General surgery
General surgeons see several patients with chronic pain mimicking chronic diverticulitis, prostatitis, and epididymo-orchitis. Patients may also present with post inguinal herniorrhaphy pain or simply idiopathic pain. Sixty-three of our 203 patients had pain/tenderness over the ASIS (anterior superior iliac spine) due to enthesopathy. This pain, especially in obese patients with panniculus, is easily mistaken for intra-abdominal conditions in the right lower quadrant (RLQ) and left lower quadrant (LLQ) of the abdomen.
Amongst females, on detailed questioning nearly 60% had dyspareunia; some had rectal pain, some had bladder symptoms, and some had gluteal and coccygeal pain. All of the above suggest pelvic pathology. The majority of these female patients have had multiple lower abdominal surgeries and several have been diagnosed with fibromyalgia. If patients give a history of 2 or 3 lower abdominal surgeries (especially a Pfannenstiel incision) and/or a history of fibromyalgia, we have to be vigilant, because nearly 70 to 80% of these patients will have tenderness in the groin and on the pubic bones on pelvic exam, suggesting that they may have POPSS syndrome.
Another interesting subset that general surgeons see are patients with undiagnosed rectal pain, pain over the ischial tuberosities (sitting bones) and coccygeal pain (coccydynia). Patients with non-bacterial prostatitis and interstitial cystitis are also seen.
Groin pain after hernia repair
Another commonly discussed topic amongst general surgeons is groin pain following repair of groin hernias. During the American College of Surgeons meeting in 2003, Dr. Robert Fitzgibbons chaired a panel discussion on “post herniorrhaphy groin pain.” Nearly 750,000 groin hernia operations are done yearly in the United States. Typically after the initial incisional pain subsides, usually within 2 to 3 weeks depending on the technique used, there is a short pain-free interval of 1 to 4 weeks. Pain of POPSS syndrome starts after 4 to 6 weeks postoperatively.
Rutkow noticed chronic groin pain in 102 patients out of 1,442 groin surgeries he performed over 3 years. More importantly, 99 of the 102 patients had pain in the groin prior to herniorrhaphy, and the majority continued to have groin pain after surgery. Our observations have been similar, and we feel that pain in the groin associated with a clinically documented groin hernia during a preoperative visit is usually due to enthesopathy. I give steroid injections during the repair and repeat one or two more injections two weeks apart during postoperative follow-up. Rutkow goes one step further in getting informed consent in patients presenting with preoperative pain: these patients are told explicitly that the herniorrhaphy is strictly intended to repair the hernia (bulge) but may not relieve the pain.
In our series all patients with postoperative groin pain were treated as enthesopathy/periosteitis with steroid injections, and we had 89% excellent to good results. Gilbert recommends the term “nerve entrapment” not be used in describing post hernia pain, preferring “postoperative neuralgia.” We prefer the term “postoperative groin pain,” since most of the patients have enthesopathy/periosteitis, and this term is not associated with a technical problem encountered during surgery.
Gynecology
Up to 10% of gynecology office consultations are for chronic pelvic pain (CPP). Chronic pain affects sleep, performance and self-esteem. This leads to depression, which in turn alters the neurotransmitter level in the brain, leads to a greater experience of pain and lowers the threshold for pain. This leads to further depression and the vicious cycle continues.
Chronic pelvic pain can manifest as pain in the groin area and in some patients as pain over the perineum, which includes coccydynia and tenosynovitis of the ischial tuberosities. It may be associated with severe physical dysfunction in relation to voiding (dysuria), defecation (tenesmus) causing frequent and painful bowel movements, and pain with sex (dyspareunia).
As many as 60% of women experience dyspareunia when the term is broadly defined as pain during and after intercourse. Women with symptoms severe enough to seek medical attention comprise a much smaller group, and many of those with persistent symptoms do not seek medical attention. Combining the patients of 13 authors (1,524 patients), no visible pathology was seen in 35%, endometriosis was seen in 33% and adhesions in 24%. Detection of endometriosis and adhesions is not a reliable predictor of pelvic pain, but they can be seen as an incidental finding.
Musculoskeletal pain is present in 22% to 80% of all patients with CPP. Unfortunately, musculoskeletal dysfunction is not routinely evaluated as a cause of pelvic pain by gynecologists. A pelvic musculoskeletal examination is simple to perform, is not time-consuming, and is one of the most important components to investigate in all chronic pelvic pain patients. In the gynecology literature, few articles have been published about the significant incidence of myofascial (musculoskeletal) origin of chronic pelvic pain; Reiter and Gambone in 1991 noticed that 30% of women in a series of 122 women with CPP had myofascial pain.
Chronic pain can also be created by spasms of the muscles that line the pelvis, the pelvic floor muscles. This “sling” of muscles, along with connective tissue called fascia, lifts and supports the pelvic organs including the bladder, uterus and rectum. Spasms in these muscles, known as pelvic floor tension myalgia or levator ani syndrome, may cause pain locally. Tight bands of muscle, known as trigger points, may be tender to the touch and may refer pain to other areas of the pelvis, abdomen and low back.
Causes of musculoskeletal pelvic pain in women
- Bony pelvis, joints and spine
- Muscles and ligaments
- Myofascial pain of pelvic floor muscles
- Myofascial pain of back or hip muscles
- Weakness of the pelvic floor: deconditioning/disuse
- Tightness of the pelvic floor and sphincters
- Tendinopathy, ligament sprain, adductors, hip flexors and piriformis muscle
- Damage to pelvic floor muscles from trauma or radiation: childbirth, prior surgeries, sports/dance, repetitive minor trauma