Pelvic Pain: Causes & Treatment

Pelvic Adhesive Disease (Adhesions)--Hidden Scars Take Their Toll

Whenever anyone has any surgery there is scarring. The only scar the patient sees is on the outside, but there are healing phenomena at work on the inside as well, resulting in internal scarring (adhesions). As a gynecological surgeon, much pelvic surgery I do is actually abdominal. Adhesions are an expected result, but fortunately there are usually no noticeable effects. Occasionally, however, a patient will present with pain from adhesions, the result of bowel or its fatty tissue sticking to pelvic or other abdominal organs, limiting the normal flexibility of their function. For instance, when feces or gas pass an area in the intestinal tract kinked or narrowed due to the distorting affects of adhesions, this area can become inflamed or painful.

There are several ways to treat the pain from adhesions. The best way is to just wait it out, because most symptoms will fade away over time. The main advantage in waiting is that surgery, a quick way to treat the adhesions by actually cutting these internal scars, freeing up the stuck structures, can actually lead to further adhesions. But sometimes surgery is the only answer.

When pain becomes so continuous or frequent that the patient can't enjoy any quality of life--exercise, sex, recreation, or work--and analgesics are being increased such that the patient is at risk for a narcotics problem, surgery needs to be offered. This is usually a joint decision between doctor and patient. The patient knows what she is feeling, and the doctor must be sure that all conservative options have been considered. Laparoscopy, placing a lighted tube into the navel, has been used in recent years to treat adhesions surgically. Laser and other specialized laparoscopic instruments can be used to break up the areas of internal scarring, restoring normal anatomy. The good thing about the laparoscope is that laparoscopy itself seems to cause very little adhesion formation.

When the adhesions are unusually severe or when important structures are involved, making an actual incision appropriate, attention is usually paid to meticulous technique, since most adhesions seem to develop due to tissue damage. It seems the actual healing process causes the adhesions; the damaged tissue seeks to seal itself off by joining to other sites. Two preventatives that have been used in the past are Hyskon and Intercede. Hyskon is a sugary substance left as a puddle in the abdomen, the internal tissues forced to slide around so they can't stick. Intercede is a cloth-like absorbable substance. Wrapped around traumatized structures, it converts to a gelatinous barrier to protect the tissue. These two and other techniques have had mixed success in preventing adhesions, so some doctors routine use them, others have discontinued using them.

The worst complication of adhesions is obstruction, the bowel being blocked, which is an emergency. This is rare as a result of GYN surgery, but no one has any special protection from complications. This is why I always run through my list of all scary possibilities before considering surgery on anyone. Is the surgery necessary? Is it indicated? If not, common sense directs us otherwise; but if so, the patient should have no unreasonable fear about surgery, because it is a legitimate therapy.

All medical management is based on risk versus benefit, and nothing exemplifies this more than treatment of adhesions.

Bladder Infections Are More Frequent In Women Than Men

Burning with urination is the classic symptom of a bladder infection, but this need not be present. Frequency of urination, urinary urgency, bloody urine, or abdominal pain may be present in addition to or instead of the burning. In fact, a bladder infection may masquerade under unrelated symptoms, meaning that if the diagnosis were made only with burning, many bladder infections would be missed.

Most infections in the childbearing period involve rectal bacteria. Two conditions of a woman's anatomy make this so: the rectum, the source for these bacteria, is very close to the opening of the urethra (the tube from which urine comes out); and the urethra itself is relatively short in women as compared to men, meaning germs have less distance to travel to get into and colonize the bladder. Tub baths can inundate the area around a woman's urethral opening with bacteria, and so women who mainly shower are less prone to suffer with this. Also, there are some women who wipe after bowel movements from back to front, causing the obvious contamination. Diet seems to play a role in the frequency of infections. Certainly, making the urine more acid makes the bladder more hostile to bacteria, so there is absolute truth to the cranberry juice remedy. Also, some blockage or foreign body, like a stone, will cause retention of urine or act like a foreign body, and any retained puddles of body fluid or a foreign body make a woman more prone to infection. The mechanical act of intercourse can drive bacteria into the opening of the urethra, so I always recommend that a woman empty her bladder before and after intercourse.

Sometimes the bladder can be irritated without actually being infected. This is a sterile cystitis. Trauma from intercourse, chemicals (medicines), and diet can trigger it. A urine culture will come up negative, and anti-inflammatories can be used. Pyridium, Urimar-T, and Urised--topical anesthetics--are taken as pills and are filtered by the kidneys to the bladder to bathe the inside walls to numb the misery.

But antibiotics are the best treatment for actual infections. Nowadays, a urine sample can be observed (cultured) for a period of time to see exactly what bacteria grow out of it. Then the specific infection can be tested against all of the applicable antibiotics. If a patient doesn't do well on a certain antibiotic, the culture can play a critical role in determining whether there is a resistance and whether the prescription should be changed. This is why it is important to get a culture before taking any medicine. Taking a couple of pills left over from the last time may alter a culture, making the information worthless and denying a patient a reasonable course of action should the therapy fail.

Recurrent urinary tract infections need to be investigated. A gynecologist can treat a simple bladder infection as well as any urologist, but I rely totally on my urologist friends when I can't explain why an infection keeps coming back in a patient. Together we take a team approach in dealing with patients who suffer from more than the rare urinary tract infection.

Endometriosis

The innermost lining of the uterus that builds up and matures in preparation for implantation of a fertilized egg is called the endometrium. (The myometrium is the middle, thick, muscular layer; the parametrium is the outermost layer.) But it's the endometrium that responds to the hormones of the menstrual cycle. Estrogen in the first half of the cycle builds it up, progesterone in the second half of the cycle matures it, and the lack of both near the end of the cycle causes it to slough away--menstrual debris consisting of bits of tissue mixed with blood and mucus.

But this menstrual tissue ends up on a tampon or pad and is discarded.

Endometrial tissue that is squeezed backwards through the tubes to spill onto the ovaries and into the abdomen is not discarded, but remains there, hormonally reactive to the ensuing cycles. (See below for other theoretical causes of endometriosis.) This is the condition called endometriosis. It is named after the endometrium--that is, endometriosis is normal tissue in abnormal locations. This very reactive tissue causes an inflammatory state that causes pain, internal scarring (adhesions), and the production of substances that mysteriously interfere with fertilization.

One of the body's best protective mechanisms is its worst enemy with endometriosis. When there's inflammation in the abdomen, the body tends to wall off these areas. Fatty tissue called the omentum (the "policeman of the abdomen") will migrate to surround and cover the offending inflammation away from the other abdominal organs. Also, inflammation will cause other structures to stick to the areas inflamed. A loop of bowel, minding its own business, may become attached to areas of endometriosis during the normal motions of peristalsis. These phenomena cause unlikely attachments of bowel to pelvic organs and blockage of the openings of the fallopian tubes.

And pain.

Besides the pain of the inflammation, there are the mechanical twangs of normally freely moving organs before endometriosis negotiating the passage of feces through kinked or suspended loops of bowel after endometriosis. Even when endometriosis "burns out," as it sometimes does, there remains still the adhesions.

Therefore endometriosis causes infertility by mechanical and chemical interference, and pain by direct inflammation and mechanical constraints. The pain often makes no sense, mere spots of it causing excruciating pain in some cases, huge masses of endometriosis (endometrioma, plural--endometriomata) being totally silent in other cases. But typically, pain is distributed throughout the abdomen where the endometriosis and resulting adhesions are.

Endometriosis can be treated surgically with laser or electrocautery through a laparoscope, or in the case of severe cases, a regular incision and conventional surgery. The ultimate treatment is a hysterectomy (with possible removal of involved ovaries), but this is a tragic final solution since endometriosis is often found during the course of a work-up for infertility. Endometriosis can be treated medically with Lupron or other GnRH agonists, Danacrine (a testosterone derivative), or non-cyclic birth control pills. All of these methods medically cause endometriosis to wither.

The best outcomes usually come from the combined surgical + medical approach. Sometimes a second laparoscopy is indicated to judge the success of treatment in a continuing infertility case. By the way, endometriosis is a surgical diagnosis, which is why we hate it so. A doctor can't just do an exam, determine endometriosis, then treat. He or she must see it surgically through a laparoscope or other operation. This means that a gynecologist who is too conservative will miss the diagnosis, possibly condemning a young woman to inability to have children later; one who is too aggressive will be doing too many needless laparoscopes. A woman's reproductive health balances on a tough line to

 walk, a specialist's integrity tottering between too conservative or too aggressive. But is a normal laparoscopy (wherein no pathology is found) a needless laparoscopy? This is debatable, since a woman finds it a lot easier to forgive pain that at least she knows is doing no harm.

Three theories of the cause of endometriosis:

1) Retrograde menstruation--the mechanism described above, wherein menstrual tissue is squeezed backwards through the tube to drip out of the ends onto the ovaries or into the abdomen (pelvis).

2) Vascular metastases--like cancer, endometrial cells from the endometrium can migrate and spread through blood vessels to even distant parts of the body.

3) Lymphatic spread--also like cancer, cells can travel through the lymphatic system to even distant parts of the body.

In pelvic endometriosis, retrograde menstruation is considered the most likely explanation, but it doesn't explain distant sites of endometriosis, like in the lung, navel, or even brain! There are reports of nose bleeds with every period and of hemoptysis (coughing up blood) during the menstrual period. Additionally, some theorize that other tissues in the body can retain the ability, like their fetal precursors, to undergo degeneration and transformation into other types of tissue.

Endometriosis is a terrible disease, often diagnosed late in the game, against which the only pre-emptive strike may involve too hasty a surgical decision. Once the diagnosis is made, too, the medical treatment, because it mimics menopause, may cause accelerated osteoporosis, just like in menopausal women. Therefore, with endometriosis there is a penalty for undertreatment and a penalty for overtreatment. The window of the perfect approach to treatment is a narrow one indeed, with so much hanging in this balance. For this reason, painful periods should never be ignored. These should be reported to a patient's gynecologist. Conservative measures should be tried, but only for a certain time limit, at which time an aggressive approach is in the patient's best interests.

Endometriosis: Another name for pain

Endometriosis is a word familiar to many in our society today. Women are often diagnosed with this "affliction" and understand that it is associated with pain, but most have no understanding of what endometriosis is or how it causes the debilitating pelvic pain during the reproductive years.

It is defined as "island of extrauterine endometrium that exhibits the histologic and hormonal responsiveness of native endometrium."

In other words, in endometriosis, cells similar to those that line the inside of the uterus, called the endometrium, are found elsewhere in the pelvis. The endometrium is the lining that is sloughed each month during a woman's period. Unfortunately, the endometrial tissue in the pelvis (endometriosis) isn't discarded like menstrual tissue, but remains inside the pelvis and is similarly capable to responding to hormone cycles in the body.

The incidence of endometriosis varies but is believed to be present in about 5-15% of all premenopausal women, and as high as 40-50% of women who undergo surgery for infertility. The average age of diagnosis of this disease is 28 years of age, with 75% of this disease occurring between the ages of 24 and 50. There is no race predilection. No one has been able to decide exactly who gets endometriosis or why. There seems to be a 8-10% increase in incidence in women who have a first degree relative who exhibits this disease (a mother or a sister), and these women tend to develop symptoms at a much earlier age. "Type A" personality traits such as over-achieving, egocentric, over anxious, perfectionist behavior tends to be associated more with endometriosis. More of these women tend to be underweight.

What causes endometriosis to develop remains a yet undiscovered mystery. No one knows if these women are born with microscopic implants of endometrial tissue which grow later, or if these cells migrate from the endometrium to other places in the body. One major theory suggests that these cells break off of the endometrium, migrate out of the fallopian tube (oviduct) and implant elsewhere in the pelvis--a sort of "backwards" menstruation. A second theory postulates that normal cells at various sites in the pelvis for some reason (probably repeated inflammation) mutate into endometrial cells, while a third considers the possibility that these cells are transported to different sites from the uterus by blood or lymphatic routes.

The truth is .. no one knows.

How pain is caused is not definitely known either. In many instances repeated swelling of this tissue causes adhesions of bowel or other pelvic organs which can cause mechanical pain, but we are not sure why individuals without adhesions or even major disease can experience debilitating pain. The extent of disease is in no way proportional to the degree of pain. In my practice I have discovered huge, painless endometrial implants incidentally at surgery, but I have also had patients who have experienced unbearable preoperative pain from implants barely visible.

Many theories explain pain based on possible secreted substances (like prostaglandins, which could be why anti-inflammatories work well) and instigation of local immune responses and inflammation. The bottom line is that we are just not sure at this time.

There are a variety of manifestations of endometriosis, none of which are diagnostic and none of which indicate the extent of disease. As we will discuss, location of disease is a much better indicator of symptoms than extent or size. Symptoms vary, but the most common is pain. Dysmenorrhea, or painful periods, is reported in 28-63% of women subsequently diagnosed with endometriosis. This pain varies with different patients from a sharp, intermittent, stabbing pain to a pressure or bearing down in the pelvic area, low back ache, or rectal pressure. Dysmenorrhea may worsen over time. Some unfortunate patients even describe sharp radiating pains into the vagina and legs. Usually these symptoms become worst the week prior to menses (period). Dyspareunia, or pain with sex, is also a frequent first complaint of women with endometriosis. This is usually due to adhesions in either the vaginal wall or ovary which are stretched during sex, resulting in pain (specifically with deep thrusting, known as deep dyspareunia).

Infertility and Endometriosis

As mentioned above, a higher percentage of women with endometriosis are infertile with the absolute infertility rate in this group being twelve times higher that the general population! In most instances the fallopian tubes are patent, but distortion of the anatomy prevents passage of the egg and sperm to and from the uterus, respectively. The third most common complaint of women with endometriosis is abnormal uterine bleeding (abnormal periods). This is probably due to endometrial implants directly on the ovary, causing damage and dysfunction. Other often-heard complaints include rectal bleeding (from rectal implants), bloody urine (from implants on the bladder), and bleeding after sex (from implants on the vagina). Rare cases can even present coughing up blood secondary to endometriosis in the lungs. Diagnosis begins with a thorough history, as with most diseases. Complaints of pain similar to symptoms listed above will alert a physician of the possible presence of endometriosis. But since there are no symptoms or signs that point exclusively to endometriosis, a history can only arouse suspicion. Physical exam can also be suggestive of endometriosis, particularly an internal vaginal exam (bimanual exam). A fixed uterus or nodules in unusual areas on bimanual exam will warrant further studies.

A definitive diagnosis remains direct visualization and biopsy- -that is, it's still a surgical diagnosis. This is most often achieved via laparoscopy (insertion of a lighted tube into the abdomen). Since there is no blood or lab work that can diagnosis this disease definitively, lab work is mostly to rule out other afflictions. Ultrasound can possibly point out endometrial implants (mostly ovarian), but it is not very specific. Various X-ray studies can point out other conditions which could cause the patient's symptoms, but as before these are basically an attempt to discover other pathology which could account for the symptoms.

Endometriosis is commonly located in a multitude of places, mostly in the abdomen and pelvis, and symptoms correlate with the location of the implants. Ovarian implants are the most common, and are the least symptomatic of all. Often these are discovered on routine hysterectomy with no previous endometriosis-like complaints. The next most common site is the floor of the pelvis, followed by the lining of the abdomen and the uterine ligaments and fallopian tubes.

Treatment For Endometriosis

Treatment of endometriosis is possible but must be tailored to the individual patient. A patient's desire to become pregnant in the future is the major concern, in which case every effort is made to retain the uterus. Observation is the first avenue that might be considered. Mild endometriosis can on occasion degenerate on its own without treatment while controlling the pain with mild analgesics (not narcotics). This is acceptable for an older patient with only mild symptoms, but not necessarily for a young female who desires children in the future. In this patient, if endometriosis were to advance there is a high probability it will cause adhesions which could cause fertility problems in the future.

The next step would be conservative surgery, which is usually undertaken conjointly with diagnosis at laparoscopy. Once located, the implants are vaporized by either burning them away or using a laser to accomplish the same effect.

A third possibility would be medical therapy. The goal of medical therapy is to decrease hormonal stimulation of the implants in hopes that without stimulation they will dissipate. Progestins (Depo-Provera) can block stimulation of the implants effectively, but has a very long duration in the system which can delay a desired pregnancy even longer. The more common mode of medical treatment these days is to induce a psuedomenopause by turning off the ovaries or blocking their effect. The two main medications on the market today are Danocrine and gonadotropin releasing hormone (GnRH) agonists, which work through different long and complicated pathways to accomplish this effect. The idea is as above, to block stimulation of the implants and hope they will disappear.

The GnRH agonists seem to be much better tolerated, have shorter duration of action, and produce less side effects, so they are more popular than Danocrine in treating this disease. It should be noted that medical management is only effective for mild to moderate disease. Severe disease requires surgical management as above to obtain any hope of cure. Often surgery is combined with prolonged medical management (usually 6 months duration, but varies) in hopes of removing disease not taken care of at surgery.

Finally, definitive treatment is accomplished with removal of the uterus and ovaries. This should be reserved for symptomatic individuals who desire no further pregnancies or those with debilitating pain unresponsive to conservative and medical therapy. After a period of time hormone replacement therapy is acceptable as it is no long thought to promote or induce relapse of disease. For a long time it was thought that pregnancy could cause reversal of disease. Now we know that pregnancy can cause a temporary remission or decrease in symptoms, but not necessarily regression of implants.

Is there any way to prevent endometriosis? Not that we know of. Early institution of oral contraceptive pills in individuals with a positive family history can possibly prevent the flow of endometrial cells from the fallopian tubes to the abdomen (one of the main theories out there on what causes this disease). Early pregnancy can postpone the onset of disease, but not prevent it.

Results of treatment are good in some but not in all cases, unfortunately. 75% of patients with mild disease, 60% with moderate disease, and 40% with severe disease conceive after treatment, with a total of 80% overall becoming pregnant within 18 months. Recurrence rate ranges from .9% in the first postoperative year to as high as 40% within 5 years, and this is independent of severity of disease.

In summary, endometriosis is a source of pain and depression in a number of women today, but there is hope in the form of treatment, the type of which should be tailored to the individual patient. Medical and surgical techniques, or a combination of the two, can offer a reasonable hope of alleviation of disease or at least make it bearable. Consultation with a physician is absolutely necessary and anyone exhibiting the above symptoms should see their gynecologist A.S.A.P! With some diseases there is no cure, but with the discussed diagnostic and therapeutic techniques discussed above we may be able to offer a light in the darkness to some of you in a world of pain and unhappiness.

Alternative Thinking About Pain, Pelvic Or Otherwise

Whose Side Are We On Anyway?

Being a conventional medicine man myself, I'm sure people often wonder what the official "medical doctor" thinks of methodologies and philosophies different from what was taught in med school. But this is not the right way to think about these things. It's not that conventional medicine has to be thought of as different from, for instance, holistic medicine, but that all of the different types of healing arts can make up a whole therapeutic outlook. Some disciplines apply in certain situations better than others. That's the perspective. Conventional medicine, of which I'm a big fan of, doesn't have all of the answers for sure. And of course neither does holistic medicine, acupuncture, chiropractic, or any other field whose radical fringe may tout themselves as the end-all for total well- being. But we are all on the same side, aren't we?

Certainly an orthopedic surgeon makes great use of physical therapy. I myself learned a great deal from midwifery while doing a rotation at Earl K. Long Hospital in Baton Rouge in my training. And there are just some back pains that end up being helped only by chiropractic manipulation. Meanwhile, competing disciplines are confrontational, and the controversies rage as to whether a benefit is all in the mind or not.

But a mind is a terrible thing to waste. Don't underestimate the mind.

It runs the show.

Even if pain is all "in the head,"-- if the head is where the pain is perceived--does that make the pain any less real? If a spiritual route or transcendental technique alters physical aspects for the better, isn't that as good as what penicillin can do for an infection?

But we mustn't use a mantra instead of penicillin for a nasty staph infection. Nor should we look to penicillin to bring us inner piece. And that's the point. The human body is a complex wonder. Our knowledge hasn't even touched the surface yet. And no one discipline is so complete that it feels it has all the answers or can rule out some of the answers from other fields. If the medical doctors are fighting with the chiropractors, and the herbalists are fighting with the pharmacologists, and the acupuncturists are fighting with the anesthesiologists, rheumatologists, and endocrinologists, might we all be better served by looking for what could possibly be cross-applied in our own fields from the others with which we choose to be confrontational?

There's hogwash in every area, but there may be a few pearls before hogs, too. Yes, the mind really is a terrible thing to waste, and the most effective way to do that is by closing it. And on that subject, there's nothing that opens a mind more than a profit motive. So I wonder what managed care's ultimate opinion will be on these areas. Conventional medicine isn't running conventional medicine anymore; managed care is. If these custodians of the "business" of medicine were to find their health subscribers swearing by a natural solution to a problem that conventional medicine has thrown too much insurance money at, how long will it take before there are Spiritual Maintenance Organizations as well as Health Maintenance Organizations? It certainly wouldn't be a change in health care any more drastic than what has happened in the last ten years.

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