Small fiber neuropathy is present in 2/3rds of patients with complex pelvic pain (refractory pelvic pain or pelvic pain associated with multiple pain or autonomic syndromes at presentation) (1). Causes of pelvic pain can be difficult to diagnose and treat and can have significant impact on quality of life, with high financial burden. In this study we present insurance data inclusive of all diagnoses and charges for one year, including pharmacy, behavioral health, and emergency visits. Our data demonstrates treating pelvic pain comes with a high annual cost, more so with the addition of each associated autonomic symptom. Our hypothesis is that the array of symptomatology, represented in diagnostic codes, can help those presenting with pelvic pain and their providers identify associated diagnoses/redirect treatment paths.

Deidentified 2022-2023 data from a Northeastern private insurer or teachers and municipal workers was queried for Pelvic pain (R10.2) as well as 14 diagnoses associated with autonomic symptoms: Arrythmia (I49.9), Bowel - (K58.9), K59.00, K59.02), Fibromyalgia (M79.7), GERD (K21.9), Migraine - (G43.x), Palpitations (R00.2), Pelvic Pain (N30), Pelvic Pain (R10.2), Postural tachycardia syndrome (G90), Ringing in the ears (H93.19), Syncope and collapse (R55), Temporomandibular Joint pain (M26.609), Urinary Hesitancy (39.11). The average cost per patient with pelvic pain compared to those with small fiber neuropathy (SFN) and those without a diagnosis of SFN but with 3 or more autonomic symptoms.

The database included 4306 members with an average cost per member of $9,280. Average age was 35.5 years old, and 53% were female. Of the 4306, 200 (4.6%) had pelvic pain. 28 (0.65%) had pelvic pain in association with 3 or more autonomic symptoms. The average cost for this population was $117,598 per member per year, totaling $3,292,748. Of note, only one of these individuals had been diagnosed with SFN (annual expense $375,105). Those with SFN without pelvic pain (N=15) = $47,594, and all comers with SFN (N = 22) had annual expenditures of $63,929. (Table 1)

Small fiber neuropathy is an emerging diagnosis that is underdiagnosed. Autonomic and pain symptomatology, when evaluated as a symptom array, can suggest the diagnosis. Patients, clinicians, and payors should understand the importance of these symptom arrays to help patients arrive at the appropriate diagnosis early in the course. Not only will patients access the help they need, but costs are likely to decrease with more directed management.

Small fiber neuropathy is associated with multiple somatic and autonomic symptoms. These patients are likely to see pelvic health specialists due to the autonomic symptoms. Patients with symptom and diagnostic arrays suggestive of SFN should be recognized and offered access to multidisciplinary diagnosis and management.

Chen A, De E, Argoff C. Small Fiber Polyneuropathy Is Prevalent in Patients Experiencing Complex Chronic Pelvic Pain. Pain Med. 2019 Mar 1;20(3):521-527. doi: 10.1093/pm/pny001. PMID: 29447372.