MECHANICALLY INDUCED PELVIC PAIN AND ORGANIC DYSFUNCTION
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CASE REPORTSCase No. 6PPOD symptoms: inguinal, suprapubic, coccygeal, para-anal and rectal pain; genital, perineal, bladder and rectal sensory loss; urinary frequency, urgency, incontinence, retention and recurring infections; excessive gas, rectal incontinence, spontaneous bowel discharge, vaginal spotting, spontaneous miscarriage. A 57 year old female was seen in response to a call for study participants to assess the effectiveness of a newly developed therapeutic protocol for treating bladder, bowel and sexual dysfunction. She presented wearing diapers for long-standing urinary and anorectal incontinence. She reported that although she was unable to recall the specific sequence of their onset, bilateral inguinal, suprapubic, coccygeal and para-anal pain all had their onset during childhood. Although these symptoms continued to persist, she had not been evaluated for their presence at that time. She married at 18 years of age, and during the next four years had become pregnant on four separate occasions. Each pregnancy had been accompanied by vaginal bleeding, and all were terminated by a spontaneous miscarriage between the 3rd and 5th month of gestation. During this time, recurring persistent bladder infections had begun to occur. At about 23 years of age, she became pregnant for the 5th time. During this pregnancy vaginal bleeding recurred, however, recumbency and activity limitation allowed her to carry this pregnancy to term at which point a normal baby girl was born. Her next two pregnancies, although complicated by a breech presentation and toxemia respectively, resulted in the cesarean delivery of baby boys. Her eighth and final pregnancy was complicated by bleeding abnormalities and ended in a spontaneous miscarriage at 3 months of gestation. Although she had been evaluated on numerous occasions during her pregnancies, no specific cause could be identified for her recurring miscarriages. About 1 year later, because of chronic pelvic pain and continued vaginal bleeding, a hysterectomy was performed. Although bleeding abnormalities were resolved, pelvic pain continued to persist. Approximately 11 years later, which was about 15 years prior to being seen by the author, she had injured her low back while working in a nursing home. Treatment consisting of ultrasound and physical therapy gradually resolved her complaints over a 6 month period. During this episode of low back pain, pelvic pain had increased in its intensity, and urological disturbances consisting of frequency, urgency and stress incontinence began to occur. Over the next several years, low back pain had periodically recurred and gradually was accompanied by the development of bilateral lower extremity pain and paresthesias. Urinary incontinence had worsened, and about 6 years prior to being seen by the author, a urological consultation resulted in the performance of a bladder suspensory surgery. Rather than improving the situation, however, urological dysfunction became more severe, taking the character of total urinary retention with secondary overflow incontinence. She was unable to voluntarily empty the bladder, and could not initiate urethral contraction to prevent overflow incontinence. She stated that there had been a loss of bladder, rectal, and perineal sensory perception so that she was unaware of bladder or rectal filling and could not feel when urine was dripping from the bladder or running over the perineum. She was trained in self-catheterization techniques which were performed 3-4 times per day for approximately 5 years. However, because of ongoing frustration and the inconvenience associated with these procedures, she discontinued catheterizing herself altogether. As a result, bladder dysfunction resulted in total urinary retention and secondary overflow incontinence with continuous urinary leaking. Bowel dysfunction had become more severe and resulted in ongoing anorectal incontinence, excessive flatus, sharp severe rectal pain, and intermittent episodes of uncontrollable spontaneous bowel discharge occurring without any sensory awareness. These episodes would typically occur from two to five or six times per day. Because of the severe and continuous nature of her bladder and bowel dysfunction, she required ongoing use of diapers. Approximately one year later, vaginal spotting, associated with what had been diagnosed as atrophic vaginitis, developed. She was given intravaginal estrogen creams for treatment, however, their administration proved to be of little help. As a result, after several months of use, she discontinued use of the estrogen creams altogether. At about this same period of time, a pelvic examination revealed the presence of a cystocele and rectocele. Although her bladder and bowel dysfunction had preceded the identification of these abnormalities, the cystocele and rectocele were judged to be a probable cause of her ongoing bladder and bowel dysfunction. However, no specific treatment had been recommended or performed. These symptoms had remained unchanged until responding to the call for study participants. Clinical examination indicated the presence of a Type II PPOD Syndrome. Treatment following the Type II PPOD protocol resulted in progressive improvement of her complaints. After 2 weeks of treatment, low back, inguinal, para-anal, coccygeal, and rectal pain was diminished, and anorectal incontinence had lessened. At approximately 3 weeks of care, she began to experience a return of bladder filling sensory perception, along with the ability to voluntarily initiate micturition. Although she could not yet completely empty her bladder, she could stop urine in midstream by contracting her urethral sphincter and pelvic floor musculature. Spontaneous bowel discharges had lessened in frequency, and were accompanied by brief periods of sensory awareness or rectal urging prior to their occurrence. After approximately six weeks of treatment, low back, lower extremity, and all areas of pelvic, coccygeal and rectal pain had all but resolved. Bladder and rectal sensory awareness had returned to normal. She had regained the ability to voluntarily empty the bladder, able to replace diaper dependency, which required changing from three to as many as six times per day, with ordinary panty liners needing changing only twice daily. Vaginal spotting had resolved, while genital and perineal sensitivity returned to normal. Although her improvement was remarkable, she does require ongoing treatment and activity limitations to sustain her improved clinical state. |
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