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Neuropathic & Pelvic Pain Pharmacotherapy

Systemic and topical pharmacotherapy for chronic pelvic pain (CPP), pudendal neuralgia, post-surgical neuropathic pain, IC/BPS pelvic-floor overlay, vulvodynia, and CP/CPPS. The treatment stack mirrors the broader neuropathic-pain framework — gabapentinoids and TCAs as first-line systemic agents, SNRIs as a second-line systemic option, NSAIDs as opioid-sparing analgesia, topical compounded agents for vulvodynia and provoked vestibulodynia, local anesthetics for nerve blocks and intravesical therapy, and antispasmodics for pelvic-floor myalgia.

For IC/BPS-specific oral and intravesical pharmacotherapy see Bladder Pain & IC/BPS. For pelvic-floor physical therapy and behavioral approaches see Pelvic Floor PT.

  • GabapentinoidsGabapentin and pregabalin. Neuropathic pelvic pain, pudendal neuralgia, vulvodynia, CP/CPPS. Pontari pregabalin RCT; Agarwal NNT 2.9 favoring gabapentin in CP/CPPS; the negative GaPP2 trial for women's chronic pelvic pain; perioperative meta-analyses; Hamed 41% sexual-dysfunction signal.
  • Tricyclic AntidepressantsAmitriptyline (workhorse), nortriptyline, imipramine. Eight urologic uses including IC/BPS (van Ophoven and Foster RCTs with the ≥ 50 mg/day efficacy threshold), childhood enuresis (imipramine — the only FDA-approved urologic TCA indication), low-dose doxepin for sleep-fragmentation nocturia, and urinary retention as the most common urologic ADR.
  • SNRIsDuloxetine, venlafaxine, milnacipran. Onuf's-nucleus mechanism for storage-phase sphincter facilitation; EU-approved for SUI but not US; PPUI bridge therapy with the Filocamo "U-turn" caveat; CP/CPPS (Zhang doxazosin + duloxetine vs sertraline); voiding-disorder OR 3.30 (Trinchieri).
  • NSAIDs & AnalgesicsIbuprofen, naproxen, celecoxib, acetaminophen, ketorolac. Renal-colic first-line; SKOPE RCT; the NOPIOIDS protocol (cystectomy / nephrectomy / RP) and ORIOLES 77% unused-opioid data; AUA expert-panel maximum-tablet table; phenazopyridine TRPM8 mechanism; nephrotoxicity considerations in the urologic patient.
  • Topical Compounded AgentsCompounded amitriptyline, baclofen, gabapentin, ketamine, lidocaine. Refractory vulvodynia and provoked vestibulodynia; topical delivery avoids systemic effects. Brutcher 2019 Ann Intern Med negative RCT context, then individual-agent evidence (Zolnoun overnight 5% lidocaine ointment, ACOG breast-cancer-survivor 4% aqueous, Mayo 85% amitriptyline-ketamine response).
  • Local AnestheticsLidocaine, bupivacaine, ropivacaine, mepivacaine. Twelve urologic domains — intraurethral jelly + cystoscopy, prostate biopsy network meta, intravesical lidocaine for IC/BPS (AUA Grade B), penile nerve block, vasectomy, PE topicals (Fortacin / EMLA), TAP block, retrograde stenting under LA, hydrodistension, plus a dedicated LAST safety section with the 20%-lipid-emulsion protocol.
  • AntispasmodicsDiazepam (vaginal suppository), cyclobenzaprine, baclofen. Pelvic-floor spasticity / levator ani syndrome; vaginal diazepam 2–10 mg suppository as the classic adjunct alongside pelvic-floor PT.