Pain.

Pain, and chronic pain in particular, is a complex phenomenon comprising physical, social, and psychological factors. Thus, a thorough patient assessment of pain must also include psychological evaluation. Women with chronic pelvic pain are at risk for extended periods of pain and psychological symptoms, with some samples of women with chronic pelvic pain experiencing their pain symptoms for more than 2 years [5]. Research has also shown that pain and urinary symptoms in women with IC/BPS are important factors in promoting maladaptive coping responses and diminished quality of life [15]. In another study, 73% of IC/BPS patients sampled reported numerous systemic pains outside the typical body areas associated with the bladder/pelvic region, with increased numbers of body pain sites being associated with greater pain severity and depression [16]. Thus, documenting and understanding comorbid pain is recommended.

Disability.

Experiencing chronic pain results in disability in many of its sufferers [13]. Women with chronic pelvic pain experience limitations in a variety of daily living activities [17]. As well, physical disability can be worsened by a patient’s negative perception of her illness, attempts to cope using illness-focused coping, and poorer emotional regulation in IC/BPS [15]. Given these findings, assessing disability holistically is important for patients with chronic pelvic pain in order to elucidate how their pain affects their functioning in a variety of contexts.

Quality of Life.

Poor health-related quality of life is a common functional limitation for patients experiencing chronic pain [13]. Chronic pelvic pain sufferers report significant negative effects of the condition on their quality of life [5, 17]. This psychological variable is particularly important to assess, as it is likely a major factor underlying treatment-seeking given that it plays a major role in patients’ well-being.

Catastrophizing.

Pain catastrophizing (i.e., negative thoughts and emotions associated with actual or anticipated pain; [18]) plays a significant role in the development [12] and maintenance [13] of many pain conditions. Shoskes and colleagues [8] identified catastrophizing as an important maladaptive coping strategy to consider among patients with pelvic pain conditions. In a sample of women with pelvic pain, catastrophizing was significantly correlated with mental health and functioning, suggesting that it plays a role in many important disease-related outcomes [5]. In a recent unpublished study, catastrophizing and difficulties in emotion regulation were found to mediate the relationship between pain and depression/pain-related disability in women suffering from IC/BPS [19]. Further, catastrophizing and depression have both been found to be predictors of patient distress in IC/BPS, with more than one in five patients reported having had suicidal thoughts [20]. This study was important because it suggested that psychosocial risk factors were worrisome over and above IC/BPS-specific symptoms and patient pain experience in predicting suicidal thinking in IC/BPS.

Depression.

While there is evidence that depressive symptomology is a consequence of experiencing chronic pain, it has also been shown to be a critical risk factor for the development of chronic pain conditions [12, 13]. Women with chronic pelvic pain experience significant levels of depression, with one study reporting more than 50% of their sample scoring above a clinical cutoff point [5]. Indeed, in a review of the research, depression was identified as an important risk factor among women experiencing recurrent pelvic pain [21]. Another study found that depression was the strongest multivariable predictor of suicidal ideation over and above IC/BPS pain and symptoms [20].

Anxiety.

Similar to depression, anxiety can be conceptualized as both a risk factor for, and consequence of chronic pain [12,13], with a similar pattern found for chronic pelvic pain. Anxiety symptoms have been identified as a key risk factor for the development of noncyclical pelvic pain [21]. Further, the majority of a sample of women with chronic pelvic pain experienced anxiety symptoms that fell in the moderate to severe range [5].

Coping Style.

One’s pain coping style can either serve to be adaptive or maladaptive, playing an important predictive role for a patient’s prognosis [12, 13]. A sample of women with chronic pelvic pain reported low levels of pain self-efficacy and low confidence in their coping skills in areas such as their ability to manage without medication [5]. IC/BPS research on coping has shown that disability is mediated by the effect of depressed mood and catastrophizing, which are precursors of illness-focused coping [22]. Women’s negative thoughts about their illness in IC/BPS have been found to be associated with behavioral illness-focused coping (e.g., pain guarding, pain induced resting, asking for assistance), while thoughts that one is in control of their illness and treatment (e.g., illness self-efficacy) has been found to be associated with using wellness-focused coping for pain (e.g., exercising/stretching, positive coping self-talk, and relaxation) [15]. Based on these findings, coping style is crucial to assess, as it could play a major role in treatment success; thus, having an understanding of how patients cope with their pain could help guide effective symptom management plans.

Social Support.

In general, individuals with chronic pain who report greater levels of perceived social support tend to fare better [12]. However, individuals who receive solicitous support (i.e., someone takes over an activity and does it for them) actually tend to fare worse than those who do not receive this type of pain-behavior reinforcement [23]. In IC/BPS, women who receive “distraction” from their spouses when in pain report that distraction actually acts to “buffer” the deleterious effects of pain on their mental quality of life [24]. In an IBD sample, greater negative spousal responses and less perceived spousal support predicted poorer IBD-quality of life [25]. In this study, helplessness catastrophizing was a mediator, acting as a mechanism between both negative spousal responses and perceived spousal support with IBD-quality of life in two separate models. Thus, social interaction variables were associated with IBD-quality of life, but patients’ experience of helplessness reduced their ability to benefit from social support [25]. Disentangling the type and amount of social support a patient is receiving can have important clinical implications for their pain management.

Sexual Functioning.

Another functional consequence of chronic pelvic pain is sexual functioning difficulties [5]. Given the high prevalence and associated distress that comes along with sexual difficulties, it is a critical area of assessment for patients with chronic pelvic pain. In one sample, a majority of these women experienced pain during intercourse ranging from at least half of the time to almost always [5]. Of note, nearly half of their sample did not even attempt intercourse. Further, our group has found that sexual functioning, employment, and pain predicted mental and physical quality of life. In particular, sexual functioning was a primary predictor of mental quality of life in women with long-standing IC/BPS, suggesting that sexual functioning may be a salient therapeutic target in the multifaceted treatment of patients with IC/BPS [26]. These findings highlight the significant impact chronic pelvic pain has on women’s sexuality.

Taken together, the reviewed research highlights many pertinent psychosocial risk and maintenance factors that are important to consider in the assessment of patients with chronic pelvic pain. The purpose was to highlight the significant impact that these factors have on how patients feel and function, as well as how central these factors can be in the case conceptualization of a patient’s disease and prognosis. Proper assessment of these factors can contribute to better clinical outcomes for patients who suffer from chronic pelvic pain.