In our practice pudendal neuralgia is defined as pain in the area of innervation of pudendal nerve. Pudendal nerve entrapment is compression of the nerve by scar tissue, ligaments, or surgical material. Pudendal neuralgia may be caused by pudendal nerve entrapment, but other conditions described in this manual may lead to pudendal neuralgia. Diagnosis of pudendal nerve entrapment is difficult, and it is often made by exclusion of those other conditions leading to pudendal pain (pudendal neuralgia). Most patients with pudendal nerve entrapment have a traumatic event that causes the onset of pain. Pelvic MRI may be helpful in ruling out other conditions causing pain and CT-guided pudendal nerve blocks narrow down the diagnosis to the pudendal nerve. Conservative treatments include avoidance of nerve reinjury, physical therapy, nerve blocks, and oral medications such as gabapentin or pregabalin. Patients may also benefit from nerve ablation procedures (pulse radiofrequency and cryoablation) and nerve stimulators. For patients who have failed all the conservative treatments, surgical decompression is an option with good outcomes.

Patients with pelvic pain are often told that their pain is “all in their head.” In many years of seeing patients for pelvic pain I have never seen one who did not have an organic reason for pain. Often patients with chronic pain, especially pelvic pain, may develop secondary depression and anxiety but neither of these conditions alone is responsible for their pain. Patients who are unable to have intercourse because of pain fear loss of the partner and become especially anxious. Additionally, because of the very personal nature of their pain they are often not able to discuss their condition with any friends or family members. It is very important to believe that the patient’s pain is real and not voice any doubts, especially in the presence of a partner. Treatment of coexisting psychological disorders such as anxiety or depression it is very important in patients with pelvic pain.

Irritable bowel syndrome (IBS) is another condition of the “evil quadruplets.” It often coexists with endometriosis and adds to the pain of this condition. The mainstay is pain that is worsened by food and improved by defecation. It is also important to remember that IBS is diagnosed based on symptoms, and endoscopy is often performed in those patients is done to rule out any other bowel disease. This condition is best managed by a gastroenterologist but it is important to note that quite a large number of patients with this condition have spasm of pelvic floor muscles and treatment of that spasm may improve some of the IBS symptoms.

Nerve pain is more often than not a cause of pelvic pain. This is particularly true in patients in whom pain started after pelvic trauma, surgery, or vaginal delivery. Unfortunately, most of gynecologists who are often physicians of primary contact for mesh patients are not trained in recognizing and treating patients with nerve injury pain. Patients with nerve injury pain can almost always pinpoint the moment when the pain started. It is often unilateral and neuropathic in nature. Patients have a burning, tingling sensation often associated with increased sensitivity to stimuli analogous to skin pain after sunburn. Pain is often exacerbated by body movements and certain body positions. It is very important for the first provider who sees patients with pelvic pain that pain may be related to nerve injury because expeditious treatment increases the chances of recovery. It is also important to instruct patients to avoid activity that started the pain in the first place and minimize activity that exacerbates the pain. Trial of muscle relaxants, gabapentin, or pregabalin may be appropriate first treatment; however, prompt referral to physical therapy, neurology, or a specialized pelvic pain center is often necessary.

Treatment of pain caused by abdominal and pelvic adhesions is possibly one of the most controversial issues among physicians taking care of patients with pelvic pain, and science is not helpful. There are publications that show that adhesions do not cause pain and others that show they do. The same goes for usefulness of adhesiolysis to relieve that pain. This discrepancy may be due to the fact that some surgeons preform more complete adhesiolysis than others and that coexisting pain conditions may be an additional confounding factor. I believe that certain adhesions cause pain and, in many cases, adhesiolysis is helpful. Laparoscopic or robotic adhesiolysis is a preferred way because chances of recurrence of adhesions is decreased. This may be due to the fact that CO2 prevents fibroblast migration. Risks of adhesiolyis including a risk of unrecognized bowel injury have to be very clearly explained to the patient and this procedure should be performed only by a skilled surgeon.

Sexual dysfunction is present in almost every patient with chronic pelvic pain and often is a most significant problem that patients experience. This is in addition to a significant decrease of quality of life from pain that further stigmatizes those very unfortunate patients. Patients who are unable to have intercourse are often abandoned by their partners and often are not able to find new partners. Sexual dysfunction therefore has to be taken very seriously and it should be addressed with both partners. Couples should be told that cure is possible and alternatives to vaginal intercourse should be discussed. Often pelvic floor muscle spasm is responsible for pain with intercourse and treatment of that condition is discussed in Chapter 20.

Pelvic floor muscle spasm is one of the most common reason for pelvic pain, and it often coexists with other pelvic pain conditions. Oral muscle relaxants do not seem to be helpful in these patients and vaginal suppositories seem to relax muscles much better. A combination of diazepam 5 milligrams placed vaginally, baclofen 4 milligrams, and ketamine 15 milligrams used before bedtime works well on pelvic muscle spasm. The mainstay of treatment of pelvic floor muscle spasm is pelvic floor physical therapy. It is best done by Women’s Health physical therapists who are specifically trained in pelvic floor dysfunction. Patients who fail physical therapy may be candidates for injections of botulinum toxin into pelvic floor muscles.

Interstitial cystitis/bladder pain syndrome (IC/BPS) is one of the evil quadruplets – diseases coexisting with endometriosis. Etiology and even the way to obtain proper diagnosis is very debatable among providers. One of the mainstays of IC/BPS is pain with full bladder, and patients with this condition urinate often because they want to avoid pain and not because they have urgency. They also always wake up at night to urinate, so if patients do not have nocturia it almost always rules out the disease. Diagnosis of IC/BPS may be done based on the symptoms but some practitioners would use potassium sensitivity test or cystoscopy with bladder hydrodistension if necessary. Treatment consists of avoiding foods that irritate the bladder and increase the pain. Oral medications such as pentosan polysulfate sodium do not seem to be as effective. Patients with IC/BPS also very often have pelvic floor muscle spasm that may be primary to the onset of bladder pain, and treatment of this spasm may be the most effective way to treat IC/BPS. Pelvic floor physical therapy and botulinum toxin A injections to pelvic floor muscles (not bladder) may be very helpful. Cystoscopy with bladder hydrodistension seems to be more effective than other treatments for IC/BPS.

Pelvic nerve disorders are often an unrecognized cause of pelvic pain. Multiple nerves innervate the pelvis and perineum and they may get injured in surgery, childbirth, or accidents. Knowledge of pelvic dermatomes is very important to any physician taking care of patients with pelvic pain because areas of innervation often overlap. Selective pelvic nerve blocks, either ultrasound- or CT-guided, may be very helpful in properly diagnosing the affected nerve. Sensory nerves such as the ilioinguinal nerve or genitofemoral nerve can be transected as long as the patient understands that she will be permanently numb in the area of innervation of the nerve. Others such as the pudendal nerve should not be transected because of its motor component and therefore treatments described in previous chapter should be applied.

Pelvic floor assessment is probably the most important part of the physical examination in patients with chronic pelvic pain and this exam is best performed by a skilled pelvic floor physical therapist. Physicians who see a large number of patients with pelvic pain should probably partner with a physical therapist and refer those patients for assessment. Some of the red flags on the history part of the assessment for pelvic floor dysfunction are urinary hesitancy (delayed onset of urine flow when trying to urinate) and pain after intercourse, or pain with physical activity (post exertion muscle soreness). Patients with pelvic floor muscle spasms also often have discomfort and pain with use of tampons, vaginal probe ultrasound, and pelvic exam. On pelvic exam when palpating with one finger muscles may feel tight and tender, often to the point where the examiner is not able to insert one finger. The obturator internus muscle is best palpated during the pelvic exam in the lithotomy position with the patient pushing with her knee against the examiner’s external hand.

Pelvic pain is a much more common condition than perceived by the medical and general community. Because it affects the most private aspects of human life such as sexuality and reproduction, patients are not willing to discuss it with their families, friends, and loved ones. Medical providers are also very likely to dismiss the symptoms and blame it on a psychological or psychiatric condition. Chronic pelvic pain is real, it is common, and it is almost always due to some identifiable disease or injury. Patients with pelvic pain need to be heard and treated with dignity and respect, and the majority of them can be helped.

Endometriosis is the most common gynecological condition leading to pelvic pain and often it is the only one recognized by gynecologists. In many cases it coexists with pelvic floor muscle spasm, interstitial cystitis/bladder pain syndrome and irritable bowel syndrome and often all four are called “evil quadruplets.” Endometriosis can be diagnosed only surgically, and pathology confirmed tissue biopsy is by far the most accurate way of diagnosis. Unfortunately, all medical treatments of endometriosis are quite inadequate because they all rely on causing a hypoestrogenic state that only provides temporary relief of pain, and soon after medication is discontinued, symptoms return. Development of drugs addressing the cause of the disease is currently not possible because the cause of the disease is known. Multiple existing theories fail to explain all the cases, leading to the possibility that different etiologies may lead to a presence of endometrial glands and stroma in the peritoneal cavity and outside. Surgical resection of endometriosis in skilled hands is effective but patients need to be warned that disease will most likely return within a few years of initial surgery. Deep infiltrating endometriosis requires a very knowledgeable surgeon and often specialized center for treatment. Additional procedures such as presacral neurectomy, although controversial and potentially risky, may alleviate dysmenorrhea symptoms in some patients. Meticulous removal of ovarian endometriomas is a must in all infertility patients and most pelvic pain patients as simple drainage will result in almost immediate return of endometrioma.

Vulvodynia is vulvar pain caused by a variety different conditions outlined in this chapter. It is often related to skin conditions, which is very different from all the other pelvic pain conditions. Vulvodynia is therefore best addressed by vulvar specialists.

Polypropylene mesh implants have been widely used for treatment of urinary incontinence and pelvic organ prolapse. Although they have been shown to be effective in the treatment of these conditions, they also have considerable cost complications including significant and long-lasting pain. Those meshes have been allowed to the market by the FDA without proper research and recently mesh for treatment of pelvic organ prolapse has been taken off the market. In my opinion, the part of the mesh that causes pain is the part that attaches to muscles or pierces through them; therefore it is important to remove that part when treating patients with pain resulting from mesh implants. This is especially important in transobturator meshes where the groin part has to be removed. Meshes that attach to the sacrospinous ligament have a risk of injuring the pudendal nerve, and patients who have developed pain after placement of such a mesh should be treated like patients with pudendal nerve entrapment.