Article two - covering adhesions, neuropathic pain and muscle/joint pain as causes of pelvic pain.
Pain from adhesions
Adhesions are areas where organs have become stuck together. Adhesions may affect fertility if they are near an ovary or fallopian tube.
What sort of pain can adhesions cause?
Adhesions that form around an ovary may produce pain that is felt on one side of the pelvis, that is particularly severe at the time of ovulation. Ovaries are sensitive organs. They like to move freely and become painful if stuck down by an adhesion. During ovulation the ovary changes in size. There is increased tension on the ovary at this time and the normal ovulation pain becomes worse. If the ovary is stretched even more by a 'functional cyst' then the pain becomes even more severe. Women who are taking the combined contraceptive pill do not normally ovulate and they experience less pain from adhesions around the ovary.
Adhesions present in other areas of the pelvis are less prone to cause pain than adhesions around an ovary. If adhesions in other areas do cause pelvic pain, it is always felt in the same part of the pelvis. It may be worse with sudden movement or during sex. A tender area in a pelvic muscle may lead to a similar type of pain.
Adhesions occurring between loops of bowel rarely cause pain, unless they prevent normal bowel function or block the bowel.
The cause of adhesions
Anything that irritates the peritoneum (the shiny lining on the inside of the pelvis, abdomen and on the pelvic organs) may lead to an adhesion. The most frequent causes are endometriosis, a pelvic infection, an operation (especially if it is performed via a large incision) or severe appendicitis where the appendix has ruptured.
Sometimes no cause for the adhesions is found. If a woman has a previous history of pelvic surgery then it is quite likely that some adhesions are present, but because most adhesions do not cause pain or problems, no treatment is required.
Diagnosis of adhesions
The only way to diagnose adhesions is during a laparoscopy or during open surgery on the pelvis. When a laparoscopy is performed, women who have many reasons for adhesions often have none, and conversely, some women have more adhesions than expected. An ultrasound will not reveal adhesions.
Adhesions may affect surgery
Adhesions can make any operation trickier. This is because:
- They can block the surgeon’s view of the pelvic organs. Dividing the adhesions to permit a better view makes the operation longer.
- They can result in there being less room for the laparoscopic instruments. This makes the operation more difficult and slower.
- Organs that are stuck together are more easily damaged when adhesions are divided.
- Adhesions may hide vital organs such as the ureter under scar tissue, making the risk of damage to vital organs more likely.
For all these reasons, adhesions make the risk of perforation of an organ greater than usual.
Prevention of adhesions
There are ways to reduce the risk of adhesions. Reducing the risk of sexually transmitted diseases reduces the likelihood of pelvic infections, which are a common cause of pelvic adhesions. This means practising safe sex. Treating endometriosis early and effectively can reduce the likelihood of adhesions. Surgery performed via a laparoscope rather than through a larger incision is likely to reduce the risk of adhesions. Gentle handling of tissues by your surgeon, and care to control bleeding are important and an adhesion barrier placed near the ovaries during surgery may keep them apart during the healing phase. There are many types of adhesion barrier, but most dissolve after one to two weeks. None are perfect and none will prevent adhesions completely, but they may make them less likely.
If you are due to have pelvic surgery or laparoscopy, discuss the issue of adhesions with your gynaecologist.
Unfortunately there is one factor that cannot be changed is your skin type. Some women have tissues that produce lots of adhesions even after minor surgery. Others have multiple operations yet produce few adhesions.
If I have adhesions, what can I do?
- Do nothing.
- Adhesions only matter if they cause pain, or infertility. No treatment may be necessary.
- Take the combined contraceptive pill. This reduces ovulation pain because it stops ovulation taking place and the ovary changing shape during ovulation.
- Have a laparoscopy to divide the adhesions. If the pelvic organs are loosely stuck together this is relatively easy. The adhesions lie like fine curtains between the pelvic organs and are easily divided with scissors or laser. If the pelvic organs are firmly stuck to each other it is an extremely difficult area of surgery. It is easy to make a perforation (hole) in a pelvic organ. This perforation then has to be repaired.
- Surgery to remove one or both ovaries. This only applies to women who have completed their families.
A major problem with dividing adhesions is that even if they are separated beautifully, they can reform. This is less likely after a laparoscopy than a laparotomy but may still happen.
Pelvic pain from nerves - neuropathic pain
Neuropathic pain is different from other types of pain. The endometriosis may have been treated successfully, no other pelvic problems have been diagnosed, but pelvic pain is still present. This is often the pain that is described by women who say that “nothing seems to work for my discomfort”.
Explanation of neuropathic pain
Usually neuropathic pain is a constant pain; it is not just a pain that occurs with periods. It is there on most days and maybe stabbing, sharp or burning. If the nerves of the abdominal wall are affected then there may be associated numbness or an unusual feeling when that area of the abdomen is touched. Many daily activities such as stretching, moving or opening your bowels cause pain. Seuropathic pain symptoms tend to vary from day to day and it is often a ‘wearing’ pain frequently disturbed sleep.
The abdomen may not look swollen, but may feel swollen in the same way that your lip feels swollen after a local anaesthetic given at the dentist. This is particularly common in women who have scars present on the abdomen that are numb when touched. There may be allodynia, hyperalgesia or wind up features to your pain Women with neuropathic pain often wake up after a surgical procedure with no pain, relieved that the pain has disappeared. This is because the two drugs used by the anaesthetist to put you to sleep are very effective at treating neuropathic pain. Unfortunately the discomfort reappears over the next few days or weeks once the effect of the medication has worn off.
What is neuropathic pain?
Neuropathic pain is a pain that begins within the nerves themselves at some point on their pathway from the pelvis to the brain. The nerve pathways from the pelvis to the pain become sensitised and well established. The nerves have learned to transmit pain extremely well and are unable to unlearn this feature. The original cause of the pain may have resolved, but the nerves are unable to forget the pain that they knew before.
Neuropathic pain has been recognised as a cause of pain in other parts of the body for many years, but the idea of neuropathic pain as a cause of pelvic pain is fairly new. Examples of neuropathic pain include pressure on a nerve from a prolapsed into vertebral disc, from diabetes or a genital herpes infection.
A prolapsed disc presses on a nerve, and even if an operation successfully removes the pressure from the nerve, the nerve may remember the pain and continue to send pain signals to the brain. Long-term diabetes can result in chemical damage to the nerves which then results in neuropathic pain.
Endometriosis, surgery or long-standing pain itself can all result in permanent structural changes within nerves, resulting in neuropathic pain.
Treatment of neuropathic pain
The treatment of neuropathic pain usually involves one medication or a combination of medication, along with lifestyle changes. Neuropathic pain may be difficult to treat, but the good news is that even if the discomfort is not completely cured, a large improvement is normally achieved.
Medication for neuropathic pain
The drugs that are used to treat neuropathic pain include the following:
- Tricyclic antidepressants such as amitriptyline. These drugs work by increasing the calming signals that are sent down from the brain, so that less pain signals get transmitted through.
- Anti-convulsant medications such as gabapentin, pregabalin and sodium valproate. These drugs are usually used to treat epilepsy, however they have been found to be very effective at treating neuropathic pain. They work by stabilising the nerves and making them less irritable.
- Anti-prostaglandin medications. If these are taken regularly once-a-day then they can improve the chemical environment around the nerves. They are best used in combination with either gabapentin, pregabalin or amitriptyline.
- Tramadol. This is an opioid medication but it seems to have other actions as well and can be effective in treating neuropathic pain.
- Other medications such as mexilitine, ketamine, magnesium, local anaesthetics or corticosteroids.
Generally normal pain medications such as codeine or pethidine do not work well for neuropathic pain.
Other treatments for neuropathic pain
- Exercise taken regularly can help. Neuropathic pain feels better after resting because there is less activity within the nerves. However, long term rest is a trap. It has been shown that you will have less discomfort if your body is fit and active. It is important to see daily exercise and increased muscle strength as part of a pain management program. It is important not to do too much too soon. Begin with gentle exercise that can be achieved easily (for example walking), do it regularly and build up slowly. The endorphin chemicals that are produced during exercise help to relieve pain and improve your sense of well-being.
- Maintain your interests. This helps by distraction technique and gives your brain other things to think about apart from the pain.
- Get sufficient sleep at night. If the body is tired then it seems that tired nerves are more irritable and lead to an increase in discomfort.
- Avoid being overweight. A heavier body weight increases the pressure on joints and muscles. The importance of this is that you do not need another cause of pain.
- Manage your stress. When the brain is relaxed it sends more ignore pain signals to balance your discomfort better.
Pain from joints or muscles – myofascial pain
Muscle pain is not generally the first thing that women would think of if they have pelvic pain. Since the 1940s we have known about tender points in the shoulders and neck, but it is only recently that similar points in pelvic muscles have been identified as a frequent cause of pelvic discomfort in women.
These tender points cause pain that feels as if it comes from the pelvic organs. This is because the nerves that transmit pain signals from the muscles of the pelvis, abdomen, back or thighs join the nerves that carry pain signals from the pelvic organs, when they reach the spinal-cord and before they reach the brain.
What are the features of joint or muscle pain
Muscle pain is usually described as a dull aching or deep pain. It is usually worse on some days than others, but is present on most days. It is usually worsened by changes in position and either made better or worse with exercise. Muscle or joint pain may be difficult to diagnose because it is often referred to other areas of the pelvis. Some examples of this include:
- A tender point in the muscle of the abdominal wall on one side which is felt as pain coming from the ovary on that side. The ovary itself is normal
- A tender point in the muscles of the low back felt as pain in the bladder or uterus. The bladder and uterus are found to be normal. Other low back conditions such as strained ligaments, facet joint pains or prolapsed disc may cause a similar pain.
- The pain from an abdominal incision following a surgical procedure may cause pain referred to the pelvis
- Tender points in the muscles of the inner thigh referred to the vagina. This pain is worse if the thighs are abducted, causing some sexual positions to be painful.
- Tender points in the muscles lining the pelvic bones, resulting in discomfort that seems to come from the ovaries or uterus.
- Tender, over active pelvic floor muscles resulting in painful sex and pelvic pain.
Diagnosis of muscle or joint pain
The diagnosis of myofascial pain is made on the history and the finding of tender spots during a physical examination that when pressed reproduce the typical pain. Neither blood tests nor scans can prove that the pain is muscular in nature. Joint pain is not common in young women, but cam be investigated with an X-ray, CT scan or MRI scan if necessary.
It is helpful to think about when the pain occurs. Is the pain aggravated by certain positions, movements or with exercise? Keeping a pain diary can be useful and involves writing down episodes of discomfort each day, along with associated activities, any emotional stress and the stage of the menstrual cycle. Gradually, a pattern of discomfort occurring at certain times or with particular activities emerges.
Muscle or joint pain is particularly frequent if:
- There is a past history of an injury to the pelvis, back or knees
- There are postural problems, such as a lumbar lordosis (sway back), a scoliosis (curved spine), a stiff or unstable sacroiliac joint, or generalised poor posture.
- You have recently gained weight or been inactive.
- You do excessive exercise or have muscle strain
It is important to rule out other medical conditions before assuming that the pain is secondary to a joint or muscle problem. The conditions that may be confused with this type of pelvic discomfort include a prolapsed intervertebral disc, a nerve trapped in scar tissue or a medical condition like arthritis, multiple sclerosis, fibromyalgia or systemic lupus erythematosis (SLE). Your general practitioner or family doctor can help you exclude these conditions.
Treatment of myofascial pelvic pain
A major part of the management is working out which factors have led to the pain. If the discomfort is due to poor muscle tone from inactivity, then exercises and improving your general health are important. If the pain is due to too much activity with muscle fatigue, then rest and modifying the causative activity will help.
The best treatment will depend on the cause of the problem. A physiotherapist who specialises in treating pelvic problems is a good person to consult. They may recommend the following:
- Specific treatment to the tender areas. This includes therapeutic massage, heat therapy, ultrasound treatment, pressure therapies and myofascial release therapy.
- Exercises to improve posture, stretch tightened muscles and to improve the strength and tone in weak muscles around the joints.
- Review your general health. Low thyroid function, low levels of B vitamins and lowered blood sugar levels may all aggravate muscle irritability.
- A TENS machine. This is a machine that is uses electrical impulses passed between two adherent pads placed over the tender area. The machine blocks pain impulses being transmitted to the brain from that particular area.
- Cool and stretch technique. A physiotherapist uses a cooling spray to reduce the discomfort around the tender joint, and the muscle is then stretched to its full length. This treatment can be repeated daily, usually for one to two weeks, and should provide quick results. It is only suitable for muscles on the exterior of the body.
- Needle injection of the tender area with an anaesthetic. It is actually the needle in the tender point rather than the anaesthetic that relieves the pain, but carrying out the procedure without anaesthetic would be too painful. Needling brings pain relief, but should be repeated weekly for about six weeks.
- Acupuncture. This has been used for hundreds of years to treat painful conditions. Generally acupuncture should be used to manage the pain whilst the underlying problem is addressed.
- Treatment for anxiety and/or depression. Both depression and anxiety can lead to muscle pain by increasing muscle tension. They may not have caused the pain, but they do tend to slow recovery.
- Medications. Non-steroidal anti-inflammatory drugs (NSAIDS) and low dose amitriptyline often help muscle pain. Botox injections can be used to relax overly tense vaginal muscles; the injections work for up to six months.
If treatment is effective and an active tender point gets better, then the discomfort should go away. But, unless the underlying cause is resolved, then the tender point may return. Therefore long-term changes in activity, posture, weight, exercise or general condition are required.
Pain from the bladder - interstitial cystitis
...continued in this article: Pelvic Pain 3