Chronic Pelvic Pain and Pelvic Functional Disorders in Female

The chronic pelvic pain may coexist with pelvic functional disorders (PFD). The skilled perineal specialist (proctologist, colorectal surgeon, urogynecologist or gastroenterologist) should be able to distinguish and interpret these complex situations. A careful objective examination may help to decide when to treat exclusively with medical therapy or when the surgery is indicated. How to explain the problem to the patient is very important, because psychological mood is fundamental to face the diagnostic-therapeutic path in the best possible way. This chapter will describe the most frequent disorders that can coexist with chronic pelvic pain, clarifying that these disorders may often complicate the therapeutic process, even when they are not the cause of the pain itself.

- CPP (chronic pelvic pain) - FPD (functional pelvic disorder) - rectocele - vulvodynia - ODS (obstructed defecation syndrome) - FI (fecal incontinence) - LUTS (low urinary tract symptoms) 1. Introduction The specialist (proctologist, colorectal surgeon, urogynecologist and gastroenterologist) who visits a patient suffering from pelvic pain (PP) should have a multi-compartmental vision of the pelvic floor. PP may be localized in a clear anatomical side or not, may be acute, arose a few days or weeks before, or persistent, present for over 3 months, or chronic, for over 6 months. Moreover, the visit of the patients or instrumental exams can detect painful lesions (abscess, anal fissure, ulcers and genital Herpes) [1], pelvic/retroperitoneal mass [2] or not. A group of these patients may present chronic pelvic pain (CPP) without clear painful lesions or coexist a prevalent associated FPD. Then, an adequate classification of the symptoms/syndromes and an objective exam can help us. 2. How can I classify and understand this type of patients? The need to simplify such a complex topic with an algorithm arose from the awareness of the multifactorial nature of the symptoms reported by the patient. The symptoms often cause syndromes. For example, a patient with levator ani syndrome [3] reports pain evoked through tension and spasm of the pelvic floor muscle, and this can translate into dyssynergic and painful defecation. In this patient, if we see a rectocele with magnetic resonance imaging (MRI) defecography, take in mind that, often, it is not indicated to operate the rectocele to solve the problem, but perhaps a rehabilitation with a muscle training program and biofeedback therapies might be more useful [4]. For an expert pelvic floor specialist, surgeon or not, this type of reasoning and therapeutic choice is easy enough, but often, we visit patients operated for rectocele and suffering from PP: the pain remains or gets worse. The type of pelvic painful syndromes may be predominantly anorectal, bladder, urogynecologist for women and prostate/bladder symptoms in men. Furthermore, the musculoskeletal and common neuropathic causes must be taken into mind to understand a lot of these cases of CPP [5]. Authors [6] who have dedicated studies about FPD and CPP understood that there is a consequential flow between the syndromes and the dysfunctional pelvic and visceral symptoms. The idea to use three intersecting circles explaining the pudendal canal syndrome with the coexistence of perineodynia, anal incontinence and urinary incontinence is brilliant. The same reasoning, supported by clinical practice and the latest published observations, has enhanced the creation of a scheme useful for visiting and diagnosing these complex patients with the concept of multifactoriality and holistic view [7, 8]. This concept is summarized in Figure 1. The three main groups are analyzed by symptoms and possible initial diagnosis. Since symptoms are often multi-organ (bladder and rectum), therapy might also proceed step by step. If the specialist is able to understand the possible causes of the pain, she or he may explain more efficiently the steps of the therapy, and this may develop a good level of trust with the patient. The three main groups are analyzed in relation to the symptoms and pain phenotypes detected during the first visit. The fundamental rule is to investigate all the functions of the perineal area as: (a) the low urinary tract symptoms (LUTS), sexual activity for the urogynecologist phenotype, (b) the anorectal area, as defecation problems, for the gastroenterologist symptoms and (c) possible associated myofascial components, such as column, orthopedic symptoms and, last but not least, the psychological aspect such as anxiety and depression mood [9]. A careful history, combined with adequate well-done examination such as digital anorectal evaluation (DARE) and/or urogynecologist visit (UGYV) gives us valuable information concerning the prevalence of the symptoms and a possible category where classifying the patient. So, it may be clearer which specialist should follow the patient, even if it will generally be a multidisciplinary team with a holistic therapeutic approach [10]. 2.1 CPP and prevalent urogynecologist disorders Allodynia, pain caused by a stimulus that should not usually be painful, and hyperalgesia, an overall painful sensation for a nociceptive stimulus, are the common symptoms in the main neuropathic syndromes when central sensitization is present [11]. A painful micturition or dyspareunia, pain during sex, are two conditions very often described by patients in particular women affected by interstitial cystitis/bladder pain syndrome (IC/BPS), vestibulodynia (provoked vestibulodynia) [12], overactive bladder (OAB) wet or dry, and endometriosis [13]. The dyspareunia described as superficial, as in the vestibulodynia or deep, for the hypertonicity of the perineal muscles, as in trigonitis [14] or every painful bladder problem, may give us important information related to neighboring functional area as the anorectal, for example dyssynergic defecation, or coexisting musculoskeletal component [15]. Particular attention must be given to the presence of previous perineal surgical interventions [16] with or without mesh. In case of PFD, such as urinary incontinence (UI) or pelvic organ prolapse (POP), it generally should not be PP. The presence of PP before the surgery might be adequately diagnosed. The therapeutic path has to consider the use of a surgical technique more adequate and potentially less complicated by pain [17]. If the pain arises after surgery, relevant research of possible complications has to be done [18]. For a detailed etiopathogenetic analysis, we recommend consulting the dedicated guidelines of CPP [19, 20]. 2.2 CPP and prevalent proctological and bowel disorders The function area mainly compromised by CPP in the group of proctological-bowel disorders generally is the defecation: (a) dyssynergia defecation in hypertonic pelvic muscles as levator ani syndrome; (b) anelastic anal canal after proctological surgery or presence of painful lesions as anal fissure, abscess and ulcers; (c) fecal incontinence (FI) in pelvic neuropathy, as the pudendal anal canal syndrome, but also in neuropathy syndromes caused by prolonged defecation efforts in obstructed defecation syndrome (ODS), obstetric anal sphincter injuries (OASIS) or (d) often associated column and postural disorders with neuropathy. Very often, these patients, mainly women, have symptoms related to irritable bowel syndromes (IBS) [21]. The IBS is a general complicating factor: even the post-surgical periods of common proctological diseases such as hemorrhoids, fistula and anal fissure may be complicated by the IBS. This clinical condition might be managed simultaneously and at the same time explained to the patient. The concept that visceral, perineal symptoms and the axis gut-brain interaction are connected has been officially codified in the new Rome IV criteria [22]. In this type of patient, pain in all its forms, visceral, peripheral and central, becomes the common denominator. The surgeon who can generally drain pain with any operation must be able to recognize the multifactorial categories of pain in particular the abdominal and pelvic areas. Furthermore, the surgeon, knowing the possible complications of a surgical technique, should choose when to do a surgical technique and when not. Above all, knowing an operating technique also allows the surgeon to discover possible complications and therefore a surgical resolution becomes mandatory [18, 23]. Furthermore, a pain during no more than 30 minutes, which typically occurs at night or at rest and is not related to defecation without evident painful lesions, goes under the name of Proctalgia fugax and generally is one of the diagnosable types of functional perineal pain [24]. This means how complex the topic of perineal pain is, whether it is acute or has become chronic. 2.3 CPP and prevalent neuromusculoskeletal disorders Why a proctologist, as I am, is considering the neuromusculoskeletal disorders during the visit of a patient with CPP and proctologic painful symptoms? Because neuromusculoskeletal disorders are often the most common causes, or almost, of many kinds of the PP [25]. I report a clinical case to explain it better: a woman arrives in my study and reports having anal pain, perineal heaviness at the end of the day, assuming that the cause was the hemorrhoids. I visit her on the Sims position, the left side as I usually visit, at first, every coloproctologist patient. In this position, I usually let the patient keep his shoes on. It is very easy to see if the heels are worn asymmetrically; this simple sign, “the heel sign,” can help us discover postural and/or column problems. The previous patient had internal hemorrhoids that were not complicated and the “heel sign”: I excluded organic lesions; during the DARE and the anoscopy (easy not painful), I detected an hypertonic puborectalis branch muscle asymmetrically on one side rigid to digital pressure. I prescribed a postural exam and a colonoscopy for age (over 50 years old). The patient resolved her symptoms by wearing shoes with suitable insoles designed by the postural physiotherapist. A careful “functional DARE” (Figure 2) with adequate digital pressure on the coccyx, the pubic bone space and the insertion of the left and right branch of puborectalis muscles and the pubococcygeus can help to make an evident painful hypertonic zone of the pelvic floor muscles with sustained contracture so-called “trigger points” [26]. The pain due to a prevalent coccygodynia or sacro ileitis, piriformis and pubalgia syndromes must be taken into mind during the visit of this kind of patient. Observe how the patient walks when entering your office, how she/he sits if she has an antalgic position or, in clear cases, if she uses crutches or is in a wheelchair. Also, when visiting anoperineal area of the patient in the Sims position, consider if present the “Heel sign.” 3. Practical therapy scheme for CPP Medical and physical therapies are two modalities of pain syndrome therapy, the right balance between them might be difficult to find. A quick list of therapies will be made, but the interactions of them with the type of pain (somatic, visceral and neuropathic) are very complex and change a lot also with the grade of chronic pain [23]. The medical therapy has three levels: first line with nonsteroidal anti-inflammatory drugs (NSAIDs) level of evidence (LE) 1b, tricyclic (LE 1a) antidepressants (LE 3), anticonvulsant as gabapentin and pregabalin (LE 1a); second line the opioid drugs (LE 1a) that need controlled prescription in relation to the possible opioids misuse, addiction, and the third line with the antiepileptic drugs (carbamazepine) or other as citalopram, paroxetine (weak recommendation and particular attention to adverse events) [20]. Physical therapies [27] are based on muscle training, such as muscle relaxation, stretching, chiropractic care, biofeedback and electromodulation [4], percutaneous tibial nerve stimulation [28], acupuncture [29], neurostimulation procedure [30], “trigger myofascial point” infiltration with lidocaine, corticosteroids or other drugs [31]. Physical therapies are associated with a weak recommendation grade for neuropathic pain [20]. However, the well-known complexity of this matter impose us to conceive tailored therapy for every patient. Physical procedures inserted in a multimodal therapy program may be useful also for the therapeutic education of the patient. Surgery procedures such as the coccygectomy for coccygodynia [32] and the liberation of the pudendal nerve in the entrapment nerve syndrome may have good results [33] in the early period after the surgery, but further data are needed for long-term results [34] and no clear evidence is available. This list of possible therapies may be further analyzed in the already mentioned guidelines of CPP [19, 20]. 4. Conclusions The way of dealing with this topic may appear unusual. It has been adopted mainly to better reflect the practical need to understand these complex patients. Often, an acute or persistent PP became chronic because it is not adequately understood and treated. The patient who lives with pain knows how to describe her/his symptoms exactly: it is up to us to be mentally prepared in order to better understand them and know how to help her/him. The scheme previously described was conceived in order to help solve such complex issues as the CPP (Figure 1). This kind of patient needs a multidisciplinary approach as soon as possible since symptoms understood by the right specialist might not become intractable. When the right path is taken in the treatment of complex syndromes and associated FPD, the patient perceives a “positive domino effect.” This can happen when the specialist is able to understand the real multifactorial nature of the patient’s category. A skilled multidisciplinary CPP pain group should be composed of the coloproctologist, urogynecologist, gastroenterologist, anesthetist, postural physiotherapist, osteopath and psychologist. Furthermore, some procedures such as muscle training rehabilitation, Tibial nerve stimulation, Sacral nerve stimulation and acupuncture should be easily accessible. Above all, correct reasoning and an adequate visit of the patient can make the difference; there is often a gap between theory and practice. The main purpose of this contribution is trying to clarify the discrepancy between well-done guidelines and the reality, where a real interplay of competencies between different specialists often appears to be missing.

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