CASE REPORTS

Case No. 8

PPOD symptoms: pelvic pain; genital pain; coccygeal pain; rectal pain; total urinary retention; recurring bladder infections; loss of bladder sensory perception; recurring urinary incontinence; chronic diarrhea; excessive flatus; rectal mucous discharge; rectal bleeding; rectal incontinence; painful intercourse; inability to achieve orgasm; loss of sexual desire; painful, irregular, and excessive menstruation; recurring vaginal infections

A 39 year old female was referred to the author for the chief complaint of chronic pelvic pain and dyspareunia (pelvic pain with intercourse). She related that left inguinal pain had its onset at approximately 18 years of age, developing shortly after all fall down a flight of stairs. A few months later, right inguinal pain had its onset. As a result she was hospitalized and an appendectomy had been performed. Tissue evaluation at that time however, revealed that the appendix had been normal. Despite removal of her appendix however, right inguinal pain persisted. Menstruation, having its onset at age 15, had initially been pain free, however, at about the time of her appendectomy, menstruation became severely painful with pelvic pain being located primarily in the inguinal (anterior pelvic) regions bilaterally, and dominant on the left. In addition, chronic diarrhea had its onset. As a result, she was re-hospitalized for evaluation and treatment. Her symptoms were attributed to an irritable bowel occurring secondary to stress, and she was released from the hospital with no change in her bowel dysfunction. About 2-3 years later, persistent vaginal discharge and recurrent bladder and vaginal infections began to occur. Treatment for what was identified as local yeast and bladder infections provided only temporary relief. Also during this period, she began to experience genital pain that radiated bilaterally into the labia and clitoris. The outer genital region became painfully sensitive to touch or contact of any type. Menstruation, which had been intensely painful, became even more severe and was accompanied by a irregularity and excessive bleeding. She was placed on estrogen for regulation of her menstrual dysfunction, however no significant improvement occurred. At 26 years of age she married, and became pregnant with her first child. Since the beginning, intercourse had been intensely painful. Pain with intercocurse would consistently be experienced in the inguinal, suprapubic (above pubic bone), coccygeal (tailbone), and rectal regions. In addition, she became aware of a complete lack of sexual desire. As a result of diminished genital sensitivity, orgasm had never been possible. She did note however, that if she could tolerate her dyspareunic (pelvic pain with intercourse) pelvic pain, intercourse could be performed to a point of culmination, at which time, rather than experiencing a pleasurable sensation associated with normal orgasm, an intense pain would occur deep within the pelvis, and spread upward through the abdominal and chest regions extending to the base of the skull and terminate in a headache which would persist for a couple of days. During this pregnancy, she began to experience the onset of low back pain. Her pregnancy ended in prolonged labor with the delivery of a normal healthy boy. Two years later, she became pregnant for the second time. At about three months of gestation, vaginal bleeding began. This pregnancy was terminated by a spontaneous miscarriage at about 5 1/2 months gestation. A few months later, she became pregnant for the third time. This pregnancy was accompanied by vaginal bleeding as before, and ended two months prematurely with the birth of a girl. Following this delivery, because of continuous pelvic pain and diarrhea (which had been present since 18 years of age) and vaginal bleeding which continued to persist following her third pregnancy, a laparotomy was performed. This procedure however failed to reveal any abnormal findings. Due to continued symptoms however, a partial hysterectomy was performed several months later. Upon awakening from this surgery, total urinary retention (inability to empty bladder), accompanied by a complete loss of bladder sensory perception had occurred. She was told by her surgeon that the nerves controlling bladder function had probably been severed during her operation. Her inability to void (urinate) required that she be trained in self catheterization techniques which had to be performed every three hours to achieve bladder emptying. At about this same period of time, bowel dysfunction, which had been continuous since its onset, worsened and consisted of chronic painful diarrhea, excessive flatus (intestinal gas), bleeding, mucorrhea (mucous discharge), and nocturnal encopresis (rectal incontinence). Accompanying the onset of nocturnal encopresis was an associated loss of rectal sensory perception. Further evaluation attributed these symptoms to proctalgia fugax and rectal fissures. Eight weeks after having undergone her partial hysterectomy, left sided inguinal pain increased and its severity. As a result, additional surgery was performed and the left ovary was removed. Histologic examination revealed the presence of numerous cysts. Inspection of the right ovary at that time however, revealed no evidence of abnormality. Following her oophorectomy however, left inguinal pain continued to persist. Over the next year, right sided inguinal pain increased in its intensity. A right oophorectomy was performed and ovarian cysts similar to what had been identified in the left ovary were found. Despite removal of the right ovary however, right inguinal pain continued unchanged. Four years later, despite the continuation of total urinary retention, stress urinary incontinence (urinary loss with straining) developed. This was accompanied by the onset of recurring bladder infections. As a result, an initial bladder suspensory surgery was performed. This improved her incontinence and infections for about one year. Approximately one year later however, urinary incontinence and recurring bladder infections returned. A second suspensory surgery was performed, which again provided relief of her incontinence and infections. These procedures however, provided no improvement in her loss of vesicle (bladder) sensory perception or urinary retentive state. Approximately six months later, she had fallen twice in the same week, and within 24 hours experienced the return of urinary incontinence. A third suspensory surgery with the addition of a supportive mesh was performed. However, because she was unable to accept of the implant, the mesh was removed and incontinence continued to persist. A second attempt at implanting the mesh was made, and following this surgery, urinary incontinence was relieved. At no time however, over the previous ten years since the onset of her urological disturbances, did any of her bladder surgeries provide any improvement in her absent vesicle sensory perception or inability to micturate (urinate). Clinical examination by the author however, revealed the characteristic clinical features of a Type II mechanically induced PPOD Syndrome with secondary bladder, bowel, gynecologic and sexual dysfunction as detailed above. Treatment following the Type II PPOD protocol provided progressive improvement of her complaints as shown in table 1. Table 2 lists the 13 unsuccessful surgical procedures that had been performed in an attempt to resolve the various PPOD complaints.

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Copyright © 1994, 1999, 2000 James E. Browning, D.C.; Thomas M. Wetherbee