Treatment is multidisciplinary and the approach is analogous to the treatment for low back pain, often involving a team of several specialists and done in stages.
1. Pain management
The initial treatment is focused on pain control: oral analgesics (preferably non-narcotics), non-steroidal anti-inflammatory drugs (NSAIDs), and passive physical therapy with ultrasound, warm and cold soaks, and electrical stimulation.
However, the mainstay is local steroid injections targeted to several entheses using ultrasound guidance, similar to epidural steroid injections for backaches. This also helps to confirm the diagnosis. This therapy is more predictable and the response more rapid.
of the pain relieved
additional relief
relief of pain
All patients received a series of three steroid injections, two weeks apart. Steroids require at least four to six days for maximum effect, and maximum relief of pain takes two to two and a half months. For the past several years these procedures have been performed under IV sedation in the pain clinic. We are seeing improved compliance, and patients rarely refuse the second and third sets of injections. Sedation also results in easier and more precise injections, even in obese and muscular patients.
NSAIDs were offered to patients who refused injections. Response to these drugs was not satisfactory; only 8% to 10% of patients responded, and the response was partial and often delayed. Gabapentin and pregabalin are helpful in some patients.
2. Physical therapy
Initially, passive therapy with ultrasound, warm/cold soaks and electrical stimulation is administered. As the pain improves, exercises are started to prevent recurrence. The author refers to physical therapists who specialize in pelvic therapies. Physical therapy, including transvaginal trigger point release and massage, is more helpful after the series of steroid injections and helps to prevent recurrence. Some authors have integrated myofascial trigger point release and paradoxical relaxation training in the treatment of chronic pelvic pain.
3. Emotional and psychological support
Chronic pain, uncertainty of the diagnosis and multiple referrals have a tremendous psychological effect. Most of these patients are depressed and dependent on pain medications; thus judicious use of antidepressants can be beneficial, as well as professional help from psychologists or psychiatrists.