Pelvic Pain Due to Placement of the Vaginal Cuff after Hysterectomy: Case Report and Osteopathic Manipulative Approach to Treatment George J. Pasquarello Abstract posterior thigh region. She also com- Hysterectomy is performed on more plained of some rectal pain as well as Family History than 570,000 women a year in the United right inguinal pain. She has been seen by Father died at 65 due to Emphysema. States8 with an estimated 21.2% of U.S. a Physiatrist for chronic pain treatment Mother died at 53 due to Breast CA. women having undergone the procedure14. over the past year with some minimal The most frequent indications are leio- improvement. She has been treated with O: Vitals: myomas, abnormal bleeding and chronic pain medications, which have given her Temp - 97.4oF Pulse - 88 pelvic pain3. While hysterectomy may some relief although she continues to Resp - 16 BP - 116/70 provide for the relief of chronic pelvic have persistent pain. She notes that the pain, it may also be a cause. Common pain is worse when moving her bowels General attachment sites of the vaginal cuff after though better afterward. She denies pain This is a pleasant 46 y.o.w.f. who ap- hysterectomy may include the cardinal, during intercourse though states that she pears her stated age. She has a moderately uterosacral or sacrospinous ligaments. is very sore in the inguinal and SI regions flat affect and appears to have a significant Proximity to levator ani and obturator after intercourse. She is worse with sitting amount of pain when moving from stand- internus makes injury to these muscles for long periods and feels better when ing to seated to supine positions. a risk for causing pelvic pain. A case walking. presentation of pelvic pain secondary to A recent MRI showed some de- Neuro obturator internus injury during attach- generative changes in the lumbar spine Cranial nerves 2-12 are grossly intact ment of the vaginal cuff will be described though no sign of disc pathology causing without focal sensory or motor deficits. with a review of the anatomy of the area. radiculopathy. A pelvic MRI was done DTR’s are +2/4 in the bilateral upper and After initial osteopathic evaluation and which showed no anatomic explanation lower extremities. Strength is +5/5 in the treatment, one patient had the vaginal for her pain. bilateral upper and lower extremities. cuff repositioned by the surgeon with Cervical compression test and straight leg significant improvement in pain. Fol- Past Medical History raise are negative bilaterally. Dermatomes lowup osteopathic manipulative treatment Chronic low back pain and pelvic L1-S2 and C5-T2 are intact bilaterally. alleviated most of the persistent pain pain. Babinski is downgoing bilaterally. symptoms. Past Surgical History Structural Exam Case Report Tonsillectomy and Adenoidectomy. Marked restriction is in right SI A patient presents with a 2-year Bladder suspension. Hysterectomy. Rec- joint with severe tenderness and edema history of pelvic pain after trans-vaginal tocele repair. around the SI joint and along the proxi- hysterectomy. mal insertion of the right gluteus medius AO is a 46 y.o.w.f. referred for evalu- Allergies and gluteus maximus. There is a positive ation of chronic low back and pelvic pain. COMPAZINE, THORAZINE, CEF- standing and seated flexion test on the AO states that her pain began 3 years ago TIN, DARVOCET, SOMA, INDOCIN. right. There is some tenderness and swell- after an abdominal hysterectomy was ing at the distal right multifidus insertion. done. The indication for surgery was vagi- Medications Right innominate is rotated anteriorly nal prolapse. After surgery, she developed Ultram 50 mg 6-8 q.d., Ativan 2 mg and inferiorly, L5 ERSr, L1 FRSr. Pubic a rectocele and a secondary surgery was t.i.d., Premarin 1.25 mg q.d. symphysis restriction is noted with in- done to repair this. It was after the second ferior pubic symphysis on the right. No surgery that her symptoms became more Social History tenderness is noted at the sacrococcygeal significant. She complained of burning Smokes 3 packs of cigarettes per day. ligament or along the insertion of levator pain around the area of the pelvis with Denies use of alcohol, no use of illicit ani. Focal tenderness is noted at the right some radiation into the right gluteal and drugs. Was working as a Nurse’s Aid, but lesser sciatic notch at the area of obturator is presently a housewife. December 2006 The AAO Journal/11 internus tendon. Pressure here reproduces Bony pelvis Joints all of AO’s symptoms of pain. The pain The bony pelvis is made up of the The pubic bones meet in the anterior is improved with external rotation of the sacrum and coccyx posteriorly and two midline at the pubic symphysis. The bones femur. innominate or hip bones which complete are connected by the superior and arcuate a skeletal ring and attach anteriorly in ligaments and a fibrocartilaginous disc. Assessment the midline at the pubic symphysis. The 1. Pelvic pain after hysterectomy and bony pelvis houses the pelvic organs and rectocele repair. provides structural support as a conduit 2. Low back pain with radiation into between the spine and lower extremities. right posterior thigh and gluteal region. Muscular attachments include muscles 3. Somatic dysfunction of the lumbar of the lower back, abdomen and lower spine, pelvis, sacrum and lower extremi- extremities. There is also a muscular sup- ties. port for the pelvic organs at the inferior 4. Myofascial trigger point in right aperture or pelvic outlet. obturator internus secondary to surgical The bony pelvis is divided into trauma. greater and lesser as well as true and false Course of Treatment Our initial treatment included coun- terstrain to the right obturator internus, The disc is strengthened anteriorly by which immediately improved AO’s symp- the inguinal ligaments and linea alba. It toms. When she walked around the office is better developed in females and often a bit her symptoms returned, though with contains a cavity. much less severity. The sacroiliac joints are complex and Over the course of the next few provide the stability and strength in trans- weeks, she was treated several times pri- mitting weight from the vertebral column marily focusing on treating obturator in- to the lower extremities. Each joint has a ternus, restoring normal lumbar and pelvic network of anterior, posterior and interos- mechanics and decreasing related somatic seous ligaments. The iliolumbar and the dysfunction. The somatic dysfunction did segments. These divisions are helpful in anterior lumbosacral ligaments attach improve significantly although the tender- discussing the relationships of structures the lower lumbar segments to the pelvis. ness at obturator internus persisted. to the bony pelvis but there is no true The sacrotuberous and sacrospinous liga- Eventually a discussion with her sur- anatomic separation. While the primary ments attach the sacrum to the ischium. geon led to laparoscopic surgery and the function of the bony pelvis is locomotor, The sacrospinous ligament blends with attachment of the vaginal cuff was moved adaptations in the female pelvis allow for the anterior margin of the sacrotuberous. from the original site at the sacrospinous parturition. The anterior surface of the sacrospinous ligament. The greater or false pelvis consists of ligament is muscular and constitutes the After surgery, AO was seen in the the iliac flanges and sacral base cephalad coccygeus muscle, which attaches to the office and was found to have a fairly dra- to an oblique line passing through the lateral margin the coccyx.18 matic improvement in her pain symptoms. sacral promontory and the pubic crest She also had improvement in her previ- known as the lineae terminales. The iliac Viscera ously noted somatic dysfunction. flanges provide part of the lateral and pos- The major structures that occupy Over the course of the next few terior walls of the pelvis and support and the true pelvis in females include the months, OMT was focused on the lumbar protect the lower abdominal organs. rectum, uterus and bladder. The ovaries and pelvic somatic dysfunction. As her The lesser or true pelvis consists of are typically positioned in the false pelvis objective findings improved, AO became the bony structures caudad to the lineae but can be mobile. Each has an inferior more functional and was able to decrease terminals which form a more complete attachment at the pelvic diaphragm and the use of pain medications. basin to house and protect the pelvic is retroperitoneal. The peritoneum that organs. A superior and inferior aperture lies over the viscera will fold around the Review of the Pelvic Anatomy bound the true pelvis from above and structures and double over onto itself The following is a review of the anat- below respectively. The sacrum and coc- forming thickenings which function as omy of the pelvis and related structures. cyx make up the posterior border while ligamentous support. The uterus is posi- An understanding of this anatomy will be the inferior portion of the ilium, ischium, tioned between the rectum and the blad- important to appreciate the potential for pubic ramus and pubic symphysis make der and ascends into the abdomen during 18 21 injury during pelvic surgery. This discus- the lateral and anterior borders. pregnancy. sion will help clarify the possible causes of chronic pelvic pain and give some in- Uterine and cervical ligaments sight into useful treatment approaches. The uterus is connected to the blad- 12/The AAO Journal December 2006 der, rectum and pelvic walls by thick- arise from the lateral margin of the uterus enings in the peritoneum that provide just below the lateral cornua and travel mechanical support and in some cases, laterally to the abdominal wall, through dynamic control.