Review
General gynecology
Gynecologic management of neuropathic pain

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Obstetrician/gynecologists often are the initial management clinicians for pelvic neuropathic pain. Although treatment may require comprehensive team management and consultation with other specialists, there are a few critical and basic steps that can be performed during an office visit that offer the opportunity to improve quality of life significantly in this patient population. A key first step is a thorough clinical examination to map the pain site physically and to identify potentially involved nerves. Only limited evidence exists about how best to manage neuropathic pain; generally, a combination of surgical, manipulative, or pharmacologic methods should be considered. Experimental methods to characterize more precisely the nature of the nerve dysfunction exist to diagnose and treat neuropathic pain; however, additional scientific evidence is needed to recommend these options unanimously. In the meantime, an approach that was adopted from guidelines of the International Association for the Study of Pain has been tailored for gynecologic pain.

Section snippets

History

In practice, diagnosis of many cases of abdominopelvic neuropathic pain occurs predominantly after a recent surgical procedure. Inadvertent suture ligation, anatomic compression (even from benign sources, such as pants or girdles), and alterations in the perineural environment that are the result of metabolic changes (such as diabetes mellitus) have all been described in cases in which treatment of the presumed underlying issue resolved the patient's symptoms. Outside of the perioperative

Testing

To enhance specificity, many experts routinely use diagnostic nerve blocks, particularly with readily accessible peripheral nerves, such as the ilioinguinal, the lateral femoral cutaneous, and the pudendal (by a transvaginal approach).54, 55 How best to perform these blocks remains controversial because of the previously noted variability in pelvic dermatopic organization and the difficulty of precisely placing these agents into the correct plane, which leads some to suggest the use of

Treatment

All patients who experience chronic pelvic pain should be given benefits of comprehensive multimodal and multidisciplinary pain treatment, which refers to interventional nerve blocks; surgical interventions that include decompression of entrapped nerves; treatment with medication that has proved to have efficacy in treatment of neuropathic pain in general; physical therapy modalities; psychologic counseling and training; and treatment with complementary alternative medicine. In this review, we

Alternative approaches

In the absence of effective treatment, >40% of patients with chronic pain seek complementary and alternative medical approaches.100 These obviously are beyond the training of an obstetrician/gynecologist, but skilled practitioners, such as physical therapists and chiropractors, should be identified readily in many communities. Manual techniques (such as physical therapy) pose minimal risk and may be appropriate when suspected concomitant myofascial dysfunction is present (such as the presence

The reign of empiric management in neuropathic pain

We reflect on a historic anecdote in closing. In 1863, John Hilton of London described a man with pain in whom it “was quite apparent that the cause must be associated with the perineal branch of the pudic nerve.” The solution to this patient's treatment was merely having “a hole made in his chair or to use a hollow cushion.”108 This approach, which we continue to see many affected women use, was from a previous era that put faith in nerves and their pathology without imaging, electrical nerve

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    Supported in part by National Institutes of Health Grant K23HD054645 (F.F.T.).

    F.F.T. has consulted for Ethicon Endo-Surgery. The other authors report no potential conflicts.

    Reprints not available from the authors.

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