Event 3: Understanding Pain

Understanding Chronic Pain: Patient Teaching

Central Sensitization


“(A)n amplification of neural signaling within the central nervous system that elicits pain hypersensitivity” (Woolf, 2011).

  • Body continues to experience pain despite healing from a precipitating injury
  • Pain in the setting of no known pathology
  • Existing pelvic pathology does not explain pain experience
  • Chronic pain is a condition
  • There is evidence that it occurs in many CPP disorders such as vulvodynia (Zhan, 2011), dysmenorrhea (Bajaj, 2002), and endometriosis (He, 2010)

Metaphors for Understanding Pain

Acute pain

The alarm system goes off (CNS) because there is an acute tissue injury or painful event

Chronic pain

The alarm system (CNS) keeps going off despite the fact there no longer is an acute tissue injury


  • Pain has impact on quality of life and functional capacity
  • Women become isolated and have difficulty communicating needs
  • Relationships become strained and sexual dysfunction can significantly impact intimate relationships
  • Pre-existing psychological issues such as PTSD exacerbated by pain
  • Anxiety and depression common

Sexual Dysfunction

  • Dyspareunia is common
  • Can lead to sexual dysfunction and strained sexual relationships
  • 68% of women with CPP have sexual dysfunction
    • Hypoactive desire 54%
    • Arousal disorder 33%
    • Orgasmic disorder 22%
    • Sexual pain 74%

For many women with CPP sexual arousal, stimulation, or orgasm worsens or stimulates pelvic pain. A pleasurable activity becomes painful and she becomes fearful that sexual touch will cause a pain flare.


(Verit, Verit, & Yeni, 2006)

Psychological, Continued

Fear Avoidance Model (Catastrophizing)

Patients develop and maintain pain long after an injury because they experience pain-related fear (Lethem, Slade, Troup, & Bentley, 1983).

In contrast, less fearful patients confront pain and recover from it.

Those who “catastrophize” avoid activities that they perceive as painful leading to inactivity and further disability.

Catastrophizing may play an important role in our understanding of patients with CPP and their ability to recover (Alappattu & Bishop, 2011; Martin, Johnson, Wechter, Leserman, & Zolnoun, 2011).

Case Study Diagnosis

46 yo with CPP: Stage IV endometriosis (cyclic component of pain treated with continuous oral contraceptives), abdominal and pelvic floor muscle pain, vestibulodynia, IBS with constipation, possible IC, anxiety and depression and sexual dysfunction.

Commentary on Diagnosis

Conducting a thorough history and systematic assessment is critical to uncovering the many etiologies of CPP.

In the case of chronic pain, it is common to find conditions that manifest as allodynia or hyperalgesia and myofascial tension and tenderness.

Comorbid conditions such as anxiety, depression and sexual dysfunction must be addressed because they exacerbate and perpetuate pain and contribute to poor quality of life.

Test Your Knowledge: Dyspareunia

What underlying conditions might be present in a patient with dysparuenia?

Correct. Endometriosis.


University of California, San Francisco
University of California, San Francisco