Two resources for pelvic pain classification and treatment

European Association of Urology (EUA) has published guidelines on chronic pelvic pain with a useful classification system and suggestions for treatment. (Engeler 2010)

http://www.uroweb.org/gls/pdf/24_Chronic_Pelvic_Pain_LR%20March%2023th.pdf

o   Axis 1

§  Specific disease associated pelvic pain

§  Pelvic pain syndrome

o   Axis 2 – System

o   Axis 3 – end organ pain syndrome

o   Axis 4 - referral characteristics

o   Axis 5 – temporal characteristics

o   Axis 6 – character

o   Axis 7 – associated symptoms

o   Axis 8 – psychological symptoms

 Recent articles in the SOWH journal do a great job at framing possible origin of pelvic pain. I suggest all PT classify signs, symptoms and treatments as tissue based or centralized.  (Hilton 2011)

Acute pain / inflammation / nociceptive pain – episiotomy pain

·         Localized symptoms

·         Localized tenderness

·         Aggravating and easing factors follow common musculoskeletal pattern

·         Responds easily to mechanical treatment

 

Subacute pain / peripheral sensitization / neuropathic pain – pudendal neuralgia

·         History of trauma with poor healing

·         Adverse neural tension signs – parasthesia, itching, dysesthesia

·         Local irritation, swelling, muscle spasm

·         Hyperalgesia – dermatomal or myotomal

·         Motor weakness

·         Lack of typical response to mechanical treatment

 

Chronic pain syndrome / central sensitization / neuropathic pain – interstitial cystitis

·         Pain longer than 12 weeks

·         Pain responds to stress and anxiety

·         Disproportionate and non mechanical pain – pain increased by small movement or no movement, diffuse and bilateral pain  - Delphi survey on clinical criterion for centralized pain – strongest predictor = disproportionate and non-mechanical pain (Smart 2011)

·         Burning shooting, crushing, non-dermatomal, allodynia or hyperalgesia (painDETECT questionnaire – very good tool)

·         Multiple systems involved – sleep, bladder, bowel, muscles, joints, immune system

·         Depression, fear avoidance, catastrophization

·         Previous treatment failure 

 

Evaluation of neuropathic pain - peripheral sensitization / central sensitization (Hilton 2011)

·         There is no direct measure, indirect assessment tools only

·         Neurodynamic assessment – directly palpate the pudendal nerve and assess ability to slide within the pudendal canal

·         Peripheral temperature changes compared to core temperature

·         Decreased 2 point discrimination

·         Visible flinch response in anticipation of touch

·         Poor body awareness - decreased localization of touch

 Smart KM, et al. The discriminative validity of “nociceptive,” “peripheral neuropathic”, and “central sensitization” as mechanism-based classifications of musculoskeletal pain. Clin J Pain 2011;27(8):655-663.

Hilton S, Vandyken C. The puzzle of pelvic pain – a rehabilitation framework for balancing tissue dysfunction and central sensitization I: pain physiology and evaluation for the physical therapist.  J of Women’s health PT. 2011;35(3):103-113

Engeler D, et al Guidelines on chronic pelvic pain Eur Urol 2010;57(1):35-48