refractory chronic pelvic pain

[244913]

This is an issue my health system is struggling with. These patients drive me crazy. I taper off all opioids or recommend rotation to safer alternatives as a last resort (tramadol, butrans). I maximize neuropathics, send for pelvic floor therapy, pain psych.

I don't like to touch these patients with needles. I don't stim them or pump them.

Does anyone have any good advice or general approach to this extremely difficult cohort that is backed by literature?

- ex 61N

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[101N]

Dan Clauw works with a guy in MI who treats a lot of these. I’ll find him.

Functional somatic syndromes: sensitivities and specificities of self-reports of physician diagnosis. - PubMed - NCBI


Department of Medicine and of Epidemiology, University of Maryland School of Medicine, Baltimore, MD 21201, USA. [email protected]

 

[Orin]

This is an issue my health system is struggling with. These patients drive me crazy. I taper off all opioids or recommend rotation to safer alternatives as a last resort (tramadol, butrans). I maximize neuropathics, send for pelvic floor therapy, pain psych.

I don't like to touch these patients with needles. I don't stim them or pump them.

Does anyone have any good advice or general approach to this extremely difficult cohort that is backed by literature?

- ex 61N

What type of pelvic pain are we talking about here? It's such a wide variety of disease states in such a stigmatized body system. Are you struggling with endometriosis or post-prostatectomy pain?

I do agree with the above but I do offer interventions for those folks in addition to doing the simpler stuff. A lot of these are pelvic pains are similar to nerve entrapment or CRPS like states that respond well to nerve/sympathetic blocks, with neuromodulation down the road PRN, if you're willing to take the associated risk with that complex patient.

Still, if you could better define the cohort, we could better talk about treatment options.

 

[244913]

What type of pelvic pain are we talking about here? It's such a wide variety of disease states in such a stigmatized body system. Are you struggling with endometriosis or post-prostatectomy pain?

I do agree with the above but I do offer interventions for those folks in addition to doing the simpler stuff. A lot of these are pelvic pains are similar to nerve entrapment or CRPS like states that respond well to nerve/sympathetic blocks, with neuromodulation down the road PRN, if you're willing to take the associated risk with that complex patient.

Still, if you could better define the cohort, we could better talk about treatment options.

To clarify- the lion's share of these in my practice have no discernible organic pathology, have already been tried on OCP's and other medications and are Medicaid/Indigent with co-morbid psych issues.

Therefore, I do not approach them with needles.

We did a lot of superior hypogastric plexus blocks/interventional approaches in fellowship but I generally found the success of the intervention to be directly proportional to the MME dose.

Thanks again

- ex 61N

 

[lobelsteve]

Nothing but FMS/P or migraines on the wrong end.

 

[Orin]

To clarify- the lion's share of these in my practice have no discernible organic pathology, have already been tried on OCP's and other medications and are Medicaid/Indigent with co-morbid psych issues.

So mostly poor women with vague pelvic pain that qualifies as either IBS, endometriosis, abdominal migraines, etc depending on which specialist first saw the patient, but they really have fibromyalgia complicated by a history of physical and/or mental trauma? It's a real difficult population as by the time you see them they've been worked over a lot.

I agree with avoiding opioids. I primarily focus on antidepressants, antiepileptics, sympatholytics such as clonidine/propranolol, topical agents for mucous membrane based pain, muscle relaxers, etc. It's all a crap shoot though and there's no magic better than the patient/provider relationship.

For post-surgical pelvic pain or even some segment of the catch-all problems such as interstitial cystitis or loin pain hematuria syndrome, neuromodulation may have some benefit as those are really more like CRPS of the visceral structures and could be treated similarly, although with your payor mix that doesn't sound lucrative.

An insight one of my attendings shared is that co-morbid psych issues should be present with severe pelvic pain, as that system is an innate and integral part of people's psyche/life. You can choose to not use the MSK system, but peeing and pooping are essential to life, so the suffering is greater

 

[painfree23]

Pelvic pain is one of the most vague things to treat. Lot of people

So mostly poor women with vague pelvic pain that qualifies as either IBS, endometriosis, abdominal migraines, etc depending on which specialist first saw the patient, but they really have fibromyalgia complicated by a history of physical and/or mental trauma? It's a real difficult population as by the time you see them they've been worked over a lot.

I agree with avoiding opioids. I primarily focus on antidepressants, antiepileptics, sympatholytics such as clonidine/propranolol, topical agents for mucous membrane based pain, muscle relaxers, etc. It's all a crap shoot though and there's no magic better than the patient/provider relationship.

For post-surgical pelvic pain or even some segment of the catch-all problems such as interstitial cystitis or loin pain hematuria syndrome, neuromodulation may have some benefit as those are really more like CRPS of the visceral structures and could be treated similarly, although with your payor mix that doesn't sound lucrative.

An insight one of my attendings shared is that co-morbid psych issues should be present with severe pelvic pain, as that system is an innate and integral part of people's psyche/life. You can choose to not use the MSK system, but peeing and pooping are essential to life, so the suffering is greater

how do you get insurance to approve a stim for pelvic pain? had one rejected the other day by bcbs b/c pt had ''not had back surgery, crps or peripheral vascular disease''...did a peer to peer and they said no.

 

[Orin]

Most of the cases I do for pelvic pain are with Interstim which is on label for the functional issues that are associated with pelvic pain such as urinary urgency/frequency.

In general though, if the pain gets better from a sympathetic nerve block, it's a sympathetically mediated pain state similar to CRPS that should be responsive to stimulation. It's just CRPS of a visceral organ which presents differently than an extremity.

 

[244913]

Most of the cases I do for pelvic pain are with Interstim which is on label for the functional issues that are associated with pelvic pain such as urinary urgency/frequency.

In general though, if the pain gets better from a sympathetic nerve block, it's a sympathetically mediated pain state similar to CRPS that should be responsive to stimulation. It's just CRPS of a visceral organ which presents differently than an extremity.

What percentage of your interstim candidates are on opioids? What percentage get off completely after interstim?

- ex 61N

 

[Orin]

What percentage of your interstim candidates are on opioids? What percentage get off completely after interstim?

Interstim and pelvic pain is a small part of my small practice, but my general philosophy is to minimize systemic opioids in everyone. If they don't have acute on chronic mechanisms, such as an active tumor, I don't see a significant benefit for opioids for urinary or GI mediated pains other than helping folks dissociate.

If they are safe from an abuse/diversion and medical comorbidity perspective to stay on it, I use the CDC cutoffs for non-malignant pelvic pain with a preference towards atypical or partial agonist agents along with adjuvants, as long as there is verifiable benefit. If they want to do an injection to assess benefit, they can stay stable if it's within the limits. If they want to do a trial, they've got to be within the limits and I use the daily MME in addition to the functional and self reporting as an indicator for success for implant.

I understand your concerns as I see a lot of providers in the local community that appear to write opioids as a carrot for interventions. I try to use the interventions as a tool to get patients off the stuff but you have to get the patient to buy into that, as they've generally been mutually abused by the system. An injection can get that buy in and keep them from ending up at the guy down the street who'll double their MMEs in a heartbeat. You do have to do a lot of hand holding with the male/female pelvic pain population as they're generally very somatic hypervigilant types, so I am finding ,many other providers don't even bother offering therapies that may help due to the patient's need to get validation/attention/interaction.

Still, pills/patches/films/etc are easier/faster/simpler and a known evil to them, so I can't say I would do it differently if I were a lay person.

If it's your health system that has a problem, a focused nurse navigator/psychology team for that patient population as they might do for cancer support would probably help guide them through the system, and ideally have the time to give them some attention/discussion.