Anatomy, Pathophysiology and Interventional Therapies for Chronic Pelvic Pain: A Review

Abstract

Background: Chronic pelvic pain (CPP) represents a group of poorly understood disorders that are often refractory to conventional treatment. Referral to pain management typically occurs later in the continuum of care; as such, many of the injections and nerve blocks commonly prescribed for such patients are potentially limited in efficacy. While neuromodulation is conventionally considered the next algorithmic step in the treatment of chronic pain after injections fail, there is a common perception that neuromodulation is largely ineffective for CPP conditions. However, there is evidence that suggests neuromodulation may in fact be a viable treatment option for this particular patient population when utilized properly. Objectives: To provide a basic overview of the pathophysiology of CPP and the relevant neuroanatomy as it pertains to various available treatment options, as well as the techniques and potential targets for neuromodulation. Study Design: Literature review. Setting: Private practice, academic and hospital setting. Methods: A comprehensive review of the available literature was performed targeting publications focused on CPP and various techniques for utilizing neuromodulation to treat it. Results: Neuromodulation is an established treatment modalities, however its usefulness as it relates to treating CPP has typically been drawn into question. In this literature review, we discuss the efficacy of various techniques for treating CPP with neuromodulation. Limitations: Evidence to support the various treatments, while encouraging, is based on small studies and case series. Large-scale randomized, placebo-controlled clinical trials are warranted to evaluate the clinical efficacy and safety of the different treatments described, particularly neuromodulation. Conclusions: In addition to the percutaneous, injection-based treatments described herein, neuromodulation remains a plausible option for recalcitrant cases that fail to respond to more conventional means. Key words: Chronic pelvic pain, neuromodulation, spinal cord stimulation, CRPS, complex regional pain syndrome, neuropathic pain.