Pelvic Pain: The Diagnostic Workup

By the time that most patients reach a comprehensive pain clinic such as ours, they have already gone through an extensive diagnostic work up to exclude the so-called organic causes of their pain. Very often this will include, gynecological examination, testing for sexually transmitted diseases, hormone manipulations, imaging studies and even laparoscopy.

Once organic causes have been excluded we can begin to look at the so-called functional causes of pelvic pain. This is usually done with a series of nerve blocks. The exact sequence of testing may vary from patient to patient but will often include a differential spinal or a differential epidural block to determine the broad mechanistic class of the pain followed by a series of autonomic nerve blocks in an attempt to localize the neuroanatomical structures involved in the mediation of their chronic pain.

In some cases these ganglionic blocks may be therapeutic in which case they can be repeated. What is seen in these cases is that the therapeutic effect outlasts the expected duration of the local anesthetic and the effect of subsequent blocks is longer and longer. In cases where repeated local anesthetic blocks have failed to produce lasting relief chemical denervation has been used with some success by Mekhail at the Cleveland Clinic.  Relief typically lasts for 8-12 months.  Concerns about repeated injection of caustic substances for nonmalignant conditions limit the general applicability of this technique.

The final step in the work up of these patients is often a trial of stimulation followed by a trial of epidural/intrathecal medication. It is often difficult to predict who will respond to which form of therapy, however Kapural first at the Cleveland Clinic and now at Wake Forest has reported good long term result after a positive trial. Our results have been the same.

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