Psychological Comorbidities in Chronic Pelvic Pain

Those with chronic pelvic pain often have comorbid psychological syndromes, such as depression, anxiety, and catastrophizing.

Chronic pelvic pain (CPP) is more prevalent than commonly thought, affecting up to 20% of women in the United States.1 CPP is an umbrella term that refers to noncyclic pain in the abdomen or pelvis that persists for more than 6 months and frequently causes functional impairment or prompts women to seek medical attention. Conditions categorized as CPP include endometriosis, pelvic myofascial pain, vulvodynia, irritable bowel syndrome, and interstitial cystitis/bladder pain syndrome (IC/BPS).

There is growing recognition that CPP is often accompanied by psychological comorbidities such as depression, anxiety, and catastrophizing. The prevalence of depression and anxiety in patients with CPP is up to 52% and 73%, respectively, compared with 10% and 12% in the general population, respectively.

Psychosocial Domains That Predict Pain Severity

Comorbid psychosocial factors are thought to contribute to the intensity of the CPP syndrome (CPPS).2 In a study of individuals with CPP (n=109; mean age, 49.3 years; 59.6% women), the following baseline symptoms were found to predict pain at follow-up: pain severity (P =.004), age (P =.02), urinary symptoms (P =.01), and depressive-anxious symptoms (P =.009).

“To our knowledge, this is the first study to longitudinally examine a broad range of psychosocial predictors of pain, urinary symptom severity, and impediments to quality of life in women and men with CPPS,” said Dr Dipl-Psych Christoph Dybowski from the department of psychosomatic medicine and psychotherapy at the University Medical Center Hamburg-Eppendorf in Hamburg, Germany. “Depressive-anxious symptomatology predicted all 3 outcomes significantly and, additionally, emerged as the only significant predictor of impediments to quality of life at follow-up.”

Pelvic Pain Does Not Only Affect Women

A study examined associations between the duration of worsened pain in urologic CPPS, chronic overlapping pain conditions, and comorbid psychosocial symptoms.3 A total of 191 men (mean age: short-duration, 42.2 years; long-duration, 50.9 years) and 233 women (mean age: short-duration, 38.0 years; long-duration, 42.1 years) were grouped by symptoms lasting <2 years or ≥2 years. Although symptom severity was not associated with duration of pelvic pain, men with long vs short symptom duration tended to have more severe urinary symptoms. Symptom duration was not found to be associated with the presence of chronic overlapping pain conditions or psychosocial comorbidities. Gender differences were slight and temporal: men who had symptoms for >2 years were more likely to have depression (P =.045), and women with pelvic pain for >2 years reported less stress (P =.013).

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An Overlooked Psychosocial Comorbidity

Another dimension that clinicians should consider is patients’ exposure to trauma.4 The first study to examine the effect of posttraumatic stress disorder (PTSD) on IC/BPS pain recruited 202 patients (mean age, 44.89 years; 79.7% women) with chronic pain. Of these, 64 had been diagnosed with IC/BPS, and rates of abuse were comparable with those of other participants without IC/BPS. A total of 42% of participants with IC/BPS were found to have “provisional” PTSD, as assessed using a self-rating scale of symptoms. Although no association was established between PTSD and genitourinary symptoms, provisional PTSD was correlated with more pain, poorer quality of life, and emotional distress. Patients with PTSD and IC/BPS had a greater incidence of childhood trauma and lifetime sexual abuse. Investigators recommend that clinicians screen for PTSD by monitoring specific symptoms such as nightmares and hyperarousal rather than asking patients directly about trauma.

Self-Management of IC/BPS With Psychosocial Comorbidities

In a systematic review (n=34 studies) of IC/BPS and psychosocial factors, investigators evaluated the impact of psychosocial comorbidities in 2912 men and women with IC/BPS.5 Seven of the 10 domains used to evaluate depression, anxiety, stress/coping, trauma, and quality of life, patients’ scores were thought to warrant clinical intervention by review authors.

Three of the studies examined in this review indicated self-management strategies (eg, guided imagery/self-hypnosis, mindfulness, and online health education) with efficacy in reducing pain and urinary urgency and providing improved overall health outcomes.

“We know that depression, anxiety, and symptoms related to posttraumatic stress accompany the condition at very high rates and can intensify pain and interfere with self-management or coping strategies,” said Lindsey C. McKernan, PhD, assistant professor of clinical psychiatry and physical medicine and rehabilitation at Vanderbilt University in Nashville, Tennessee. “Often, it is a treatable aspect of the clinical picture, and patients can feel increased self-efficacy to manage their symptoms and can experience reductions in pain if psychological symptoms are addressed. We see that patients feel validated and are open to addressing this aspect of their health when it is discussed in appointments, particularly after we explore the connections between stress, symptom flares, and pain.”

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1. Till SR, As-Sanie S, Schrepf A. Psychology of chronic pelvic pain: prevalence, neurobiological vulnerabilities, and treatment [published online October 31, 2018]. Clin Obstet Gynecol. doi: 10.1097/GRF.0000000000000412

2. Dybowski C, Löwe B, Brünahl C. Predictors of pain, urinary symptoms and quality of life in patients with chronic pelvic pain syndrome (CPPS): a prospective 12-month follow-up study. J Psychosom Res. 2018;112:99-106.

3. Rodríguez LV, Stephens AJ, Clemens JQ, et al. Symptom duration in patients with urologic chronic pelvic pain syndrome (UCPPS) is not associated with pain severity, non-urologic syndromes and mental health symptoms: a multidisciplinary approach to the study of chronic pelvic pain (MAPP) network study [published online November 16, 2018]. Urology. doi: 10.1016/j.urology.2018.11.015

4. McKernan LC, Johnson BN, Reynolds WS, et al. Posttraumatic stress disorder in interstitial cystitis/bladder pain syndrome: relationship to patient phenotype and clinical practice implications [published online October 23, 2018]. Neurourol Urodyn. doi: 10.1002/nau.23861

5. McKernan LC, Walsh CG, Reynolds WS, Crofford LJ, Dmochowski RR, Williams DA. Psychosocial co-morbidities in interstitial cystitis/bladder pain syndrome (IC/BPS): a systematic review. Neurourol Urodyn. 2018;37(3):926-941.