Many women do not realize that pelvic pain can
actually be due to muscle problems in the abdominal
wall or even back problems of the spinal discs or
bones that are referred or perceived as being in the
pelvic area. This type of pain is broadly categorized
as myofascial pain. Some doctors fail to thoroughly
evaluate this possibility as a cause of chronic pelvic
pain.
A recent article, Myers CA: Musculoskeletal factors
of chronic pelvic pain. OBG Management 1999; Feb:10-12,
gave us some information to answer questions about
this uncommon cause of pelvic pain.
How can pain actually be "referred"
from another site to the pelvis?
The spinal cord is a complex electrical connection
system. The nerve roots of the spinal cord send off
neurons that sense pain from skin, muscles, bones,
ligaments and internal pelvic organs. The same spinal
nerve roots that innervate the ovaries may also innervate
abdominal wall muscles. Low back pain can arise from
pain in the uterus, bladder, faloppian tubes, and
cervix because the same nerves innervate those organs
as well as the lumbar discs, ligaments and muscles.
Conversely, abdominal wall pain, especially around
an incision, may actually feel as if it is arising
from the uterus or deeper in the pelvis when its origin
is from the skin near an incision. Neurologists think
that sometimes the spinal cord just gets confused
when there are many pain impulses coming in and by
the time your brain perceives the pain, it cannot
tell whether the source is in the internal organs
or the external muscles.
There are also internal muscles lining the pelvic
bone such as the piriformis, puboccocygeus, obturator
internus and externus muscles. The muscles can present
with cramps and achiness and a woman perceives the
pain as uterine or ovarian.
How is musculoskeletal pain differentiated
from pain arising in the pelvic organs?
Certain questions help to categorize the pain as more
likely to be musculoskeletal in origin rather than
urogenital organ in origin if:
you have a history of musculoskeletal injury to the
back, hips or knees.
your occupation is sedentary or labor intensive.
you have repetitive musculoskeletal or postural stressors.
physical activity worsens or lessens the pain.
positional changes (lying to sitting, sitting to standing)
worsen or relieve the pain.
the pain changes with the time of day.
there is noticeable muscle weakness or numbness or
tingling.
there is a history of inflammatory or collagen vascular
disease such as rheumatoid arthritis or lupus.
On physical exam, what findings suggest musculoskeletal
dysfunction?
If there is any abnormal curve in the spinal canal
such as a curvature to the right or the left (scoliosis),
excessive curve of the thoracic spine like a hunch-back
(kyphosis) or increased arching of the small of the
back (lordosis), these changes make it more likely
for the pain to be musculoskeletal. The doctor will
also have you lie flat on an exam table, raise your
knee and will rotate the knee from side to side to
see if any of the internal and external hip rotators
are tight and cause pain with rotation. Next you will
be asked to bring the one knee up to the chest. If
the straight leg whose knee is not being raised comes
up off the table or gives pain, this means the iliopsoas
muscle and/or the rectus femoris (hip flexor) muscles
are tight and may actually be the source of deep pelvic
pain mistaken for internal organ pain. The doctor
will also check for any pain in the abdominal muscles
and touch the skin of the abdomen and back to see
if there are places on the skin that "trigger
the pain".On pelvic exam the doctor will have
you try to tighten the muscles around two fingers
placed in the vagina and will palpate the muscles
of the interior pelvic wall to see if any of them
are exquisitely tender. All of these screening exams
can be checked for by you at home to see if they are
abnormal.
If pelvic pain is actually coming from the
back and spine, how is it treated?
Certain postural problems, especially kyphosis and
lordosis, have been clinically correlated with pelvic
pain as have other muscle weaknesses and spasms. Treatment
of those problems has also been shown to help the
pelvic pain. If there is any suspicion that pelvic
pain has a myofascial cause, a woman should be referred
to a physical therapist for a more in-depth evaluation
and plan for treatment. Physical therapy and muscle
exercises can significantly help these problems.
What are trigger point injections and are
they helpful?
Trigger points are areas of skin on the abdominal
wall that follow along one dermatome, the area of
skin innervated by one specific nerve root. When touching
them lightly even with a Q- tip, pain is elicited
that feels as if it arises deep in the pelvic organs.
When these areas are injected with a local anesthetic,
there is pain relief that lasts longer than the expected
duration of the specific anesthetic used. After about
5- 6 weekly injections or less, the pain totally goes
away. This is thought to work somewhat like acupuncture
in that the pain sensation the level of the spinal
cord gets rearranged to know that the pain does not
actually arise in the pelvic organ where it is perceived.
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