Brian P. Jacob, David C. Chen, Bruce Ramshaw, Shirin Towfigh (eds.) - The SAGES Manual of Groin Pain-Springer International Publishing (2016)

12. Chronic Pelvic Pain in Women
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bladder symptoms, nausea, or diarrhea to accompany severe dysmenorrhea,
and treating the latter hormonally may also improve urologic or
gastrointestinal symptoms.
Psychological Factors
Mood disorder s, a history of sexual abuse, and sexual dysfunction
are all commonly encountered in patients with pelvic pain [ 38 – 41 ]. The
careful clinician cannot ignore these important influences, but must also
tread lightly. Patients with pelvic pain are frequently accustomed to
being made to feel their symptoms lie on the first side of an artificial
psychiatric/organic divide. Asking too soon about depression, anxiety,
or whether a patient has seen a therapist can create a barrier difficult to
overcome. By its nature, sexual abuse or current sexual dysfunction may
be difficult to talk about freely in a traditional medical setting. After
establishing patient–clinician trust—not necessarily on the first visit—
the clinician can preempt apprehension with an explanation of psychological
factors having a symbiotic, rather than causal, relationship with
pelvic pain. For example, although a history of sexual abuse is more
common in patients with CPP than without, clearly not all abuse victims
develop chronic pain, and there are many women with pain and no history
of abuse. With depression, pain thresholds are lowered even in
people without chronic pain. It makes intuitive sense that struggling
with daily pain could easily lead to a depressed disposition.
Determining the cause is less important than simply treating pain and
mood symptoms to the degree that they are present. Sensitively suggesting
consideration of enlisting a therapist’s help can be presented as
augmenting treatment of pain symptoms instead of conveying that a
woman’s discomforts are simply supratentorial.
Recognizing catastrophization, the belief that things are as bad as
they can be and are unlikely to improve, is likewise important. This trait
is often seen in patients with CPP [ 42 ] and presents one of the more
refractory obstacles in treating these women. Catastrophizing is often
supported by well- meaning family members and spouses who reinforce
the sick role with kind attention and devoted attempts to help. These
situations especially are best served with a multidisciplinary approach
to treatment.