Pharmacological treatment and regional anesthesia techniques for pain management after completion of both conservative and surgical treatment of endometriosis and pelvic adhesions in women with chronic pelvic pain as a mandated treatment strategy
More details
Hide details
Pain Clinic, Department of Anaesthesiology and Intensive Care, Medical Centre for Postgraduate Education, Warsaw, Poland
Department of Continuous Education in Anaesthesiology and Intensive Care, Medical University, Warsaw, Poland
1 st Department of Obstetrics and Gynaecology, Medical Centre for Postgraduate Education, Warsaw, Poland
Ann Agric Environ Med. 2015;22(2):353–356
Chronic pelvic pain syndrome occurs in 4–14% of women. Pain pathomechanism in this syndrome is complex, as it is common to observe the features of nociceptive, inflammatory, neuropathic and psychogenic pain. The common findings in women with pelvic pain are endometriosis and pelvic adhesions.

Aim of the study was to test the effectiveness of pharmacological treatment and regional anesthesia techniques for pain control as the next step of treatment after the lack of clinical results of surgical and pharmacological methods normally used in the management of endometriosis and pelvic adhesions.

Material and Methods:
18 women were treated between January 2010 – October 2013 in the Pain Clinic of the Department of Anaesthesiology and Intensive Care at the Centre for Postgraduate Education in Warsaw due to chronic pelvic pain syndrome related to either endometriosis or pelvic adhesions. During the previous step of management, both conservative and surgical treatments were completed without achieving satisfactory results. Initial constant pain severity was 3–9 points on the Numeric Rating Scale, while the reported paroxysmal pain level was 7–10. The pharmacological treatment implemented was based on oral gabapentinoids and antidepressants, aided by neurolytic block of ganglion of Walther, pudendal nerve blocks and topical treatment (5% lidocaine, 10% amitriptyline, 10% gabapentin).

In 17 women, a significant reduction of both constant and paroxysmal pain was achieved, of which complete and permanent cessation of pain occurred in 6 cases. One patient experienced no improvement in the severity of her symptoms.

The combination of pain management with pharmacological treatment, pudendal nerve blocks, neurolysis of ganglion impar (Walther) and topical preparations in cases of chronic pelvic pain syndrome seems to be adequate medical conduct after failed or otherwise ineffective causative therapy.

Stannard C, Kalso E, Ballatyne J. Evidence–Based Chronic Pain Management. Oxford: Blackwell Publishing, 2010.
Meltzer-Brody S, Leserman J, Zolnoun D, Steege J, Green E, Teich A. Trauma and posttraumatic stress disorder in women with chronic pelvic pain. Obstet Gynecol. 2007; 109(4): 902–908.
Latthe P, Mignini L, Gray R, Hills R, Khan K. Factors predisposing women to chronic pelvic pain: systematic review. BMJ. 2006; 332: 749–755.
Sękowska A, Malec-Milewska M. Bóle miednicy mniejszej i bóle krocza u kobiet. In: Malec-Milewska M, Woroń J (eds.). Kompendium leczenia bólu. Warsaw: Medical Education; 2012: 211–227.
Howard F. The role of laparoscopy in the chronic pelvic pain patient. Clin Obstet Gynecol. 1998; 46: 749 -766.
Fall M, Baranowski AP, Elneil S, Engeler D, Hughes J, Messelink EJ, et al. EAU guidelines on chronic pelvic pain. Eur Urol. 2010; 57: 35–48.
Mathias SD, Kuppermann M, Liberman RF, Lipschutz RC, Steege JF. Chronic pelvic pain: prevalence, health related quality of life, and economic correlates. Obstet Gynecol. 1996; 87: 321–327.
Zondervan KT, Yudkin PL, Vessey MP, Jenkinson CP, Dawes MG, Barlow DH, et al. Chronic Pelvic Pain in the community- symptoms investigations and diagnoses. Am J Obstet Gynecol. 2001; 184: 1149– 1155.
Tu CH, Niddam DM, Chao HT, Chen LF, Chen YS, Wu YT, et al. Brain morphological changes associated with cyclic menstrual pain. Pain. 2010; 150: 462–468.
As-Sanie S, Harris RE, Napadow V, Kim J, Neshewat G, Kairys A, et al. Changes in regional gray matter volume in women with chronic pelvic pain: a voxel-based morphometry study. Pain. 2012; 153: 1006–1014.
Kaya S, Hermans L, Willems T, Roussel N, Meeus M. Central sensitization in urogynecological chronic pelvic pain: a systematic literature review. Pain Physician. 2013; 16(4):291–308.
Macrae W. Chronic post-surgical pain: 10 years on. Br J Anaesth. 2008; 101: 77–86.
Foster DC, Dworkin RH, Wood RW. Effects of intradermal foot and forearm capsaicin injections in normal and vulvodynia-afflicted women. Pain. 2005; 117:128–136.
Neziri AY, Haesler S, Petersen-Felix S, Müller M, Arendt-Nielsen L, Manresa JB, et al. Generalized expansion of nociceptive reflex receptive fields in chronic pain patients. Pain. 2010; 151: 798–805.
Fauconnier A, Chapron C. Endometriosis and pelvic pain: epidemiological evidence of the relationship and implications. Hum Reprod Update. 2005; 11: 595–606.
Stratton P., Berkley K.J. Chronic pelvic pain and endometriosis: translational evidence of the relationship and implications. Hum Reprod Update. 2011; 17: 327–346.
Vercellini P, Crosignani PG, Abbiati A, Somigliana E, Vigano P, Fedele L. The effect of surgery for symptomatic endometriosis: the other side of the story. Hum Reprod Update. 2009; 15:177–188.
Steege JF, Stout AL. Resolution of chronic pelvic pain after laparoscopic mlysis of adhesions. Am J Obstet Gynecol. 1991; 165: 278–281.
Stones RW, Cheong YC, Horward F. Interventions for treating chronic pelvic pain. Cochrane Database Syst Rev. 2005; 4: CD000387 2005.
Practice Committee of the American Society for Reproductive Medicine. Treatment of pelvic pain associated with pelvic endometriosis. Fertil Steril. 2008; 90: 260–269.
Jenkins TR, Liu CY, White J. Does response to hormonal therapy predict presence or absence of endometriosis? J Minim Invasive Gynecol. 2008; 15: 82–86.
Osteen KG, Bruner-Tran KL, Eisenberg E. Reduced progesterone action during endometrial maturation: a potential risk factor for the development of endometriosis. Fertil Steril. 2005; 83: 529–537.
Słabuszewska-Jóźwiak A, Ciebiera M, Baran A, Jakiel G. The effectiveness of laparoscopic surgeries In treating infertility related to endometriosis. Ann Agric Environ Med. 2015; 22(2): 329–331.
McCleane G. Topical analgesics. Anesthesiol Clin. 2007; 25:825–839.
Vancaillie T, Eggermont J, Armstrong G, Jarvis S, Liu J, Beg N. Response to pudendal nerve block in women with pudendal neuralgia. Pain Med. 2012;13:596–603.
Rhame EE, Levey KA, Gharibo CG. Successful treatment of refractory pudendal neuralgia with pulsed radiofrequency. Pain Physician. 2009;12:633–638.
Malec-Milewska M, Horosz B, Kolęda I, Sekowska A, Kosson D, Kucia H, et al. Neurolytic block of ganglion of Walter for the management of chronic pelvic pain. Videosurg Other Mini-invas Tech. 2014 (In press).
Agarwal-Kozlowski K, Lorke DE, Habermann CR, Am Esch JS, Beck H. CT-guided blocks and neuroablation of the ganglion impar (Walther) in perineal pain: anatomy, technique, safety, and efficacy. Clin J Pain. 2009; 25:570–576.