Chronic Pelvic Pain

From: Helen Dynda (olddad66@runestone.net)
Mon Jan 29 22:10:13 2001


[]] Chronic Pelvic Pain

What is Chronic Pelvic Pain?

Pelvic pain is considered chronic when it lasts more than six months. Some patients with chronic pelvic pain go on to develop what is termed Chronic Pelvic Pain Syndrome, with emotional and behavioral changes due to the duration of the pain and stress produced by the discomfort. We have all been taught from infancy to avoid pain, so when pain is persistent and there seems to be no remedy, it creates tremendous tension. Most of us think of pain as being a symptom of tissue injury. However, in chronic pelvic pain almost always the tissue injury has ceased but the pain continues. This leads to a very important distinction between chronic pelvic pain and episodes of other pain that you might experience during your life: usually pain is a symptom, but in chronic pelvic pain, pain becomes the disease.

There are six basic characteristics of Chronic Pain Syndrome:

* Pain is present for six months or longer

* There is very little relief from conventional medical or surgical treatment

* Pain is not necessarily proportional to tissue damage

* Vegetative signs of depression (sleep disturbances, constipation, slow body movements) are present

* There are limitations of physical activity

* Emotional roles in the family are altered (wife, mother, partner, etc.)

Therefore, chronic pelvic pain is different from other pain that you may have experienced. There is no simple single answer to pain relief since the tissue damage has already occurred and usually ceased. Emotional changes over a long period of time, coupled with behavioral changes, may result in development of Chronic Pelvic Pain Syndrome. It is very important to realize that this pain is not psychological. The pain is not in your head and you are not crazy. The pain is real. The pain is usually not dangerous in a physical sense. All chronic pain is neither purely physical nor purely psychological. Rather, due to the chronic nature, it is physical and psychological.

Elements of Chronic Pelvic Pain and Pain Management

There are three basic elements important to the management of chronic pelvic pain:

1.) The pathology at the site of origin.

If the pathology in the pelvis that is stimulating the nerve fibers is not dealt with, pain will continue. Our bodies have visceral and somatic nerves. Visceral nerves innervate the intra-abdominal and thoracic structures. Somatic nerves innervate muscles, skin, and superficial tissues. Specialized nerve endings in the visceral, or autonomic nervous system, transmit the pain from the site of origin to the spinal cord and if tissue injury persists, these nerves will continue to be stimulated.

2.) Antidromic pain or referred pain.

Antidromic pain is pain that is referred to the abdominal wall or superficial tissues (subcutaneous fat, fascia, muscles) that will develop after visceral nerves have been stimulated over a long period of time. The reason for this is that the visceral nerves synapse on the same nerve cell in the spinal cord that the somatic nerves synapse. After chronic stimulation of the visceral nerves, the somatic nerves will transmit the electrochemical impulse in a reverse manner down the nerve cells to the periphery and cause tender areas to develop in the abdominal wall and superficial tissues. This is what is called trigger points or referred pain. Many patients with chronic pelvic pain will have this as their primary source of pain.

3.) Central modulation by the brain.

The patient's mood and behavior that is produced through their brain then modifies the perception of pain by either inhibition or increasing sensitivity. This is a central modulation that must be managed at the same time the pathology at the site of origin and antidromic pain is being treated. When dealing with chronic pelvic pain, all three components must be treated at the same time for best results. Therefore, the treatment goals include: treating the pelvic pathology, treating the antidromic and central modulation components of pain, and training the patient to control the pain rather than allowing the pain to control the patient. Physicians need to be aware that there is rarely one single or simple cause for the pain and that simultaneous evaluation and treatment of contributing factors must take place. It is impossible to determine the amount of pain due to each factor. As a physician, this requires a different approach to our history and physical examination, diagnostic testing, medications management, and surgical management.

On taking a history, we are interested in the pattern of pain (where it hurts), the intensity of the pain, and what activities will increase or decrease the pain. We also need to know how and when the pain developed, what type of body changes have occurred because of the pain such as back pain, joint pain, muscle pain, or constipation. We also need to know what previous diagnostic tests have been done so these will not be repeated. We also need to know what type of response was had to previous treatments. You will be asked to complete a pelvic grid which gives you a chance to specifically point out in which areas in the pelvis you sense pain. This is very helpful, because it tells us what nerve areas and what level of the spinal cord we are dealing with. Very often patients are able to exactly pinpoint the pain for us by carefully marking which body areas are involved.

Occasionally, nerve entrapment pain will be present. The ilioinguinal and the iliohypogastric nerves that run in a downward fashion from the hipbone toward the vulva are involved in chronic pain. These nerves either become sensitive due to antidromic pain or they have been trapped by old scar tissue. Your physical examination will delineate this as we look for trigger points. Trigger points can be discovered by distinguishing deep areas of tenderness from superficial areas of tenderness in the abdominal wall. The "head raising test" allows us to press on skin, muscle, and subcutaneous tissue without putting pressure on the internal organs. If tenderness is present while raising the head, the source of the pain is somatic rather than visceral and trigger points can be delineated and marked by lightly pressing over the distribution of the nerves involved.

Once these trigger points have been delineated, injection with local anesthetic and a certain type of neuromuscular massage called Myofascial Release can desensitize these areas and lead to significant pain relief. Also, anti-inflammatories such as nonsteroidal anti-inflammatory drugs (Toradol, Relafen, Daypro, Trilisate, etc.) can afford some relief. Certain trigger points that are neuromuscular can also be injected with steroids that decrease their sensitivity. Some patients will positively respond to transcutaneous electrical nerve stimulation (TENS) units and we will determine whether the pain would respond to this type of therapy. Occasionally, abdominal and pelvic hernias may be responsible for the pain and these will be checked at the time of examination.

Vestibulitis is a common component of pelvic pain. The vestibular glands are just on the very outer aspect of the vagina inside the minor lips of the vulva. We will check for tenderness in this area and treat when appropriate. The most common symptoms this produces is painful intercourse, specifically pain on penetration. Also, the pelvic floor muscles can be in spasm and these will be examined carefully with each muscle palpated separately to gain some idea about how tender and spastic they are. Specific therapy for this pelvic floor myalgia may be instituted. One of the pelvic muscles most commonly affected is the piriformis muscle. This muscle lies high in the pelvis and can be palpated with some difficulty through the birth canal. If this muscle is in spasm, specific physical therapy exercises will be instituted. Most patients who have piriformis spasm will experience pain in their buttocks and down the back of the leg, as well as discomfort with intercourse. Palpation of the area behind the uterus and in the rectum to search for endometriosis will also be performed at the time of physical examination.

Certain diagnostic studies such as ultrasound and plain x-rays are not very helpful in delineating the cause of chronic pelvic pain since they will not pick up endometriosis or adhesions, which are two of the most common causes of chronic pelvic pain. Occasionally, a CT scan or MRI will be done for the purpose of determining nerve compressions or spinal problems that might contribute to the pelvic pain. Cystoscopy is often necessary by a urologist if history and physical indicate bladder pathology as a potential contributing factor to the pelvic pain.

The most important diagnostic test for chronic pain is Laparoscopy. The purpose would be to discover any endometriosis, adhesions, or other pathology at the site of origin in order to correct it. This can be done either with a small needle-like laparoscope in the office or under general anesthesia as an outpatient. In certain cases, patients might undergo operative laparoscopy with neuroablative procedures such as LUNA (Laparoscopic Uterosacral Nerve Ablation), interrupting nerves from the womb, LPSN (Laparoscopic Presacral Neurectomy), interrupting a nerve from transmitting pain from the midline of the pelvis, or LUVE (Laparoscopic Uterovaginal Ganglion Excision), interrupting nerves lying on each side of the cervix. It is important to remember that pain is not proportional to tissue damage. Therefore, surgery is only part of an overall treatment plan.

Medical therapy is instituted usually before surgery in order to obtain as much relief as possible. This usually will include nonsteroidal and anti-inflammatory drugs anti-depressants, and vitamin supplementation. There will also be recommendation for decreasing the stomach acidity through medication that would protect against ulcer formation from the nonsteroidal anti-inflammatory drugs. The principle of medical management includes multiple medications in order to maximize symptomatic relief. This is called drug stacking and pain control treatment. Narcotics are rarely, if ever, used in order to prevent any dependency from developing. For the same reason anxiolytics, such as Valium and Xanax are not used because they rarely contribute to pain control and can become habit forming.

You will take the medicine at an appointed time, independent of the degree of pain you are experiencing. This is called time contingent dosing. It has been shown to be much more effective in controlling chronic pain than taking it on an as-needed basis. It is important that you follow explicitly the directions for each medication and not change your medicine or time of dosage without checking with your doctor first. If you are running low on medication, please be sure to let us know at the time of your appointment so you will not have to call in for medicine. Always stay a little ahead with each medication and have enough to get you to your next appointment. It is our policy not to phone medication in to your pharmacist unless it is a true emergency. In that case, you are usually directed to go to the emergency room. Please report any adverse reactions to the medications so that we can modify them if necessary.

Physical therapy is also a very important part of recovery from chronic pelvic pain. General posture, strengthening exercises, and flexibility need to be evaluated and treated. Low back exercises are often necessary as well as piriformis stretching in order to maximize your recovery. If pain relief is being obtained, but no attention is given to muscle conditioning, as soon as you begin to be more active you will have an increase in pain. We want to prevent this from happening through physical therapy. Psychological support, behavior modification, and biofeedback are a very important part of treating the chronic pain syndrome. We will recommend such treatment at the appropriate stage of your recovery.

In summary, our treatment principles include: treatment of all components simultaneously, gradually tapering off treatment as pain lessens, and seeing our patients on regular office visits. It is important to keep your appointment. If you are not seen at the intervals prescribed, your recovery will be much slower and might even be jeopardized.

We wish to speak with family members during the course of your treatment in order to let them know what contributing factors we have found and keep them abreast of your progress. It is very important for your recovery to have family support. If they understand this is a physical problem and that we are in the process of rehabilitation, it will make your job much easier.

It is very important that we have realistic expectations when dealing with chronic pelvic pain. The pain has occurred over a long period of time and will not go away in a short period of time. Your recovery will be a process. Many modes of therapy will be used over the course of your treatment. We regard management of your pain as success. If we can have our patients functioning with low levels of discomfort, resuming their roles as wives and mothers without narcotics, we consider our therapy successful.

Our Understanding of Pain

The old theories of pain transmission which were believed before 1965 were inadequate to explain our observations and the clinical presentations of patients with pain. These older theories were based on the Cartesian Theory. It simply stated that there was a network of fibers from nerve endings in the skin and other tissues which transmitted pain to the spinal cord and then on to the higher centers of the brain. The brain then interpreted this pain and led us to react to it. We have learned that pain production and perception are much more complex.

In 1965, researchers Melzack and Wall proposed the theory called Gate Control. This theory is more accurate anatomically and physiologically. It explains many of the reasons why chronic pain is so difficult to treat. A simplified statement of this theory is that nerve endings transmit pain impulses from the periphery to the spinal cord and synapse or connect there to another nerve cell that, in turn, transmits the impulse to a control transmission cell in the spinal cord. This, in turn, synapses with other nerve cells in the higher brain centers of the thalamus and on to the nerve cells in the cerebral cortex. At each one of these synapses or connections, there is a gate.

The gate can be opened or closed. If the gate is closed, transmission will cease. If the gate is partially closed, then only a portion of the pain impulse will be transmitted. Correspondingly, if the gate is open, transmission will proceed. Part of what may happen in chronic pain is that these gates remain open even after tissue damage has been repaired. For example, this allows us to explain the presentations of chronic pain patients with neuropathic pain, which is persistent pain after injury to a major nerve due to continued transmission of pain impulses from the nerve even after it has healed. In the treatment of chronic pain, one of our challenges is to close these gates.

There are actually four steps from tissue injury to subjective realization of pain:

1. Transduction

2. Transmission

3. Modulation

4. Perception

Transduction is the translation into neurochemical energy (the chemical reactions that occur in nerves to activate them) of the chemical, heat, or mechanical energy produced at the site of tissue damage. Next, the electrochemical impulse is transmitted through the nerve axon to the spinal cord. This is called transmission. As the impulse ascends to the brain, there are other impulses created in the brain and sent back down through the various areas of the mid-brain and spinal cord that will either increase or decrease the nerve threshold, thereby modifying how much pain is perceived. This is called modulation. As the nerve impulse finally reaches the cerebral cortex, subjective awareness of pain occurs. This is called perception.

Again, at each one of these steps, pain can be modified. An understanding of this neurophysical process helps us target our therapy both medically and surgically. If we feel that we can interrupt the transmission by certain neuroablative surgery (cutting the nerves or transmission lines), then this may be proposed. If we can modify the tissue injury and thereby prevent transduction, surgical therapy may also be indicated. This is why we must be certain that we have dealt with, for example, all endometriosis, scar tissue, and adhesions. If we can decrease the nerve sensitivity by influencing the modulation of pain either at the periphery or centrally, medical therapy such as nonsteroidal anti-inflammatory drugs or central nervous system modulators such as anti-depressants (e.g., amitriptyline) can be helpful.

We can see that according to the Gate Control Theory the transmission of pain impulse is a two-way street. The intensity of the pain may be modified in both directions; up from the periphery to the central nervous system and down from the central nervous system to the periphery.

Conclusion

We understand your suffering. It is our desire to alleviate your pain as quickly as possible. We will often ask you to undergo treatments that you might not wish to pursue. However, every measure that we take is well thought-out and has helped many patients. We see our treatment plan as a journey that we take together. Each time we institute therapy such as trigger point injections, neuromuscular massage, psychological support, or behavior modification, we have thoroughly thought out the implications of this and recommended treatment at a time we feel would be most beneficial to you. You can quit at any time. We are dedicated to your health without reservation. We will never abandon you. We always understand and believe you and will do everything possible to maintain your trust. Please feel free to discuss any areas you do not understand. Unless we have your confidence and trust, we will not be effective.

http://www.aarpc.com/pain/gyn/CPP.htm


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