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P E LV I C PA I N M A NAG E M E N T
P E LV I C PA I N M A NAG E M E N T

EDITED BY

A S S I A T. VA L OV S K A , M D
Director, Pelvic Pain Center
Brigham and Women’s Hospital
Instructor in Anesthesia and Pain Management
Harvard Medical School
Boston, Massachusetts

1
 1
Oxford University Press is a department of the University of Oxford. It furthers
the University’s objective of excellence in research, scholarship, and education
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Press in the UK and certain other countries.

Published in the United States of America by Oxford University Press

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© Oxford University Press 2016

All rights reserved. No part of this publication may be reproduced, stored in

a retrieval system, or transmitted, in any form or by any means, without the
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address above.

You must not circulate this work in any other form

and you must impose this same condition on any acquirer.

Library of Congress Cataloging-​in-​Publication Data

Pelvic pain management / edited by Assia T. Valovska.
p. ; cm.
Includes bibliographical references and index.
ISBN 978–0–19–939303–9 (alk. paper)
I. Valovska, Assia T., editor.
[DNLM: 1. Pelvic Pain—therapy. 2. Chronic Pain—therapy.
3. Physical Therapy Modalities. WP 155]
RD549
617.5′5—dc23
2015036946

1 3 5 7 9 8 6 4 2
Printed by Webcom, Canada

This material is not intended to be, and should not be considered, a substitute for medical or other
profes­sional advice. Treatment for the conditions described in this material is highly dependent on the
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 CONTENTS

Preface vii 9. Functional Abdominal Pain Syndrome 76

Acknowledgments ix Jason Litt, Karina Gritsenko,
Contributors xi and Yury Khelemsky
10. Pudendal Neuralgia 82
1. Pelvic Pain Management: Michael Hibner
An Introduction 1 and Mario E. Castellanos
Louis Saddic, Richard D. Urman,
11. Incapacitating Pelvic Congestion
and Assia T. Valovska
Syndrome 96
2. Anatomy of the Abdomen and Pelvis 6 Neeraj Rastogi, Nii-​Kabu Kabutey,
Mona K. Patel and Assia T. Valovska Gillian Lieberman, and
Ducksoo Kim
3. Pain Mechanisms in Chronic Pelvic Pain 13
Juan Diego Villegas-​Echeverri, 12. Male Pelvic Pain 107
José Duván López-​Jaramillo, Michel A. Pontari
Ana Lucía Herrera-​Betancourt, and Emmanuel A. Ghormoz
Jorge Darío López-​Isanoa, and
13. Musculoskeletal Causes of Chronic
María del Pilar Pardo-​Bustamante
Pelvic Pain 117
4. Multidisciplinary Approaches to Pelvic Chris R. Abrecht, Lesley E. Bobb,
Pain Treatment: A Physical Therapist’s and Assia T. Valovska
Perspective 28
14. Pelvic Cancer Pain 124
Stephanie Prendergast
Jonathan Snitzer, Yury Khelemsky,
5. Pharmacological Management and Karina Gritsenko
of Pelvic Pain 34
15. Surgical Treatment of Pelvic Pain 134
Michele L. Matthews and
Vesela Kovacheva Adam R. Duke
and Karen Wang
6. Dyspareunia and Vulvodynia 44
16. Chronic Pelvic Pain and Psychological
Adeoti Oshinowo, Alin Ionescu,
Disorders 143
Tanya E. Anim, and Georgine Lamvu
Mohammed Issa and Raheel Bengali
7. Endometriosis: Treatment and Pain
Management 58 17. The Physical Therapy Approach
to Pelvic Pain: Evaluation 149
Adham Zayed, Karina Gritsenko,
and Yury Khelemsky Lila Bartkowski-​Abbate
and Amy Stein
8. Painful Bladder Syndrome and
Interstitial Cystitis in Women 64
Sybil G. Dessie and Eman Elkadry
vi Contents

18. The Physical Therapy Approach 20. Sample Clinical Cases 190
to Pelvic Pain: Treatment 167 Bethany Skinner, Nichole
Amy Stein Mahnert, and Courtney S. Lim
19. Implantable Devices for the Treatment
of Pelvic Pain 180 Index 207
Chris R. Abrecht, Alison M.
Weisheipl, and Assia T. Valovska
 P R E FA C E

This book was inspired by my patients and writ- Usually, the patients are evaluated by phy-
ten by leading experts in the field of pelvic pain. sicians across multiple specialties—​ gynecology,
The demand to understand pelvic pain is driven urology, gastroenterology, surgery, and more. Not
by the perplexity of their suffering. Over the years uncommonly, these people are subjected to inva-
working as a pain physician, I realized that I need sive procedures that do not provide pain relief.
knowledge that was not taught in medical school The procedural ineffectiveness and the increasing
or during the pain fellowship; even my teachers demand for opioids prompt a last-​resort referral
were struggling to treat these patients. to the pain clinic. The lack of interdisciplinary
Pelvic pain is a complex disease. The abun- care coordination and management is a common
dance of organs, nerves, vessels, and muscles in the cause for failed treatment.
abdomen and pelvis ensure that the clinical picture The emerging need for comprehensive educa-
is confusing, misleading, and often presented with tion across the specialties about the complexity
poorly defined symptoms. Involvement of distant of pelvic pain causes, pathology, evaluation, and
organs as well as the musculo-​skeletal system fur- treatment strategies is the driving force behind
ther adds to the diagnostic dilemma. this book. The goal is to provide the healthcare
Pelvic pain touches every aspect of the patient’s practitioner with background knowledge as well
life—​physically, emotionally, socially, professionally skills to diagnose the origins of pelvic pain, to
and sexually. The exhausting experience is a cause perform a proper physical examination, and to
for low self-​ esteem, depression, anxiety, which develop a treatment plan with emphasis on mul-
further worsen the pain. tidisciplinary management.
Misunderstanding the complicated aspects and
challenges of treating pelvic pain are the emerging Assia T. Valovska, MD
reason for delayed or improper diagnosis. Boston, Massachusetts
 AC K N OW L E D G M E N T S

I am eternally thankful to my patients for mak- To my husband: You are always next to me,
ing me who I am. My determination to never lending a shoulder to lean on. I love you dearly
give up the fight is fuelled by your resilience. for that.
My deep appreciation for my colleagues from To my beautiful daughters and budding
the Pain Management Center at Brigham and physicians: Thank you for growing smart and
Women’s Hospital, Boston, MA—big thank you strong. Study hard, the rest is going to come on
for your support and understanding. its own!
What would I do without the nursing team To mom and dad: Thank you for tirelessly
“Tenderloin” on “Pearl Thursday”? Your tireless helping me achieve my dreams.
work and deep compassion lighten my days. I
consider you my biggest friends and supporters. Assia T. Valovska, MD
Thank you for putting up with my long hours.
Keep wearing those pearls!
 C O N T R I BU TO R S

Chris R. Abrecht, MD Sybil G. Dessie, MD

Resident Division of Urogynecology
Department of Anesthesiology, Perioperative, Mid-​Atlantic Permanente Medical Group
and Pain Medicine Upper Marlboro, Maryland
Brigham and Women’s Hospital
Boston, Massachusetts Adam R. Duke, MD
Fellow
Tanya E. Anim, MD Department of Obstetrics and Gynecology
Assistant Clinical Professor Division of Minimally Invasive Gynecologic
Family Medicine Residency Program Surgery
University of Florida University of Tennessee College of Medicine
Gainesville, Florida Chattanooga, Tennessee

Lila Bartkowski-​Abbate, PT, DPT, MS, Eman Elkadry, MD

OCS, WCS, PRPC Clinical Instructor
New Dimensions Physical Therapy, PLLC Harvard Medical School
Manhasset, New York Fellowship Director, Female Pelvic Medicine
and Reconstructive Surgery
Raheel Bengali, MD Department of OB/​GYN
Fellow, Interventional Pain Management Mount Auburn Hospital
Harvard Medical School Boston, Massachusetts
Brigham and Women’s Hospital
Boston, Massachusetts Emmanuel A. Ghormoz
Temple University School of Medicine
Lesley E. Bobb, MD Philadelphia, Pennsylvania
Resident
Department of Anesthesiology, Perioperative, Karina Gritsenko, MD
and Pain Management Co-Director Resident Rotations: Acute Pain,
Brigham and Women’s Hospital Regional, Chronic Pain
Boston, Massachusetts Co-Associate Regional Fellowship Director
Assistant Professor of Anesthesiology, Family &
Mario E. Castellanos, MD, FACOG Social Medicine, and Physical Medicine and
Creighton University School of Medicine Rehabilitation
Assistant of Obstetrics and Gynecology Montefiore Medical Center/Albert Einstein
St. Joseph’s Hospital and Medical Center College of Medicine
Division of Gynecologic Surgery Bronx, New York
Phoenix, Arizona
xii Contributors

Ana Lucía Herrera-​Betancourt, MD, FACOG Vesela Kovacheva, MD, PhD

Advanced Laparoscopy and Pelvic Pain Instructor in Anesthesia
Unit—​Algia Harvard Medical School
Clínica Comfamiliar Attending Anesthesiologist
Pereira, Colombia Department of Anesthesiology, Perioperative
and Pain Medicine
Michael Hibner, MD, PhD, FACOG, FACS Brigham and Women’s Hospital
Creighton University School of Medicine Boston, Massachusetts
Professor of Obstetrics and Gynecology
St. Joseph’s Hospital and Medical Center Georgine Lamvu, MD, MPH
Division of Gynecologic Surgery Gynecologic Surgery and Pain Specialist
Phoenix, Arizona Department of Surgery, Veterans
Administration (VA) Medical Center
Alin Ionescu, MD University of Central Florida
Division of Advanced and Minimally Invasive Orlando, Florida
Gynecology
Department of Graduate Medical Education Gillian Lieberman, MD
Florida Hospital Director of Radiologic Education
Orlando, Florida Harvard Medical School
Beth Israel Deaconess Medical Center
Mohammed Issa, MD Boston, Massachusetts
Harvard Medical School
Clinical Instructor Courtney S. Lim, MD
Brigham and Women’s Hospital Departments Clinical Assistant Professor
of Anesthesiology and Psychiatry Department of Obstetrics and Gynecology
Boston, Massachusetts University of Michigan
Ann Arbor, Michigan
Nii-​Kabu Kabutey, MD
Department of Vascular and Endovascular Jason Litt, MD
Surgery Fellow, Pain Medicine
University of California, Irvine Department of Anesthesiology
UC Irvine Medical Center Division of Pain Medicine
Irvine, California Icahn School of Medicine at Mount Sinai
New York, New York
Yury Khelemsky, MD
Assistant Professor Jorge Darío López-​Isanoa, MD
Program Director, Pain Medicine Fellowship Advanced Laparoscopy and Pelvic Pain
Department of Anesthesiology Unit—​Algia
Division of Pain Medicine Clínica Comfamiliar
Icahn School of Medicine at Mount Sinai Pereira, Colombia
New York, New York
José Duván López-​Jaramillo, MD
Ducksoo Kim, MD Advanced Laparoscopy and Pelvic Pain
Professor of Radiology Unit—​Algia
Boston University School of Medicine Clínica Comfamiliar
Boston Medical Center Pereira, Colombia
Director of Cardiovascular and Interventional
Radiology Nichole Mahnert, MD
Boston VA HealthCare Kaiser Permanente Northern California
Boston, Massachusetts Associate Physician
Obstetrics and Gynecology
Walnut Creek, California
 Contributors xiii

Michele L. Matthews, PharmD, CPE, BCACP Jonathan Snitzer, MD

Associate Professor of Pharmacy Practice Fellow, Pain Medicine
Massachusetts College of Pharmacy and Health Department of Anesthesiology
Sciences University Division of Pain Medicine
Advanced Pharmacist Practitioner in Pain Icahn School of Medicine at Mount Sinai
Management New York, New York
Brigham and Women’s Hospital
Boston, Massachusetts Amy Stein, MPT, DPT, BCB-​PMD, IF
Owner/​Founder
Adeoti Oshinowo, MD, MPH Beyond Basics Physical Therapy, LLC
Gynecology Specialists of Garland New York, New York
Baylor Medical Center
Garland, Texas Richard D. Urman, MD
Associate Professor of Anesthesia
María del Pilar Pardo-​Bustamante, MD Harvard Medical School
Advanced Laparoscopy and Pelvic Pain Brigham and Women’s Hospital
Unit—​Algia Boston, Massachusetts
Clínica Comfamiliar
Pereira, Colombia Juan Diego Villegas-​Echeverri, MD, FACOG
Advanced Laparoscopy and Pelvic Pain
Mona K. Patel, MD Unit—​Algia
Interventional Pain Fellow Clínica Comfamiliar
Department of Anesthesiology, Pain and Pereira, Colombia
Perioperative Medicine
Brigham and Women’s Hospital Karen Wang, MD
Boston, Massachusetts Instructor
Associate Director MIGS
Michel A. Pontari, MD Fellowship Director
Temple University School of Medicine Brigham and Women’s Hospital
Philadelphia, Pennsylvania Boston, Massachusetts

Stephanie Prendergast, MPT Alison M. Weisheipl, MD

Pelvic Health and Rehabilitation Center Instructor in Anesthesia and Pain Management
Los Angeles, California Department of Anesthesiology, Perioperative
and Pain Medicine
Neeraj Rastogi, MD Harvard Medical School
Department of Vascular and Interventional Brigham and Women’s Hospital
Radiology Boston, Massachusetts
University of Massachusetts Medical School
Worcester, Massachusetts Adham Zayed, MD
Fellow, Pain Medicine
Louis Saddic, MD, PhD Department of Anesthesiology
Department of Anesthesiology Division of Pain Medicine
Pain and Perioperative Medicine Icahn School of Medicine at Mount Sinai
Brigham and Women’s Hospital New York, New York
Boston, Massachusetts

Bethany Skinner, MD
Department of Obstetrics and Gynecology
University of Michigan
Ann Arbor, Michigan
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