How to Cure Chronic Pelvic Pain
Usually, patients with low-grade serous carcinomas have an indolent course that might last as long as 20 years (9,10). Approximately 50 of patients with low-grade serous carcinoma ultimately succumb to their disease because of widespread intraabdominal carcinomatosis. But the tumor generally maintains its low-grade appearance and low proliferative index throughout its course (10). This contrasts with high-grade serous carcinoma, which presents as an aggressive neoplasm that spreads rapidly and is associated with a poor outcome. Analysis of nonserous ovarian tumors including muci-nous, endometrioid, clear cell carcinomas, and malignant Brenner tumors reveal that they are often associated with cystadenomas, borderline tumors, and intraepithelial carcinomas (2). Furthermore, it has been long recognized that endometrioid carcinoma and clear cell carcinoma are associated with endometriosis in the ovary or pelvis in 15-50 of cases (11,12). This finding suggests that endometriosis is a...
The clinicopathological observations described earlier, provide the basis for a proposed model of ovarian carcinogenesis, in which there are two main pathways, corresponding to type I and type II tumors. The tumor types, putative precursor lesions and associated molecular genetic alterations are summarized in Table 1. It should be emphasized that the terms, type I and type II, refer to tumorigenic pathways and are not specific histopathological terms. Type I tumors (low-grade serous carcinoma, mucinous carcinoma, endometrioid carcinoma, malignant Brenner tumor, and clear cell carcinoma) develop in a stepwise fashion from well-recognized precursors, namely borderline tumors, which in turn, develop from cystadenomas adenofibromas (Fig. 1 Table 1) (14). The benign tumors appear to develop from the surface epithelium or inclusion cysts in the case of serous and mucinous tumors and from endometriosis or endometri-omas in the case of endometrioid and clear cell tumors. Type I tumors are...
Serous cystadenoma adenofibroma Atypical proliferative serous tumor Intraepithelial low-grade carcinoma Mucinous cystadenoma Atypical proliferative mucinous tumor Intraepithelial carcinoma Endometriosis Endometrioid adenofibroma Atypical proliferative endometrioid tumor Endometriosis The stepwise progression of type I carcinomas closely simulates the adenoma-carcinoma sequence in colorectal cancer. In mucinous carcinoma for example, morphological transitions from cystadenoma to an atypical proliferative tumor, to intraepithelial carcinoma, and invasive carcinoma have been recognized for some time. Also, an increasing frequency of KRAS mutations at codons 12 and 13 has been described in cystadenomas, borderline tumors, and mucinous carcinomas, respectively (45-49). In addition, mucinous carcinoma, and the adjacent mucinous cystadenoma, and borderline tumor share the same KRAS mutation (45). Similarly, in endometrioid carcinomas, mutation of p-catenin has been reported in approximately...
In the 1800s,Hugh Lenox Hodge designed the lever pessary to treat uterine retroversion thought to be a cause of pelvic pain.1 As modifications of the lever pessary were made, other indications were proposed for its use. In 1961,Vitsky2 suggested that cervical incompetence was attributable to a lack of central uterine support. Uterine retroversion has also been associated with infertility and pelvic pain. Placing a lever pessary would displace the cervix posteriorly, thus lifting the weight of the uterus off of the incompetent cervix. Women diagnosed with an incompetent cervix were treated during pregnancy with a Hodge pessary from 14 to 38 weeks' gestation, with an 83 success rate.3 Currently, cervical cerclage is the treatment of choice for women with cervical incompetence. There is great controversy regarding the possible causative role of uterine retroversion in many gynecologic conditions including pelvic pain, infertility, and sexual dysfunction.
These symptoms occur in a subset of patients. In some of these cases, the surgery was undertaken in an attempt to relieve refractory symptoms that subsequently proved to be functional or medically unexplained in the first place. This often occurs with hysterectomies performed to relieve pelvic pain and in some patients who undergo surgery to relieve chronic back pain. In other cases, persistent disproportionate symptoms may be perpetuated by secondary gain of a financial or social nature, or by opiate dependence. Undiagnosed and untreated mood and anxiety disorders, and somatoform disorders, may also contribute to persistent symptoms. The consultation psychiatrist may be called upon to identify these factors and to help distinguish these factors from undetected medical surgical pathology or inadequate pain regimens.
More than 9 million women have pelvic pain, and their management entails more than 2.8 billion in direct and greater than 555 million in indirect costs.1 The prevalence of chronic pelvic pain (CPP) in women is approximately 3.8 . Chronic pelvic pain is a symptom, not a disease, and it rarely reflects a single pathologic process.Various pelvic floor structures and disorders may be the cause of CPP.The origin of pain may be or psychological. Therefore, systemic evaluation, and different and combined therapies are required for patients with CPP.Therapies include invasive and noninvasive modalities. Noninvasive therapies include behavioral therapy, nutrition, physical therapy, and acupunc-ture.Dietary modification might help,because certain types of food,such as acidic foods,caffeine, and alcohol are common triggers for interstitial cystitis and irritable bowel syndrome. Pain in the patients with these diseases might respond to an appropriate change in diet. Pharmacologic therapies...
Genital prolapse by itself is not usually relevant to the symptoms of IC but may coexist. A rectal examination should assess for other sources of perineal pain such as anal fissure, and the presence of masses. Rectovaginal and bimanual examinations may reveal masses or implants suggestive of endometriosis. In the classic IC patient, palpation of the anterior wall reveals a tender bladder base pelvic floor muscle spasm and tenderness are also usually found. Occasionally trigger points may be found along the levator ani muscles.
Endometriosis is characterized by cyclical pain, usually beginning prior to menses. Deep dyspareunia and sacral backache with menses are common. B. Infertility is a frequent consequence of endometriosis. Premenstrual tenesmus or diarrhea may indicate rectosigmoid endometriosis. Cyclic dysuria or hematuria may indicate bladder endometriosis. D. Ultrasound may identify adnexal masses. Endometriosis can be definitively diagnosed only by laparoscopy.
Pelvic pain is particularly difficult to manage because it is often vague, poorly localized, and tends to be bilateral or to cross the midline. Thus, a systematic approach to pelvic pain is the best approach. A careful review of history and physical examination may give a clue about the source and type of pain. Cooperation with a specialist in gynecology, urology, or colorectal surgery is helpful in identifying the most likely location of the painful stimulus during a directed pelvic examination. A. Superior hypogastric plexus block Specifically useful for pelvic pain arising from the uterus and upper vagina, bladder, prostate, urethra, seminal vesicles, testes, and ovaries pelvic pain secondary to radiation sympathetically maintained pain (e.g., after rectal anastomosis, abdominoperineal resection, etc.) and chronic pelvic inflammatory processes.1
Obturator neuropathy is an uncommon mononeu-ropathy usually associated with a well-defined event or an invasive procedure.75 There have been several isolated case reports of obturator nerve injury due to compressive causes and entrapment. Obturator nerve injury has been reported after retroperitoneal hemorrhage, after fractures of the pelvis, invading pelvic tumors, endometriosis, and after aneurysms of the hy-pogastric artery and obturator hernias.76-79 It has also been described after procedures such as total hip replacement, forceps vaginal delivery, urologic surgery, and prolonged positioning in the lithotomy posi-tion.80-83 The insult to the obturator nerve in these isolated cases is apparent from the clinical history and description. The etiology of obturator neuropathy without such external insults is much more uncertain. Until recently there have been no athletic or sports-related cases reported. Bradshaw and col-leagues36 reported their observations on 32 surgical cases of...
Osteitis pubis is not only a diagnostic problem but also a therapeutic dilemma often requiring a multi-disciplinary approach. Making the diagnosis of osteitis pubis is not particularly difficult when the radiographs corroborate the diagnosis. However, the physician is faced with a difficult diagnostic challenge when an athlete presents with groin pain and nondiagnostic radiographs, especially if the symptoms are chronic. In this particular clinical setting, a referral to a general surgeon to rule out an inguinal hernia, spermatic cord problems, abdominal wall defects, and other urologic conditions is warranted. And, in the female athlete, a gynecologist referral to evaluate for conditions such as ovarian cysts, endometriosis, and pelvic inflammatory disease is appropriate.
Endometriosis Endometriosis is the abnormal growth of endometrial tissue at ectopic sites in the peritoneal cavity. It is a major cause of infertility in women of reproductive age, as well as of severe pelvic pain. Establishment of the lesions presumably requires their ability to revascularize at ectopic sites. A wide range of studies have implicated VEGF in this. The increase in VEGF expression in the superficial endometrium just prior to shedding during menstruation may make fragments that enter the peritoneal cavity prone to implantation there 10 . Estrogen, relaxin, and hypoxia could all be involved in the regulation of VEGF expression by endometriotic tissue. Uterine cancer Expression of VEGF is significantly increased in most tumors, including uterine cancers. Circulating levels of VEGF even correlate with uterine tumor stage and burden. This strongly suggests that VEGF is an important angiogenic factor in endometrial carcinoma. Inhibition of VEGF action is being actively...
Titus-Ernstoff, C.C. Hsieh, A. Hanberg, J. Baron, Trichopoulos, H.O. Adami, Organochlorine compounds in relation to breast cancer, endometrial cancer and endometriosis an assessment of the biological and epidemiological evidence, Crit. Rev. Toxicol. 25, 463-531 (1995).
Pelvic floor dysfunction and, in particular, pelvic pain, represents as much a dilemma for TCM acupuncture as it does for Western medicine. Precise diagnoses are difficult to differentiate. Indeed, every medical condition mentioned in this book can cause pelvic dysfunction in male and females. Acupuncture does have a role in the treatment of these patients. Fortunately, the TCM acupuncture approach is a much broader diagnostic system and therefore the available treatments will work theoretically for most conditions in the general pelvic region. Symptoms are just as important as a diagnosis, as is the patient's overall health and well-being to form a holistic picture of the disease or distress. Modern randomized clinical trial studies have been done investigating acupuncture for a variety of pelvic dysfunctions. However, there is still only a limited number of such studies. The largest number of trials concern the syndrome of interstitial cystitis.1-6 Then, there are generalized pelvic...
Functional BOO is a condition, that deserves further attention. Terms such as female aseptic dysuria, female prostatitis, abacterial cystitis, and, most often, the urethral syndrome have been used to describe this condition in the literature.16,17 Such variation in terms reflects both the common symptoms among these patients (recurrent episodes of urinary frequency, urgency, and dysuria without pelvic pain) and the lack of consensus over the etiology and pathophysiology of this condition. Some authors suggest that the urethral syndrome is probably the most frequent reason for urological consultation among
Endometriosis Endometriosis is abnormal growth of endometrial tissue in the peritoneal cavity. Women with this disorder have dysmenorrhea, dyspareunia, chronic pelvic pain, and infertility. Danazol (Danocrine) is a 2,3-isoxazol derivative of 17a-ethynyl testosterone (ethisterone) that has weak virilizing and protein anabolic properties. It is effective in endometriosis through its negative feedback
Agents that interfere with the development of the reproductive system and the normal hormonal patterns necessary to regulate development may alter the intricate processes involved in a number of different ways. For example, the normal structure of the ovaries, uterus, oviducts, cervix, and vagina can be altered during development, resulting in interference with fertility and pregnancy. This was the case with the drug diethylstilbestrol (DES), a potent synthetic estrogen used in the 1950s and 1960s to prevent spontaneous abortion. Unfortunately, the drug was not effective in preventing labor but had profound effects on the development of the reproductive system in both boys and girls exposed before birth and produced a rare form of cancer (vaginal adenocarcinoma) in females not detected until after puberty (28). Synthetic androgens and antiandrogens also alter the structure of reproductive organs by interfering with the normal hormonal milieu during development. For example, ethinyl...
Gonadotrophin-releasing hormone receptors (GnRH and LHRH) are found in cancers of reproductive tissues, including those of the prostate, ovarian, and breast, and gonadotrophin-releasing hormone can inhibit growth of cell lines derived from such cancers. A radiolabeled LHRH ligand could be useful in diagnosing diseases that produce high levels of LHRH-receptors, such as ovarian cancer, endometriosis, uterine carcinoma, and prostate cancer.
Ogy other than pelvic prolapse, such as recurrent infections, pelvic pain, and urethral pain. Another limitation is that a collapsed rectocele may not be visualized because of competition among prolapsing pelvic organs for limited introital space. In fact, physical examination has been shown to be slightly more accurate in demonstrating rec-tocele formation than MRI. Additionally, the study must be performed supine, simply because there are no upright MRI machines available at this time. However, dynamic MRI with relaxing and straining views has been shown to clearly demonstrate organ prolapse during straining in the supine position. An erect MRI is the next logical advancement. Finally, claustrophobic patients and those with cardiac pacemakers cannot go into the enclosed magnet. Despite these limitations, dynamic MRI has become the study of choice at our institution for evaluating high-grade pelvic prolapse and pelvic floor relaxation. Because this is a new technique, a standardized...
In women, GnRH agonists are sometimes given along with FSH when stimulating follicles in fertility treatments this addition prevents premature ovulation caused by the release of pituitary LH. Uterine leiomy-omas and endometriosis regress when gonadotropin secretion is decreased. GnRH analogues relieve these conditions, but the relief usually lasts only as long as the analogue is administered, and the condition generally returns within a few months after therapy ceases. The main side effects are a result of estradiol deprivation
Athletic pubalgia in female athletes is very rare. Although the exact reason for this is unknown, it is hypothesized that anatomic differences in the pelvis may play a major role. Although athletic pubalgia is a possible cause of groin pain in women, endometriosis- Other sources of groin pain in women have been noted to be ovarian cystic disease, pelvic inflammatory disease, symptomatic Crohn's disease, and men-strually cyclical nonexertional pain that was without a known cause. It has also been suggested that with a direct connection between the uterus and frequent finding of endometriosis embedded in the round ligament that traction has something to do with the accompanying pain. If one of these pathologies is suspected, then laparoscopy is suggested to confirm and correct any abnormality that may be present.
Many patients are more obsessed by the associated nonspecific symptoms of bloating, abdominal and pelvic pain, and nausea. Therefore, objective scoring systems have been developed to better describe this difficult problem, as well as to obtain a universally objective definition of constipation. The Rome II criteria are the most widely accepted to define constipation (Chapter 7-4). However,the Rome II criteria do not qualify the severity of disease. Therefore, our constipation score is derived based on answers to questions in a symptom-based questionnaire (Table 14-2.5).13
An out-pouching of dura containing CSF may occur through a defect in the body of the sacrum (anterior spina bifida). This may be an isolated defect or may be in association with a more severe developmental abnormality of the whole caudal region of the embryo, as in caudal agenesis, where abnormalities of the genitourinary tract, rectum and anus may also occur in association with sacral agenesis. Presumably, the defect in the bone is the primary abnormality and, with the pressure of CSF, the meningocele gradually enlarges. The meningocele may contain sacral nerve roots. As the meningocele enlarges into the pelvis or retroperitoneal space, it produces symptoms of compression of the pelvic organs, including constipation, urinary frequency and abdominal or pelvic pain, as well as low back pain. Anterior sacral meningoceles are more common in females and may present as an incidental mass identified on pelvic examination or ultrasound. The diagnosis is
Dyspareunia is currently the only female sexual dysfunction in which organic factors are hypothesized to play a major role. Abarbanel (80) has devised a useful tripartite classification of medical aetiologies associated with dyspareunia anatomical, pathological, and iatrogenic. Anatomical factors comprise congenital or developmental impairments such as a rigid hymen or vaginal atrophy. Pathological factors include acute and chronic infections of the genital tract, such as endometriosis. Iatrogenic factors are conditions induced by a physician usually as a consequence of a surgical procedure such as episiotomy.
Duration, characteristics, and severity of the incontinence, precipitating factors and reversible causes should be assessed. Dysuria, urgency, pelvic pain, dyspareunia, constipation, fecal incontinence, pelvic prolapse, or abnormal vaginal discharge should be sought. A history of diabetes, thyroid disease, spinal cord injury, cerebral vascular accidents, urethral sphincter
Tarlov cysts are commonly seen in MRI studies of the lumbosacral spine. The cysts were described by Tarlov in 1938 and bear his name. In most instances the cysts are an incidental finding, have no clinical relevance, and are not responsible for the patient's symptoms. In a small number of patients, especially those with large cysts, symptoms such as back pain, radicular pain, and pelvic pain may be caused by the cysts.
It is important to note that CA-125 is not exclusive to ovarian cancer and is also elevated in 40 of patients with advanced non-ovarian intra-abdominal malignancy, as well as other abdomino-pelvic conditions such as liver cirrhosis, pancreatitis, endometriosis, pelvic inflammatory disease, pregnancy and also in 1 of healthy individuals.
Patients can present with many symptoms. These symptoms include urgency, frequency, pelvic pain, pelvic pressure, bladder spasm, dyspareunia, dysuria, awakening at night with pain, and pain that persists for many days after intercourse. The location of pain includes the vaginal area, the lower abdomen, suprapubic area, groin, or low back. Many symptoms are aggravated by menstruation and most of the patients believe that sexual intercourse exacerbates their symptoms.
Detrusor instability (urge incontinence) is defined as the involuntary loss of urine associated with a sudden and strong desire to void (urgency). Spontaneous uninhibited detrusor overactivity results in detrusor contractions. Patients with this condition complain of an inability to control voiding and experience a sudden urgency to void, which is sometimes unsuppressible. These patients report urinary frequency ( 7 times day), nocturia ( 1 time night), enuresis, and pelvic pain. Although detrusor instability is most often iatrogenic, secondary causes include urinary tract infection, anti-incontinence surgery, bladder stones or foreign bodies, and bladder cancer.
The incidence of athletic pubalgia in various sports is listed in decreasing order soccer, hockey, football, track and field, baseball, basketball, racquet sports, and swimming. It can be inferred that this type of injury occurs most commonly during the autumn sports. Also, more than 90 of the patients that we have diagnosed with athletic pubalgia have been male. Most female patients are found to have other causes for their pain, such as endometriosis.93 The precise explanation for the difference in gender incidence is not known. Two possible hypotheses for the higher incidence in male patients are (1) a relatively low participation (until recently) of women in highly competitive sports and (2) a difference in pelvic anatomy. Our thought is that the latter hypothesis is much more likely.
14 of cases in a series by Smith et al. (13). Fielding et al. reported noncalculus urinary pathology in 14 and nonurinary diagnoses in 11 of cases (14). Commonly encountered extraurinary causes for abdominal or pelvic pain including diverticu-litis, appendicitis, inflammatory bowel disease, ruptured abdominal aneurysm, and ovarian masses thought to have undergone torsion can all be detected with CT, as well as nonstone related urinary tract disorders such as pyelonephritis and renal masses (17).
Training for dyssynergia, incontinence, or pain begins with the systematic shaping of isolated pelvic muscle contractions. Observation of other accessory muscle use such as the gluteal or thighs during the session is discussed with the patient. Excessive pelvic muscle activity with an elevated resting tone more than 2 V may be associated with dyssynergia, voiding dysfunction, and pelvic pain. Jacob-son's progressive muscle relaxation strategy implicates that, after a muscle tenses, it automatically relaxes more deeply when released. This strategy is used to assist with hypertonia, placing emphasis on awareness of decreased muscle activity viewed on the screen as the PFM becomes more relaxed. This repetitive contract-relax sequence of isolated pelvic muscle contractions also facilitates discrimination between muscle tension and muscle relaxation. Some patients, usually women, have greater PFM descent with straining during defecation associated with difficulty in rectal expulsion....
Dysmenorrhea is a condition of painful menstruation and there are two classifications primary, which occurs soon after menstruation begins and declines with age and after childbirth and secondary, which develops later in life and is the result of endometriosis or other pelvic diseases. The development of cramps, when the uterus goes into spasm, is caused by high levels of hormonelike fatty acids called prostaglandins. Endometriosis develops when cells from the lining of the uterus migrate outside the uterus. These cells still respond to the monthly hormonal cycles and release blood during menses. However, the blood has nowhere to go and so the area becomes inflamed and painful. Uterine fibroids are benign muscle tumors produced when estrogen activity is high as they depend on estrogen for growth. They appear in pre-menopausal women and shrink at menopause and in the absence of estrogen replacement therapy. They do not turn malignant. Birth control pills add to estrogen levels in the...
Cancer of the anus, rectum, vagina, cervix, or uterus can give rise to rectovaginal fistulas. Leukemia, aplastic anemia, agranulocytosis, and endometriosis have also been implicated. Approach to these types of fistulas is dependent on the extent and stage of the disease. Malignant fistulas carry a poor prognosis. When surgical removal is not practical, they are treated palliatively with fecal diversion or endoluminal stenting. Therapy for
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.