PITA Pain In The A** And Other Pains You May Not Have Heard Of. Allan S. Gordon MD Neurologist and Director Wasser PMC/ MSH

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1 PITA Pain In The A** And Other Pains You May Not Have Heard Of Allan S. Gordon MD Neurologist and Director Wasser PMC/ MSH

2 Wasser Pain Management Centre Clinical care, education and research in chronic non-cancer pain An integral Centre of Excellence at Mount Sinai Hospital A recognized local, national and international leader in chronic management Developing leaders in CPM Dependent on a variety of funding sources

3 Multiprofessional and Multimodal Neurology (2) Anaesthesiology (7+) Dentistry (4) Gynecology (1) Psychiatry (1) Nursing (2) Addiction Medicine (1) Physiatry (1) Sex Therapy (1) Family / Behavioural Medicine (1) Acupuncture, RMT, Chiropractor, Physical Therapy Plus partners (Urology) Plus Fellows, Residents, Graduate Students, Summer Students Admin Staff

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5 1500 new cases per year and growing 3500 active cases & 8000 patient visits Widespread clinical care and consultation to the community Working to change practices Outpatient and inpatient service See cases other clinics do not see Innovative programs

6 Programs of Care Wasser Pain Management Centre Pain and Addiction Assessment of Individuals with Complex Pain Problems Genital and Pelvic Pain in Men and Women Neuropathic Pain Headache and Facial Pain Muscle and Arthritis Pain Transitional Pain Clinic Inpatient services

7 Causes of Chronic Non Cancer Pain Low Back Pain Headache Fibromyalgia Post traumatic or postsurgical pain Post-herpetic neuralgia Diabetic Neuropathy Scrotal pain Arthritis Vulvodynia Pudendal neuralgia Endometriosis Irritable bowel Inflammatory bowel Interstitial cystitis Ehlers Danlos Syndrome (III)

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9 Research Output Pudendal Neuralgia PGAD Pain interventions for chronic headache Music therapy in FMS and TMD Pain interventions for genital pain Pain and TMD Gourlay output Education of medical students: Knowledge Transfer (CAHR) Use of mindfulness in chronic pain Migraines in emergency departments Headache and sexual pain Pain and addiction

10 Pudendal Neuralgia: Clinical Diagnosis and Management Allan Gordon MD Neurologist and Director Wasser Pain Management Centre

11 Definition (Antolak 2006) Perineal and other pelvic pain that is aggravated by sitting and reduced or relieved by sitting on a toilet seat The pudendal territory is extensive and may include suprapubic, inguinal, genital and perineal pain, vulvodynia, coccydynia, and proctalgia Bladder, bowel and sexual dysfunction are common Pudendal neuropathy encompasses a spectrum of pudendal dysfunction including hyperesthesia, hypoesthesia, and urinary and fecal incontinence. Increase in pudendal nerve terminal latency sometimes helpful Pudendal neuralgia involves pain in the nerve distribution Issues of central sensitization

12 No published data on prevalence Female : male is 2.5 : but mean age in 6 th decade An important consideration in the differential of genital and perineal pain syndromes in men and women 150 possible cases referred in 2014 to the WPMC

13 Team needed: Multidisciplinary and Unique in Canada Neurology Anaesthesiology Urology Behavioural therapies Unfortunately no surgeons in all of Canada do the surgery Nursing Gynecology Psychiatry Sex therapy Imaging Neuromodulation

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15 Schematic anatomy of pudendal nerve. (Courtesy of the Mayo Foundation) Drawing illustrates pudendal nerve arising from sacral nerve roots S2 S4, exiting pelvis to enter gluteal region through lower part of greater sciatic foramen and reentering pelvis through lesser sciatic foramen. Pudendal nerve gives rise to inferior rectal nerve, perineal nerve, and dorsal nerve of penis or clitoris.

16 Nerve entrapment Near ligament Alcock s canal Sub pubic Uncertain

17 Central sensitization sometimes is associated with pain outside the normal nerve distribution and persisting causing pain in feet, toes, buttocks Typically gradual onset, severe burning and aching Foreign body sensation in the rectum, urethra or vagina (e.g. golf ball, or fist, red-hot bowling ball) Pain when digit applied against ischial spine during rectal or vaginal exam Often allodynia and hyperesthesia or hypoesthesia Guilt is common

18 Pathophysiology Slow and gradual compression but sometimes acute Bicycle riding. Pressure applied by cyclists to perineum are above the pressure known to cause ischemic pressure Pressure or trauma to nerve may lead to neuropraxia of to demeylination Can occur with delivery Can occur with prolapse Role of sexual trauma

19 Clinical differentials Vulvodynia Clitorodynia Endometriosis Interstitial cystitis Scrotal pain Other neuropathic pain

20 Management Medical diagnosis and treatment Surgical diagnosis and treatment Comprehensive management approach to include: interventions with blocks, neurostimulation, radiofrequency, pelvic and general physiotherapy, hormonal therapy, pharmacotherapy, behavioural therapy including CBT and mindfulness, alternative therapies, acupuncture, sexual therapy

21 Issues Need for a dedicated centre for genital and pelvic pain including scrotal pain Could be provincial centre Role of Sinai Health in developing rehabilitation and psychological therapies Comprehensive care

22 Ehlers Danlos Syndrome (TYPE 3) Hypermobile Type EDS is a hereditary connective tissue disease first comprehensively described in 1892 Common features include joint hypermobility, skin hyperextensability, and tissue fragility EDS 3 has hypermobility as its hallmark Clinical diagnosis is facilitated by the use of the Beighton Score Genetic testing of limited value in this variant

23 Villefranche (1988, 1997) 6 major types and several minor types EDS 3 is most common subtype with an estimate prevelance of 1 in 10,000 to 15,000 Family studies suggest Autosomal Dominant Hypermobility is the hallmark Beighton score (1983) measures mobility of the thumb, 5 th digit, elbows, knees, and trunk (>/ 5 of 9)

24 Beighton Score Criteria Hypermobility is diagnosed with a score 5/9 One point if while standing, patient can bend forward and place palms on the ground with legs straight One point for each elbow that bends backwards One point for each knee that bends backwards One point for each thumb that touches the forearm when bent backwards One point for each little finger that bends backwards beyond 90 degrees.

25 But there are many other features Fatigue Widespread pain IBS Bladder/IC Genital numbness Mast cell disturbances Marfinoid The way they sit Headache TMD Tethered cord Chiari Hypotension POTS syndrome

26 Consider EDS 3 The New Fibromyalgia Widespread pain Multiple systems Complex Multidisciplinary Care Aggravated by trauma Support and other groups

27 Issues 2 Program in widespread pain (Complex Pain) Fibromyalgia and Ehlers Danlos Syndrome (type 3 or hypermobile) and SFSN Medical, rehabilitation and psychological services necessary..models available Possibility of unique educational, research and management program on the Bridgepoint site

28 Issues 3 Music and Medicine (MaHRC) ASG cross appointed to Faculty of Music Published study on music and fibromyalgia Current projects on vibro-acoustic chair in TMD and EDS/Fibro Opportunity with Bridgepoint experience to introduce music therapy within Sinai site

29 Cannabinoids THC and CBD Pills.Nabilone Spray sativex Medical Marijuana prescribed under certain restrictions Not recommended under the age of 25 Why important?

30 STEPWISE PHARMACOLOGIC MANAGEMENT OF NEUROPATHIC PAIN (Moulin et al, 2014) + Limited randomized controlled evidence to support add-on combination therapy TCA Gabapentinoids SNRI Tramadol Cannabinoids Opioid Analgesic Add additional agents sequentially if partial but inadequate pain relief + Fourth line agents * Topical lidocaine (second-line for postherpetic neuralgia), methadone, lamotrigine, lacosamide, tapentadol, botulinum toxin

31 Useful in myofascial pain Commonly used in inflammatory bowel disease