Pelvic Pain Syndrome Affects Everyone—How Compounding Pharmacists Can Improve Outcomes
Everyone experiences acute pain at some point in their lives, whether it comes in the form of a severe headache, an excruciating toothache, a sprain, appendicitis or childbirth. But chronic pain is a different experience and it’s one that’s impossible to fathom if you’ve never been there. Any type of chronic pain, including the pain of pelvic pain syndrome, can wear people down. It can prevent them from socializing with friends and cause them to miss work. Essentially, those with chronic pain seldom go a day without suffering. As if to add insult to injury, pelvic pain is the epitome of a condition that’s poorly understood and difficult to manage. Compounding pharmacists can make a difference by offering guidance about pain relief and by simplifying the regimen with compounded options.
Pelvic Pain Syndrome Isn’t Just for Women
Chronic pelvic pain syndrome is an accepted diagnosis in women, but it suffers from a slight identity crisis in men. Pelvic pain is often used synonymously with chronic prostatitis, which is understandable since a panel from the National Institutes of Health recommended using the Chronic Prostatitis Symptom Index as the primary diagnostic tool. By comparison, the International Association for the Study of Pain (IASP) acknowledges that nonbacterial prostatitis may fall under the pelvic pain umbrella, but offers a broader definition.
Pelvic Pain in Men
According to the IASP, symptom-based evaluations suggest that chronic pelvic pain occurs in 2.7 to 6.3 percent of men.1 It may develop at any age, but young to middle-aged men are most likely to be affected. Pelvic pain in men is defined as:
- Chronic pain, pressure or discomfort localized to the pelvis, perineum or genitalia.
- Symptoms last more than three months.
- Not caused by infection, neoplasm or structural abnormality.
- Also called prostatodynia and chronic nonbacterial prostatitis.
Labeling chronic pelvic pain as prostatodynia is discouraged in current practice, notes Richard A. Watson, MD, Professor of Surgery (Urology) at the University of Medicine and Dentistry of New Jersey-New Jersey Medical School.2 Prostatodynia implies prostate involvement, while current research shows numerous extraprostatic causes of pelvic pain.
Pelvic Pain in Women
Chronic pelvic pain is more common in women, affecting about 15 percent and representing 10 percent of all referrals to gynecologists. The current definition for pelvic pain in women includes the following criteria:3
- Non-menstrual pain lasting at least six months.
- Pain localized below the umbilicus to the anatomic pelvis.
- Pain severe enough to affect quality of life.
- Pain intensity requires medical treatment.
Non-gynecologic causes are responsible for about 70 percent of cases of chronic pelvic pain in women. The current theory, which supports the use of multimodal therapy, suggests that this condition leads to central sensitization, its subsequent state of high reactivity and altered pain pathways that result in ongoing pain.
The Challenge of Diagnosing Pelvic Pain Syndrome
The etiology of pelvic pain syndrome in men and women is hard to unravel. It’s best described as a complex combination of dysfunction in one or more systems—primarily the immune, neurologic and endocrine systems—plus psychological factors. Symptom flare-ups are often associated with stress and depression. Patients often face the frustration of being told their pain is psychosomatic. But research indicates that stress and depression influence cytokine production in the pelvis, which directly exacerbates inflammation and pain.
Physicians can narrow the differential diagnosis using patient history and the description and severity of pain, but the list of possible diagnoses exceeds 60 conditions, many of which affect both sexes, from painful bladder syndrome and pelvic floor dysfunction to inflammatory diseases. When a specific cause can be targeted, it’s usually prostatitis, chronic orchialgia and prostatodynia in men. Women have many more possibilities, including vulvodynia, endometriosis and ovarian lesions. For compounding pharmacists, it’s important to know the depth of the challenge so that you can approach patients with an understanding of how difficult it is to live with chronic pain for which there are no easy answers.
Treatment Options Target Pain Relief
Treatment goals focus on getting the patient back to living life, managing pain and preventing a relapse, which often requires simultaneous pharmacological, psychological and physical therapies. With such a complex syndrome, treatment must be tailored for each individual patient—a process that’s normal operating procedure for compounding pharmacists. When you have the opportunity to counsel patients, make sure they know all the possible treatment options:
Psychological counseling: Relaxation therapy, stress management and biofeedback can reduce the frequency and severity of chronic pain.
Physical therapy: Patients can try a variety of physical therapy techniques, such as hot or cold applications, stretching exercises, ultrasound therapy, transcutaneous electrical nerve stimulation, traction and massage. Be sure patients know they can usually schedule a consultation with a physical therapist without a doctor’s referral.
- Tricyclic antidepressants—Centrally acting medications are preferred for chronic pelvic pain and tricyclic antidepressants, especially amitriptyline, are a mainstay of treatment.4 Patients start on a low dose and titrate up to limit adverse effects and improve compliance. They should reach and maintain a moderate dose for six to eight weeks before deciding the treatment isn’t working. Reach out to patients each time their dose changes to ask about side effects and to encourage them to stick with the regimen long enough to feel a difference.
- Selective serotonin reuptake inhibitors—Duloxetine relieves a variety of pain syndromes, but other SSRIs are also considered for treatment. The downside is that higher doses may be required, which increases the risk of serotonin syndrome.
- Anxiolytics—Some anxiolytics provide an analgesic effect, but with the risk of misuse, they should be limited to short-term relief of pain at night when it interferes with sleep.
- Neuroleptics—The GABA analogues gabapentin and pregabalin effectively relieve pelvic pain. They’re titrated and must be tapered off, so you’ll have more opportunities to connect with patients and monitor progress.
- Analgesics: Depending on the severity of their pain, patients may first try OTC analgesics. Acetaminophen is the first choice, followed by NSAIDs. When OTC doses are ineffective, patients may step up to prescription-strength NSAIDs.
Compounding Options to Improve Quality of Life
Compounding pharmacists offer unique advantages to all their patients, but even more so for patients struggling with complex conditions such as chronic pelvic pain syndrome. It often takes multiple medications and a lot of experimenting with doses to find the optimal pain relief for each person. Whether you offer to compound multiple meds into a single tablet or mix a dose that’s not available in prepared pharmaceuticals, don’t hesitate to talk with these patients about how you can simplify and improve their lives.
Pharmaceutica North America provides high-quality bulk APIs, including NSAIDS and tricyclic antidepressants to help patients with chronic pelvic pain. Contact us today to talk about the latest research and uses for our pharmaceutical products.
- “Male Chronic Pelvic Pain Syndrome,” 2012, http://www.iasp-pain.org/files/Content/ContentFolders/GlobalYearAgainstPain2/VisceralPainFactSheets/7-MaleCPPS.pdf ↩
- “Chronic Pelvic Pain in Men,” January 2015, http://emedicine.medscape.com/article/437745-overview ↩
- “Chronic Pelvic Pain in Women,” January 2015, http://emedicine.medscape.com/article/258334-overview ↩
- “Caring for Patients With Chronic Pelvic Pain,” January 2015, http://contemporaryobgyn.modernmedicine.com/contemporary-obgyn/news/caring-patients-chronic-pelvic-pain?page=0,0 ↩