By Pramod Wasudev, M.D.
It is estimated that in the USA alone, literally millions of patients are reported as having chronic groin, abdominal and pelvic pain. Nearly 15 million women have chronic pelvic pain (CPP) and in this subset 46% have dyspareunia (painful intercourse). The annual medical cost of diagnosis and treatment is almost $1.2 billion. And the cost of loss of productivity is estimated to be $15 billion annually.
About the Pelvis
The pelvis is a compact space packed with several structures: 45 muscles, ligaments, fascia, nerves and blood vessels. Amongst all these structures, important viscera (organs), urinary bladder, vagina, uterus tubes/ovaries and rectum are packed like a cocoon. There are numerous causes for having pelvic pain, depending on the condition (disease) affecting each organ. As expected, if disease starts in one structure, several other adjoining structures are affected, such as:
• Gynecological diseases affecting vagina, uterus, ovaries and tubes. Some of these conditions coexist with musculoskeletal.
• Urology condition affecting urinary bladder like Interstitial Cystitis (I.C.). Some of the patients with musculoskeletal pelvic pain are mistaken for I.C.
• Pelvic bone itself with all the joint, attached ligaments and more importantly the lining of the bones called periosteum which can get inflamed and is very painful.
• Musculoskeletal. In this article we will be primarily addressing this condition.
• Idiopathic – unknown etiology.
It is very confusing for the patients to understand and express the symptoms associated with pelvic pain and very few come to our office stating they have “Pelvic Pain.” Pain usually radiates to the surrounding structures where pain is noticed, for example:
• Lower abdomen and groin
• Perineum, sitting bones (ischial tuberosities) and tail bone (coccyx) and they have a hard time sitting for a long time
• Lower back
• Hip bones
• A rather interesting situation is when patients have vaginal or deep pelvic pain causing painful intercourse and pain when using tampons. There is a stigma about this condition and patients rarely complain, even to their gynecologist.
Musculoskeletal pain is present in 22% to 80% of all patients with CPP.
Causes of Musculoskeletal Pain:
Chronic pelvic pain in women may have multifactorial etiology and 22% have pain associated with musculoskeletal causes. Some of the causes of pelvic pain are as follows:
• Bony Pelvis/Joints/Spine
• Myofascial pain of pelvic floor muscles
• Myofascial pain of back or hip muscles
• Weakness of pelvic floor: deconditioning/disuse
• Tightness of pelvic floor and sphincters
• Tendinopathy, ligament sprain, adductors, hip flexors and piriformis muscle
• Damage to pelvic floor muscles from trauma or radiation: childbirth, prior surgeries, sexual abuse, sports/dance, repetitive minor trauma, for example, “Sportsman’s hernia”
Patients and Methods: Retrospective study of total of 203 patients seen between 1983 and 2006: 49 males (24%) and 154 females (76%). Precipitating factors were previous lower abdominal surgeries in 46%, infections in 7.3%, sports activities in 3.9% and non-specific in 33.4% of patients.
Results: Out of 203 patients, 139 (68%) had excellent results, 43 (21%) had good results, 6 (3%) had satisfactory and 9 (4%) had partial to poor response. Six were lost to follow-up.
Musculoskeletal Dysfunction is Important to Evaluate
Unfortunately, musculoskeletal dysfunction is not routinely evaluated as a cause of pelvic pain by gynecologists. A pelvic musculoskeletal examination is simple to perform, is not time-consuming, and is one of the most important components to investigate in all chronic pelvic pain patients.
The muscles, joints and nerves in the pelvis can be injured just like any other part of your body. For instance, tissues can be overstretched, torn or cut in childbirth or surgery; muscles can weaken or tighten from disuse and injury; and poor postures and movements can slowly stretch or compress structures in the pelvis, leading to pain and dysfunction.
In the majority of patients, diagnosis includes a thorough clinical exam, taking a detailed history and conducting a detailed exam of the abdomen, including a pelvic and rectal exam. The following signs are suggested and practiced and are very helpful:
• Rectus flexion sign
• Adductor resistance sign
• Vaginal hook sign
• Trans vaginal sacroiliac sign
Very few patients need CT scans, MRI, GI endoscopy and laparoscopy. Diagnosis can be confirmed by a giving series of steroid injections.
Multidisciplinary Approach to Treatment
Management of this myofascial component of chronic pelvic pain involves a multidisciplinary approach including physicians, physical therapists and psychiatrists. Treatment strategies include behavioral management, medications, physical therapy, trigger point injections and botulinum toxin injection.
Chronic pain can be created by spasms of the muscles that line the pelvis, also known as the pelvic floor muscles. This “sling” of muscles, along with connective tissue called fascia, lift and support the pelvic organs including the bladder, uterus and rectum. Spasms in these muscles — known as pelvic floor tension myalgia or levator ani syndrome — may cause pain locally. Tight bands of muscle, known as trigger points, may be tender to the touch, and they may refer pain to other areas of the pelvis, abdomen and low back.
Many women with chronic pain suffer from anxiety, depression, or both, which worsens pain. Recurring or chronic pain can cause some women to feel depressed. These feelings are normal. In other cases, pelvic pain can be a symptom of depression or anxiety. It’s essential to address depression or anxiety with therapy and medications as needed.
Pramod Wasudev, M.D.
Dr. Pramod B. Wasudev graduated from the Topiwala National Medical College, University of Mumbai, Mumbai, Maharashtra, India in 1962. He specializes in General Surgery and Pain Management. Dr. Wasudev is affiliated with Saint Thomas Midtown Hospital, Tristar Centennial Medical Center, Tristar Medical Center and Tristar Skyline Medical Center.
3443 Dickerson Pike, Suite 600
Nashville, TN 37207
I was experiencing some pain, so it was decided that I had to get a total hysterectomy. I went through my surgery and still noticed that I had a lot of the same pain. I let my OB/GYN know and he stated that it was post-op pain from the total hysterectomy. I figured that I would wait to see if it eased. I went back for a checkup from the surgery and when I was getting the examination, I noticed that the pain was almost unbearable. Then I knew that something was not right with my body. I would ask my doctors what was the matter with me and no one could give me an explanation as to why I was experiencing this pain, except that it was from adhesions (healing of the body). I gave it some time to heal but it was getting unbearable. The pain was taking a toll on me, my personal life, my social life and my daily activities. Just when I began to get very aggravated with myself and the pain, I ran across Dr. Wasudev on a professional level. He told me what he could do and, just to reassure me, he spoke to a patient that had the same symptoms as I was experiencing and this patient told me about Dr. Wasudev and what he was doing to help people with the pain. I went to see him and he performed a full examination on me. He found every painful spot and came to the conclusion that I had tendonitis. I was experiencing pain in both lower quadrants, severe pain in my left groin, and dyspareunia for at least 6 to 8 months. He had asked me if the pain got worse with physical activities, and yes it did. I decided to go through with the injections that he had explained would help me. He informed me that I would have 3 sets of steroid injections also known as POPSS Injections. I proceeded with the first injections and the pain was not completely gone, but I did notice a difference like it had eased some. I went back for my second set of injections, and during those injections I could feel that he was hitting the exact spots because I almost came off the table. I had realized that the pain was about 60 to 70% gone. I felt so relieved that something was finally going to help me. When I had my 3rd set of injections, I was pain free and even the dyspareunia improved. I was so relieved that someone understood me and what I was going through. Dr. Wasudev is a life saver and he has helped me in many ways. I respect him for being so compassionate and caring towards his patients. I believe that if it was not for him, I would still be going through all of the pain. Dr. Wasudev is a very personal man and he really understands his patients. When I began seeing him, I felt like I was not just another patient, I was like his daughter. He showed me respect and reassurance that there is someone out there who cares and will not make you feel like you are crazy, like it’s all in your head. I felt so imprisoned by the pain and I could not even get out and do yard work or even my activities of daily living. I would like to let Dr. Wasudev know that he has changed my life and I respect him for that. If I ever have pain, I will not think twice about going to Dr. Wasudev. Thank you so very much! — Cindy B.