Chronic pelvic pain (CPP) is a complex condition that severely affects quality of life, impedes physical functioning, and inhibits the ability to work or perform the usual activities of daily living for many women. In addition, CPP affects psychological well-being and interpersonal relationships. Sexual pain is common and coupled with depression and anxiety can lead to strained intimate relationships. Women often consult their primary care providers first regarding the source of their pain. If the cause of CPP is not found, they are then referred to a number of different specialists, including gynecologists, urologists, and gastroenterologists. As a result, they endure a myriad of invasive and noninvasive diagnostic tests, such as colonoscopy, cystoscopy, and laparoscopy that are used to examine the organs of the pelvis. If no pathology is found or their pain is not sufficiently resolved, women may resort to the advice of a psychiatrist, pain management specialist, or alternative care provider. Chronic pelvic pain has a profound impact on women's lives, so they are willing to go to great lengths to find the source of their pain and to obtain relief. Unfortunately, many women do not find a definitive cause for their CPP, and their encounters with the health care system leave them feeling frustrated, invalidated, and hopeless.
When caring for women with CPP it is best to offer a holistic approach, including mind, body, and spirit and investigate all of the potential sources of pain. Chronic pelvic pain is a multifaceted condition that encompasses physiological and psychological morbidities, making it challenging to diagnose and treat. Most providers are inadequately trained to assess and manage women with CPP, and no evidence-based guidelines are available to instruct them. For instance, women's health providers have been taught to competently perform a pelvic exam, but they are usually not trained to assess the pelvic floor and abdominal musculature for myofascial sources of pain. In addition, most providers are not properly trained to conduct an adequate sexual history. When caring for women with CPP, developing skills in psychosocial assessment and patient–provider communication is essential. This will help foster rapport and facilitate identification of anxiety and depression. The provider should collaborate with the woman to set realistic treatment goals and should listen sensitively to her concerns.
Most women's health providers are reasonably knowledgeable about the management of acute pain, but they are not sufficiently educated in the management of chronic pain. Our understanding of chronic pain continues to evolve with the introduction of concepts such as central sensitization, a postulated explanation for the development of chronic pain. As our understanding of the physiological mechanisms of pain changes, so does our grasp of the psychological responses to pain. For instance, “catastrophizing,” a coping mechanism observed in patients with low back pain, has been introduced as an important concept to consider when delivering care for women with CPP. Those who provide care for patients with chronic pain must stay abreast of this changing field of health care.
Many conventional medications are used to treat CPP from hormonal contraceptives to opioid analgesics to antidepressants, and forming an interdisciplinary care team comprising physical therapy, pain management, psychology, sexology, and alternative providers such as traditional Chinese medicine is often necessary to deliver comprehensive care. Mind–body modalities, including breathing exercises, progressive muscle relaxation, imagery, and meditation play an important role by harvesting the power of the parasympathetic nervous system to treat pain. The use of conventional and alternative modalities provides an array of treatment options for management of this difficult to treat condition.
I am delighted to be guest editor for this In Focus series because I am quite passionate about caring for women with CPP, which can have a devastating impact on women's lives. Providers frequently feel overwhelmed and inadequately prepared when confronted with this condition. It is my hope that this series will offer information that nurses can directly apply to clinical practice and will thereby boost nurses’ confidence in caring for these women.
In the first article in this series, Learman and I present an overview of the causes of CPP and discuss approaches to assessment and treatment. A distinguished clinician, educator and researcher, Dr. Learman is a leader in the field of CPP. This article is based on the wisdom we have gathered over the years while working with patients with CPP and is supported by a recent review of the literature. We present a unique perspective, as I am a board-certified holistic nurse trained in integrative medicine and have training in pain management.
Myofascial sources are some of the most common yet frequently overlooked sources of pain in women with CPP. In the second article, two very experienced physical therapists specializing in CPP, Pastore and Katzman, carefully describe the proper assessment of women with CPP, including examination of the pelvic floor and identification of trigger points. In addition they discuss a physical therapist's treatment approach, including myofascial release, self-care management strategies, and relaxation techniques.
Sexual pain is common among women with CPP, but it frequently goes unaddressed. In the third article, Howard, a board-certified clinical sexologist specializing in CPP, describes the sexual challenges faced by women with CPP and their partners. She incorporates their words and perspectives throughout the article and provides practical advice on how to obtain a sexual history and to provide counseling for women with CPP.
It is difficult to provide comprehensive care for women with CPP during a typical office visit. In the final article, Chao and I describe a 10-session holistic program called Centering CPP that we developed to meet the complex health care needs of women with CPP. Centering is a model of group health care delivery that offers assessment, support, and education at each visit. It has been widely adopted for the delivery of prenatal care, particularly among nurse-midwives. The curriculum was designed to empower women to improve the quality of their lives and to learn how to better manage their symptoms. We are currently conducting research to explore the acceptability, feasibility, and efficacy of this program.
Nurses are critical members of the interdisciplinary CPP health care team. They are skilled in assessment, advocacy, education, and coordination of care. They approach the care of patients in a holistic manner that is essential in the context of this condition. In their roles as nurse practitioners and midwives they are pivotal in identifying, assessing, and managing women with this condition. Nurses trained in research are uniquely capable of using qualitative and quantitative methodologies to better understand CPP and to evaluate the care provided.