This article is from Pain Medicine News.
Pain Physicians Find Key to Successful Treatment of Chronic Pelvic Pain
Patients with chronic pelvic pain, like 32-year-old Gladys Stone (not her real name), often are passed from family doctor to gynecologist to pain specialist to urologist to psychiatrist. Most are put on analgesics or receive cognitive-behavioral therapy without achieving any permanent pain relief.
After seeing several specialists and receiving many ineffective treatments, Ms. Stone finally found pain relief with Denniz Zolnoun, MD, director of the Vulvar Clinic, Department of Obstetrics and Gynecology at the University of North Carolina (UNC) School of Medicine in Chapel Hill.
Dr. Zolnoun, who has conducted extensive research on vulvodynia and other types of chronic pelvic pain (CPP) (see Int J Gynaecol Obstet 2011;113:225-228), may have found a successful way to treat CPP and hopes to see a significant shift in how most physicians approach the problem.
“Taking a woman and sending her to a psychiatrist to discuss her history of sexual abuse is going to work only for only about 20% of CPP patients. For the majority, sexual abuse is only a predisposing factor and a very thorough physical exam is necessary to uncover the physical abnormalities underlying their pain,” explained Dr. Zolnoun. “Unfortunately, people in most specialties do not perform such an exam, nor do they administer the therapy and follow-up that are necessary.”
Resolving Ms. Stone’s Pain
Like many CPP patients, Ms. Stone first received topical corticosteroids to treat her vulvodynia. This treatment only made the pain worse, causing skin thinning and irritation. Other patients are given an empiric antibiotic or antifungal agent, which rarely are effective.
Months later, Ms. Stone had a laparoscopy with a cystoscopy, which also did not stop the pain. Following laparoscopy with cystoscopy, patients often receive a long-term prescription for self-administered local anesthetic; this therapy is sometimes combined with an oral contraceptive or leuprolide acetate (Lupron, Abbott). In Ms. Stone’s case, she placed 1% lidocaine into her bladder via a catheter, every day for one year. The next step would have been to see a psychiatrist—since most CPP patients have a psychiatric comorbidity and about half have a history of sexual abuse—but Ms. Stone ended up in Dr. Zolnoun’s clinic first.
“I took a detailed history and gave her a thorough physical exam. I found a history of sexual abuse and some anxiety, but most importantly she had peripheral neuropathy that was affecting her bladder,” recounted Dr. Zolnoun. “So I proceeded with a nerve block—which I’ve been trained to do by the head of pain medicine at UNC, Richard Boortz-Marx, MD, who comes to my clinic regularly—and I started her on a centrally acting agent.”
Dr. Zolnoun also explained to Ms. Stone that her objective bladder symptoms were exacerbated by her heightened perception of them. [webslave's comment: this is called hyperalgesia, or sometimes allodynia] Using guided imagery and deep breathing, combined with a benzodiazepine, Ms. Stone was pain-free within 10 weeks.
A New Approach
Ms. Stone is among hundreds of patients who have been treated successfully using this multifaceted method. The team, including Drs. Zolnoun, Boortz-Marx and an obstetrician-gynecologist fellow who specializes in pelvic pain, is tracking the outcomes and noting continuous improvements.
“My and Dr. Zolnoun’s approach is that if you treat the patients and document your outcomes then the reimbursement will come … rather than doing procedures willy-nilly without a scientific approach,” Dr. Boortz-Marx told Pain Medicine News. “Our society cannot continue to afford multiple procedures that have no outcomes data aligned with them. I truly believe this collaborative approach, involving documented outcomes, will be valued and reimbursed within the next decade.”
There are only a limited number of people with Dr. Zolnoun’s breadth of expertise—and even fewer who have an active interchange with pain physicians. Dr. Zolnoun has been actively working to change this situation by lecturing and participating in workshops. For example, in July she attended a National Institutes of Health workshop on vulvodynia in which she made the case for creating discrete, evidence-based phenotypic categories in CPP. Currently, patients are given a global management approach rather than one tailored to their particular history and cluster of symptoms.
“Dr. Zolnoun and I have clinics together, and we involve a physiologic psychologist or a psychiatrist,” said Dr. Boortz-Marx. “We discuss the issues related to the pain problem. Then we talk to the patient about options. These can include a diagnostic nerve block, which may be a peripheral block or one that involves deeper structures.”
Although Drs. Boortz-Marx and Zolnoun usually find a physical cause for patients’ pain, they do not discount the role that psychiatric comorbidity and a history of sexual abuse can play. “All providers within women’s health should consider asking about sexual abuse history as part of routine care, just as it’s routine to ask about menses,” said Samantha Meltzer-Brody, MD, MPH, associate professor of psychiatry and member of the CPP team at UNC. “If a CPP patient has corresponding psychological issues, such as post-traumatic stress disorder, in addition to the chronic pain, that is going to strongly influence whether they respond to simple psychiatric interventions or whether they need more complex, multifaceted interventions” (see Obstet Gynecol 2007;109:902-908).
Physiatrist and CPP researcher Colleen Fitzgerald, MD, praises the UNC team’s work and said the Rehabilitation Institute of Chicago (RIC), where she is director of Women’s Health Rehabilitation Programs, also employs experts in many disciplines to help CPP patients heal.
“Here at the RIC we have 15 pelvic floor therapists, and we also have many physiatrists. My biggest area of interest is CPP; in fact, most of the handful of American physiatrists who specialize in CPP were trained here,” said Dr. Fitzgerald.
Dr. Fitzgerald is actively engaged in CPP research in the Multidisciplinary Approach to Chronic Pelvic Pain network, which focuses on teasing out its components and etiology. This initiative brings together researchers who have expertise in the clinical, epidemiologic and basic science approaches to CPP research. Dr. Fitzgerald is part of the team working on neuroimaging/neurobiology studies.
“If we don’t know the exact mechanisms that are causing the pain we won’t be able to relieve it. Women in pain deserve answers and it is our job to solve the problems underlying their pain,” said Dr. Fitzgerald.
—Rosemary Frei, MSc
Disclosures: Drs. Fitzgerald, Boortz-Marx and Zolnoun report no significant conflicts of interest. Dr. Meltzer-Brody receives research funding from GlaxoSmithKline.
