Melanie Cole, MS (Host): Welcome to Back to Health, your source for the latest in health, wellness, and medical care, keeping you informed so you can make informed choices for yourself and your whole family. Back to Health features conversations about trending health topics and medical breakthroughs from our team of world-renowned physicians at Weill Cornell Medicine. I'm Melanie Cole. And today, we're talking about treating chronic pelvic pain.

Joining me is Dr. Carolyn Kloepping. She's an Assistant Attending Anesthesiologist at New York-Presbyterian Hospital/Weill Cornell Medical Center, and an Assistant Professor of Clinical Anesthesiology at Weill Cornell Medical College Cornell University.

Dr. Kloepping, thank you so much for joining us today. As you see both male and female patients, what are some of the key differences that you can point out when we think of how pain management especially, how pain management specialists really work with them, especially when we're talking about chronic pelvic pain, which can sometimes be a little bit difficult to diagnose?

Carolyn Kloepping, MD: Thanks for having me, Melanie. I'd like to discuss chronic pelvic pain in regards to how it impacts our patient population, and specifically in regards to male and female patients. Chronic pelvic pain is essentially the area below the belly button between the hips and down to the genital and rectal area. So, it's a wide area that can be affected. Because there are so many organs close to each other, it can sometimes be difficult to pinpoint which organ or which source is resulting in the patient's pain. When we think about chronic pelvic pain, we typically think about pain that's been ongoing for at least three to six months, impacting patient's quality of life and their ability to carry out their day-to-day activities, resulting in discomfort.

In regards to our female patient population, there are some common things we see in relation to chronic pelvic pain. Some of those diagnoses may include endometriosis, pelvic inflammatory disease, cystitis, pelvic floor dysfunction. In regards to our male patients, some of the more common diagnoses we may see include prostatitis or inflammation of the prostate, cystitis, scrotal-related pathology and also pelvic floor dysfunction.

Chronic pelvic pain tends to go underdiagnosed or misdiagnosed because it is, again, difficult to pinpoint the source. So, it's important that patients bring up any chronic pelvic pain complaints with their primary care doctor so they can get routed to the appropriate consultant for management.

Melanie Cole, MS: Well, then, what is the first step to diagnosing it since it's a little bit difficult, and pain is somewhat subjective when we're thinking about the pain and where it is. Sometimes it could even be treated as back pain. They think it's maybe back pain. What's the first step, Doctor?

Carolyn Kloepping, MD: Yeah, that's a great question. So, the first step is seeking medical care so that we can kind of begin the process about how to best figure out the source. So, your patient comes into the office with complaints of chronic pelvic pain. You'd want to ask them when did it start. What are the associated factors? Like, are there any symptoms that are urinary or bowel-related, that go along with the pelvic pain? Is it cyclical? Is it constant? Does it come and go? What factors make it worse? What factors make it better? And from there, we'd want the patient to be directed to a consultant, if appropriate. So for example, if they have a lot of GI symptoms going along with their chronic pelvic pain, we'd have them see a gastroenterologist to determine if certain procedures or imaging are warranted.

Likewise, if the pain is coming from a urologic source, perhaps seeing a urologist or seeing an OB-GYN, if we believe it's related to a gynecologic issue. Through that process of getting evaluated by our consultants, we should hopefully be able to pare down what the actual cause is. And from there, figure out a game plan for addressing our patient's pain Sometimes we need to involve multiple specialists in addressing a patient's chronic pain. So, that may include physical therapists, cognitive behavioral therapists. And then, from there, determining if we'd need to involve medications in a patient's pain management plan; interventions, like basic injections that we offer in our pain management office or more advanced procedures that may be offered if someone does not respond to some of the basic injections.

Melanie Cole, MS: Wow. It certainly is an interesting field that you're in. Let's start with females, Dr. Kloepping. So as we know, we've all experienced pelvic pain at one time or another, and maybe not from endometriosis or a condition. But, I mean, it could be really anything. And I know myself, I've had those ultrasounds and those transvaginal ones. And I mean, they can show some things. So, tell us a little bit when you're figuring out for a female, because there are so many factors that could be involved. What do you usually see? What's the most common reason? And as I said, are ultrasounds the main way to look and find out what's going on?

Carolyn Kloepping, MD: Yeah, that's another great question. So, the most common thing that we've been seeing is pain related to endometriosis. Sometimes that may or may not show up on an ultrasound. We work with our OB--GYNs who can help determine if more advanced imaging is needed. Some of our patients will end up having to complete an MRI of their pelvis. And imaging though sometimes doesn't always show the total picture of a patient's pathology. So, a lot of what we do to deduce like where the pain is coming from, the source, is in collaboration with the consultant the patient is seeing. So if the imaging points to a certain issue, so if there are, let's say endometrial tissue areas highlighted on imaging, the OB-GYN may suggest medication management, for example, and/or surgical intervention to address the endometriosis-related pain. But big thing is that the patients do get routed to the appropriate consultant, and then working together for symptom relief.

Chronic pelvic pain arises as a result of something that's causing the pelvic pain. So while we're able to provide nerve blocks to help address the pain, we really want to get to the source if possible.

Melanie Cole, MS: That's certainly so important. And you mentioned some of the reasons that men might experience this pain as well. So, let's get onto treatments in your field, which, I mean, really anesthesiology and pain management is a burgeoning field-- a very exciting time in your field, Dr. Kloepping-- because there's so many tools now in your toolbox to help people with various forms of chronic pain. So, speak about males and females and some of the treatment options that are really exciting that are out there right now.

Carolyn Kloepping, MD: Yeah. So after someone has gone through basic conservative care, they've seen their consultants, they've tried pelvic floor physical therapy. Some of the more advanced procedures we offer can include diagnostic or therapeutic nerve blocks. If we believe the patient's pain is coming from a nerve entrapment or nerve impingement, and they're having nerve-related pain, we can do an injection either under ultrasound or under x-ray guidance to try and give medication to surround that nerve, to confirm that it is the pain generator. Some of these injections, like I'd mentioned, are diagnostic meaning to help confirm or rule in/rule out that the nerve is the source of their pain. Some of the injections we do are therapeutic, meaning that we use a corticosteroid to help provide longer lasting pain relief.

In addition to nerve blocks and some of the nerves we may consider blocking would include the pudendal nerve or ileogastric nerve, Ilioinguinal or ileohypogastric nerve. We may also do trigger point injections if a patient's pain is believed to be related to muscle spasm of muscles that support the pelvic structures. Some of the more advanced blocks we offer are hypogastric plexus blocks and ganglion impar blocks. These are blocks to large nerve bundles that deliver the information of pain from the pelvis up to the spinal cord and up to the brain. So, we try to stun the flow of that painful information, so someone has improved pain, really following that block.

And if someone does not respond to some of these more conservative blocks, we sometimes offer something called spinal cord stimulation, which is a little bit more advanced, but has very promising results for patients with chronic pelvic pain.

Melanie Cole, MS: Wow, so many therapies available. Dr. Kloepping, what have you seen as far as outcomes. Tell patients when they come to see you and they're suffering from some sort of chronic pelvic pain and they've had trouble in the past, getting it help. You know, what do you've seen as far as these therapies and the outcomes and long term? Is it really helping that well?

Carolyn Kloepping, MD: So, every patient's story and their journey will be different. But we find that if we're able to hone in on what their source of pain is, they have pretty good response to some of our basic measures. So as long as we have a multifaceted, a multimodal approach to addressing their pain, we find that patients do respond well and are able to get back into a more normal day-to-day routine. It's important to remember that chronic pelvic pain affects a lot of elements of our life. So, it can lead to anxiety and depression. It can lead to sexual dysfunction, it can lead to trouble being able to complete day-to-day work activities and your normal routine.

So if we're able to ensure that we are addressing patient's mental health, we're addressing their physical wellbeing and also addressing their source of their pain, we find that they respond really well to these therapies. And a lot of these therapies have been in place for a while. So, we do have data to support their effectiveness for patients.

Melanie Cole, MS: Dr. Kloepping, before we wrap up, you just mentioned multimodal and for patients that really don't know what that means and we think about opioid stewardship that we're learning more and more about now. And many of these patients probably have been put on opioids at one point or another to deal with this pain before they figure out what's going on. And so when you say multimodal, what does that really mean and where does that fit into this stewardship, where we're trying to look at balancing the use of some of these high intensity pain medications with some of the therapies that you've talked about today?

Carolyn Kloepping, MD: Yeah. So when we talk about multimodal pain therapies, we want to ensure that we're using pain medications that are specifically targeting a patient's pain quality. So for example, if your patient has a lot of burning, nerve--related pain, that type of pain doesn't respond well to opioids. So typically, for that type of pain, we'd use a medication like gabapentin or Lyrica. If someone has a lot of muscle spasms associated with their pain, we may consider using a muscle relaxant. In addition to those medications, anti-inflammatories and Tylenol can be helpful. Topical medications as well, like lidocaine.

Opioids can be helpful for some patients, but it's not our primary consideration. It's not our primary go-to medication because it can be habit-forming, it may lead to tolerance down the line and it may not overall help a patient progress as much as using non-opioid medications and non-habit forming medications.

Melanie Cole, MS: This has been such great information. Give us your final best advice for people that are suffering from pelvic pain in both males and females. When you see people every single day, what do you tell them about dealing with this, figuring out what it is and following a great action plan to get this taken care of?

Carolyn Kloepping, MD: Yeah. So, the most important thing when patients comes into our office for evaluation of chronic pelvic pain is to listen to them, because a lot of them have seen multiple physicians, they may have tried different kinds of therapies and have not made much headway. But we tell our patients that, you know, we're here for them. We're here to help figure out why they're dealing with this chronic pain and how we can help them get to a better place where they're able to participate more in activities that they used to enjoy that they can't do anymore.

So, we always let patients know that we have different modalities that we could offer them. they're all elective if patients wanted to consider them. And we're always happy to help try newer therapies if it's something that a patient would like to review or discuss that they may have learned about through other resources.

Melanie Cole, MS: Great information. That was so educational today. Thank you so much, Dr. Kloepping, for joining us today. And Weill Cornell Medicine continues to see our patients in person as well as through video visits, and you can be confident of the safety of your appointments at Weill Cornell Medicine. That concludes today's episode of Back to Health. We'd like to invite our audience to download, subscribe, rate, and review back to Health on Apple Podcast, Spotify, iHeart, and Pandora. For more health tips, go to weillcornell.org and search podcasts. And parents, don't forget to check out our Kids' Health. We have so many great podcasts there. I'm Melanie Cole. Thank you so much for joining us today.

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