Chronic Pelvic Pain:  Finding the Cure FREE

Dismayed by the recent Institute of Medicine report of $650 billion annually spent on pain care¹ and a 2011 meta-analysis reporting that pain treatments reduce pain by less than 30% in only half of those treated,² I report a current case of a young woman with chronic pelvic pain attributed initially to endometriosis and later interstitial cystitis.

This 28-year-old woman was referred for consultation after 8 years of uncontrolled pelvic pain. The pain worsened despite laparoscopic and adhesiolyses, an ovariectomy, and later abdominal hysterectomy, and ongoing cystoscopies and bladder distentions. Each procedure failed to clarify the cause for her pain but exacerbated her pain and prompted an escalation of her opioid dose. Intravesicular medications had no measurable benefit and further increased opioid intake. Physicians were frustrated. She was hopeless and so severely disabled that her mother assumed care of her 4 young children. Her marriage was failing and she was desperate to “find a cure.”

She reported a history of adolescent sexual abuse and an escape to marriage at age 18 years to a verbally and physically abusive man. She told me pregnancy permitted her to avoid sex for at least 9 months a year and she could not tolerate intercourse at all now. She performed repeatedly painful bladder self-catheterization, increasing her pain and opioid use. Increased frequency of visits to physicians and worrisome opioid drug seeking had her labeled “an addict.” Longstanding physical abuse by her husband accelerated.

Our monthly clinic visits stressed the importance of “nonmedical” issues, especially her early and continuing adverse life experiences. Validating her pain as “real” during each of our clinical encounters, I redirected the perception of her suffering from painful genital sensations and, instead, to her overwhelmingly severe adverse life events. Therefore, our attention shifted from “let us treat your pelvic organs” to “you hurt because of what has happened in your life, so let us treat this.” Within 2 visits, empathy in the face of chronic pain led to dramatic treatment success. At 6 months, she abruptly stopped taking opioids, and at 7 months she completed an intensive substance abuse treatment program, after access was delayed by her insurer and she had to endure a long wait list for a low-cost treatment program. With no coverage for individual counseling, she started attending a twice-per-week abuse victims group along with frequent Alcoholic Anonymous meetings. She separated from her husband and filed for divorce and began to share care of her children along with her mother. When I last saw her several months ago, she had only intermittently required a urinary catheter and has abstained from using opioids. Though she reports “just” 30% less pain intensity, she feels unequivocally improved. Her urologist still recommends bladder distention procedures, confusing the both of us, yet we remain skeptical that they are worth “the pain.”

This story is frequently encountered in cases of chronic pelvic pain. It surely illustrates that effective outcomes in chronic pain syndromes is not always accomplished through more medical diagnoses, medications, and costly procedures. For challenging cases of refractory pain, the history often reveals the mystery. Careful listening can discern other causes of pain and suffering beyond physical injuries and official diseases. These can point to more effective treatments for pain and suffering. Decreasing time and financial incentives for effective patient and physician communication, combined with incentives to prescribe pills and perform procedures, means that we will continue to fail to either control costs or improve pain care outcomes.