Treatment consists of reassurance, education, stress reduction, bulk-forming agents and other symptomatic treatments, and low-dose tricyclic antidepressants. A multidisciplinary management approach consisting of medical and psychological approaches is recommended. Patients should eliminate triggers in their diet, such as food containing lactose, sorbitol, alcohol, fat, and fructose. Products that contain caffeine can cause abdominal bloating, cramping, and more frequent bowel movements. After the patient has tried these lifestyle changes, if she remains symptomatic, a short-term trial of antispasmodics such as dicyclomine or hyoscyamine can be given (105). Multidisciplinary therapy addresses the cognitive, affective, and behavioral components of the pain. Therapy may decrease the intensity of nociceptor stimulation as well as change the patient’s interpretation of the meaning of pain (105).
Antispasmodic agents relax the smooth muscle and reduce contractility of the gastrointestinal tract. While antispasmodics and laxatives may produce symptomatic relief of bowel symptoms, the pain symptoms of IBS may respond to antidepressants. Low-dose tricyclic antidepressants (TCAs) can alleviate the pain of IBS as shown in a number of randomized controlled trials. TCAs can also reduce excessive gastrointestinal contractility and are approved for use as antispasmodics. TCAs may be used for women with moderate to severe pain, who were refractory to other therapies. Although the dose to achieve the analgesic response is much lower than that used for antidepressive effects, TCAs may be increased to higher dosages in patients with co-existing depression. Selective serotonin reuptake inhibitors (SSRIs) and serotonin/ norepinephrine reuptake inhibitors (SNRIs) were used successfully in the treatment of IBS and can be used in those patients failing TCA treatment or those who are depressed or are unable to tolerate the side effects of TCAs.
Urologic Etiology Chronic pelvic pain of urologic origin may be related to recurrent cystourethritis, urethral syndrome, sensory urgency of uncertain cause, and interstitial cystitis/bladder pain. With an appropriate diagnostic workup, infiltrating bladder tumors, ureteral obstruction, renal lithiasis, and endometriosis can easily be ruled out as possible causes.
Urethral Syndrome Urethral syndrome is defined as a symptom complex including dysuria, frequency and urgency of urination, suprapubic discomfort, and often dyspareunia in the absence of any abnormality of the urethra or bladder (107). The cause of urethral syndrome is uncertain and is attributed to a subclinical infection, urethral obstruction, and psychogenic and allergic factors. The symptoms of urethral syndrome may actually evolve into the initial stages of interstitial cystitis.
Urinary urgency, frequency, suprapubic pressure, and other less frequent symptoms such as bladder or vaginal pain, urinary incontinence, postvoid fullness, dyspareunia, and suprapubic pain are commonly observed.
Physical and neurologic examinations should be performed. Anatomic abnormalities, including pelvic relaxation, urethral caruncle, and hypoestrogenism, should be evaluated. The patient should be evaluated for vaginitis. The urethra should be carefully palpated to detect purulent discharge.