How to Cure Chronic Pelvic Pain
Physical and sexual abuse have also been linked to somatiza-tion disorder. Walling et al. (1994) observed that childhood physical abuse was a better predictor of somatization disorder than other early traumatic experiences. Morrison (1989) reported that 55 of women with somatization disorder, compared with 16 of women with affective disorders, reported a history of sexual abuse. Regarding somatizing behavior more broadly, chronic pelvic pain and abdominal functional symptoms are more common in women who were sexually abused in childhood (Leser-
Considering the number of anatomic structures, there are many disease processes that cause pelvic and rectal pain. In some patients, no actual disease process can be identified. Table 39-2 describes a classification system that provides the clinician with a systematic approach to the diagnosis and management of pelvic pain syndromes. Organic Inflammatory Diseases That Affect the Pelvis and Anorectum Common anorectal disorders that present as perineal or pelvic pain readily lend themselves to diagnosis these include abscesses (cryptoglandular, intramuscular), fistulas, Crohn's disease, and ulcerative proctitis. These conditions must be excluded as the source of pelvic pain. In the male patient, chronic or acute prostatitis may present as rectal or pelvic pain. Urinary symptoms are often present and should be elicited in questioning. Digital rectal examination in men should always include careful prostatic palpation to exclude these conditions. Transrectal ultrasound may be helpful to...
The total cost of the most common STDs and their complications is conservatively estimated at 17 billion annually (USDHHS, 2000). Women generally suffer more serious STD complications than men, including pelvic inflammatory disease, ectopic pregnancy, infertility, chronic pelvic pain, and cervical cancer from the human papilloma virus (USDHHS, 2000).
Should be performed when the diagnosis is made to prevent too big a build up of menstrual blood, which may lead to a haematometra8 and consequent increased risk of endometriosis (secondary to retrograde menstruation). A transverse vaginal septum, due to failure of fusion or canalization between the M llerian tubercle and sino-vaginal bulb, may present like an imperfo-rate hymen but is associated with a pink bulge at the introitus as the septum is thicker than the hymen. Great care must be taken during surgery to prevent annular constriction rings and the procedure should only be performed in dedicated centres by experienced surgeons. When there is a transverse septum it has been found to be high in 46 per cent of patients, in the middle of the vagina in 40 per cent and low in the remaining 14 per cent. It is the patients in the last two groups who have higher pregnancy rates after surgery
The etiology of dysorgasmia is not well understood. It has been postulated that the physiologic bladder neck closure that occurs contemporaneous with orgasm in the men, translates into spasm of the vesico-urethral anastomosis, or pelvic floor musculature dystonia in the RP population. This phenomenon has been purported to be associated with penile and testicular pain in men with chronic pelvic pain disorder 21 . The latter group frequently reports orgasmic pain, and the similarity of the complaints between the two groups at this center are striking. The muscle spasm concept is supported by the experience that amelioration of dysorgasmia can be seen using the a-blocking agent tamsulosin (Boehinger-Ingelheim, Germany) 19 . In 98 patients, 77 patients reported improvement in pain and 8 noted complete resolution of their pain using tamsulosin, 0.4 mg po QD. Using a visual analog scale (0 to 10) for pain tamsulosin therapy resulted in a statistically significant decrease in pain, with a...
Fig. 6.5. (A) Bone scan shows extensive uptake in half of the pelvis in this patient with nocturnal pelvic pain. (B) Plain film shows coarse trabeculae over the acetabulum (black arrow) and a thickening of the iliopectineal line (white arrow), findings seen with Paget's disease. Fig. 6.5. (A) Bone scan shows extensive uptake in half of the pelvis in this patient with nocturnal pelvic pain. (B) Plain film shows coarse trabeculae over the acetabulum (black arrow) and a thickening of the iliopectineal line (white arrow), findings seen with Paget's disease.
In the female ovary, malignant tumours, endometrioid carcinomas, are thought to arise from foci of endometriosis and the majority of such endometriotic foci are clonal (Jimbo et al., 1997). Endometriosis arises either from implantation of shed endometrial cells, or from metaplasia of the pelvic peritoneum if patch size considerations can be excluded, this means from a single endometrial or mesothelial cell. Endometriotic foci can show aneuploidy and loss of heterozygosity at candidate tumour-suppressor loci in 9p, 11q and 22q. The derivative tumours, the endo-metrioid carcinomas, are clonally derived, arising from a monoclonal proliferation that itself can show genetic defects.
Untreated gonorrhea in women can develop into pelvic inflammatory disease (PID). About 1 million women each year in the United States develop PID. Women with PID do not necessarily have symptoms or signs. When symptoms or signs are present, they can be very severe and can include strong abdominal pain and fever. PID can lead to internal abscesses (pus pockets that are hard to cure), long-lasting pelvic pain, and infertility. PID can cause infertility or damage the fallopian tubes (egg canals) enough to increase the risk of ectopic pregnancy. Ectopic pregnancy is a life-threatening condition in which a fertilized egg grows outside the uterus, usually in a fallopian tube
If not adequately treated, 20 to 40 percent of women infected with chlamydia and 10-40 percent of women infected with gonorrhea develop upper genital tract infection, also called pelvic inflammatory disease (PID). Among women with PID, scarring will result in involuntary infertility in 20 percent, potentially fatal ectopic pregnancy in 9 percent, and chronic pelvic pain in 18 percent. Ectopic pregnancy is the leading cause of first trimester pregnancy-related deaths among American women. The ectopic pregnancy rate could be reduced by as much as 50 by early detection and treatment of STDs.
Aberrant avp3 integrin expression has been associated with endometriosis and may identify some women with decreased cycle fecundity due to defects in uterine receptivity.4041 Integrins and E-cadherins are involved in the shedding of endometrial tissue during menstruation and in the attachment of endometrial tissue fragments to the peritoneum.3040 Retrograde menstruation is considered an important factor in the development of endometriosis. Meyer et al.42 demonstrated that inflammatory hyd-rosalpinges adversely affect endometrial receptivity. The expression of avp3 integrin was less in the mid-luteal-phase endometrium of women with hydrosalpinges42 and of recurrent spontaneous abortors.43 In patients with polycystic ovarian syndrome (PCOS), the expression of avp3 was either delayed or absent in the endometrium.44 Lack or poor expression of some of the integrins in endometrial cells may lead to failure of embryo-endometrial interaction and implantation.20 This disruption of integrin...
Introversion and masculinity-femininity for males, and all scales except social introversion for females (59). A 1988 study of 25 women with chronic pelvic pain indicated that this group not only had more substance abuse problems than their controls, but had more somatization, adult sexual problems, reported history of sexual abuse, and depression (60,61). Others have reported similar associations between substance abuse and sexual physical abuse histories in chronic pelvic pain patients (62). Understanding how psychological perspectives develop, change over time (with and without effective treatment), and affect treatment success could provide valuable information for development of effective treatment programs.
As previously stated, proctalgia fugax, levator spasm, and pelvic pain can involve overlapping presentations. Pain syndromes may involve any or all of the structures of the pelvis. Disorders of the following organs or organ systems can lead to the complaint of pelvic pain. A complete assessment should exclude each of these as potential causes. An integrated approach may be required and may necessitate orthopedic, neurosurgery, gynecology, and urology consultation. Primary and secondary diseases of the pelvic girdle and the lower axial skeleton may present as pelvic pain. Trauma, inflammatory conditions, or malignancy can affect these supporting structures. Coccygodynia refers to primary coccygeal injury that causes pain localized to the coccyx. Used in this specific fashion, the term denotes a coccyx that is tender to touch and movement. Pelvic Musculature
Women have also reported undiagnosed and untreated pelvic pain. Of 55 women trafficked to Israel for sex work, 43 reported having had gynecologic problems during the previous five years (Cwikel, Ilan, and Chudakov, 2003). At the time of the interviews, 49 reported having current vaginal pain, 35 had pelvic pain, 31 experienced vaginal numbing, and an additional 27 had pelvic numbing.
Several visceral diseases may present with back pain as a chief symp-tom.5 These include nephrolithiasis, endometriosis, and abdominal aortic aneurysm. Abdominal aortic aneurysm causes low back pain by compression of surrounding tissues or by extension or rupture of the aneurysm. Patients report dull steady back pain unrelated to activity, which radiates to the hips or thighs. Patients with an acute rupture or extension of the aneurysm report severe tearing pain, diaphoresis, or syncope, and demonstrate signs of circulatory shock.29
Up to 40 of women with untreated chlamydia will develop PID. Undiagnosed PID caused by chlamydia is common. 20 of women with PID will become infertile 18 will experience debilitating, chronic pelvic pain and 9 will have a life-threatening tubal pregnancy. Tubal pregnancy is the leading cause of first-trimester, pregnancy-related deaths in American women.
Vaginismus is an involuntary spasm of the vaginal muscles that prevents penile penetration. Arousal and orgasm may be present, but penetration is impossible. This spasm is a conditioned response to the anticipation of pain with intercourse phobic avoidance of intercourse is often present. Etiology may include incidents of rape, painful attempts at coitus, vaginal and pelvic conditions that engender pain with sexual contact (vaginal infections, endometriosis,
Dyspareunia is similar to vaginismus in that there is pain associated with sexual intercourse however, the involuntary vaginal muscle spasm is absent. Dyspareunia may be caused by insufficient vaginal lubrication due to lack of sexual arousal, senile vaginitis, or reactions to medication. It may also result from gynecological disorders such as herpes, vaginal infection, endometriosis, rigid hymen, or hymeneal tags. When pain accompanies intercourse, anxiety results, arousal diminishes, and there is avoidance of sexual encounter. Complete physical and pelvic examinations are required in the assessment and treatment of dys-pareunia because of the many physical factors that could contribute to the pain.
Previous pelvic surgery can also produce pain in this region. Dissection of the pelvic floor during a low anterior resection of the rectum can produce mechanical trauma, which might result in pain in some patients, although the pain most likely is caused by an infection. Inflammatory conditions or malignancy of the prostate and seminal vesicles can be diagnosed in men by eliciting tenderness of these structures on digital rectal examination. In women, diseases of the vagina, uterus, fallopian tubes, or ovaries may present as pelvic pain. Careful inspection and bimanual examination of the female patient are critical to an accurate assessment of pelvic pain. Malignancy and inflammatory conditions of the lower alimentary tract may produce complaints of pain. Any condition that affects the cauda equina, roots S-2 through S-4, and the pudendal nerve can cause pelvic pain. Degenerative disease of the spine, primary or metastatic disease of the spine, primary or metastatic tumors, cysts, and...
Characterized syndrome and may be associated with benign prostatic hypertrophy (BPH), infection, or inflammation from acute prostatitis, chronic pro-statitis chronic pelvic pain syndrome, seminal vesi-culitis, seminal vesicular calculi, or ejaculatory duct obstruction, a treatable cause of male infertility 122-125 . Nickel reported that 18.6 of men with lower urinary tract symptoms (LUTS) diagnosed with clinical benign prostatic hyperplasia reported painful ejaculation 123 . Men with BPH and painful ejaculation have more severe LUTS and reported greater bother, and had a higher prevalence of erectile dysfunction and reduced ejaculation, than men with LUTS only 78 . Treatment of men with LUTS with a-blocking drugs may be associated with painful ejaculation. A lower incidence of pain has been reported with the uroselective a-1 blocking drug, alfuzosin 126 .
The hypothalamic-pituitary-adrenal axis (HPAA) has been of particular interest as the major pathway through which the brain responds to psychological stress. Corticotropin-releasing factor (CRF) from cells of the par-aventricular hypothalamus acts as a releasing hormone for adrenocorticotropin (ACTH) in the pituitary, and ACTH releases corticosteroids from the adrenal cortex. Cortico-steroids (cortisol, corticosterone) are essential for the body and allow psychological and physical adaptation to stressors. In addition, they exert a negative feedback on the release of CRF and ACTH. Disturbances of the HPAA are associated with both mental and physical illness. CRF can easily be activated by stress and promotes depression, anxiety, and other forms of behavioral pathology. By activating the autonomic nervous system, CRF further links psychological stress to gastrointestinal and cardiovascular disorders. Although homeostasis of the HPAA is maintained by negative feedback, permanently...
51 Tips for Dealing with Endometriosis
Do you have Endometriosis? Do you think you do, but aren’t sure? Are you having a hard time learning to cope? 51 Tips for Dealing with Endometriosis can help.