Contributor: Joseph Abdelmalak, MD, Department of Pain Management
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Most patients with chronic pelvic pain (CPP) stand to benefit from seeing their condition for what it really is — a chronic disease, not a symptom. So says Joseph Abdelmalak, MD, a physician in Cleveland Clinic’s Department of Pain Management with a special interest in CPP.
“Many patients come to me with deep-seated pelvic pain expecting that their pain will go away with a simple injection,” says Dr. Abdelmalak. Instead, he explains, patients are better off if they accept CPP as a condition like hypertension or diabetes that may require a long-term relationship with a physician who understands it. That is because various treatments often need to be tried, sometimes in combination. Once an effective treatment is found, it may need to be used on an ongoing basis.
“That’s the approach we use at Cleveland Clinic for patients with this complex condition whose causes often are hard to pinpoint,” Dr. Abdelmalak adds.
What is chronic pelvic pain?
Chronic pelvic pain (CPP) is defined as nonmenstrual pain in the pelvis that lasts more than three months, interferes with daily life and requires medical therapy. It is typically a deep-seated, aching pain that disrupts sleep and work. In many cases, it causes pain with sex and/or urination and leads to feelings of frequently needing to urinate. Between 70 and 80 percent of CPP cases are in women, but men can be affected too, especially if they have chronic prostatitis. Many factors can contribute to CPP, and identifying the cause(s) is often difficult. In fact, 30 to 50 percent of CPP cases are classified as having no obvious cause, which can make effective management a challenge.
Teamwork often needed
In up to half of cases, the underlying cause of CPP is not clearly identified. That makes a careful examination extremely important so that all potential factors are explored thoroughly by physicians with the right expertise.
“Depending on a patient’s symptoms and medical history, I may refer her or him to one of my colleagues in another specialty — such as urology, gynecology or gastroenterology — to look for an underlying cause of the pelvic pain,” says Dr. Abdelmalak.
Psychiatrists are among the specialists Dr. Abdelmalak consults with, as psychiatric disorders are sometimes associated with CPP.
Intensive rehab program
Some patients with CPP may be candidates for Cleveland Clinic’s Chronic Pain Rehabilitation Program, an intensive hospital-based program that runs five days a week for three weeks. Patients participate in physical, occupational and group therapies to learn to better manage their pain and they meet with a psychiatrist every day. Education is offered for family members as well. Cleveland Clinic is one of only a few health centers in the nation with a rehabilitation program of this type for patients with CPP.
Wide range of therapies available
For less severe cases or patients who cannot attend the three-week program, Dr. Abdelmalak has a range of therapies to offer. “I often start with conservative measures such as lifestyle modifications, dietary changes, exercise or pelvic floor muscle relaxation therapy taught by one of our specialized physical therapists,” he says.
He may consider medications as well, ranging from anti-inflammatory drugs to anticonvulsants to hormonal therapies. The next options are minimally invasive procedures, including various nerve blocks.
Additional options, if needed, include surgical approaches such as implanting a spinal cord stimulator, which delivers an electrical current to control the pain, or a special pump to deliver small doses of powerful opioid painkillers. Cleveland Clinic is one of only a few medical centers that use spinal cord stimulators for CPP, and results have been good in well-chosen patients.
Regardless of the therapy, treatment goals are to restore normal function, improve quality of life and prevent relapse of chronic symptoms.
“If you have deep-seated pelvic pain for more than a few months without relief, consider seeing a pain management physician,” Dr. Abdelmalak advises. “There are many options for treating CPP that your primary doctor may not be fully familiar with.”
Dr. Abdelmalak sees patients at Cleveland Clinic’s main campus and Fairview Hospital. To schedule an appointment with him, call 216.445.7370.