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Musculoskeletal Dysfunction Has Role in Pelvic Pain 50 Women’s Health FAMILY P RACTICE N EWS • May 1, 2005 Musculoskeletal Dysfunction Interstitial Cystitis Often Has Role in Pelvic Pain Seen With Adenomyosis BY MIRIAM E. TUCKER long-term effect on amenorrhea BY PATRICE WENDLING A standardized abdominal exam was performed Senior Writer rates of endometrial resection by Contributing Writer on all patients that included a single-digit intra- Nd:YAG laser versus resectoscope. vaginal palpation of the levator ani and piriformis N EW Y ORK — Interstitial cys- Despite alleviation of their uter- C HICAGO — Up to one-fourth of women with muscles, and either a Kegel contraction to iden- titis frequently coexists with ine bleeding, 60% (172) reported chronic pelvic pain also have piriformis or levator tify the levators or an external hip rotation to iden- adenomyosis, just as it does postoperative chronic pelvic pain, ani tenderness, according to a study presented by tify the piriformis. with endometriosis, Stephen A. along with urinary urgency and Dr. Frank Tu at a meeting sponsored by the In- A visual analog score of 0-10 was assigned by Grochmal, M.D., said at an inter- frequency, dysuria, rectal pain, ternational Pelvic Pain Society. the physician to rate the degree of clinically national congress of the Society perineal pain, dysmenorrhea, de- Musculoskeletal dysfunction—including ten- meaningful tenderness. of Laparoendoscopic Surgeons. creased sexual intimacy, and de- derness and spasms of the levator ani and piri- Piriformis and levator ani tenderness was pos- “How many patients do we creased quality of life. formis—has been reported as a treatable cause of itively associated with the number of painful ab- have who continue to have pain Following a review of their chronic pelvic pain. The efficacy of treatments dominal-pelvic locations reported, pain associat- after endometrial ablation or after surgical pathology reports and such as manual therapies, electrical stimulation, ed with bowel movements, and higher Beck hysterectomy? Before we send examination of uterine shavings injected medications, and surgeries ranges from Depression Inventory and McGill Pain Question- them to a psychiatrist, perhaps we or laser-excised tissue strips to 20% to 90%, according to the literature, which is naire scores. ought to give them a 5-minute exclude subbasalis diagnoses, mostly comprised of case studies. Patients with levator ani tenderness reported screening questionnaire to see if “pure” adenomyosis was con- “Although musculoskeletal dysfunction is in- 4.6 pain locations, compared with 3.7 locations for they have associated interstitial firmed in 48 (28%) of the creasingly implicated as a cause of many pelvic those without such tenderness; patients with and cystitis,” Dr. Grochmal of the di- women. Of them, 32 (67%) had pain conditions such as interstitial cystitis, we re- without piriformis tenderness reported 4.6 and 3.8 vision of operative gynecology, a score greater than 6 on the ally don’t have much information about the di- pain locations, respectively. endoscopy, and laser surgery at PUF scale, suggesting IC. Of agnosis, evaluation, treatment, and epidemiology Pain with bowel movements was reported by Howard University, Washington. those 32, 27 (84%) had positive of this particular condition,” Dr. Tu said. “This is 372 study patients, including 51% of those with If the patient’s score on that potassium sensitivity test scores. the first study to look at the frequency of these levator ani tenderness 50% of those with piri- questionnaire—the Pelvic Pain With use of established criteria disorders in a large referral clinic population.” formis tenderness. and Urgency/Frequency (PUF) for cystoscopy/hydrodistention, A retrospective study of 987 women referred to Levator ani tenderness was positively associat- patient symptom scale—suggests IC was confirmed in 25 (78%) of a pelvic pain clinic at the University of North Car- ed with a higher number of surgeries for pain. Of interstitial cystitis (IC), then di- the 32 women, and in 1 (6%) of olina, Chapel Hill, for chronic pelvic pain, found the 212 patients with levator ani tenderness, 23% agnostic tests are indicated. the 16 women with PUF scores levator ani tenderness in 22% and piriformis ten- had no previous surgeries, 61% had one-to-three In 2002, Maurice K. Chung, less than 6. derness in 13% of the 942 of patients evaluated surgeries, and 17% had more than three surgeries, M.D., and associates described Of the remaining 124 chronic for those conditions. compared with 30%, 60%, and 10%, respectively, the “evil twins” of endometriosis pelvic pain patients who did not There were no differences between those with of those without levator ani tenderness. and IC in chronic pelvic pain syn- have adenomyosis, 54 were ran- piriformis tenderness and those with levator ani Neither condition was associated with pain drome after finding a 70% over- domly selected for the same test- tenderness in age (mean 30 years), pain duration, that worsened with intercourse, although there lap of the two conditions in 60 ing. Of those, 6 (11%) also had or sexual abuse history. Of the 987 women stud- was a trend toward a higher proportion with pir- women (JSLS 2002;6:311-4). confirmed IC, in contrast to the ied, 288 had a history of sexual abuse, said Dr. Tu, iformis tenderness. “I considered that we might total 60% of those with adeno- noting that the proportion of women with a his- The data suggest that the prevalence of piri- see the same thing with adeno- myosis. In patients who have tory of abuse did not differ between the women formis and levator ani tenderness may be in- myosis. After all, it is en- chronic pelvic pain after treatment with and without musculoskeletal dysfunction. creased among women with more intense chron- dometriosis of the myometri- for excessive uterine bleeding, ade- In all, 85% of patients had pain for at least 6 ic pelvic pain, said Dr. Tu, director of the division um,” Dr. Grochmal explained. nomyosis may be the cause of the months, and most had daily pain. Two-thirds of of chronic pelvic pain, department of ob.gyn., So he retrospectively analyzed bleeding and the bladder may the the cohort had a diagnosis of depression, based on Evanston (Ill.) Hospital. A possible association 287 women who were part of an cause of the chronic pelvic pain, the Beck Depression Inventory. with dyschezia also may exist. I ongoing study that compared the Dr. Grochmal said. I Women With Vulvar Disease More Chronic Pelvic Pain Could Likely to Have Bladder, Bowel Pain Signal Interstitial Cystitis S AN F RANCISCO — In a potassium sensitivity test, cys- BY MARY ANN MOON women who were being treated at The higher prevalence of painful large majority of women pre- toscopy with hydrodissection, Contributing Writer a vulvar disease clinic, and com- bladder and painful bowel syn- senting with chronic pelvic and laparoscopy. During the pared them with the rates among dromes in women with vulvar dis- pain, the bladder is the pain- laparoscopy, the investigators WASHINGTON — Women who 321 control subjects attending a ease may reflect a common etiol- generating organ, Edward J. biopsied suspicious lesions have vulvar disease should be asked general gynecology clinic. ogy for all these disorders. The Stanford, M.D., said at the and removed all adhesions. specifically about bladder and bow- Of the women with vulvar dis- design of this study, however, did annual meeting of the Amer- Although 64% of the el pain, and treated accordingly, ease, 12% reported bladder pain, vs. not allow the researchers to tease ican Association of Gyneco- women had adhesions, the Colleen M. Kennedy, M.D., advised. 6% of the controls. Similarly, 23% out whether there is a common logic Laparoscopists. pain could not be attributed to Such women are twice as likely of those with vulvar disease had etiology “or whether treatments In three studies involving that, Dr. Stanford said. In 70%, as are general gynecology patients bowel pain, vs. 11% of controls. for one disorder may exacerbate or almost 300 women with the bladder was the pain-gen- to have bladder pain and bowel The data showed that women cause the other disorders. chronic pelvic pain, the erating organ, 28% had biop- pain. “We hypothesize that certain with bladder pain were 2.2 times “From a clinical point of view, it prevalence of interstitial cys- sy-proven endometriosis, and vulvar or vaginal diseases are not more likely than those without to is clear that women with vulvar titis ranged from 70% to 82%, 20% had vulvar pain. isolated clinical entities, but rather have been treated for vulvar dis- disease should be queried about said Dr. Stanford of St. Therefore, in the differen- represent symptoms of a global or ease. Women with vulvar disease bladder and bowel pain, and treat- Mary’s Good Samaritan Med- tial diagnosis of chronic generalized pelvic floor disorder,” had a mean score of 20.3 on the ed accordingly,” Dr. Kennedy said. ical Center, Centralia, Ill. pelvic pain, interstitial cystitis she said at the annual meeting of Urinary Distress Inventory’s pain That the study also showed that In the most recent and must be ranked first, with ir- the Central Association of Obste- subscale, compared with 5.3 for women with vulvar disease had thorough of these studies, Dr. ritable bowel syndrome, en- tricians and Gynecologists. women without vulvar disease. nearly a fourfold higher risk of un- Stanford followed 64 women dometriosis, and vulvodynia Dr. Kennedy and her associates at Likewise, women with function- dergoing hysterectomy than did with chronic pelvic pain for a a distant second, third, and the University of Iowa, Iowa City, al bowel disorders were 2.1 times the general gynecology patients. year. Each completed the fourth, respectively. Recur- assessed the rates of painful bladder more likely than were those with- “To our knowledge, ours is the Pelvic Pain and Urgency/Fre- rent urinary tract infection syndrome (interstitial cystitis) and out such disorders to have been first large clinic comparison to re- quency questionnaire and un- was cited in 7% of the cases.
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