UROLOGY CAPE TOWN

{UROLOGY CAPE TOWN}{25 D.F. Malan St}{Foreshore}{8001}{Cape Town}{South Africa}{(021) 424-1626}
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Pelvic Organ Dysfunction

What is Pelvic Organ Dysfunction?

Many men and women experience symptoms related to the urinary bladder, bowel and rectum, and/or sexual organs for which no obvious cause can be found. The urinary symptoms may include frequency, urgency, and a sense of pressure in the bladder or burning in the urethra. There may be a feeling of incomplete emptying and difficulty urinating. Bowel problems may occur with constipation or frequent stooling with urgency, haemorrhoids, anal irritation/itching. Sexual dysfunction includes diminished libido, erectile dysfunction, premature ejaculation, and in females, orgasmic problems and painful intercourse.



These symptoms are often associated with chronic pain involving the pelvic organs and may be experienced in the bladder, rectum, or more vaguely localized. In men, pain may be experienced in the prostate, penis, testes; and in women, in the vagina or vulva. Pain may involve the muscles and fascia around the pelvis leading to lower abdominal pain, low back pain, pelvic floor (perineal) pain, pain involving the coccyx, and upper thighs. Names have been given to these painful syndromes such as prostadynia, vulvodynia, proctalgia, coccydynia. They often look like infections and receive labels like cystitis, prostatitis, urethritis, vaginitis. Chronic pelvic pain of uncertain cause can be debilitating and crippling. Patients despair because their doctors cannot find anything wrong with them. Antibiotics sometimes help but never result in a cure.

What are the causes of this dysfunction and pain? How does it develop? Is there a cure?

The following brief survey of this subject is based on scientific references such as the European Association of Urology Guidelines on Chronic Pelvic Pain. There will be other references at the end of the text. A few of the concepts and recommendations are based on Dr Eppel's more than 30 years of experience in Urology and Neuro-Urology.



Chronic pelvic pain and/or pelvic organ dysfunction, when not associated with obvious pathology, is thought to result from five processes (pathogenic mechanisms) either singly or, more usually in combination.

  1. Central/ Peripheral Sensitization
    In many patients, there is a history of an event or series of events, which result in long term sensitisation of the peripheral and central nervous system long after the event has passed. The event may include a bladder or prostate infection, or some other infection within the pelvic organs, or series of infections; or a period of bladder or rectal dysfunction associated with a time of stress. Sometimes there is an obvious dramatic cause such as sexual abuse, rape or significant pelvic surgery or trauma. Occasionally, the precipitating cause cannot be recalled by the patient. (Woolf)

  2. Inflammation
    In many patients, a process of inflammation of the end organ is established and perpetuates the symptoms. These changes may be demonstrated histologically in the bladder, the prostate, or the vulva, and are thought to be caused by a combination of neurological, immunological and endocrine factors. (Graziotin)

  3. Neurological Plasticity/Habituation
    Pelvic organ function is highly complex and involves a network of nerves, muscles, neurotransmitters, hormones and receptors in a complex, integrated network. This complex system is delicately balanced via multiple reflexes and messages, and is fairly easily upset by external and internal factors such as diet, toxins, stress, anxiety, poor toilet habits, as well as poor general health, and other disease processes. In addition, the different organ systems within the pelvis profoundly influence each other. For example, problems with the bowels may adversely affect bladder performance, and vice versa; sexual dysfunction can lead to chronic pelvic pain syndromes.

  4. Stress and Mind/Body relationship
    There is an increasing body of scientific evidence showing how profoundly the mind influences the body processes, and vice versa. Factors such as stress, emotional status, and psychosocial factors result in profound changes in the neural, endocrine and immunological systems. This has been further studied in the field of psychoneuroimmunology. (Whitesman)

  5. Genetic factors
    There is increasing evidence that the tendency to chronic pain as well as pelvic organ dysfunction has a genetic basis, and may run in families.

How do we make the diagnosis of Pelvic Organ Dysfunction (POD) and/or Chronic Pelvic Pain (CPP)

The patient is firstly very carefully assessed by taking a careful history and examination and only including special tests when necessary. Very often the picture becomes clear during the consultation.



It is important to rule out obvious organic pathology such as urinary tract infections, kidney stones, tumours involving the pelvic organs, endometriosis, organic bowel pathology or neurologic problems such as early diabetes or multiple sclerosis, vitamin deficiencies, spinal cord problems and to treat those conditions appropriately. Special investigations such as cystoscopy (looking inside the bladder), ultrasound examinations or Xrays may be necessary.

Approach to Management

Once we have confidently ruled out obvious organic causes, the pathophysiological nature of this pelvic organ dysfunction is explained to the patient with the aid of slides and diagrams, including a discussion of the cause in that particular patient. This is not an imagined or psychosomatic condition. These patients have very real symptoms often with demonstrable but subtle changes in the biology of the pelvic organs, muscles, fascia and the nervous system.



The treatment approach is tailored to the person's particular dysfunction or symptoms, but in general, the following principles are followed:



Firstly is the common sense, practical approach to general health. The pelvic organs, like other tissues and organ systems in the body are profoundly affected by the person's health or ill health, mental and physical. Therefore, we encourage attention to diet, exercise, stress relief, discourage toxins such as tobacco and excess alcohol, and certain foodstuffs known to irritate the lower urinary tract. Patients are urged to consider the practice of yoga, or other meditative type exercises, as these generally incorporate an overall healthy life style and remind us to be mindful of our bodies, including the pelvic floor and pelvic organs.



Attention is then directed at specific exercises and routines involving the pelvic floor and pelvic organs. These give the patient the tools to directly improve their symptoms.



The goal is to give the patient the understanding and practices to improve their overall health and specifically the functioning of their pelvic organs. Initially we try to avoid medication and other more invasive options, especially in early cases with mild symptoms.

When the symptoms are more severe

The dysfunction may be so well established, with persistent urinary and/or bowel symptoms, pelvic pain etc., that other methods of management need to supplement the above holistic approach. Excellent medication is available which has been developed to target specific organs and symptoms. For example, the newer antimuscurinic agents act on specific receptors within the bladder and are effective in reducing urinary frequency and urgency. Analgesics are available which act on neurologic pain and may be effective in pelvic pain syndromes. A multidisciplinary approach is necessary for more complex cases, and patients may be referred to a Gynaecologist, Pelvic Function Physiotherapist or Pain Specialist (www.capepelvicpain.co.za)



There are more invasive options for patients with very severe bladder symptoms, such bladder hydrodistension, and the instillation of special substances into the bladder. The injection of Botox (ref) into the bladder can be effective in very refractory cases of overactive bladder.



Sacral Nerve Stimulation (ref) is an option for patients with very severe bladder symptoms and/or bowel problems/pelvic pain not adequately responding to the more conservative approach or who are unable to tolerate the medication. This involves the placement of a fine wire lead through the skin and tissues of the sacral area, so that it lies next to one of the sacral nerves. Stimulation of the sacral nerves results in neuromodulation of the dysfunctional reflexes within the pelvis and pelvic floor, with significant improvement in up to 75% of these people who are nearly crippled by their symptoms.

Botox bladder injection

Sacral Nerve Stimulation

In Summary

We have outlined our holistic and comprehensive approach to people with Pelvic Organ and Chronic Pelvic Pain and welcome the opportunity to consult on these patients. We also welcome any comments/suggestions. Please email seppel@urologycapetown.co.za

References

1. Central sensitization: Implications for the diagnosis and treatment of pain
Clifford J. Woolf
Program in Neurobiology and FM Kirby Neurobiology Center
Childrens Hospital Boston, Department of Neurobiology, Harvard Medical School, Boston, MA, USA



2. American Urological Association (AUA) Guideline
Diagnosis and Treatment of Intestinal Cystitis/Bladder Pain Syndrome
Philip M. Hanno, David Allen Burks, J. Quentin Clemens, Roger R. Dmochowski, Deborah Erickson, Mary Pat FitzGerald, John B. Forrest,
Barbara Gordon, Mikel Gray, Robert Dale Mayer, Diane Newman, Leroy Nyberg Jr., Christopher K. Payne, Ursula Wesselmann, Martha M. Faraday



3. Protective and Damaging Effects of Stress Mediators Bruce S. McEwen, PH.D.
Seminars in Medicine of the Beth Israel Deaconess Medical Center
Jeffrey S. Flier, M.D., Editor Lisa H. Underhill, Assistant Editor



4. EAU guidelines on chronic pelvic pain.
Fall M, Baranowski AP, Elneil S, Engeler D, Hughes J, Messelink EJ, Oberpenning F, de C Williams AC; European Association of Urology.
Source
Department of Urology, Sahlgrenska Academy, Gteborg University, Gteborg, Sweden. magnus.fall@urology.gu.se



5. Psychoneuroimmunology - mind-brain-immune interactions
Simon Whitesman, Roger Booth
April 2004, Vol. 94, No. 4 SAMJ



6. Graziottin A. The mastcell, director of chronic pelvic pain orchestra: implications for the the gynaecologist - Plenary lecture
XIX World Congress of Gynecology and Obstetrics, organized by the International Federation of Gynecology and Obstetrics (FIGO), October 4-9, 2009, Cape Town, South Africa



7. Results of Sacral Neuromodulation Therapy for Urinary Voiding Dysfunction: Outcomes of a Prospective, Worldwide Clinical Study
Philip E. V. van Kerrebroeck
0022-5347/07/1785-2029/0 2029 The Journal Of Urology?Copyright 2007 by American Urological Association Vol. 178, 2029-2034, November 2007



8. Botulinum Toxin for the Treatment of Idiopathic and Neurogenic Overactive Bladder: State of the Art
Victor W Nitti, MD . Rev Urol. 2006 Fall; 8(4): 198208.

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