Pelvic Organ Dysfunction and Chronic Pelvic Pain in Cape Town, South Africa

Many men and women experience symptoms related to the urinary bladder, bowel, 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 with or without urination. There may be a feeling of incomplete emptying and difficulty urinating. Women receive the erroneous diagnosis of “recurrent bladder infections” when there is no evidence of infection. Lower bowel problems may present with constipation or frequent stooling with rectal urgency, anal irritation and pain. This spectrum of disorders is often associated with sexual dysfunction which may include 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 including the bladder, rectum, or the prostate in men.Pain may be experienced in the genitalia ( penis, urethra, testes in men, vagina or vulva in women). 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 seem to help but never result in a cure.

The following brief survey of this complex and challenging subject is based on current scientific evidence. Several key references will be provided. A few of the concepts and recommendations are based on Dr Eppel's more than 30 years of experience in Urology and Neurourology.

CPP may be defined as : chronic or persistent pain perceived in structures related to the pelvis of either men or women present for 3 to 6 months. It is often associated with negative cognitive, behavioural, sexual and emotional consequences as well as with symptoms suggestive of lower urinary tract, sexual, bowel, pelvic floor or gynaecological dysfunction.

Classification : International societies including the NIDDK, EUA, ESSIC have agreed upon the following classification – Chronic Prostatitis/ Chronic Pelvic Pain Syndrome (CP/CPPS) in men, and Interstitial Cystitis/Bladder Pain Syndrome (IC/BPS) in women which are useful terms for description and research but not all inclusive of the various clinical presentations.

Several pathogenetic (causal) pathways have been proposed to explain how CPP arises and is maintained. This area remains the subject of research and debate but the picture is becoming clearer.

In some of the clinical presentations of this complex spectrum of disorders evidence of inflammation can be demonstrated, such as in classical interstitial cystitis (visible inflammatory changes in the bladder ) and vulvodynia ( tissue inflammation-often mast cell predominating– on vulval biopsy). In these cases an inflammatory pathogenetic mechanism is proposed. In some of these cases there is evidence of an autoimmune process such as occurs in Sjogren’s disease or rheumatoid arthritis.

However in most of the cases of CPP and POD, the myriad of different presentations that are seen by doctors show no visible inflammation or any other pathology.

It is now recognized that the maintenance of chronic pain states (the chronification of pain) such as CPP is due to changes that take place in the brain and the relationships between the brain, the mind (psychological pathways) and the peripheral neural, immune and hormonal pathways as well as genetic factors.There is good evidence that cross communication occurs between the nervous(neural) system and immune system, and that disruption of this communication may play a part in pain chronification. One of the major changes that occur in the nervous system is known as central sensitization which can be simply described as an upregulation of the neural pathways which transmit and process pain signaling. The role of stress and its effects on the hormonal and immune systems have long been recognized. It is also important to recognize that CPP is unique among the chronic pain syndromes because of the complex psychosexual associations of the pelvic organs with the human psyche.

Even when inflammation can be demonstrated, these central mechanisms orchestrate the experience of pain. What is Pain ? How exactly does it become chronic ? Some understanding of these concepts helps doctors and their patients along their journey to improvement.

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 neurological reflexes and signals, 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 be associated with bladder and/or bowel dysfunction. Temporary bladder or bowel dysfunction occurs in almost all of us on occasion. Sometimes, owing to psychosocial factors in a particular context, the dysfunction becomes habituated or entrenched.

The patient is firstly very carefully assessed by taking a careful history and examination with special tests utilized when necessary. Very often the picture becomes clear during the first consultation particularly as most of the patients who come to us have seen several specialists and undergone sufficient testing.

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 including blood tests, cystoscopy (looking inside the bladder), ultrasound examinations or other imaging studies may be necessary.

Once we have confidently ruled out obvious organic causes, the pathophysiological nature of this pelvic organ dysfunction/chronic pelvic pain is explained to the patient with the aid of slides and diagrams, including a discussion of the possible causes in that particular patient. This is not an imagined or “purely psychological” 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, hormonal and immune systems.

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

Experts agree that because these patients often experience a complex array of different interrelated symptoms, a multimodal approach is best employed. This is optimally done through a Multidisciplinary Team (MDT), where various specialists ( such as urologist, gynaecologist,physiotherapist,psychological/behavioural therapist, colorectal specialist, neurologist, pain specialist ) are able to assess the patient and share their opinions with the rest of the team. The establishment of such MDT’s should be logistically easier with use of virtual meeting platforms.

It is important that one of the specialists (usually the urologist or gynaecologist ) who has a particular interest in CPP take the lead in managing the patient. More than the customary consultation time is required to interact with the patient, particularly at the initial consultation. References need to be provided, and lines of communication kept open eg. email.

The initial advice includes 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. There are specific exercises and techniques to relieve pelvic pain. One of the goals is to downregulate (calm) the upregulated nervous system.

If POD is the major issue with minimal pain involved, then attention is 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 there is significant pain or multi-system dysfunction, the patient needs to be introduced to other members of the MDT – most often the pelvic function physiotherapist and/or psychological/behavioural therapists.

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. Alpha receptor blocking drugs improve bladder emptying. Analgesics are available which act on neuropathic pain and may be effective in chronic pelvic pain syndromes. There are also many centrally acting drugs such as certain anti-epileptics, antidepressants, other psychoactive drugs which may be useful in certain cases.

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

Sacral Nerve Stimulation 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 appropriately selected patients who are nearly crippled by their symptoms.

Established Interstitial Cystitis (IC) also known as Hunner’s type cystitis is unique among the CPP syndromes, in that it is associated with obvious and severe organic pathology. It will not be addressed extensively in this article. The bladders in these patients have small capacities, show visible, sometimes extensive inflammation(including Hunner’s ulcers) and require intensive frequent interventions which may include oral medication, bladder instillations ( eg.cystistat ), hydrodistension, fulguration of Hunner’s lesions, and intravesical Botox (injected into the bladder muscle).

IC is a very challenging condition about which much is written.

Central sensitization: Implications for the diagnosis and treatment of pain

Clifford J. Woolf. Sept 2010

Program in Neurobiology and FM Kirby Neurobiology Center

Childrens Hospital Boston, Department of Neurobiology, Harvard Medical School, Boston, MA, USA
The Hidden Spring. A Journey to the Source of Consciousness.

Mark Solms. Profile Books Ltd. 2021
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. 2015
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. 2006
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. 2015
Psychoneuroimmunology - mind-brain-immune interactions

Simon Whitesman, Roger Booth

April 2004, Vol. 94, No. 4 SAMJ
Graziottin A. The mast cell, 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
Results of Sacral Neuromodulation Therapy for Urinary Voiding Dysfunction: Outcomes of a Prospective, Worldwide Clinical Study

Philip E. V. van KerrebroeckThe Journal Of Urology 2007 Vol. 178, 2029-2034.
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.
A Bayesian account of ‘hysteria’

Mark J. Edwards, Rick A. Adams, Harriet Brown, Isabel Paree sand Karl J. FristonBrain Advance Access published May 28, 2012
The Emerging Science of Interoception: Sensing, Integrating, Interpreting, and Regulating Signals within the Self.

Wen G. Chen, et al.Trends in Neurosciences Special Review February 2021
A pain neuromatrix approach to patients with chronic pain

G. L. Moseley. Dept of Physiotherapy, University of Queensland, Australia, Royal Brisbane Hospital, Brisbane, Australia Manual Therapy (2003) 8(3), 130–140 Elsevier Ltd.
Neuroimmune Interactions in Pain and Stress: An Interdisciplinary Approach

Caroline M. Sawicki, Michelle L. Humeidan, and John F. SheridanThe Neuroscientist1–16. 2020

UROLOGY CAPE TOWN

UROLOGY CAPE TOWN

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Chronic Pelvic Pain (CPP) and Pelvic Organ Dysfunction (POD)

Dr Stephen Mark Eppel

What are the causes of CPP and pelvic organ dysfunction? How are they maintained in the absence of visible pathology? Is there a cure?

Prevalence

Pathogenesis

For more information on this theme we invite you to watch the following presentation given at Southern Africa’s first webinar on CPP in March 2021 :

A word on Pelvic Organ Dysfunction with or without pain

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

Approach to Management

When the symptoms are more severe

Interstitial Cystitis

In Summary

Links to CPP Webinar

SAUA 2021 Chronic Pelvic Pain Webinar: 20th and 21st March

References

Central sensitization: Implications for the diagnosis and treatment of pain

The Hidden Spring. A Journey to the Source of Consciousness.

American Urological Association (AUA) Guideline

Protective and Damaging Effects of Stress Mediators Bruce S. McEwen, PH.D.

EAU guidelines on chronic pelvic pain.

Psychoneuroimmunology - mind-brain-immune interactions

Graziottin A. The mast cell, director of chronic pelvic pain orchestra: implications for the the gynaecologist - Plenary lecture

Results of Sacral Neuromodulation Therapy for Urinary Voiding Dysfunction: Outcomes of a Prospective, Worldwide Clinical Study

Botulinum Toxin for the Treatment of Idiopathic and Neurogenic Overactive Bladder: State of the Art

A Bayesian account of ‘hysteria’

The Emerging Science of Interoception: Sensing, Integrating, Interpreting, and Regulating Signals within the Self.

A pain neuromatrix approach to patients with chronic pain

Neuroimmune Interactions in Pain and Stress: An Interdisciplinary Approach