically administered as 15 minute therapies which are repeated weekly or every other week for a series of weeks.
Manual Physical Therapy
Dr. Sherri Lorraine, our director of pelvic floor physiotherapy, will initiate manual therapy to pelvic and abdominal muscular trigger points utilize manual therapy to lengthen muscle contractures, and release scars and thickened connective tissue.
When pain symptoms are not managed by other first and second line therapies, we will work with your pain management doctor who may provide prescription analgesics.
Third, Fourth, And Fifth Line Treatments For IC
Although some of these treatments have been shown to be effective for other bladder conditions, there is very little medical evidence demonstrating efficacy for IC. Nonetheless, many patients to respond. Options include hydrodistention of the bladder, Interstim®, and Botox® bladder injection.
How About Low Level Laser Therapy?
Dr. Zipper and his partners have developed the world’s first method and device for applying Low Level Laser Therapy (LLLT) to the bladder and soft tissues of the pelvis for the treatment of pelvic pain and overactive bladder disease. This device remains in IRB approved clinical trials. The pain trials are ongoing in the Netherlands. Although preliminary results seem encouraging, this therapy remains in clinical trials and has not yet been approved for marketing by the FDA. Patients with CPP and or OAB may have the opportunity to participate in our clinical trials with LLLT.