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The Unmentionable Symptoms of Arachnoiditis: Bowl, Bladder and Sexual Dysfunction; Pelvic Pain by Dr. Sarah Smith PELVIC
PAIN Pain in and around the pelvis, lower abdomen, saddle area and genitalia is a common problem in arachnoiditis. Often patients are diagnosed with one of the following non-specific diagnoses: PROCTALGIA FUGAX: Fleeting
pains in the rectum. Proctalgia Fugax is an
uncontrolled spasm or contraction of the muscles in the rectal area and
pelvis. This condition was first described in Ancient Rome over 2000 years ago and still carries the Latin name meaning "fleeting rectal pain." It is not uncommon. Health surveys of the general population estimate that around 5% of individuals experience the symptoms occasionally, usually less than 6 attacks per year. The pain, although brief, lasting about 20 minutes, can wake sufferers from sleep; it is described as : "like a knife sticking deep in the rectum." The cause is not known. It is not caused by haemorrhoids, fissures, polyps, or other rectal conditions, nor does it increase the risk of colon cancer, colitis, hemorrhoids, anal fissures or other bowel disorders. It is not triggered by a bowel movement; in fact, passing wind or a bowel movement may end the attack. A flexible sigmoidoscopy or colonoscopy may be performed to exclude any serious problem. The
attacks are generally too short for any medical therapy to be effective,
but there have been some reports of benefit from the asthma inhaler
salbutamol to abort prolonged episodes. The most common measure used to
reduce the symptoms is simply pushing on the anal area . This may be
done manually or by straddling the edge of a bathtub. Soaking in a warm
bath may help, but usually the pain may well have begun to subside
before the bathtub is even filled. Immediately eating or drinking has
been found (anecdotally) to be of some help. LEVATOR ANI SYNDROME: Chronic or recurring pain or aching in the rectum, with episodes lasting 20 minutes or longer, with no apparent organic (physical) disease to account for the pain. Levator ani syndrome seems to involve muscle spasm in the pelvic floor muscles. This syndrome may therefore be diagnosed rather than the more likely cause of persistent rectal pain in arachnoiditis, which is pudendal neuralgia. Treatment
of levator ani syndrome includes (a) hot baths, (b) non-steroidal
anti-inflammatory drugs(NSAIDs), (c) muscle relaxants, (d) levator
muscle massage, (e) electrical stimulation, and (f) EMG-based
biofeedback. CHRONIC PELVIC PAIN: Chronic
pelvic pain may arise from a variety of different causes. Causes
may broadly be divided as follows: Urinary
tract causes: A.
Infection(UTI); B. Interstitial Cystitis: an inflammatory condition of the
bladder. Gastrointestinal
causes: A.
Irritable Bowel Syndrome (IBS) associated with abnormal bowel
habit (diarrhoea or constipation or fluctuating between the two; B. Inflammatory
Bowel Disease : Crohn’s/Ulcerative
Colitis; these conditions will be associated with abnormal bowel
habit, usually diarrhoea, often with blood in the stool. Crohn’s can
affect any part of the gastrointestinal tract (mouth to anus) whereas UC
tends to only affect the large bowel. Both are autoimmune conditions.
C. Hernia:
abdominal or inguinal (groin): women should be examined standing to
check for this as lying down, the hernia may not be apparent. Gynaecological causes: A. Endometriosis(abnormal deposits of the lining of the womb in areas outside the womb, in various sites in the pelvis and/or abdominal cavity, leading to internal bleeding (low grade) inflammation as a response and subsequent scarring (fibrosis); B. Chronic Pelvic Inflammatory Disease( inflammation often after an acute infection, becoming chronic and resulting in scar tissue which causes C. adhesions (which ‘glue’ pelvic/abdominal organs to each other, damaging their structure and function); D. Mittleschmertz ( benign pain during ovulation); E. Ovarian Remnant Syndrome(after total hysterectomy, part of ovary may remain); F. Ovarian cysts; G. Pelvic congestion Syndrome; H. Cyclic pelvic/uterine pain varies with the menstrual cycle: includes painful menstruation (dysmenorrhoea) and may be associated with heavy menstrual bleeding (menorrhagia); I. Uterine fibroids: non-malignant growths in the wall of the womb. May also be associated with painful and/or heavy periods, abdominal discomfort, low back pain.J. Pelvic congestion syndrome varicose veins in the pelvis. Musculoskeletal causes: Especially Fibromyalgia, which is frequently associated with chronic pelvic pain, and it is quite common to see overlap between fibromyalgia and conditions such as Irritable Bowel Syndrome and Interstitial Cystitis. Other musculoskeletal causes include Pelvic floor tension myalgias: spasms of the muscles in the pelvic floor; muscle spasms in general are common in arachnoiditis; Piriformis syndrome: due to entrapment of the sciatic nerve as it passes through the buttock muscles (gluteals); if these are in spasm there will be pain on internal rotation of the hip against resistance; often associated with fibromyalgia (which may occur secondary to arachnoiditis) Commonest in individuals who sit for long periods. Psoas inflammation: this muscle may be affected by pelvic adhesions; when lying on the side, pain is felt on extending (straightening) the leg. Sacroiliac joint inflammation: the joint between the back of the hip girdle and the sacral part of the spine; this may lead to pain in the buttock. Fractured coccyx: tension in the pelvic floor may cause the bone to swing forward. Psychological causes: A. Major depression; B. history of sexual abuse. Neurological causes: see below NEUROLOGICAL CAUSES OF PELVIC PAIN: Looking at the anatomy, we see the following: spinal level : T9-10: supplies the outer part of the fallopian tubes, the upper ureter (where it enters the kidney) and the ovaries. Sympathetic nerves(involved in involuntary processes) are also involved at this level. T11-12 : supplies: uterine fundus (top of the womb); inner third of the fallopian tube; broad ligament (supports the womb), upper bladder, proximal large bowel and appendix. S2-4 : supplies perineum (saddle or crotch area); vulva (opening of the vagina) ;vagina; lower uterus and cervix; posterior urethra; trigone area of the bladder (where ureters enter); lower ureter; rectosigmoid colon(lowest part of the large bowel). Pudendal neuralgia: this affects the area around the anus, the rectum and the vulva /vagina or penis/testicles. Differential diagnosis (alternative possibilities): Acute testicular pain requires medical assessment to exclude hernia, orchitis or testicular torsion. Chronic testicular pain may be due to chronic epididymitis (usually there is a history of bouts of acute epididymitis, or scrotal/groin surgery) :pain may be on one or both sides. This condition is chronic inflammation of the epididymis, which is part of the testicle. In women, vulvodynia, pain in the vulva, and dyspareunia (pain in the vagina on intercourse)may be due to a variety of problems including infection. Rectal pain in both sexes should be checked out to exclude local pathology such as anal fissure. The pudendal nerve (union of spinal nerves S2-S4) supplies the sensory nerves to the perineum, skin of the scrotum, the penis, the labia and clitoris, lower part of the vagina and the vulva and the skin around the anus. It also supplies the perineal muscles (pelvic floor), some of the muscles involved with erection of the penis, and the external anal sphincter. The pudendal nerve may be affected by arachnoiditis in the cauda equina at the lower end of the spinal cord. If pudendal neuralgia occurs, it is likely that there will be other associated symptoms such as pins and needles or numbness in the saddle area and/or reduced rectal/bladder sensation, difficulties with bladder, bowel and sexual function. Pudendal neuralgia can be a prolonged, even unremitting deep burning pain which is highly distressing. We can therefore see that it is entirely feasible to propose that the majority of persistent pelvic/perineal pain in arachnoiditis patients is likely to arise as a direct result of nerve root damage. PPOD SYNDROME PPOD (‘pea-pod’) stands for pelvic pain and organic dysfunction syndrome. Information about this syndrome and the mechanical causes of it can be found on the Internet, on a site written by a Chiropracter.(James E. Browning, DC.) PPOD syndrome has numerous similarities with arachnoiditis, in that chronic pelvic pain, bladder, bowel and sexual dysfunction can occur. Note also that menstrual difficulties (painful/irregular menstruation, heavy menstrual loss/ clotting, vaginal spotting mid cycle) are also a feature of this condition. One can extrapolate this to lumbosacral arachnoiditis. The website which describes PPOD deals with so-called ‘mechanically-induced PPOD’ which the author suggests results from “‘atypical’ mechanical disorder of the spine”. In correspondence with the author, James Browning, I have established that he has had numerous patients who have a history of epidural injection prior to onset of PPOD. This ties in with an association with arachnoiditis. He does seem to have some success with chiropractic treatments of patients with PPOD. However, in cases of arachnoiditis, I would doubt that improvement can be sustained in the longer term, and there is, of course, a risk of exacerbating the condition if manipulative treatment is too strenuous. |
