Pathogenesis of Chronic Pelvic Pain Yong-Chul Kim Department of anesthesia and pain medicine, Seoul National University College of Medicine 1
Overview Anatomy Nerve innervation CPP by pathology CPP by pain nature Introduction of various syndromes 2
A Headache in the Pelvis: A new understanding and treatment for chronic pelvic pain syndromes David Wise, Ph.D. Rodney Anderson, M.D. 3
Pelvic anatomy Bones Pubic arch Sacrum Coccyx Ilac bone Joints Sacroiliac joint Symphysis pubis 4
Pelvic anatomy Ligaments Anterior sacroiliac lig. Posterior sacroiliac lig. Interosseous sacroiliac lig. Iliolumbar lig. Lumbosacral lig. Sacrotuberous lig. Sacrospinous lig. 5
Pelvic anatomy Muscles and fasciae Levator ani muscle Coccygeous muscle Piriformis muscle 6
Perineal anatomy Boundary Ant. - pubic symphysis Post. - coccyx Lat. - ischial tuberosities Anterolat. - ischiopubic ramus Posterolat. - sacrotuberous lig. 7
Perineal anatomy Muscles and fasciae Sphincter ani externus m Corrugator cutis ani Ischiorectal fossa Inferior rectal vessels Perineal nerve Perforating cutaneous branch of pudendal plexus Posterior scrotal vessels and scrotal nerve 8
Ilioinguinal n. Genital branch of genitofemoral n. Perineal branch of Posterior femoral cutaneous n. Perineal n. of pudendal n. Pudendal n. 9
Nerve innervation Visceral innervations by sympathetic nerve and parasympathetic nerve system Celiac plexus, Aorticorenal G Aortic plexus Inferior mesenteric plexus Superor hypogastric plexus Inferior hypogastrtic plexus Lumbar sympathetic plexus 10
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Nerve innervation Superior hypogastric plexus Splanchnic nerve of L3 and L4 & aortic plexus Sensory nerve from uterus and cervix parasympathetic nerve originated from pelvic splanchnic nerve of inferior hypogastric plexus Inferior hypogastic (= pelvic) plexus Sacral splanchnic nerves Sympathetic nerve from S4~coccygeal nerve Pelvic splanchnic nerves Parasympathetic nerve from S2~S4 12
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Nerve innervation Pudendal plexus innervation of perineum Vetral rami of S2 and S3 or S4 Branch Visceral br. muscular br. 15
Nerve innervation: Lumbosacral plexus Pudendal n: S2-4 Perineal nerve Inferior rectal nerve Dorsal nerve to penis/clitoris Nerve to coccygeous and levator ani m: S3 and S4 Posterior femoral cutaneous branch : S1-3 Inferior buttocks Posterior perineum: perineal branches Posterior thigh Inferior hemorrhoidal nerve 50% : directly from S3 and S4 50% : from pudendal nerve Ext. sphinctor muscle Nerve innervation of perianal skin 16
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Medial cluneal : S1-3 Nerve innervation: Other non-plexus nerves Branches of dorsal rami Sensory : Sacral and medial buttocks 18
Chronic Pelvic Pain by Pathology 19
Chronic Pelvic Pain by Pathology Gynecological-extrauterine & uterine disease G-I tract desease Urologic disease Musculoskeletal disease Other diseases 20
Gynecological-extrauterine disease 21
Gynecological-uterine disease 22
GI tract disease 23
Urologic disease 24
Musculoskeletal disease 25
Other diseases 26
Chronic Pelvic Pain by Pain Nature 27
Visceral pain Pelvic organ Uterus, ovary, prostate, bladder, urethra, rectum, sigmoid colon, descending colon, etc Sympathetic related pain Lumbar sympathetic ganglion/plexus Sup. hypogastric plexus Hypogastic nerve inf. hypogastic plexus Pudendal plexus Gangion impar 28
Somatic pain Somatic organ Skin, vulva, vaginal canal, etc Musculoskeletal organ Vertebral lesion, GI or urologic lesion (referred pain) Abdominal myofascial pain Muscle sprain/strain Lumbar discogenic pain Pelvic floor myalgia (levator ani muscle) Rectus tendon strain Coccygodynia 29
Neuropathic pain Central neuropathy Intramedullary lesions Tumor, multiple sclerosis, abscess, trauma Spontaneous, burning pain Migrating pain Tumor related pain: associated with LBP, tenderness Lumboscaral radiculopathy Peripheral neuropathy Pudendal neuralgia Piriformis syndrome Border nerve syndrome: ilioinguinal, iliohypogastric, and genitofemoral nerve neuropathy 30
Syndromes? 31
Abdominal myofascial pain Intense and profound pain in the abdominal region originating from myofascial triggering points women > men (54% vs. 45%), especially women aged 30 40 years. Contributing factors Muscle wasting and ischemia Radiculopathic compression of motor nerves Trauma: tension, contusions, or repetitive muscle use Mechanical factors: inadequate posture, or lack of ergonomic adequacy during work Degeneration of bone and joints Endocrine and metabolic deficiencies Nutritional vitamin and mineral deficiencies Viral and parasitic infections Anxiety Mary L.L.S. Montenegro, et al. Abdominal myofascial pain syndrome must be considered in the differential diagnosis of chronic pelvic pain. European Journal of Obstetrics & Gynecology and Reproductive Biology 147 (2009) 21 24 32
Other myofascial pain Levator ani Rectal tightness Muscle spasm Burning pain Adductor magnus Pelvic pain Intercoitus pain Pain when sleep 33
Pudendal neuralgia Essential diagnostic criteria Pain in the territory of the pudendal nerve from the anus to the penis or clitoris Pain is predominantly experienced while sitting The pain does not wake the patient at night Pain with no objective sensory impairment Pain relieved by diagnostic pudendal nerve block Jean-Jacques Labat, et al. Diagnostic criteria for pudendal neuralgia by pudendal nerve entrapment (Nantes criteria). Neurourology and Urodynamics 27:306 310 (2008). 34
Pudendal neuralgia Complementary Diagnostic Criteria Burning, shooting, stabbing pain, or numbness Allodynia or hyperalgesia Rectal or vaginal foreign body sensation Worsening of pain during the day Predominantly unilateral pain Pain triggered by defecation Presence of exquisite tenderness on palpation of the ischial spine Jean-Jacques Labat, et al. Diagnostic criteria for pudendal neuralgia by pudendal nerve entrapment (Nantes criteria). Neurourology and Urodynamics 27:306 310 (2008). 35
Obturator n Genitofemoral n Pudendal n Inferior cluneal n 36
Border nerve" syndrome Characteristics Iliohypogastric, ilioinguinal, and genitofemoral nerve Most common in patients with operation or trauma Herpes, pelvic tumor compressing the nerves Traction or compression of nerve or partial avulsion 37
Border nerve" syndrome Signs & symptoms Burning or aching pain Iliohypogastric nerve injury Inguinal area, superior pubic bone Ilioinguinal nerve and genitofemoral nerve injury Inguinal area Labrum major/ scrotum and root of penis Tenderness Hyperalgesia or allodynia 38
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