Definitions for the level of evidence (1-4) and grade of recommendation (A-C) are provided at the end of the "Major Recommendations."
Guidelines for Use of Non-steroidal Anti-inflammatory Drugs (NSAIDs) and Cyclooxygenase Isoenzyme 2 (COX2) Selective Agents
- Non-selective, low potency NSAIDs should be used in the first instance. They are most likely to be of help if there is an inflammatory component to the pain. More potent NSAIDs should be reserved for those conditions in which the low potency drugs have been tried and failed to produce significant benefit.
- COX2 selective drugs should be used with caution as an alternative to the non-selective drugs where there is an increased risk of gastric complications. They should be avoided in patients with known cardiovascular disease.
- NSAIDs should be taken with food and consideration must be given to the use of gastric protective agents.
- The benefits of the NSAIDs must be demonstrated to outweigh the risks.
- All NSAIDs are contraindicated in active gastrointestinal ulceration/bleeding and renal disease. They may exacerbate asthma and produce fluid retention.
- Even if stronger analgesics such as opioids are added, the NSAIDs can be continued as they are likely to have a synergistic action improving pain control above and beyond that obtained with opioids alone.
- Paracetamol should be considered as an alternative to, or given with, NSAIDs as it is well tolerated with few side effects.
Neuropathic Analgesics
See Figure 8 in the original guideline document for guidelines for the use of neuropathic analgesics, including antidepressants and antiepileptics. N-methyl-D-aspartate (NMDA) antagonists and sodium channel blockers were considered but not recommended. They must be instigated by experts in the field.
Guidelines for the Use of Opioids in Chronic/Non-acute Urogenital Pain
- All other reasonable treatments must have been tried and failed.
- The decision to instigate long-term opioid therapy should be made by an appropriately trained specialist in consultation with another physician (preferably the patient's family doctor).
- Where there is a history or suspicion of drug abuse, a psychiatrist or psychologist with an interest in pain management and drug addiction should be involved.
- The patient should undergo a trial of opioids.
- The dose required needs to be calculated by careful titration.
- The patient should be made aware (and possibly give written consent):
- That opioids are strong drugs and associated with addiction and dependency.
- The opioids will normally only be prescribed from one source (preferably the family doctor).
- The drugs will be prescribed for fixed periods of time and a new prescription will not be available until the end of that period.
- The patient will be subjected to spot urine and possibly blood checks to ensure that the drug is being taken as prescribed and that non-prescribed drugs are not being taken.
- Inappropriate aggressive behaviour associated with demanding the drug will not be accepted.
- Hospital specialist review will normally occur at least once a year.
- The patient may be requested to attend a psychiatric/psychology review.
- Failure to comply with the above may result in the patient being referred to a drug dependency agency and the use of therapeutic, analgesic opioids being stopped.
- Morphine is the first-line drug, unless there are contraindications to morphine or special indications for another drug. The drug should be prescribed in a slow-release/modified release form. Short-acting preparations are undesirable and should be avoided where possible. Parenteral dosing is undesirable and should be avoided where possible.
Morphine
There is no compelling evidence that one opiate is better than another. Morphine is the traditional gold standard and the opioid many physicians are most familiar with. In an acute situation, the daily morphine requirement may be calculated by titration of rapid-release morphine. In chronic pain situations, starting with a low dose of slow-release morphine and titrating the dose every 3 days to 1 week is adequate.
Transdermal Fentanyl
Transdermal fentanyl is used when oral absorption is restricted or when the patient suffers with intolerable side effects from other opioids. Patients with rapid bowel transit times (e.g., ileostomy) may find transdermal preparations beneficial. Patches are generally changed every 72 hours.
Methadone
A practitioner familiar with its use as an analgesic should prescribe methadone.
Other Opioids and Opioid-like Agents
Other opioids are available as slow- or modified-release preparations. They may be useful for opiate rotation if side effects or tolerance is a problem.
Buprenorphine and pentazocine both have agonist and antagonist properties and can induce withdrawal symptoms in patients used to opioids. Naloxone may only partly reverse respiratory depression. Buprenorphine topical patches are now available and may offer a similar advantage to topical fentanyl.
Codeine and dihydrocodeine are effective for the relief of mild-to-moderate pain. They are limited by side effects (notably constipation) and genetic variance of metabolism that affects analgesic efficacy.
Tramadol has fewer typical opioid side effects (especially less respiratory depression, less constipation and less addiction potential) and is available in a slow-release preparation. A Cochrane review suggests that there is a role for tramadol in neuropathic pain management.
General Treatment of CPP
| Type of Pain |
Level of Evidence |
Grade of Recommendation |
Comment |
| Paracetamol for somatic pain |
1b |
A |
Benefit is limited and based on arthritic pain |
| cyclooxygenase (COX2) antagonists |
1b |
A |
Avoid in patients with cardiovascular risk factors |
| Non-steroidal anti-inflammatory drug (NSAIDs) for dysmenorrhoea |
1a |
B |
Better than placebo but unable to distinguish between agents |
| Tricyclic antidepressants |
1a |
A |
Neuropathic pain |
| Tricyclic antidepressants |
3 |
C |
Evidence suggests pelvic pain is similar to neuropathic pain |
| Anticonvulsants Gabapentin |
1a |
A |
For neuropathic pain |
| Opioids for chronic non-malignant pain |
1a |
A |
Limited long-term data
Should only be used by clinicians experienced in their use
|
| Opioids for neuropathic pain |
1a |
A |
Benefit is probably clinically significant
Caution with use, as above
|
Nerve Blocks
Neural blockade for pain management is usually carried out by a consultant in pain medicine with an anaesthetic background. Textbooks have been written on the techniques employed, and individual specialists using neural blockade must be well versed in assessment of the patient, the indications for specific procedures, and the general and specific risks associated with the procedures, as well as possible advantages.
Procedures may be performed for diagnostic reasons, therapeutic benefit or possibly both. Diagnostic blocks can be difficult to interpret and a clear understanding of the many mechanisms by which a block may be acting must be understood. Temporary but consistent responses to nerve blocks may lead a specialist to proceed with a neurolytic nerve block or to a pulsed radiofrequency neuromodulation procedure. Neurolytic nerve blocks are rarely indicated for a benign process, and to proceed with a neurolytic nerve block may result in disastrous results.
Published guidelines emphasize that all nerve blocks should be performed with appropriate attention to safety, including the presence of skilled support staff and appropriate monitoring and resuscitation equipment. The use of block needles, nerve location devices and imaging (i.e., X-ray image intensifier, ultrasound or computerized tomography) appropriate for the procedure is essential.
The evidence base for nerve blocks is not strong, but suggests that:
- Peripheral nerve blocks, such as ilioinguinal/iliohypogastric/genitofemoral, may be useful in the management of neuropathic pain associated with nerve damage, such as following hernia repairs.
- Blocks around the spermatic cord may be useful diagnostically prior to testicular denervation.
- Lumbar (L1) sympathetic blocks may be helpful in the management of testicular pain, renal pain and possibly a range of pelvic pain conditions with afferents that pass via the L1 level.
- Pudendal nerve blocks may be useful in the management of pudendal nerve injury related pain and possibly pelvic floor muscle spasm. Where pudendal neuralgia is suspected, pudendal nerve blocks may have a diagnostic role. Multiple other nerves close to the pudendal nerve may also be associated with neuropathic symptoms and differential nerve blocks using neurotracing may be of help in understanding the process.
- Pre-sacral blocks and the ganglion Impar block may have a role in the management of pelvic pathology, particularly cancer pain.
- Sacral root nerve blocks may be helpful in the diagnosis of those conditions that might respond to sacral root stimulation.
The above list is not exhaustive and readers are advised to look at the major textbooks in this area.
Transcutaneous Electrical Nerve Stimulation (TENS)
The rationale behind using surface electrical nerve stimulation to relieve pain is the stimulation of myelinated afferents and thus activation of segmental inhibitory circuits. Urinary frequency may also be reduced.
TENS involves the use of a pulse generator with an amplifier and electrodes. The pulses may be delivered continuously or as trains of varying duration. Continuous stimulation seems to be preferable when treating pain.
Counselling of the patient before the start of the treatment is necessary. A specially trained nurse with the time necessary to communicate the technical instructions is a good option. The patient should be confident with the feeling of strong stimulation and view self-treatment without fear. The induction time for TENS to produce analgesia varies widely. The effect is cumulative. Since onset and progression are usually rather slow in interstitial cystitis, the standard recommendation so far has been 0.5-2 hours of treatment twice daily. The duration of an individual treatment session depends on the severity of pain.
Sacral Neuromodulation in Pelvic Pain Syndromes
Sacral neuromodulation (SNS) has been shown to have benefits in patients with refractory motor urge incontinence, urinary retention, and chronic pelvic pain. Neuropathic pain and complex regional pain syndromes may also be treated successfully with neurostimulation applied to dorsal columns and peripheral nerves.
Definitions:
Levels of Evidence
1a Evidence obtained from meta-analysis of randomized trials
1b Evidence obtained from at least one randomized trial
2a Evidence obtained from one well-designed controlled study without randomization
2b Evidence obtained from at least one other type of well-designed quasi-experimental study
3 Evidence obtained from well-designed non-experimental studies, such as comparative studies, correlation studies and case reports
4 Evidence obtained from expert committee reports or opinions or clinical experience of respected authorities
Grades of Recommendations
- Based on clinical studies of good quality and consistency addressing the specific recommendations and including at least one randomized trial
- Based on well-conducted clinical studies, but without randomized clinical studies
- Made despite the absence of directly applicable clinical studies of good quality
