Pelvic Pain

There are many possible reasons for one to experience ongoing pain in the bladder and genital area. The causes of pain and the perception of pain severity vary tremendously from person to person. Because there are so many structures that pass thru the pelvis it is often very difficult to determine the underlying source or multiple sources of the pain. Because both urologic and gynecologic sources may be involved it is very important to see the “whole picture” and not approach this only thru the eyes of a gynecologist or a urologist.

Some of the main pain categories include:

INTERSTITIAL CYSTITIS (IC)
IC is also known as the painful bladder syndrome. It affects women of all ages. In general, it feels like a bladder infection (UTI) that never seem to go away. It is often misdiagnosed as a recurrent UTI. Patients often experience pain in the mid lower pelvis and or in the vaginal area. In general, the pain is worse as the bladder becomes full. For some people it may be triggered by stress, certain foods (tomato based foods, spicy foods, acidic foods- certain juices) and by sexual intercourse. Patients typically must frequently urinate to help reduce the pain. The symptoms often increase and decrease over time for no apparent reason. The only way to help differentiate IC symptoms from those of a UTI is to have your urine sent to a laboratory for a culture (NOT an in the office urine analysis). There are many effective treatments for IC- unfortunately there is no standard treatment for everyone. Treatment becomes a process of trial and error to establish what treatment work specifically for you.

We have had tremendous success treating IC symptoms with various medications, bladder instillations, physical therapy / biofeedback and nerve blocks.

Here are some links you may find helpful for more information on IC:
The IC Network: http://www.ic-network.com/
Interstitial Cystitis Association: http://www.ichelp.org/

VULVODYNIA
This condition results in ongoing vaginal pain. The pain is often exacerbated by any contact to the vaginal area such as wearing tight clothing or sitting on a hard seat. It often times makes sexual intercourse very painful or impossible

Helpful links: http://www.nva.org/about_vulvodynia/what_is_vulvodynia.html

LEVATOR SYNDROME (pelvic floor dysfunction) This condition is thought to be caused by spasms in the pelvic floor muscles. These muscle spasm results in ongoing vaginal pain that is often felt deep in the vagina or at the bladder. Stress, sexual intercourse, a full bladder, constipation or any of the many pelvic pain syndromes often exacerbates it. In addition to pain, the tightening of the pelvic floor (levator) muscles may make it difficult to pass urine and stool.

ENDOMETRIOSIS This condition often results in either constant pain or more commonly pain that fluctuates with the menstrual cycle. It is believed to be caused by abnormal deposits of endometrium (the hormone sensitive lining of the uterus) throughout the pelvis. The endometrial tissue may even deposit in the bladder and cause you to have blood in your urine at the time of your period.

Helpful links: http://www.endometriosis.org/endometriosis.html

URETHRITIS / URETHRAL SYNDROME Pain that originates from the urethra- often results in burning during urination and sexual intercourse. Again, the symptoms may be similar to those of a UTI however the urine culture is negative.

Helpful links: http://www.emedicine.com/med/topic3081.htm

URETHRAL DIVERTICULUM The urethra is the tube that carries urine from the bladder out of your body. A diverticulum is an out pouching or a pocket that forms in the urethra. It may present as a firm mass protruding from the vagina. It is associated with causing pain during sexual intercourse, recurrent UTIs and dribbling urine when you stand after urinating (post void dribbling). If they are symptomatic that may be treated surgically. In many cases they found during a gynecological exam and otherwise do not cause any symptoms- these can be left alone.

PUDENDAL NEURALGIA (PN)/ NEUROPATHIC PAIN

The pudendal nerve is the main nerve innervating the perineum. It carries sensation from the external genitalia of both sexes as well as the skin around the anus and perineum. It also supplies the motor innervation to various pelvic muscles, including the external urethral sphincter and the external anal sphincter.

The pudendal nerve is paired, one on the left and one on the right side of the body. Each is formed as three roots. The three roots are derived from the ventral rami of the second, third, and fourth sacral spinal nerves, with the primary contribution coming from the fourth. Inside the pudendal canal, the nerve divides into branches, first giving off the inferior rectal nerve, then the perineal nerve, before continuing as the dorsal nerve of the penis (in males) or the dorsal nerve of the clitoris (in females).

Pudendal neuropathy can occur in men and women although about 2/3 of patients are female. It is considered rare and many doctors are just now becoming aware of this illness. Sometimes it is referred to as cyclist’s syndrome, pudendal canal syndrome, or Alcock’s syndrome. Pudendal neuropathy can have similar symptoms to another disease or be misdiagnosed as another disease. Those most often associated with or confused with PN are chronic non-bacterial prostatitis, levator ani syndrome, proctalgia fugax, interstitial cystitis, vulvodynia, vestibulitis, chronic pelvic pain syndrome, hemorrhoids, piriformis syndrome, coccydynia, ischial bursitis, idiopathic (of unknown cause) orchialgia, or idiopathic prostadynia.

The pudendal nerve has both motor and sensory functions. The pudendal nerve can be compressed or stretched, resulting in temporary or permanent neuropathy.

If the pelvic floor is over-stretched, acutely (e.g. prolonged or difficult childbirth) or chronically (e.g. chronic straining during defecation caused by constipation), the pudendal nerve is vulnerable to stretch-induced neuropathy. Pudendal nerve entrapment, also known as Alcock canal syndrome, is very rare and is associated with professional cycling. Systemic diseases such as diabetes and multiple sclerosis can damage the pudendal nerve via demyelination or other mechanisms.

Possible Causes of PN
There is no one cause of pudendal neuralgia. It may be related to:

Symptoms
The main symptom of PN is pain. This can be highly variable Possible symptoms include burning, numbness, increased sensitivity, electric shock or stabbing pain, knife-like or aching pain, feeling of a lump or foreign body in the vagina or rectum, twisting or pinching, abnormal temperature sensations, hot poker sensation, constipation, pain and straining with bowel movements, straining or burning when urinating, painful intercourse, and sexual dysfunction – persistent genital arousal disorder (genital arousal without desire) or the opposite problem - loss of sensation.

Diagnosis
The diagnosis is usually made based on the patient’s symptoms, history, and exclusion of other illnesses such as infection or tumor. While no test is 100% accurate some of the more commonly used tests are the pudendal nerve motor latency test (PNMLT), electromyography (EMG), diagnostic nerve blocks, 3T MRI using special software and settings, and magnetic resonance neurography (MRN).

The final diagnosis of pudendal neuralgia is based on a person having several or all of these criteria:

  1. Typical PN symptoms
  2. An abnormal electro physiological test
  3. A positive response to the nerve block
  4. A distinct abnormality on a 3T MRI or an MRN
  5. Pain elicited upon pressing along the course of the nerve
  6. Elimination of other diseases being the cause

Treatment Options

Anatomy video link: https://vimeo.com/40977886

Pictures

Pudendal nerve diagram
Pudendal nerve diagram
Pudendal nerve innervation of female external genitalia