My Treatment: Pelvic Pain - Treatment Options: Medications

Pelvic Pain Medications

Pain medication given to patients with chronic pain has been standardized by the World Health Organization guidelines for pain control.

Anti-Inflammatory
For mild pain, the recommendation includes the use of acetaminophen or a nonsteroidal anti-inflammatory agent (ibuprofen, naproxen sodium).

Opioids
Opioids are reserved for patients who do not have pain relief from initial therapy. For patients with unresolved chronic pain, the use of long-acting opioids, including methadone, have proven very effective.¹ Providing long-term opioids to patients with chronic pelvic pain is a controversial topic. For the most part, physicians in multiple specialties in all regions of the United States have little concern about tolerance, dependence or addiction when prescribing opioids to treat chronic pain. The doctor must be aware, however, that prior addiction and some aspect of sexual abuse are prevalent in the chronic pelvic pain population. Doctors should use an informed consent as it allows these patients to autonomously choose to accept the risk of addiction and accept responsibility to be aware of the increased possibility of dependence. This allows for the sharing of responsibility and provides patients with self-confidence.³

Anti-depressants
Tricyclic antidepressants are effective as an additional therapy, especially given the high prevalence of depression in chronic pelvic pain patients. Medications that are typically used are imipramine, amytriptiline, or doxepin. These medications have been shown to improve pain tolerance, restore normal sleep, and help reduce depression.⁴ Amytriptyline has been shown to be effective in increasing the patients' activity level and reducing the intensity of pain.⁵

Many doctors are combining the tricyclic anti-depressants with the newer anti-depressant medications, called selective serotonin reuptake inhibitors (SSRIs). The tricyclic medications are being used at smaller doses, helping relieve pain but limiting the side effects, while the SSRIs are helping with depression. This form of treatment has been seen to be extremely effective with patients with chronic pelvic pain and interstitial cystitis. Anti-depressants have been shown to be extremely effective in the treatment of patients who have psychogenic pain or somatoform pain disorder by reducing pain when compared with placebo.⁶

Anti-convulsants
Anticonvulsants have proven effective in the treatment of post-herpetic or pudendal neuralgia. Gabapentin has proven to be beneficial for the use of relieving burning or lancing pain as seen with interstitial cystitis.⁷ Pregabalin is related to gabapentin and is approved to treat neuropathic pain, specifically diabetic peripheral neuropathy and postherpetic neuralgia. It may have potential for other chronic pain disorders.

Other medications
There are many medications that are effective when they act with other medications, causing a synergistic effect. Hydroxyzine may have an additive effect with opioids. Clonidine has been shown to have a synergistic effect with morphine.⁸ It has also proven effective in treating proctalgia fugax (painful muscle spasm of the rectum).⁹

The above medications can be used for any cause of chronic pelvic pain of unknown origin. There are some medications that are effective in the use of a particular cause of the pelvic pain.

The use of pentosan polysulfate sodium has been hypothesized to help increase the repair of the damaged bladder mucosa resulting in decreased inflammation and possible pain. It has shown a 28% to 32% improvement of symptoms.¹⁰ Pentosan polysulfate sodium has been shown to control pain and urination frequency and urgency.¹¹

Medications for Irritable Bowel Syndrome
Patients have seen improvement with tricyclic antidepressants, anti-cholinergics (dicyclomine hydrochloride, hyoscyamine sulfate) for irritable bowel syndrome.¹² Daily use of fiber — if used religiously — is effective in significantly relieving symptoms. It is effective in increasing stool bulk, and water content and decreases transit time, decreasing pain and constipation and providing for more formed, regular bowel movements.¹³

Hormones
Controlling the menstrual cycle pain through the use of hormones, such as birth control pills, continuous progestogens, or a GnRH agonist, may help IC, endometriosis, and pelvic congestion syndrome. Hormones are usually chosen when NSAIDS (non-steroidal anti-inflammatory drugs) have failed in decreasing discomfort. The use of GnRH agonists is an effective approach to providing relief for patients with chronic pelvic pain and may be useful in clinical diagnosis of endometriosis.¹⁴

References:

Garrido MJ, Troconiz. Methadone: a review of its pharmacokinetics/ pharmacodynamics properties. J Pharmacol Toxicol 1999;42: 61-66.

Turk DC, Brody MC, Okifuji EA. Physicians' attitudes and practices regarding the long-term prescribing of opioids for non-cancer pain. Pain 1994;59(2):201-208.

Cohen MJM, Jasser S, Herron P, Margolis C. Ethical perspectives: opioid treatment of chronic pain in the context of addiction. Clin J of Pain 2002;18(4):s99-s107.

Berlin EV. Imipramine in the treatment of chronic pelvic pain. Psychosomatics 1986;27:294-297; Kvinesdal B, Molin J, Froland A. Imipramine treatment of painful diabetic neuropathy. JAMA 1984;251:1727-1730; Zitman, FG, Linssen ACG, Edelbroek PM, Stijnen T. Low dose amitriptyline in chronic pain: The gain is modest. Pain 1990;42:35-42.

Pilowsky I, Barrow CG. A controlled study of psychotherapy and amitriptyline used individually and in combination in the treatment of chronic intractable, psychogenic pain. Pain 1990;40(1):3-19.

Fishbain, DA, Cutler RB, Rosomoff HL, Rosomoff R. Do antidepressants have an analgesic effect in psychogenic pain and somatoform pain disorder? A meta-analysis. Pschosomatic Medicine 1998;60(4):503-509.

Sasaki K, Smith CP, Chuang YC, et al. Oral gabapentin (Neurontin) treatment of refractory genitourinary tract pain. Tech Urol 2001;7:47-49.

Cousins M, Power I. Acute and postoperative pain. In: Wall PD, Melzack R, eds. Textbook of Pain, 4th ed. Edinburgh: Churchill Livingstone, 1999: 447-491.

Moldwin RM, Sant GR, Interstitial cystitis: a pathophysiology and treatment update. Clin Obstet Gynecol 2002; 45:259-272; Parsons CL, Benson G, Childs SJ, et al. A quantitatively controlled method to study prospectively interstitial cystitis and demonstrate the efficacy of pentosan polysulfate. J Urol 1993; 150:845-848.

1Hwang P, Auclair B, Beechinor D, Diment M, Einarson TR. Efficacy of pentosan polysulfate in the treatment of interstitial cystitis: a metanalysis. Urology 1997;50:39-43.

Horwitz BJ, Fisher RS. The irritable bowel syndrome. N Engl J Med 2001; 344: 1846-1850.

Drossman DA, Thompson WG. The irritable bowel syndrome: Review and a graduate multicomponent treatment approach. Ann Intern Med 1992;116:1009-1016.

Ling FW. Randomized controlled trial of depot leuprolide in patients with chronic pelvic pain and clinically suspected endometriosis. Obst Gynec 1999;93:51-58.