Conditions We Treat for Women
Pelvic pain is women is a common symptom, which accounts for up to 30% of visits to a gynecologist, yet it is thought that close to 70% of cases of pelvic pain are not of a gynecological origin. By definition chronic pelvic pain is defined as pain which it is present for 6 months or longer, is localized to pelvis and is severe enough to cause functional disability requiring treatment. It is estimated that chronic pelvic pain affects 15% of women in United States sometime during their lifetime, yet almost 60% of those patients do not have a proper diagnosis (and therefore treatment). This is due to the fact that this pain usually spans more than one specialty, and treatment requires physicians who are specifically trained in chronic pelvic pain. Those statistics are even more staggering because over 20% of women with pelvic pain miss work, close 50% feel depressed and in 90% of women it affects their sexual life. Pain during or complete inability to have intercourse significantly affects personal relations between the patient and her partner and further adds to suffering. Despite the fact that chronic pelvic pain in women is more common than coronary artery disease, asthma or migraine headaches very few physicians specialize in its treatment. Pain is often blamed on psychological issues and patients are often referred to a mental health provider, instead of getting treatment for their true, existing disease.
Multiple conditions may cause pelvic pain and often they coexist together in one patient. Some of the more common conditions are:
- Interstitial cystitis/bladder pain syndrome
- Irritable bowel syndrome
- Spastic pelvic floor syndrome
- Adhesions in the pelvis and abdomen
- Pelvic congestion syndrome
- Pelvic nerve neuralgias
- Pain caused by pelvic mesh
Arizona Center for Chronic Pelvic Pain offers comprehensive treatment for those and many other conditions causing pelvic pain.
Pudendal Nerve Block
Pudendal Neuralgia in Men
Pudendal neuralgia is defined as pain in the area of innervation of the pudendal nerve. In men, areas affected can be the penis, scrotum, perineum, and rectum. Pudendal nerve entrapment is described as compression of the pudendal nerve from ligaments, scar tissue, or surgical materials which leads to pudendal neuralgia. Some patients with pudendal nerve entrapment experience burning pain but others may have the sensation of numbness. It may be present on one or both sides and some patients experience problems with erection and pain with ejaculation. Penile numbness is one of the frequent signs of pudendal neuralgia in men.
Pudendal nerve entrapment is less common in men than in women and the exact incidence is not known. It is usually related to a traumatic or painful event in the pelvis, penis, scrotum, or anus. It has also been noted in men who masturbate excessively or who insert objects in their rectum. Pain or numbing sensation may occur after one significant trauma or multiple repetitive smaller traumatic events. An example of repetitive smaller trauma is bike riding where a narrow bicycle seat may crush the nerve against ischial tuberosities (sitz bones).
The Pudendal Nerve in Men
Pudendal neuralgia is the pain that a patient feels in the area of innervation of the Sciatic nerve, dorsal nerve, and pudendal nerve. If the patient is a male—the areas affected can be the penis, scrotum, perineum, and rectum (dis colon rectum). If the patient is a female—the pudendal nerve runs from the lower back—along with the pelvic floor muscles to the perineum. This can cause the patient not just perineal pain, but also great pelvic pain—such as chronic pelvic pain and vaginal pain.
In addition—the pudendal nerve crosses between two muscles. These two muscles are called the coccygeus and the piriformis muscle. Piriformis muscle spasm may also affect the pudendal nerve—controlling our bladder and bowel.
Pudendal neuralgia is less common in men compared to women. The perineal pain and pelvic pain—such as chronic pelvic pain and vaginal pain caused by pudendal neuralgia in a female are commonly related to a painful or traumatic event in the sciatic nerve, pelvis, or anus. While for males—their pudendal neuralgia or the dis colon rectum—is related to painful or traumatic events in the penis, scrotum, anus, or the dorsal nerve.
Symptoms of Pudendal Nerve Involvement
There are some areas along the pudendal nerve’s path (pudendal canal)—where it can be squeezed by other structures—which causes it to become irritated. When the pudendal canal is compressed—that is when pelvic pain and chronic pain in the pelvic area happen.
The pain signal that a patient with pudendal neuralgia is usually described as stabbing and burning or chronic pain in the pelvis. Sometimes—the pain signal can be a tingling sensation or numbness. A pain signal can be worsened by any activity—involving bending your hip—such as squatting or sitting down for too long.
For pain relief—aside from injection with a numbing medicine—the patient can try standing or lying down. There are also some cases where sitting on the toilet gives pain relief to the patient. Since the perineum nerve has so many functions—pressure on the perineum nerve may contribute to a similar pain signal such as— erectile dysfunction, or the pain during ejaculation or urination—as well as—urinary urgency or frequency, bowel or bladder incontinence—and the like.
If any pain medicine doesn’t give any pain relief anymore—then it is the best idea to call a doctor right away. Pain medicine should be able to give pain relief to the patient. Otherwise—pudendal nerve blocks might be necessary.
Pudendal Nerve Blocks
Pudendal nerve blocks are historically a common regional anesthesia technique or also known as the local anesthetic technique. This local anesthetic technique provides perineal anesthesia during an obstetric procedure—such as vaginal birth during the second phase of labor, vaginal repairs—as well as—anorectal surgeries—which include hemorrhoidectomies.
Pudendal nerve blocks are less commonly utilized local anesthetic techniques to provide anesthesia for urological procedures. Nevertheless—this local anesthetic technique is very safe and effective for the patient. The pudendal nerve blocks are used in comforting pain associated with pudendal neuralgia.
Pudendal nerve blocks are more helpful than pain medicine in evaluating—as well as—managing both pelvic and groin pain around the anus, perineum, and genitals. A pain physician gives an injection with numbing medicine with a needle placement on the pudendal artery to determine what is causing your pain.
A pain physician just doesn’t give out an injection with a numbing medicine injected anywhere on your body. A proper needle placement—specifically on the pudendal artery is necessary. Pudendal nerve blocks can be executed via a perirectal approach with the use of a nerve stimulator. A nerve stimulator can stimulate contractions of the outer anal sphincter
The aim of pudendal nerve blocks is to block the nerve as it enters the lesser sciatic foramen—1 cm inferior and a medial comparative to the extension of the sacrospinous ligament to the ischial spine. The sacrospinous ligament is a very thin ligament that is attached to the ischial spine. On the other hand—the sacrotuberous ligament is a stabilizer of the sacroiliac joint. The sacrotuberous ligament also connects the bony pelvis to the vertebral column.
What Conditions Can Pudendal Nerve Blocks Treat?
A pudendal nerve block is used in treating conditions characterized by symptoms of genital/rectal pain (pudendal neuralgia)—which is caused by pudendal nerve entrapment while passing through the pelvic region. It may also become inflamed caused by local trauma—including stretch injury. However—the most common for its inflammation is due to skin-tight clothing, pregnancy, weight gain—or obesity.
How is it Performed?
A team of health professionals will help the patient to be in the proper position to make sure the procedure is done properly and can be completed with the smallest amount of discomfort for the patient. The patient’s skin is cleansed using a sterilizing solution (chlorhexidine). Next—a local anesthetic medication will be given to numb the skin. To find the target—fluoroscopy (x-ray) or ultrasound is done next.
A very thin needle is then directed to the desired location. Then—a local anesthetic and/or steroids are injected. During the entire process—the patient will be constantly monitored by a team of health professionals. A small badge is then placed on the skin after the injection. The patient will be given time after the procedure to ensure that the patient feels fine and is not experiencing and side-effects before leaving the clinic/hospital.
What Kind of Medication is Injected?
The medication inside the injection includes a combination of anesthetic ( bupivacaine or lidocaine) and steroid (dexamethasone, cortisone, or Kenalog). The local anesthetic will be the one responsible for the immediate relief—while the steroid is used to supply more long-term relief.
Does the Entire Procedure Hurt?
The procedure is normally well-tolerated. The most common and uncomfortable part of the procedure is a localized burning sensation from the anesthetic. During the procedure—patients often experience a pressure sensation—which typically resolves within a few minutes. The patient may also feel a minor soreness for a week after the procedure—which is totally normal.
How Long Does Usually the Procedure Take?
The procedure normally takes about 15 minutes. We advise patients to arrive at the hospital/clinic 1 hour prior to allow pre and post-procedural protocols.
For more details on pudendal neuralgia, you may refer to the page on pudendal neuralgia in women. Treatment of pudendal neuralgia in men is similar to treatment in women and surgical decompression of the pudendal nerve (transgluteal pudendal neurolysis) is also done in a similar manner since the anatomy of the nerve in men and women is virtually identical.
Endometriosis is a condition in which the tissue that normally is present inside the cavity of the uterus, called endometrium, starts growing on the pelvic walls, ovaries, fallopian tubes, bladder, bowels and occasionally pelvic nerves. Despite extensive research it is unclear how patients get endometriosis. There are multiple theories attempting to explain the etiology of this disease. One of the most popular, called Sampson’s theory, states that endometrial cells travel to the pelvis through the fallopian tubes with menstrual blood. Those cells then implant on the pelvic organs, ovaries, fallopian tubes, bowel, bladder and pelvic side walls. The second theory called Myers theory of coelomic metaplasia states that cells that have a potential of becoming endometriosis are already present in the peritoneal lining of the pelvis. Those cells become activated due to environmental or hormonal factors then turn into endometriosis. Unfortunately, neither one of those theories fully explains all the cases of this disease which means that endometriosis may form in several different pathways (may be multifactorial).
Endometriosis implant on the abdominal wall. Bowel on the bottom.
Approximately 10% of women have endometriosis but only half will experience pelvic pain due to this condition. It may be present in about 70% of patients with pelvic pain, and about a third of patients who are undergoing laparoscopy for pain are found to have endometriosis. In patients who have laparoscopy for other reasons than pain 5% has endometriosis. Endometriosis may also lead to infertility which occurs in about 30% to 50% of patients with this condition. The rate of infertility in patients with endometriosis is 2 to 3 times higher than in general population.
Endometriosis is inheritable condition. Children and siblings of people with endometriosis are six times more likely to have this condition themselves. It is not known which genes are responsible for inheritance of endometriosis, but it appears that low level of progesterone hormone or progesterone receptor defect may increase the risk of this condition.
The most common symptom of endometriosis are painful menstrual periods. They occur in approximately two thirds of all the patients with this disease. Those painful periods usually start at the time of the first menstrual period (menarche) and with time get progressively worse. Eventually the pain is not only present during menstrual period but becomes continuous. Patients also experience pain with intercourse, urination, bowel movement and physical activity. Pain in endometriosis is mostly caused by uterine cramping but also cramping of the muscles of the pelvis and abdomen. Irritation of pelvic nerve endings and release of inflammatory substances is also responsible for the pain.
The only way to diagnose endometriosis is to perform surgery (laparoscopy or robotic laparoscopy) and visually confirme the presence of endometriosis implants. Because some conditions may resemble endometriosis, I strongly believe that pelvic lesions which look like endometriosis need to be removed and sent to pathology for microscopic confirmation.
Treatment of endometriosis may be medical or surgical. Medical treatment of endometriosis entails the use of medications which lower the levels of estrogens. Those medications may be effective, but they usually have side effects such as hot flashes, irritability, vaginal dryness and loss of libido. They generally mimic the symptoms that older patient would experience during menopause. Also, because of significant risk of osteoporosis, those medications should not be used for prolonged time. Unfortunately, when those medications are discontinued, endometriosis simply comes back. Research shows that medical treatment of endometriosis with anti-estrogen medications may be beneficial in mild form of endometriosis; in more severe cases they are not effective.
Surgical resection of endometriosis using robotic assisted laparoscopy or in some cases simple laparoscopy is the best treatment for this condition. Resection of endometriosis as opposed to ablation of endometriosis allows for much more precise removal of all the lesions minimizing the risk to vital pelvic and abdominal organs. This procedure, because of the complexity of pelvic anatomy, should be done by trained and experienced surgeon. Since endometriosis often involves bowels, bladder, diaphragm or other or abdominal/pelvic organ it is important that the surgeon is adequately trained to operate not only on reproductive organs but also on urinary and gastrointestinal systems. When lesions presumed to be endometriosis are resected, they should be then sent to the pathology to confirm that they are indeed endometriosis. There is ample research which shows that there are lesions appearing to be endometriosis which are not, and conversely endometriosis may sometimes appear like normal healthy tissue. Patients with severe endometriosis often develop endometriosis in the ovary. It is called an endometrioma. Endometriomas may cause significant pain but also are source of infertility. It is extremely important that surgery to remove endometrioma is done by a very experienced surgeon to preserve as much of a healthy ovary as possible for future fertility and hormone production.
Ovarian endometrioma (bottom of the picture with da Vinci robot instrument pressing on it). Uterus on top of the picture
Surgical removal of endometriosis is successful in treatment of pelvic pain related to endometriosis. One of the most comprehensive studies demonstrated that patients who undergo surgical removal of endometriosis are 10 times less likely to have pain than those who just had diagnostic laparoscopy (surgery to look, without removing any endometriotic lesions). After surgical resection of endometriosis patients usually experience a long pain free period, but endometriosis will most likely return. Because we do not know how endometriosis happens in the first place, we do not know how to prevent it from re-occurring. In some cases (endometriosis in the ovary) birth control pills may delay the return of endometrioma, but in most of the cases birth control pills do not prevent or delay a relapse. A large study of over 850 women have shown that within five years from resection of endometriosis approximately half of the patients will have a reoccurrence of pain requiring another surgery.
In patients with endometriosis who are done with childbearing hysterectomy may be a good treatment option. Hysterectomy by itself does not prevent endometriosis from coming back, but because pain in patients with endometriosis is often from cramping of the uterus, it may prevent the reoccurrence of pain. In the study mentioned previously in seven years from the initial surgery 23% of patients who underwent hysterectomy had another surgery for endometriosis but only 8.3% of patients that had hysterectomy and ovaries removed needed another procedure.
Endometriosis on the diaphragm. Bottom of the picture – liver. Implants of endometriosis on the diaphragm fulgurated (coagulated) with argon beam coagulator.
Patient undergoing surgery for endometriosis may benefit from additional procedures in order to decrease pain. One of those procedures is presacral neurectomy. Presacral neurectomy is a procedure in which one of the nerves in the pelvis responsible for transmitting cramping sensation may be severed decreasing that sensation. Multiple studies have shown that patients with endometriosis undergoing presacral neurectomy have decreased pain (86% of patients are pain free one year from resection of endometriosis and presacral neurectomy versus 57% who just had resection of endometriosis). Presacral neurectomy is done in close proximity to very large pelvic veins (vena cava) and it should only be performed by very experienced surgeons.
Presacral neurectomy with visible vena cava
One of the most important concepts in treatment of endometriosis is that it coexists with other pain causing conditions in the pelvis. For that reason, endometriosis has been called by some an “evil quadruplet”. The other three are spasm of the pelvic floor muscles, painful bladder syndrome (interstitial cystitis) and irritable bowel syndrome. When suffering from endometriosis it is very important to be treated by a physician who is not only trained and complicated resection of endometriosis but also can address those other conditions. Surgical resection of endometriosis without treatment of coexisting conditions may not bring the desired effects.
Conditions that coexist with endometriosis (IC – interstitial cystitis, IBS – irritable bowel syndrome, PFT – pelvic floor tension)
If you or anyone you know suffers from endometriosis, contact our office at 480 599-9682 or [email protected] to learn more about available treatments.
Robotic resection of mild endometriosis
Robotic resection of moderate endometriosis
Robotic resection of severe endometriosis and endometrioma
Robotic resection of diaphragm endometriosis
With aging, childbirth and changes in hormonal status over 50% of women will develop urinary incontinence and prolapse. Those diseases of pelvic floor may be treated non-surgically and surgically. For many years pelvic floor surgeries surgeries were preformed using patients own tissue (native tissue repair), but in 1996 first polypropylene pelvic mesh for treatment of stress urinary incontinence was introduced. It quickly replaced traditional surgical procedures and mesh based procedures became the mainstream treatment for stress urinary incontinence in women. In 2004, mesh for treatment of pelvic organ prolapse was introduced and soon after FDA started receiving information of patients who have developed problems after this surgery. In 2008 FDA issued the first warning regarding the dangers of pelvic mesh; in 2016 pelvic mesh was reclassified as type class III device requiring extensive research before brining devices to the market and in 2019 polypropylene mesh for pelvic organ prolapse was taken off the marked altogether. Polypropylene mesh used in retropubic and transobturator slings continues to be used for treatment of stress urinary incontinence.
Many patients who underwent implantation of polypropylene mesh either for incontinence or prolapse are satisfied with the procedure and do not have any complications. When complication occur, they may range from transient discomfort, to more significant complication of erosion, to absolutely debilitating neuropathic pelvic pain. Some patients also develop significant autoimmune reaction to mesh, which may add to the devastating pain they already experience.
Severe neuropathic pain
Even though severe pain after mesh implantation is rare, when it happens can be completly incapacitating to the patient. This pain may be caused by muscle spasm, nerve injury, inflammation, scarring or foreign body reaction.
Direct nerve injury is one of the most serious complications of mesh implantation. This injury may occur with mesh kits that were designed to attach to, or pierce through the sacrospinous ligament. Anatomically pudendal nerve runs behind the sacrospinous ligament, so any mesh that attaches to this ligament is at risk of injuring the nerve. Mesh kits that attach to the sacrospinous ligament include Prolift, Avulta, Pinnacle, Uphold and several others. Even though the surgeon is advised to place the mesh at the certain distance from the nerve, the blind placement makes it virtually impossible to know the exact location. Patients who sustain direct injury to the nerve will generally experience immediate and severe pain upon waking up from surgery. This type of injury is a true emergency and mesh needs to be removed as quickly as possible to avoid permanent damage. The surgery does not only involve removal of the mesh, but decompression of the pudendal nerve which has to follow. This procedure, therefore, has to be performed by a surgeon who is very knowledgeable in preforming transgluteal pudendal nerve decompression.
Mesh attaching to the sacrospinous ligament in the proximity of the pudendal nerve
Muscle spasm and delayed nerve injury involves mesh kits that perforate or attach to different pelvic muscles. When woven polypropylene mesh is placed in the muscle it is causing it to spasm through mechanical irritation. With time mesh shrinks adding to even more irritation and spasm. This explains why sometimes pain starts months to years from implantation surgery. Transobturator meshes include products like TVT-O, Monarch, Obtryx, Elevate, Prolift and many, many others. The older transobturator meshes were designed to pierce through several muscles in the groin including obturator internus muscle and exit on the skin of the thigh. In case of those mesh kits, the adductor muscles (muscles that bring legs together) are often affected, so patients experience groin pain with walking and almost any movement of lower extremities.
Transobturator (older type) mesh piercing multiple muscles in the groin
Transobturator mesh (newer type) attaching to the obturator internus membrane/muscle
The newer products are made to attach to obturator internus membrane/muscle without penetrating any other muscles. Those meshes may still mechanically irritate the obturator internus muscle triggering it to spasm. The obturator internus muscle is respo
Blue arrow shows the approximate location where transobturator mesh pierces obturator internus muscle. Green line shows the approximate course of pudendal nerve within obturator internus muscle (Alcock’s canal-pink). Yellow line shows approximate course of the obturator nerve to the obturator canal
Pudendal nerve runs through the obturator internus muscle through the part known as Alcock’s canal. When obturator internus muscle is spasming it is putting pressure on the pudendal nerve in the Alcock’s canal giving patients symptoms of pudendal neuralgia such as burning pain in the perineum, rectum, clitoris and vagina which is typically worse with sitting.
Obturator internus muscle with Alcock’s canal containing pudendal nerve
Groin mesh removal
Those transobturator meshes are also placed in the proximity of the obturator nerve, but rarely cause direct injury to this nerve. They may injure obturator nerve in the indirect mechanism though since the spasming obturator internus muscle is putting pressure on the obturator nerve at the obturator canal. Patients develop symptoms of obturator neuralgia such as groin pain and pain on the inside of the thigh which is worse with walking.
Groin mesh removal with identification of obturator nerve
Delayed mesh injury also occurs with retropubic meshes. Those meshes pierce through pelvic floor muscles and when they irritate them, they also may cause them to spasm. Spasming pelvic floor muscles also place pressure on pudendal nerves triggering symptoms of pudendal neuralgia.
Retropubic mesh perforating pelvic floor muscles
Robotic removal of mesh
In my practice close to 50% of patients who have developed pain after mesh placement have also developed new onset autoimmune condition which they did not have prior to the mesh placement. Most common conditions observed were Sjögren syndrome, lupus and Hashimoto’s thyroiditis. Patients often experience unexplained rashes on the legs, arms, muscle aches and fatigue. Symptoms are usually quite debilitating and not amenable to treatment unless mesh is removed. Fortunately, when mesh is completely removed autoimmune symptoms improve
If patient has symptoms of nerve injury (pudendal, obturator or other pelvic nerves) it is of utmost importance that she is treated by a provider who specializes in treating mesh complications, preforms complete mesh removal surgery, but also is knowledgeable in pelvic nerve injury and surgical nerve decompression. Dr. Michael Hibner is the only provider in United States, who is board certified in Female Pelvic Medicine and Reconstructive Surgery (urogynecology) who performs complete mesh removals and specializes in pelvic nerve decompression surgery.
Removal of mesh from pudendal nerve
Dr. Hibner strongly believes that it is the arms of the mesh deeply embedded into the pelvic muscles that have a potential of causing severe pelvic pain. Removing just the vaginal part of the mesh in most of the cases is not going to help with pain. It is the arms that need to be removed in order to help with pain and it may be much more difficult to remove those arms if the vaginal part has been previously removed. It is best to remove the entire mesh in one piece during the same surgery. The complete mesh removal is also very important in patients who have developed autoimmune symptoms after mesh placement. In order to alleviate autoimmune symptoms every piece of polypropylene has to be removed.
If you or someone you know have developed pelvic pain or autoimmune symptoms after mesh placement call our office 480 599-9682 to learn more about available treatments.
Pelvic Floor Muscle Spasm
Pelvic Floor Muscle Spasm is one of the most common conditions leading to pelvic pain both in women and in men.
This condition is one of the “evil quadruplets” since it tends to co-exist with endometriosis, interstitial cystitis/bladder pain syndrome, and irritable bowel syndrome. The condition is like having a charley horse in the muscles that surround the vagina, urethra, and rectum. There are multiple reasons why this spasm happens.
Most often it is some other pelvic pain condition, that through complex neural mechanisms is irritating the pelvic muscle(s). Patients who have chronic pain from endometriosis, chronic pelvic pain syndrome, pelvic floor disorder, or pelvic trauma may develop the spasm, which unless treated, may last for many years. Some patients may also develop spasms after psychological trauma or even without any significant precipitating event.
Most commonly patients with pelvic floor spasm(s) will experience pain during intercourse, urination, and bowel movement as well as any physical activity. Generally, this pain persists from hours to days after the sexual function or sexual intercourse. It may also persist after urination or bowel movement. Patients with muscle spasms may also have trouble in starting the urine flow or difficulty in completely emptying the bladder. Because of that incomplete emptying, they often get up at night multiple times to urinate.
Pelvic floor spasm(s) may be easily identified during a physical exam or womens health exam by a trained pelvic pain physician or pelvic floor physical therapist. Treatment consists of pelvic floor physical therapy and muscle relaxants.
The majority of patients are helped by those two modalities. In cases where muscle spasm is not relieved by pelvic floor physical therapy and muscle relaxants, botulinum toxin injections to the pelvic floor may be necessary. Treatment of the underlying pain is also very important.
In cases where pelvic floor muscle spasms developed because of other symptoms such as endometriosis, treatment of that underlying condition is very important. If someone has developed pelvic floor muscle spasm after placement of pelvic mesh, the mesh has to be addressed first before addressing muscle spasm.
At Arizona Center for Chronic Pelvic Pain, we work with physical therapists in the Phoenix area and throughout the United States. We strongly believe that pelvic floor physical therapy is the most important part of relieving pelvic muscle spasm(s). In most cases, we will be able to recommend a physical therapist in your area or provide you with resources to find one. Strengthening weak pelvic floor muscles through pelvic floor exercises is critical.
Muscle relaxants are usually used in the form of a vaginal or rectal suppository and seem to be more effective than oral medications. Different formulations of suppositories exist, and they will be discussed with you during the visit. Botulinum toxin A (BotoxÒ) injections are offered to patients when physical therapy and suppositories fail. Those injections relieve muscle spasms and pain in the great majority of patients, but they may need to be repeated every few months. Because those injections are painful, they should always be done under sedation.
If you have difficulty finding a pelvic floor physical therapist in your area, please contact our office. We collaborate with therapists around the country, and we may be able to help you find one in your area. You can also visit the page of the International Pelvic Pain Society (pelvicpain.org), Women’s Section of American Physical Therapy Association (aptapelvichealth.org), or Herman and Wallace Pelvic Rehabilitation Institute (hermanwallace.com) to find a provider in your area.
What to expect after BotoxÒ injection?
- BotoxÒ injections to pelvic floor muscles are almost always done in conjunction with pudendal nerve(s) block. The block is done to decrease pain after the procedure. When you wake up from the sedation after BotoxÒ injection, you will feel numbness in the pelvis, and you may have numbness in one or both of your legs. Numbness is completely normal and will disappear when the local anesthetic wears off.
- If you have numbness in your legs, you should avoid walking until the numbness goes away. You should have someone help you walk the first time you get up after the procedure.
- After the procedure, you may have difficulty emptying your bladder. Pelvic floor muscles are irritated immediately after the injection, and some patients may need a urinary catheter for a few days. Difficulty emptying the bladder goes away after BotoxÒ starts working and relaxes pelvic floor muscles.
- You may experience vaginal bleeding for 2-3 days after the procedure. It is completely normal, as long as the amount of bleeding is less than the menstrual period.
- After the local anesthetic wears off your pain may come back, and it may come back worse than it was before the procedure. This is because muscles are irritated from the injection. BotoxÒ starts working about one week after the procedure, but it may take 10-14 days to feel the relief of pain.
- It is very important to continue physical therapy after BotoxÒ Botulinum toxin by itself does not permanently cure muscle spasm, but it allows physical therapist to work more aggressively on your pelvic floor muscles.
- BotoxÒ wears off approximately 3-4 months after the injection. Some patients will not go back into spasm, but most will need a repeat injection. If you or your physical therapist feel your muscle spasm is returning, call our office to be scheduled for a repeat procedure.
Interstitial cystitis (bladder pain syndrome) is a condition which is characterized by the bladder pain during the filling phase. Patients usually complain of pain as the bladder gets full and because of that they urinate frequently to avoid pain sensation. Patients also complain of urgency (got to go sensation) and getting up at night multiple times to urinate. There is always pain with intercourse especially in positions where bladder is directly irritated by the partner’s penis. Patients often have pain outside the bladder, in the vulva, lower back and abdomen. Certain foods and drinks, especially acidic, spicy, containing coughing or alcohol are known to trigger pain and urgency in patients with bladder pain syndrome. Drinks include coffee and tea (both caffeinated and decaffeinated), soda, alcohol, citrus juices, and cranberry juice. Fruits which acidified urine are lemons, limes, oranges, grapefruit, pineapple, kiwi fruit as well as vegetables such as chili peppers, onions, sauerkraut, tomato products and pickles worsen interstitial cystitis symptoms. Processed cheese, dark chocolate and yogurt are also known to aggravate the bladder.
Pathophysiology of interstitial cystitis is not known, and many different theories have been proposed to explain this disease. They range from an infection which is not easily detectable by available techniques to autoimmune process to pelvic floor muscle spasm and incomplete emptying. This lack of understanding of how patients get interstitial cystitis makes the treatment of this condition much more difficult.
There is also a big disagreement among providers on how to diagnose interstitial cystitis, and most diagnose it based on patient’s symptoms. Additional studies such as urine analysis, urine culture and cystoscopy may be necessary to rule out other conditions that may be adding to bladder pain. Looking for glomerulations on cystoscopy or potassium sensitivity test are not used in modern diagnostic process of interstitial cystitis.
There are multiple available treatments for interstitial cystitis which include diet modifications, relaxation techniques oral medications but one of the most important concepts is treatment of the pelvic floor muscles. Additionally, treatments involving hydrodistention of the bladder may be very beneficial.
If you or someone you know suffers from interstitial cystitis/bladder pain syndrome call our office at 480-599-9682 or email [email protected] to learn more about available treatments.
Pelvic Congestion Syndrome | What conditions are associated with Pelvic Congestion Syndrome?
Varicose Veins or Vein Engorgement
When blood pools in the pelvic vein or ovarian vein, it may result in enlarged veins, causing pain, tenderness, and redness. Varicose veins usually develop in the legs, calves, and feet, but can also occur in the pelvic region, leading to pelvic congestion syndrome.
Deep Vein Thrombosis (DVT)
DVT occurs when a blood clot forms in a deep vein, and this can occur in the pelvis. The clot then restricts blood flow, which in turn causes pain, swelling, and often varicose veins, such as in the left ovarian vein.
Compression on the renal vein can affect urine flow and backing up of urine into the left kidney, causing pelvic congestion syndrome symptom. As a result, affected individuals may report chronic pain and frequent urination.
Peripheral Artery Disease (PAD)
Cholesterol and fat can build up in the arteries forming plaque that blocks blood flow. This leads to peripheral artery disease, wherein the reduction of blood flow affects the iliac arteries in the pelvis. Those affected may suffer from pain and cramps. Men may also experience erectile dysfunction.
Who is at Risk for Pelvic Congestion Syndrome?
Since studies have shown a link between pregnancy and pelvic congestion syndrome, women who have given birth are at risk for developing this condition. Women who have had multiple pregnancies (carrying more than one baby, e.g. twins) are even more at risk than those who have had a singleton pregnancy (carrying one baby), as they are more likely to develop pelvic varices or enlarged veins in the pelvic region.
In addition, those who have a history of pelvic congestion syndrome in the family are also at risk. If you are suffering from chronic pelvic pain and believe you might have this condition, get in touch with a qualified healthcare provider like AZCCPP.
Can I manage Pelvic Congestion Syndrome on my own?
While this condition is not fatal, if left undiagnosed or untreated, pelvic congestion syndrome can lead to further health complications like chronic pelvic pain and permanently damaged vein. Only qualified healthcare professionals like our team at AZCCPP can help you manage it properly through treatments such as interventional radiology and ovarian vein embolization.
We strongly advise you to get in touch with us so we can make the right diagnosis and provide the best pelvic congestion syndrome treatment option for your case.
What are Pelvic Varicosities?
Pelvic congestion syndrome is a condition where pelvic veins become engorged and form pelvic varicosities. Pelvic varicosities usually occur during pregnancy and disappear after. In some patients, they remain, causing pelvic congestion syndrome. It may occur after a full-term pregnancy, but also after preterm birth, miscarriage, or even after ectopic pregnancy. The mechanism in which varicosities cause pain is not well understood, but it may be due to stretching of the vein wall, pressure on the surrounding nerves, or changes in tissue pH. Some varicosities occur in the ovarian veins and veins around the uterus but some patients have varicosities in the vulvar area pressing against the nerves innervating the clitoris, urethra, and labia.
Depending on the location of congested veins patients will experience different symptoms. Congestion of ovarian and uterine veins leads to the sensation of heaviness in the pelvis which is worse with sitting and standing for a prolonged time and better with laying down. On top of the sensation of heaviness, there is occasional sharp shooting pain in the lower abdomen usually on the left side lasting several seconds at a time which may occur a few times a day to a few times per week.
Pelvic congestion may be diagnosed on pelvic MRI or ultrasound but the gold standard test for diagnosis is transfundal venogram.
Typical appearance of pelvic congestion syndrome on transfundal venography
Treatment of pelvic congestion may be done by an interventional radiologist who obliterates the congested veins in an attempt to decrease pain. Congested veins may also be closed off surgically by isolating them from the surrounding structures such as nerves and arteries and sealing with a vessel sealing device. An additional benefit of surgical treatment using da Vinci robot over radiological treatment is that surgical treatment of pelvic congestion allows to precisely survey the pelvis and address any other cause of pelvic pain.
Congestion of the veins around the clitoral or perineal branch of the pudendal nerve can only be seen during a special ultrasound examination. This congestion will lead to pain in the clitoris, urethra, and labia and it is worse with sitting and standing. Patients may also experience the sensation of persistent sexual arousal. This type of congestion may be treated by injecting a sclerosing agent into the congested vein in a similar manner as it is done into varicosities in the legs.
Doppler ultrasound demonstrating congestion in the clitoral vein
What are the Signs and Symptoms of Pelvic Congestion Syndrome?
Again, pelvic congestion syndrome affects everyone differently. It will depend on which pelvic structure the varicose veins are affecting. Here are some signs and symptoms of this condition:
- Your vulva is swollen or you have varicose veins in your genital area.
This happens when pelvis varicose veins go out into the vulva or vagina.
- You have an irritable or painful bladder.
When the pelvic varicose veins push on the bladder, you may feel discomfort or pain when urinating.
- You have hemorrhoids.
Pelvic varicose veins that go into the anus and around the back of the passage may result in bleeding, discomfort, or pain in this area, especially when passing stool.
- You have an irritable bowel.
When the pelvic varicose veins push on the bowel, you may experience symptoms similar to irritable bowel syndrome (IBS): bloating, gas, abdominal pain, cramping, diarrhea, and constipation.
- You experience discomfort or pain during and after sexual intercourse.
This is due to the pelvic varicose veins pushing on the gynecological organs.
- Your pelvic pain worsens during your menstrual cycle.
When the weight of the blood in the veins pushes down on the pelvic floor, you may feel an unusual level of discomfort during your period. You may also experience abnormal bleeding.
- Your pelvic pain worsens throughout the day, especially after physical activities.
Usually, the pain intensifies after sitting or standing for too long, or after physical exercise such as walking, jogging, and lifting weights.
- You feel exhausted.
PCS can be just as draining emotionally as it is physically due to the accompanying
discomfort or pain. Hence, many women claim they also suffer from fatigue and even
Since various conditions exhibit the same signs and symptoms as pelvic congestion syndrome, it is important to consult with a trusted physician for accurate diagnosis and proper treatment.
What Causes Pelvic Congestion Syndrome?
Normally, the arteries send blood from the heart to the rest of the body. Then, the veins send blood from the body back to the heart. This flow is made possible by valves within the veins, which keep the blood from going into reflux or flowing backward.
When the veins become dilated, the valves do not close properly. Reflux then occurs, which leads to pooling of blood within the affected organ–in this case, the pelvis. This results in varicose veins and pelvic congestion syndrome.
While the reason for this condition is unknown, most people who suffer from it are women between the ages 20 and 45 who have had previous pregnancies. One theory suggests that the following can cause pressure within the ovarian veins, leading to vein dilatation:
- Age (particularly during childbearing years)
- Polycystic ovaries
- Retroverted uterus
- Anatomic changes in the pelvic structure due to pregnancy
- Hormonal changes due to pregnancy
- Hormonal dysfunction due to pregnancy
- Weight gain due to pregnancy
- Fluid buildup due to pregnancy
- Increase of blood volume due to pregnancy
- Increase of estrogen due to pregnancy
How Can You Avoid Pelvic Congestion Syndrome?
Since the cause of pelvic congestion syndrome remains unclear, it is not always possible to avoid this condition. However, the risk may be reduced by doing the following:
- Eat a healthy diet
- Exercise regularly
- Quit smoking
- Maintain a healthy weight
- Maintain a healthy body mass index (BMI)
- Wear compression garments during pregnancy
- Wear compression garments on a routine basis after pregnancy
Pelvic Congestion Syndrome in Pregnancy
When a pregnant woman suffers from pelvic congestion syndrome, symptoms usually worsen as the baby grows. The baby’s weight and size exert pressure on the varicose veins of the pelvis, causing great discomfort or pain. The pain may be a dull ache, throbbing, or sharp.
Sitting or standing for a long time can cause the pain to worsen at the end of the day. The best way to relieve it is by lying down. Additionally, every subsequent pregnancy may also worsen the pain.
Pelvic Congestion Syndrome may not be fatal, but it can greatly affect your quality of life. For instance, symptoms like hemorrhoids, pelvic pain, and fatigue can take a toll on your physical, mental, and emotional wellbeing.
Fortunately, the symptoms can be minimized and managed with treatments. Your physician might also recommend counseling to help you cope with chronic pain associated with this condition.
To know your treatment options, consult with your doctor.
If you or someone you know has pain that started after pregnancy and has symptoms of pelvic congestion, call our office at 480-599-9682 or email [email protected] to learn more about available treatments.
Adhesions are the scar tissue which forms in the abdominal cavity and pelvis between the loops of the bowel, the bowel and the walls of the pelvis, the pelvic organs and the content of the abdomen. They may range from few areas of fine scar to the very dense obliterated abdominal and pelvic cavity. Adhesions form as a result infections, trauma or previous surgeries. Patients with intra-abdominal and pelvic adhesions generally experience sharp pain which may be more severe with physical activity, rapid movement, especially turning from side to side at night.
There is a disagreement among providers if adhesions cause pain and if removing adhesions relieves pain. In my practice however most of my patient’s significantly benefit from removal of scar tissue. If surgery can be accomplished using minimally invasive techniques such as laparoscopy or robotic assisted laparoscopy the return of adhesions is less likely. Surgical removal of adhesions (adhesiolysis) is not only a compilated and lengthy procedure, but also carries risks which will be discussed with each patient individually.
It is of utmost importance that removal of adhesions (adhesiolysis) is performed by surgeon who is very knowledgeable in pelvic and abdominal anatomy, knowledgeable in bowel, urinary and reproductive surgery as well as in minimally invasive techniques.
If you or someone you know has pelvic or abdominal pain caused by adhesions call our office at 480-599-9682 or email [email protected] to learn more about available treatments.
Pudendal neuralgia is a relatively unknown cause of severe pelvic pain.
In my practice, I define it as a pain located in the area of innervation of the pudendal nerve. Pudendal nerve entrapment is an impingement of the pudendal nerve caused by scar tissue, surgical materials, or mesh. Pudendal nerve entrapment is, therefore, one of the causes of pudendal neuralgia, however other causes such as inflammation, spasm of the surrounding muscles, or other nerve diseases may also be a reason for pain.
Innervation of the perineum
Pudendal nerve entrapment is almost always caused by some traumatic event to the pelvis. This may be pelvic surgery (with or without mesh), difficult childbirth, athletic injury, falls, and other accidents. A repetitive injury such as bicycle seat pressure on the pelvic floor may also lead to pudendal nerve entrapment (cyclist syndrome).
Diagnosis of pudendal nerve entrapment is not easy and relies heavily on taking a detailed history. Pain is located in the vagina, vulva, clitoris, perineum, and rectum, and it may involve one or all of those areas. Pain is more severe with sitting than with standing or laying down and sitting on the toilet is generally better than sitting on the chair. Most of the patients with real nerve injury have pain on one side only, or one side is significantly more painful than the other. Pain is generally more severe with urination, bowel movements, and intercourse. Some patients may also have difficulty emptying their bladder (hesitancy) and bowel (constipation). One of the most debilitating symptoms of pudendal nerve entrapment is a sensation of continuous sexual arousal (persistent genital arousal disorder – PGAD). Patients often reduce this sensation by masturbation which only provides temporary relief.
A pioneer in the treatment of pudendal nerve entrapment and my mentor, Professor Roger Robert, has developed Nantes criteria which greatly assist in diagnosing this condition. Studies have shown that patients who more closely meet the criteria have better outcomes from the surgical decompression of the nerve.
Inferior rectal nerve
Cutaneous branch of the obturator nerve
Lateral cutaneous branch of iliohypogastric nerve
Femoral branch of genitofemoral nerve
Posterior femoral cutaneous nerve
Lateral femoral cutaneous nerve
Genital branch of genitofemoral nerve
Other nerves innervating the pelvis
Pain in pudendal nerve entrapment is of neuropathic nature, which means that patients feel burning tingling and numbing sensation (paresthesia). Some patients have the sensation of a foreign body located in the rectum or vagina (allotriesthesia) and may describe it as a “red hot poker” in the rectum. Some patients do not experience any pain but have complete or partial numbness in the area of innervation of the pudendal nerve.
Additional tests such as magnetic resonance neurography (MRN), pudendal nerve motor terminal latency (PNMTL), another electrophysiologic testing, or sensory threshold testing are generally not accurate enough to diagnose pudendal nerve entrapment. A CT-guided pudendal nerve block is a part of Nantes criteria, and an important step in the diagnosis and treatment of pudendal nerve entrapment. Lack of relief of pain immediately after a CT-guided pudendal nerve block means that pain originates in another structure or is transmitted by a different nerve other than pudendal.
Conservative treatments of pudendal neuralgia consist of:
- Avoidance of additional injury – patients need to immediately stop the activities that lead to injury of the nerve in the first place. For example, if nerve pudendal neuralgia was caused by riding a bicycle, the patient has to immediately stop cycling. Of course, this cannot be done in cases where the patient developed pudendal neuralgia as a result of surgery or childbirth
- Protecting the nerve by using sitting cushions, zero gravity chairs, or kneeling chairs
- Medications including oral medications and vaginal/rectal suppositories
- Appropriate pelvic floor physical therapy (to minimize pelvic floor muscle spasm)
- Botulinum toxin A injections to pelvic floor muscles (to minimize pelvic floor muscle spasm)
- Pudendal nerve blocks using CT, ultrasound, or in some cases unguided transvaginal blocks
- Pudendal nerve injections with amniotic fluid and liquified amniotic membrane
- Ablation procedures – pulse radiofrequency ablation (pRFA) and cryoablation
- Nerve stimulators and spinal cord stimulators
- Surgical decompression of the nerve. Pudendal nerve decompression can be done using several different approaches: transgluteal, transischorectal, transperineal, and laparoscopic/robotic.
The transgluteal approach is an original technique described by Professor Roger Robert in Nantes, France, and very significantly modified by me. This approach offers by far the best access to the pudendal nerve, therefore allowing for the most complete decompression. One of the earlier drawbacks of the technique was cutting of the sacrotuberous ligament which in some cases could lead to pelvic instability. The risk of that instability was eliminated when I began repairing the sactotuberous ligament. Cutting of that ligament allows access to the nerve and frees it from the scar tissue or surgical materials, but after nerve decompression is accomplished sacrotuberous ligament should be repaired.
Other modifications that I have introduced to the pudendal neurolysis surgery were:
- Use of surgical microscope for better visualization of the nerve and surrounding structures
- Use of Nerve Integrity Monitoring System (NIMS monitor) to aid with identification of pudendal nerve. It is especially helpful in cases when the nerve is significantly scarred, and in cases of repeat surgery.
- Use of a pain pump that delivers a local anesthetic to the nerve for about seven days after surgery. This decreases pain levels and is thought to reverse central sensitization (memory of pain in the brain). This step may lead to faster recovery and resolution of pain after surgery.
- Nerve wrapping with an adhesion prevention barrier decreases the risk of scarring or re-scarring of the nerve after surgery. Several years ago, I switched from regular nerve wraps to wrapping the nerve with an amniotic membrane product. In addition to anti-adhesion (anti-scarring) properties, the amniotic membrane contains nerve growth factors that promote nerve healing. It also may have the ability to attract your own body’s stem cells close to the nerve, which further helps with nerve regeneration.
- Use of suction dressing after the closing of the skin to minimize the risk of wound infection
The microscope used for transgluteal pudendal surgery. On the left of the screen NIMS monitor used for monitoring the nerve during surgery
Laparoscopic/robotic procedure is less invasive, but it does not offer as good of access to Alcock’s canal as transgluteal procedure does. It may be effective in cases where the nerve compression is limited to the small area, but the location of compression may be difficult to determine prior to surgery.
In my practice, I perform both transgluteal and robotic nerve decompression procedures, but I believe that since the transgluteal technique offers better access and allows for decompression of the larger part of the pudendal nerve, it should be a preferred approach. Even though the recovery time is longer compared to the laparoscopic procedure, the benefits of more complete nerve decompression are very important when considering the choice of surgery.
Overall, the results of surgery show that the majority of patients have significantly decreased pain, and benefit from pudendal nerve decompression procedures.
If you or someone you know experiences pain with sitting in the clitoris, vulva, penis, scrotum, perineum, or rectum, call 480 599-9682 or email [email protected] to learn more about available treatments.
View of the pudendal nerve through the microscope (nerve in the blue rubber band – vessel loop)
What to expect before and after transgluteal nerve decompression surgery
1. Prior to surgery Dr. Hibner and his team will use some or all available non-invasive methods to help you with your pain. They may include physical therapy, suppositories, oral medications, nerve ablations, injections of amniotic fluid/membrane products.
2. Decision for the surgery is made together by the patient and Dr. Hibner. It is based on all the information from the patient’s history, exam, radiology results, any additional testing. Also, the fact that all offered conservative treatments have failed is taken into account when deciding on surgery.
3. Transgluteal pudendal nerve decompression is Dr. Hibner’s preferred way to free up the nerve from scar tissue but in certain cases robotic approach or highly selective approach to the pudendal nerve, branches may also be chosen.
4. Prior to the surgery please follow all the pre-operative instructions which will be given to you during the visit
5. For the transgluteal decompression surgery you will be positioned on your abdomen (prone) and the incision will go on the buttock on the operated side. It will measure anywhere from 2 to 4 inches.
6. When you wake up from surgery in the recovery area you will have a catheter in your bladder, a pain pump dripping local anesthetic on your nerve, and negative pressure dressing on the skin over the incision. You will receive a bag to wear over your shoulder for the pain pump and device providing suction to the dressing). It is very important to be gentle with the pump to avoid dislodging the catheter. If the pain pump catheter is dislodged, it cannot be replaced.
7. You should feel numbness in the area of the pudendal nerve (where the pain was before surgery) but the incision over the buttock will be quite tender. Pain pump medication does not reach the muscles or skin of the buttock, and it is only meant to provide pain relief in the nerve.
8. Most patients spend one night in the hospital. A very rare two-night stay is required
9. You should be active and try to walk with support the next day after surgery. This prevents a loss of muscle and could also decrease the risk of nerve scarring. Please be very careful when moving and walking not to pull the pain pump.
10. You will be discharged home with pain medications and instructions on how to use the pain pump and negative pressure dressing. You may need to return to the clinic for the dressing and pain pump removal, or we will instruct you how to do it yourself. When the pain pump comes out your pain may increase until the nerve begins healing.
11. You can shower 2 days after surgery. Try to avoid making the area of the incision wet. You can wrap that area with a large garbage bag for the time of surgery. Water is not going to contaminate the incision but may make the adhesive covering the pain pump catheter wet leading to the earlier removal of the pump.
11. Most patients can travel within 5-7 days after surgery but a longer stay is encouraged before traveling back home.
12. You can resume the activity after surgery but avoid doing things that significantly increase your pain. Sitting should be avoided. If surgery was done on one side only try to sit on the opposite buttock.
13. Do not flex your hip(s) over 90 degrees. This may lead to pulling apart the sacrotuberous ligament which was repaired during surgery. This ligament takes approximately 6 months to heal. You should therefore avoid squatting, taking two steps at a time when walking upstairs, etc.
14. You should resume pelvic floor physical therapy approximately 6 weeks from surgery. You will be given instructions for you and your physical therapist regarding recommended therapy.
15. It may take 3-4 months to start feeling the improvement in pain. It is normal to have better and worse days. When you have a better day please be careful not to overexert yourself. Follow the instructions of your pelvic floor physical therapist on physical activity.
16. Please continue to take all your medications until you are instructed to stop. You can continue vaginal/rectal suppositories, but you should be decreasing the number of narcotic pain medications you take.
17. Generally we do not schedule patients for in-person postoperative visits. Care can be done over the phone or by telemedicine.
18. Maximum healing may take 18 to 24 months from surgery. After 2 years from surgery majority of patients have less pain or no pain. If you continue to be in pain, we will look for other solutions to help you with your condition.
Outcomes of this procedure depend on the causes of nerve compression, the degree to which the nerve was compressed, and how much time elapsed between the injury and surgery. Unfortunately, the degree of nerve damage is difficult to assess before surgery. From my extensive experience of doing hundreds of pudendal decompression surgeries, approximately two-thirds (66%) of patients benefit from this procedure. This number includes all the patients, even those with severe nerve injury. That means that patients with less severe nerve injury may benefit from the procedure even more.
Patient positioned for Pudendal decompression surgery. The incision the buttock marked with a pen. Electrodes are placed for monitoring the pudendal nerve (NIMS monitor).
A little history…
Pudendal neuralgia has been recognized by medicine in the book published in Philadelphia in 1871 – “The Change of Life in Health and Disease”. The knowledge of pudendal neuralgia was almost lost until the late 1980s. French neurologist Dr. Gerard Amarenco reported on a series of patients with “syndrome du cyclist”, the cyclist syndrome which occurs when a pudendal nerve is compressed between narrow bicycle seat and medial surface of ischial tuberosity (sitz bone). The first procedure to surgically decompress the pudendal nerve through transperineal technique (incision around the anus) was described in 1992 by Egyptian surgeon Dr. Ahmed Shafik. Soon after my mentor Professor Roger Robert from Nantes, France described transgluteal pudendal neurolysis – decompression of the pudendal nerve with an approach through the buttock. Professor Robert is not only an outstanding neurosurgeon, but also an anatomist, and this unique combination allowed him to develop the whole new procedure for pudendal nerve decompression.
I graduated from my fellowship in gynecologic surgery at Mayo Clinic in 2003 and opened pelvic pain practice in Phoenix in 2004. I started seeing patients with pelvic pain whose condition could not be explained by any disease known to me. So, in early 2005 I googled the symptoms: perineal/vaginal bringing pain with sitting. Several medical articles showed up, but most of them had one common name as one of the authors: Roger Robert. I then send the letter to Nantes France to Professor Robert if I could come to visit him and learn from him. In the summer of 2005, I traveled to Nantes and worked with Professor Robert for almost 3 weeks assisting him on numerous surgeries and seeing many patients in the office with him. I also worked with wonderful Dr. Jean Jacques Labat, a neurologist who assisted Professor Robert with diagnosing and treating patients before surgery, and with amazing radiologist Dr. Thibault Riant who taught me how to perform CT-guided pudendal nerve blocks. When I returned to Phoenix, I started seeing more and more patients with pudendal neuralgia and pudendal nerve compression, and I performed my first transgluteal pudendal nerve decompression in the fall of 2005. It was in the patient who developed pudendal neuralgia after removal of Bartholin’s gland. She did well after surgery and soon many more patients have followed. From the very first surgery, I started modifying the original procedure developed by my great mentor, Professor Robert. The first modification was repairing of the transected sacrotuberous ligament. There was a concern that leaving this ligament not repaired may cause instability in the sacroiliac joint. So, from the very first patient, I would repair sacrotuberous ligament the same way that an orthopedic surgeon repairs a ligament in the knee. Next, I incorporated the use of a neurosurgical microscope into the procedure. This allowed for significantly improved precision. The next modification was the use of an On-Q pain pump placed next to the nerve towards the end of surgery to provide postoperative analgesia and decrease central sensitization (memory of pain in the brain). The third modification was the incorporation of NIMS (nerve integrity monitoring system) to allow to the identification of the nerve in the setting of significant scarring. The next modification was the use of nerve wrap to prevent the reoccurrence of adhesions. Initially, I was using a collagen nerve conduit but a few years ago I switched to an amniotic membrane which in addition to preventing adhesions also contains factors/chemicals promoting nerve healing. The last major modification was the method in which I cut the sacrotuberous ligament. Cutting it in a Z fashion allows me for better access to the nerve and facilitates the repair at the end of surgery. Up to today, I have done several hundred of those procedures, most likely more than any other provider with exception of my amazing mentor, Professor Roger Robert.
From the left: Dr. Jean-Jacques Labat, me, Professor Roger Robert and Dr. Thibault Riant
For more information visit:
Drawing of the steps of transgluteal pudendal neurolysis by Professor Roger Robert
View of the opened space between the sacrotuberous and sacrospinous ligaments by Roger Robert
One of my numerous publications on pudendal neuralgia
Hard work and knowledge of many, many people went to the development of transgluteal pudendal decompression surgery the way I perform this procedure today. I would like to take this opportunity and thank: Professor Roger Robert, Professor Oskar Aszman, Dr. Jamie Balducci, Dr. Jacek Bendek, Dr. Mario Castellanos, Dr. May Nour, Cindy Love, and many others. Big thank you from me and on behalf of my patients whom I was able to help with pain.
Pain with sitting may be very debilitating since it often prevents patients from working (sitting at the desk) and participating in daily social activities (sitting to have a meal, travelling, going to the movies etc.) It may range from mild discomfort to severe pain preventing patient from sitting at all. Some patients find sitting on the doughnut cushion beneficial, others use zero gravity chairs or kneeling chairs and some patients do not set at all. They arranged their workspace using various types of standing desks.
Pain with sitting may be caused by the following conditions:
- pudendal nerve entrapment
- spastic pelvic floor syndrome
- pelvic congestion syndrome
If you or someone you know experience pain in the vaginal or rectal area related to sitting please call our office at 480-599-9682 or email [email protected] to learn about available treatments.
Most of the patients with pelvic pain feel better when they are standing unless it is a standing for prolonged time.
Pelvic pain typically related to standing is caused by pelvic congestion syndrome however patients with pudendal nerve entrapment may also have pain after prolonged standing.
Pelvic pain with standing may be related to hip or other joints or bones which are outside of scope of my practice.
If you or someone you know has pain with standing, call our office at 480-599-9682 or email [email protected] to learn more about available treatments.
Pain with urination is a common symptom seen in many different conditions. Occasionally all of us experience it when we have a urinary tract infection. It becomes problematic when it is chronic and happens every time we go to the bathroom. It may range from mild discomfort to severe pain. It is very important to distinguish between pain when the bladder gets full, pain during urination, and pain at the end of urination.
Pain during and after urination is typically related to the spasm of the pelvic floor muscles. Pain in a full bladder is caused by interstitial cystitis/bladder pain syndrome.
Pain with intercourse is present in almost all patients with chronic pelvic pain. It is the single most common symptom for which patients present to our practice. Understandably, lack of intercourse may cause loss of intimacy, often leading to significant anxiety and emotional suffering. I regard restoring the ability to have pain free intercourse to be one of the most important aspects of my practice.
Certain characteristics related to sexual activity allow to differentiate between the causes of pain.
Pain with sexual arousal or foreplay may be caused by pudendal neuralgia or pelvic congestion.
Pain with entry may be caused by pelvic floor muscle spasm.
Pain with deep thrust may be caused by endometriosis or adhesions.
Pain with deep thrust in patients who had a hysterectomy may be caused by neuroma of vaginal cuff.
Pain with intercourse in rear entry (“doggy”) position is common in patients with interstitial cystitis/bladder pain syndrome
Pain after intercourse sometimes lasting for a few days is difficult in patients with pelvic floor muscle spasm or pelvic congestion.
If you or someone you know experiences pain during or after intercourse, please call our office at 480-599-9682 or email [email protected] to learn more about available treatments.
Pelvic pain with physical activity is usually caused by spasm of pelvic floor muscles. It may also be caused by abnormalities in hip joints and bones which is outside the scope of my practice.
If you or anyone you know experiences pelvic pain with physical activity, please contact our office at 480-599-9682 or email [email protected] to learn more about available treatments.
Pain with menstruation is typically caused by endometriosis or adenomyosis. It is important to remember though that because of the hormonal fluctuations, pain threshold is lowered during that part of menstrual cycle and any pain may be perceived as more severe.
If you or someone you know experiences significant pain during menstruation, call our office at 480-599-9682 or email [email protected] to learn more about available treatments.
Childbirth is one of the happiest moments in any woman’s life. Unfortunately, some patients may develop pelvic pain after delivery. In most cases this pain goes away within few weeks but in some it remains for much longer. There are multiple causes of pelvic pain after childbirth but most commonly it is of musculoskeletal origin. Some patients, especially after vaginal delivery, may develop spasm of pelvic floor muscles. This is more likely to happen in patients who had a big baby, had a procedure to help deliver the baby (vacuum or forceps) or had a big episiotomy or tear. In a small percentage of those patients, pain may be caused by nerve injury, specifically pudendal nerve or one of its branches. It is hard to initially distinguish between nerve and muscle injury because symptoms are similar, and diagnosis requires a physician who is familiar with pelvic floor disorders and nerve disorders to make that diagnosis.
Another type of pain which may occur after delivery is caused by pelvic varicosities which form during pregnancy. It is called pelvic congestion syndrome. It is characterized by heaviness sensation in the lower abdomen with prolonged sitting or standing with occasional sharp shooting pain. Many gynecologists do not recognize pelvic congestion as a condition which may lead to pelvic pain and that is why it is so important to see a provider who specializes in pelvic pain and can offer treatments for pelvic congestion.
If you or someone you know is experiencing pain after vaginal childbirth, please contact our office at 480-599-9682 or email [email protected] to learn more about available treatments.
Pain with ovulation is called mittelschmerz. It is experienced by about 20% of women in some or all cycles. It occurs roughly halfway between menstrual cycles. It is usually sharp seven and located in the lower abdomen either on the left or right side. It is unknown why this condition happens and usually treated with nonsteroidal anti-inflammatory medications.
Pain with ovulation may also happen in patients who have pelvic adhesions which occurred as a result of previous surgery, endometriosis, infections or trauma. When ovary is trapped in the scar tissue it is not able to freely release an egg and causes pain. This pain may be relieved by surgically removing the adhesions.
If you or someone you know experiences pain with ovulation after surgery, infection, trauma or in the setting of endometriosis please call 480 599-9682 or email [email protected] to learn about available treatments.
Motor vehicle accident or any other accident is very traumatic and painful event. It is even more traumatizing when pain remains after healing ends. Some patients may develop persistent pelvic pain after a traumatic event even if there was no direct trauma to the pelvis. Patients who develop pain after accident often develop spasm of the pelvic floor muscles. Without direct trauma this spasm develops when patients are bracing for impact. Pelvic floor muscle spasm may be appreciated on the pelvic exam by a provider knowledgeable in this condition. Alternatively, patients with pelvic pain after accident may also suffer from compression or injury of one of the pelvic nerves. If pain is located in the vulva, vagina, penis, scrotum, perineum or rectum it may be caused by injury to the pudendal nerve. If that pain is in the lower abdominal or groin it may be caused by injury to ilioinguinal or genitofemoral nerve.
If you or someone you know experience pelvic pain after traumatic accident, please contact our office at 480-599-9682 or email [email protected] for more information on available treatments.
Patients undergo surgery with hope of treating the existing problem, so when the pain develops after the procedure, it is very disheartening even if the original problem was successfully addressed. This is even more complicated when patient had surgery to help with existing pain and ends up with the pain that is more severe than the pain she went in.
Pain after surgery depends on the type of surgery, positioning for the procedure and type of surgical materials used.
Type of surgery – pelvic surgery may lead to pelvic floor muscle spasm. Back surgery may lead to back muscle spasm which may lead to pelvic floor muscle spasm. Any open abdominal or pelvic surgery may lead to adhesions which may cause pelvic pain. Minimally invasive procedures such as laparoscopy or robotic surgery decrease the risk of adhesion formation after surgery. Any incision in the abdomen whether open or minimally invasive has a small risk of injuring abdominal wall nerves such as ilioinguinal or iliohypogastric.
Positioning for surgery may cause compression of certain pelvic nerves which in turn may lead to pain. Nerve blocks and nerve ablations may help in cases of nerve pain related to positioning.
Surgical materials – relates to the use of permanent vs. dissolvable sutures and pelvic mesh. In surgery both permanent and dissolvable sutures are used however, the latter are used much more often. Sometimes permanent sutures may have higher risk of causing inflammation and pain. For that reason, review of operative reports of previous surgeries is particularly important. Pelvic mesh is known in some cases to cause pelvic pain. In patients who have developed pain after surgery involving use of polypropylene mesh the possibility of mesh causing pain should be considered very seriously.
If your pain started as a result of surgical procedure it is very important that you provide us with the operative report and pathology report (if any) of this procedure. It is best if they are uploaded early so they can be reviewed prior to your visit. On instructions how to upload your documents please see section “New Patients”
If you or someone you know developed pain after pelvic surgery, call our office at 480-599-9682 or email [email protected] to learn more about available treatments.
Psychological traumatic event may be devastating to any patient at the time when it happens, but a lot of patients develop lasting effects of such a trauma. They are seen in women and men who are survivors of sexual violence, domestic violence, who have lived through sickness or death of a close relative or friend and many other traumatizing situations. It may happen in people who have highly stressful jobs or who have survived an accident, even without any trauma to the pelvis. In children it may happen during the divorce of their parents.
Many patients develop pelvic floor muscle spasm after psychological trauma and is seen both in women and men. It is a mechanism seen in some animals who tuck their tails under in response to stress or trauma and is caused by the spasm of the pelvic floor muscles. Many highly effective treatments are available for pelvic floor muscle spasm ranging from medications, to physical therapy and injections.
If you or someone you know is experiencing pelvic pain related to psychological trauma, please call our office at 480-599-9682 to learn more about available treatments.
It is estimated that up to 90% of women experience pain with onset of menstrual periods (menarche). It is called primary dysmenorrhea and by itself it does not mean any specific disease. With time and use of non-steroidal anti-inflammatory (NSAID’s) medications or oral contraceptives as well as healthy lifestyle, menstrual period pain in most of the patients improves. If this pain continues for 12 months after menarche, then it is called secondary dysmenorrhea. This ongoing pain with increases the chance of a specific condition causing pain. It is estimated that approximately 70% of patients with secondary dysmenorrhea have endometriosis. Diagnosis of endometriosis can only be done by the surgical procedure (laparoscopy, robotic procedure) and it cannot be reached by any other test. Physician may have a high suspicion of endometriosis but unless it is surgically proven, it is only a suspicion. It is especially important that this surgery is done by a provider who is familiar with diagnosis, treatment endometriosis and minimally invasive surgery.
If you or someone you know is experiencing pain which started at first menstrual period, please call our office at 480-599-9682 or email [email protected] for more information about available treatments.
Ovarian cysts occur quite commonly in women, and some of them form as a result of ovulation during menstrual cycle. They may cause sharp pain in the lower abdomen and pelvis, but often they are asymptomatic. Great majority of ovarian cysts are benign and generally when discovered they should be allowed time to regress on its own. It they persist or are large in size then surgical removal is warranted. In cases of benign cyst regardless of the size, this surgery should always be done using minimally invasive techniques such as laparoscopy or robotic assisted laparoscopy. This allows for significantly higher precision of surgery when separating cyst from healthy ovary, therefore preserving as much of the healthy ovarian tissue as possible. This is important for future fertility and hormonal function. Patients with endometriosis may form cysts called endometrioma. Endometriomas should only be removed by experienced surgeons, to minimize negative effects on future fertility.
If you or anyone you know suffers from recurrent ovarian cysts, contact our office at 480 599-9682 or email [email protected] to learn about available treatments.
In women, internal reproductive organs such as fallopian tubes, uterus, and upper part of the vagina derive from Müllerian ducts. Müllerian ducts are structures present in the fetus. Those ducts during fetal development undergo multiple changes including fusion of the left and right sides. Abnormalities in the formation of the Müllerian ducts lead to anomalies such as bicornuate uterus, vaginal septum, or vaginal agenesis. Patients born with vaginal agenesis, also called Mayer–Rokitansky–Küster–Hauser syndrome (MRKH), do not have a uterus, cervix, or most of the vagina. Generally, the syndrome is discovered around the time of menarche because patients, despite normal sexual development, do not have a menstrual period.
Surgical treatments are available to create a functional vagina. One of the most successful procedures in patients with MRKH syndrome is the minimally invasive Vecchietti procedure. A fully functional vagina comparable to a normal vagina can be reconstructed using this procedure. It requires only three small laparoscopic incisions which are cosmetically very desirable for a young patient.
A genitourinary fistula is a permanent opening between the bladder and the vagina, the ureter and the vagina, or the rectum and the vagina. Those fistulas may result from traumatic childbirth, pelvic surgery, trauma or radiation therapy. The symptom of the fistula is loss of urine (vesicovaginal fistula) or stool (rectovaginal fistula) from the vagina.
Genitourinary fistulas need to be repaired surgically but surgery may be very complex, and the repair sometimes requires more than one procedure. Some of the fistulas may require grafting (moving) of the surrounding tissues to accomplish the repair. It is very important that genitourinary fistulas are repaired by an experienced surgeon with training in female pelvic medicine and reconstructive surgery (urogynecology).
What is Rectovaginal Fistula
A rectovaginal fistula is an abnormal bond between your rectum and vagina that looks like a tunnel opening—while the rectovaginal septum is the thin structure that separates the vagina and rectum. The vaginal tissue damage causes the tissue to die allowing the rectovaginal fistulae to form. Once the rectovaginal fistulae are formed—it lets gas and stool enter your vagina—and inflammatory bowel disease is one of the common causes of it. Other causes of rectovaginal fistulae are:
- Injury during delivery of a baby
- Crohns disease, colorectal disease—and other inflammatory bowel disease
- Radiation injury therapy for gynecologic cancers
- Complications during the surgery in the pelvic area—such as colorectal surgery
The same thing with inflammatory bowel disease—rectovaginal fistulae may cause the patient both physical discomfort and emotional distress—which greatly impacts intimacy and self-esteem.
Symptoms to Look Out For That You Need to Undergo a Rectovaginal Fistula Repair
A rectovaginal fistula repair or rvf repair is a surgical repair where the healthy tissue between your vagina and rectum is stitched jointly to protect and fix the fistula. During the rectovaginal fistulas repair—doctors will need to do an incision or make a cut either between your vagina and anus or inside the vagina—and then the healthy tissue is brought together with several separate layers.
When do you need a rectovaginal fistula repair? Relying on the fistula’s location and size—you may carry minor symptoms such as:
- fecal incontinence or leakage of stool and from the vagina
- Vaginal discharge with a bad odor
- Urinary tract or recurrent vaginal infections
- Discomfort in the vagina, vulva, and perineum (the area between your vagina and anus)
- Pain or discomfort during sexual intercourse
Injuries During Childbirth
Obstetric trauma—such as delivery-related injuries to a patient is the most common cause of a rectovaginal fistula. These delivery-related injuries include rips in the perineum—extending to the bowel, an infection of an episiotomy—a surgical cut to widen the perineum during vaginal or normal delivery.
Childbirth injuries—such as obstetric fistula may happen during a long and difficult labor. An obstetric fistula may also involve injury to the anal sphincter. An anal sphincter is the ring of muscle at the end of your rectum. In addition—the anal sphincter is the one responsible for helping you hold in stool.
The second most common reason for having a rectovaginal fistula, as well as fistula tract is crohns disease. Crohns disease is an inflammatory bowel disease—in which the digestive tract lining is inflamed (ulcerative colitis).
Radiation Treatment Within Pelvic Area
A patient with a cancerous tumor in their cervix, vagina, rectum, anal canal—or uterus could result in a rectovaginal fistula. Radiation therapy is done by a colorectal surgeon—such therapy can cause a fistula that usually forms around six months to two years after the patient receives the treatment.
Perineal laceration or Any Surgery That Involves your Perineum, Vagina, Anus, or Rectum
Prior to perineal laceration or the surgery in your lower pelvic region—such as the removal of your uterus (hysterectomy)—can lead to the development of a rectovaginal fistula in rare cases. The fistula may form as an outcome of an injury during surgery—leak or infection.
In rare cases—a rectovaginal fistula may be formed by infections in your rectum or anus or rectum—infections of little, swelling pouches in your digestive tract (diverticulitis)—dry and hard stool that gets stuck in your rectum (fecal impaction)—long-term colon and rectum (ulcerative colitis)—and vaginal injury unrelated to delivery.
How Doctors Can Help You:
Our doctor performs a physical exam on patients in trying to locate the rectovaginal fistula—and our doctor also checks for a possible tumor mass, abscess, or infection. Overall—Arizona Center For Chronic Pelvic Pain’s doctor’s exam includes vaginal, anus—and perineum inspection.
Unless the fistula is located very low in the vagina and can be seen—our doctor may use a speculum for seeing the inside of your vagina. In addition—our doctor might also take a sample of tissue during the procedure for biopsy or lab analysis.
There are instances when a physical exam may not be enough in finding a fistula—which is why we also offer other tests for locating and evaluating a rectovaginal fistula. These tests also help the medical team in planning for surgery.
Computerized Tomography (CT) Scan
A CT scan done on your pelvis and abdomen has more detail compared to what a standard X-ray does. Through CT scan—it is easier to locate a fistula—as well as determine its cause.
In contrast tests, doctors use a barium enema or vaginogram that helps in identifying a fistula—which is located in the upper rectum. Contrast material is used during these tests that show the vagina on an X-ray image.
Blue Dye Test
A blue dye test involves placing a tampon into the vagina—then injecting a blue dye into your rectum. The blue staining on the tampon implies a fistula.
The anorectal ultrasound is a procedure, which uses sound waves in producing a video image of your rectum and anus and the doctor inserts a narrow and wand-like instrument into your rectum and anus. This anorectal ultrasound test can assess the structure of your anal sphincter and may also show a childbirth-related injury.
Magnetic Resonance Imaging (MRI)
MRI is a test that creates images of the soft tissues inside your body. This test can also show the location of a fistula—and whether your other pelvic organs are involved—as well as if you have a tumor.
This test calculates the sensitiveness—as well as the function of your rectum—which can give more information about the rectal sphincter and your ability to hold stool passage. Anorectal manometry does not locate fistulas—but it may greatly help in planning the fistula repair.
If the doctor suspects you of having inflammatory bowel disease—the doctor may order a colonoscopy to examine your colon. During the procedure—the doctor may take tiny tissue samples for lab analysis—which also helps in confirming chrons disease.
Most patients will need to undergo surgery to close or repair a rectovaginal fistula. But, before surgery is done—the skin and the surrounding tissue of the fistula need to be healthy. It has to have no signs of infection or inflammation at all. Most doctors might recommend waiting at least three to six months prior to having the surgery—in order to make sure that the skin and the surrounding tissue are healthy.
Surgery needed to close a fistula is performed by either or both a gynecologic surgeon and a colorectal surgeon. The goal for the surgeons for such surgery is to remove the fistula tract and seal the opening by stitching together healthy tissue.
When do You Need to See a Doctor?
A fistula could only be the first warning of a more serious problem—for example—an infected—pus-filled area (abscess) or cancer. Reading about the symptoms in the health library is not enough if the symptoms persist. Make sure to see and consult your doctor if you are experiencing any symptoms or signs of a rectovaginal fistula and bring your medical records with you if you have any.
Consult with Arizona Center For Chronic Pelvic Pain—and we’ll identify the cause of the fistula and determine the right treatment plan for you.
Contact our office at 480 599-9682 or email [email protected] to learn more about available treatments.