How is pelvic pain managed?

Management of Pelvic Pain

I notice the question asks about "Fimbrolygia" which appears to be a misspelling - the provided evidence addresses pelvic pain management, which I will answer comprehensively.

Initial Diagnostic Approach

Begin with serum beta-hCG testing in all reproductive-age women presenting with pelvic pain to exclude pregnancy-related causes, particularly ectopic pregnancy, before proceeding with imaging or treatment. 1

Key Clinical Assessment Points

• Minimum diagnostic criteria for pelvic inflammatory disease (PID) require all three findings: lower abdominal tenderness, adnexal tenderness, and cervical motion tenderness 1
• Maintain a low threshold for diagnosing PID, as many episodes go unrecognized and even mild disease can cause reproductive damage 1
• Additional supportive findings include oral temperature >38.3°C, abnormal cervical/vaginal discharge, elevated ESR or CRP, and laboratory documentation of gonorrhea or chlamydia 1

First-Line Management Strategies

For Endometriosis-Related Pain

Hormonal therapies, including oral contraceptives and progestins, are the primary pharmacological treatments for endometriosis-related pelvic pain. 2

• GnRH agonists provide significant pain relief and can be used even without surgical confirmation of endometriosis 2
• Note that pain severity has little relationship to the extent of lesions seen on laparoscopy, though lesion depth correlates with pain intensity 2
• No medical therapy completely eradicates endometriosis lesions 2

For Bladder Pain Syndrome/Interstitial Cystitis

Start with behavioral modifications and stress management as first-line interventions for all patients. 1

• Modify fluid intake to alter urine concentration/volume 1
• Avoid common bladder irritants (coffee, citrus products) 1
• Apply local heat or cold over the bladder or perineum 1, 2
• Avoid pelvic floor strengthening exercises (Kegels) if pelvic floor tenderness is present, as these may worsen symptoms 2

Second-Line Pharmacological Options

Oral Medications for Bladder Pain

Consider amitriptyline, cimetidine, hydroxyzine, or pentosan polysulfate as second-line oral agents (no hierarchy implied among these options). 1, 2

• These medications have Grade B or C evidence and unpredictable individual efficacy 1
• Associated with only minor adverse events 1

Intravesical Treatments

Dimethyl sulfoxide, heparin, or lidocaine may be administered as second-line intravesical treatments. 1, 2

• These have Grade B or C evidence with minor adverse events 1

NSAIDs for General Pelvic Pain

Ibuprofen 400 mg every 4-6 hours is effective for mild to moderate pelvic pain, including dysmenorrhea. 3

• For dysmenorrhea specifically, begin at earliest onset of pain 3
• Doses above 400 mg show no additional benefit in controlled trials 3
• Maximum daily dose should not exceed 3200 mg 3

Physical Therapy Interventions

Manual physical therapy techniques targeting muscular trigger points, muscle contractures, and connective tissue restrictions are recommended for patients with pelvic floor tenderness. 2

• This approach helps resolve specific musculoskeletal contributors to pain 2
• Again, avoid strengthening exercises in the presence of pelvic floor tenderness 2

Multimodal Pain Management

Implement multimodal approaches combining pharmacological treatments, stress management, and manual therapy for all patients. 1, 2

• Consider antidepressants (SNRIs, tricyclic antidepressants) and anticonvulsants (gabapentin, pregabalin) for neuropathic pain components 2
• Avoid opioids for chronic pelvic pain; if absolutely necessary, use the lowest effective dose and reevaluate regularly 2
• Refer to pain specialists if standard approaches fail to provide adequate control 1, 2

Advanced Interventions for Refractory Cases

For Bladder Pain with Hunner Lesions

If cystoscopy with hydrodistension identifies Hunner lesions, perform fulguration (laser or electrocautery) and/or triamcinolone injection as the primary treatment. 4

• This is the most effective intervention for this specific IC/BPS subtype 4
• Hunner lesions become easier to identify after distention when cracking and mucosal bleeding appear 1, 4

For Severe Bladder Pain Without Hunner Lesions

Consider in sequence:

• Sacral neuromodulation 4
• Cyclosporine A 4
• Intradetrusor botulinum toxin A injections 4
• Substitution cystoplasty or urinary diversion with/without cystectomy only as last resort for severe, unremitting symptoms after all other options have failed 4

Surgical Options for Endometriosis

Surgery can provide significant pain reduction for endometriosis, but up to 44% of women experience symptom recurrence within one year. 2

• Consider surgical intervention for severe endometriosis when medical treatment is insufficient 2
• Hysterectomy should be considered only as a last resort if pain appears uterine in origin, with significant improvement occurring in only about 50% of cases 5

Critical Pitfalls to Avoid

• Never offer long-term oral antibiotic administration or intravesical BCG for IC/BPS 4
• Do not perform CT imaging in pregnant patients (positive b-hCG) for suspected gynecological causes due to radiation exposure 1
• Recognize that IC/BPS is chronic with flares and remissions; set realistic expectations 4
• Discontinue ineffective treatments after appropriate trial periods 4

Imaging Considerations

Pelvic ultrasonography should be the first-line imaging examination to identify causative conditions including endometriosis, adenomyosis, pelvic varices, and chronic infection. 6

• Transvaginal ultrasound has 93% sensitivity and 98% specificity for tubo-ovarian abscess 1
• MRI is more accurate than ultrasound for diagnosing and assessing the spread of endometriosis 6
• For pregnant patients with nongynecological causes, contrast-enhanced CT may be necessary for timely intervention despite radiation concerns 1