Generic treatment options

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Because many urogenital pain syndromes are poorly understood, generic treatment options may be considered. These will be most effective for neuropathic conditions with or without central sensitiza-tion and muscle spasm, trigger points or hyperalgesia.

Neuropathic pain therapy

Chong & Hester [61] have summarized the current knowledge in relation to the role of neuropathic analgesics in urogenital pain.

Tricyclic and tetracyclic antidepressant drugs may have a role if the clinical presentation suggests pain of neuropathic origin. The best evidence is for amitriptyline. SSRIs and SNRIs may have a role. The best evidence in neuropathic pain is for venlafax-ine (but this has cardiac side effects) and duloxetine (which may also reduce stress incontinence).

Antiepileptic drugs have become very popular and several studies have suggested that gabapentin and pregabalin may have a role in urogenital pain. Other antiepileptics may be considered.

Opioids should be considered providing appropriate precautions are undertaken - see above.

Differential nerve blocks

Very little has been published on the therapeutic role of differential nerve blocks in urogenital pain [62]. However, it is clear that they may have a diagnostic role [63] as well as a possible therapeutic role. The evidence for a therapeutic role is often indirect and draws upon the evidence from pain perceived at other sites.

A comprehensive understanding of the anatomy is essential to be able to diagnose specific nerve involvement and access the nerves in a safe manner. The sympathetic, parasympathetic and somatic nerves can be blocked separately. Using appropriate imaging and neurotracing techniques allows nerves to be identified sequentially. For instance, in the region of the piri-formis, the sciatic nerve, posterior femoral cutaneous nerve and its perineal nerve, inferior gluteal nerve, the nerve to obturator internus and the pudendal nerve can be separated out. A lot of attention has been paid to blocking these posterior nerves recently as well as the anterior nerves such as the ilio-inguinal, iliohypogastric and genitofemoral nerves. In our clinic, we now have to assess many more patients with nerve compression in the groin, buttock region and perineum than was done a few years ago. Some patients do gain long-term benefit from injections occasionally combined with pulsed radiofrequency neuromodulation while others are referred on for peripheral nerve surgery.

Trigger point treatments

There is no doubt that the muscles of the pelvis can develop trigger points similar to striated muscles at other sites with referred pain. The conditions seen may manifest as one or two trigger points with referred pain

Box 14.1 Treatment options

Condition

Intervention

Interventions supported by evidence Prostate pain syndrome

a Blockers NSAIDs

Biofeedback and muscle-based therapies

Bladder pain syndrome

Hydroxyzine

Amitriptyline

PPS oral/intravesicular

Intravesicular dimethyl sulfoxide

Intravesicular vallinoids (contradictory results and side effects result in this treatment not having a high recommendation) Transurethral resection of Hunner's lesion Psychology

Muscle hyperalgesia

Relaxation+/-biofeedback+/-physical therapy (mainly male pelvic pain) Multidisciplinary pain management (for well-being/quality of life)

Commonly used interventions currently unproven Prostate pain syndrome Muscle relaxants

Antimicrobial therapy (in certain cases where response to trial occurs, quinolones probably best)

Opioids (as part of multimodal therapy for treatment-refractory pain in collaboration with pain clinics)

5-a-Reductase inhibitors (if benign prostatic hyperplasia is present)

Bladder pain syndrome

Analgesics

Intravesicular hyaluronic acid

Intravesicular chondroitin sulfate

Nerve blockade

Bladder training

Physiotherapy

Acupuncture

Bladder resection and other surgery (for small-volume bladders, recurrent infection, reflux)

Peripheral neuralgia in pelvic pain

Nerve blocks

Tricyclic antidepressants

Anticonvulsants

General treatments

Paracetamol NSAIDs

Tricyclic antidepressants Anticonvulsants

Interventions refuted by evidence Prostate pain syndrome Bladder pain syndrome

Antimicrobial therapy (in certain cases where no response to trial occurs) Bladder distension

or as a more complex regional condition with central changes resulting in widespread muscle hyperalgesia and visceral dysfunction.

As with any other trigger point pathology, the patient needs to be considered as a whole. In particular, the core muscles external to the pelvis may need addressing, e.g., paraspinal, gluteal and anterior abdominal wall muscles. The adductors and iliopsoas also need to be assessed and managed. Within the pelvis muscles such as coccygeus, iliococcygeus and pub-ococcygeus/rectalis may have trigger points, as may the piriformis and obturator internus muscles which span from the pelvis to the hip. The ischiocavernosus and bulbocavernosus may also be involved.

All these muscles can be reached for injection with appropriate imaging. Once more, the research in this field is minimal. However, evidence from other areas suggests that injecting, particularly if combined with postural work, stretching and pacing, may benefit these patients. We have a number of patients in whom botulinium toxin injections into some of these deeper pelvic muscles under CT guidance has given a significant response where other treatments have failed.

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