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CHRONIC PERINEAL ALGIAS :
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WHAT ARE WE TALKING ABOUT ?
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Mansour Khalfallah1, Martine Cornillet-Bernard2, Thibault Riant3, (1) Neurosurgeon, Pain doctor (2) Physiotherapist, ARREP member and (3) Anesthesiologist, Pain doctor,
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Summary of a collaboration between the PELVIPERINEOLOGY REEDUCATION NETWORK ASSOCIATION
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and
CONSULTATION OF PERINEAL ALGIA OF MONTLOUIS Clinic of Montlouis, 8 rue de la olie Regnault Paris 11.
INTRODUCTION
Over the past three decades, the management of pelviperineal pain has undergone significant developments.
A multidisciplinary approach is essential. It involves pain physicians, various organ specialists, physiotherapy and osteopathy. A better understanding of the influence of the psyche on the mechanisms of pain makes it possible to call upon a good number of complementary therapies such as sophrology, psychology, hypnosis. The care has moved from a focal then regional approach to a global or holistic approach.
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What are we talking about ?
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When we talk about chronic pelvic-perineal pain, we mean any pain in the pelvic or perineal region that has developed over the past 6 months, whether or not they are associated with an underlying lesion. This definition includes persistent pain despite treatment of the cause.
This definition includes:
- pain that can be qualified as lesional . They result from the lesion of a tissue or organ such as a nerve lesion (pudendal neuralgia, clune neuralgia, etc.), a muscle lesion (piriformis syndrome, obturator internus syndrome, psoitis,) or a lesion of the bone framework (tailbone, fracture or fissure of the bone framework).
- These tissues can also be involved in painful phenomena without injury . We then speak of dysfunction . Pain is most often expressed through an organ without the latter showing any anatomical or visible lesion. We talk about vulvodynia or vulvar discomfort, prostatodynia, proctalgia, cystalgia, or irritable colon. Chronic, traumatic, inflammatory or infectious local irritation (repeated urinary and / or vaginal infections, endometriosis, anal fissure, recurrent hemorrhoidal episodes) is often found in the history of these patients, causing moderate episodic and recurrent pain. Sometimes there is a single painful episode but the intensity of which was very important. A migraine, or anxio-depressive, or post-traumatic stress, or fibromyalgia are sometimes but not
systematically associated. Physiopathologically, these 2 mechanisms (lesion and dysfunction) can be associated. These lesions or / and dysfunctions can evolve beyond 6 months due to diagnostic or therapeutic difficulties.
They can remain focal, or induce a regional or more global reaction of the whole nervous system and of these effectors (muscle, viscera, bones) more commonly called “hypersensitization”. This reaction is a response to the intensity and / or chronicity of the pain. The changes put in place are real. They are at the origin of an alteration of physiological mechanisms at the peripheral, central, medullary and cortical level. They will result in an exaggerated and / or diffuse reaction in response to a painful or non-painful stimulus. This impact can extend to functions such as urination or defecation. We are no longer within the framework of a systematization corresponding to a given nerve or muscle. The reaction can become completely autonomous and continue in the presence or absence of the initial lesion. The latter will only have played an inducing role or may only be a catalyst in patients who are sometimes but not systematically predisposed as we have mentioned (field of fibromyalgia, anxiety, neurosis, other chronic pain, etc.). This situation generates pain syndromes more commonly known in the limbs and formerly called algoneurodystrophy. The English-speaking term "reflex sympathetic dystrophy" was also used in the presence of vegetative signs. However, their inconstant character led to the preference for the term complex regional pain syndrome (CRPS). It can be expressed through a limb or an organ, or a region of the body. At the perineal level, it corresponds to what was mentioned previously under the name of prostatodynia (or even abacterial prostatitis), cystalgia, vulvodynia (apart from any infection) or functional colopathy. They are grouped under the name of complex pelvic pain syndrome (CPPS). These symptoms can be isolated or combined. In a somewhat simplistic way, we can say that SDPC = hypersensitization, which would explain the richness and polymorphism of the symptoms observed.
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Our approach:
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It is inspired by this equation. The symptoms are listed and analyzed. We are talking about the dismemberment of the painful picture. Our objective is to identify the possible initial lesion which will have to be systematically treated if the latter is still present (nerve compression, etc.) and to differentiate it from reactive pains, witnesses of secondary hypersensitization. This algorithm requires knowledge of the descriptive anatomy of the region, its somatic and vegetative innervation.
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The vegetative and somatic nervous system (SNV)
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Our entire body surface is innervated by somatic and vegetative fibers. It is the same with striated muscles, our joints.
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SNV
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Anatomically, the parasympathetic system accompanies the nerves, while the orthosympathetic system accompanies the vessels. It is mainly through the orthosympathetic system that the vegetative system participates in the nociception pathways. However, the functional balance between the 2 systems remains present. Consequently, a drop in parasympathetic tone, coupled with hyper sympathetic activity, as diffuse as pain, can partly explain certain dysfunctions (dysuria, erectile dysfunction, etc.) This system presents a metameric organization as we know it. for the somatic system, however, it is not as precise. The so-called vegetative pain can be identified by its diffuse nature, by its description (feeling of cold), it can be associated with a feeling of discomfort, sometimes even of a foreign body in the orificial pains, even "of uneasiness". This system presents a partly unknown organization. Starting from the spinal cord, in a segmental manner, the efferent vegetative fibers of the intermediate horns leave the spinal cord to join a para-vertebral ganglion structure. These ganglionic structures are stepped, and connected by an interganglionic branch. They contain afferent fibers which participate in nociception. They will do the opposite. From the organ, they will join a plexus (eg hypogastric plexus) or a paravertebral ganglion, then join the spinal cord via the communicating branches. They will project at the level of the posterior horn. The ganglia are interconnected and located symmetrically on either side of the spine. At the height of the sacrococcygeal region, this chain ends with a single ganglion, the impar ganglion. The anesthetic blocks, made at the level of this ganglion, reveal to us its implication in the painful cutaneous and visceral sensitivity of the whole of the plevi-perineal region. Its role in visceral functioning is still being explored. Its chemical destruction is effective in sweat disorders and cancer pain in the region. Anatomically it receives afferents from the para-vertebral ganglion chain, but also from the pudendal nerve. We find efferences towards the last sacral roots (S4, S5), the sacrococcygeal plexus and the coccygeal nerve. The results of the anesthetic block carried out in painful situations are in favor of a participation of the impar ganglion in the innervation of all the integuments of the perineum, the bladder, the urethra, the penis, the glans, the anus, the rectum but also the sphincters of the region. Its involvement in functional disorders, hypersensitization and pain quite often leads us to propose an impar ganglion test block in a process of dismemberment and treatment.
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THE Somatic SN: Figure 1: The somatic nerve-muscle relationship. Canal structures
The somatic nervous system participates in perineal pain that we sometimes observe through injury or compression of nerves within ductal structures (pudendal neuralgia, clune neuralgia, obturator neuralgia, sciatic compressions under piriformis). In the context of painful hypersensitization, the associated myofascial syndrome will in turn cause irritation or compression of neighboring nerve fibers. Anatomical knowledge of nerves and roots starting from the thoraco-lumbar hinge to the perineum is essential. Knowing their anatomical path, their promiscuity with certain muscles, and their innervation territory makes it possible to understand the mechanisms involved, as well as the extent of the painful territories. Certain neuralgias are essential to know in order to manage patients suffering from perineal pain, pudendal neuralgia and clune neuralgia.
Pudendal neuralgia: Figure 2: areas of pudendal nerve conflict
It results from compression of the pudendal nerve as it leaves the endopelvic region. 3 areas of conflict are identified: under the piriformis muscle, opposite the ligament clamp formed by the sacro-tuberous and sacrospinous ligaments, and in the Alcock canal. Other elements can also complicate the path of the pudendal nerve, but for reasons of understanding, we will limit ourselves to the 3 areas of conflict previously described.
When sitting, these duct structures narrow and put pressure on the pudendal nerve. On a soft seat, the para rectal fat is pushed back in depth and laterally. It increases the pressure around the pudendal nerve significantly. These patients suffer from pain in the territory of the pudendal nerve when sitting (median territory extending from the genitals to the anus). The pain presents a mechanical schedule, relieved standing and on the toilet seat. They do not wake up the patient. The clinical examination does not find an objective neurological deficit. Pelvic and spinal images are normal. When these 4 clinical elements are present, the diagnosis will be confirmed by functional blockage (anesthesia) of the pudendal nerve in the areas of conflict (ligament clamp at the level of the SLE and Alcock channel).
The transient decrease in seated pain of at least 50% confirms the diagnosis. In order to avoid false negatives or false positives, these tests must be carried out under scanner, with contrast product, by a team trained in their performance and evaluation.
These criteria, which are essential for diagnosis (Nantes criteria), are associated with a good number of symptoms favored by the chronicity of pain and hypersensitization. Sometimes medical treatment alone brings relief, but often partial and transitory. He can postpone a decompression gesture. A correlation between the duration of compression and the prognosis of recovery has not been shown. This is probably related to a factor that is difficult to assess: the extent of nerve pain. The infiltrations (pudendale), essential for the diagnosis cannot be considered as treatments (13% of patients improved). The use of corticosteroids has been shown to have no additional benefit and is no longer recommended.
Currently, the only validated treatment is surgical decompression of the nerve as part of comprehensive care:
- Treatment of the various components of hypersensitization (muscles, drug blockage of the pain pathways, possibly blockage of the impar ganglion and psychological care,)
- Treatment of the lesion of the nerve induced by this chronic compression (neuropathic pain) by drug treatment, skin stimulation. Residual pain at 1 year after surgery may benefit from treatment by spinal cord stimulation with promising long-term results. When the latter was first considered, improvements are absent or transient, and unsustainable.
Figure 3: sensory territories: A / ilioinguinal nerve, ilio-hypogastric nerve, B / pudendal nerve, C and D / cluneal nerve.
Clune neuralgia
It results from compression of the posterior cutaneous nerve of the thigh or of these clune branches in their course sometimes under the lateral edge of the sacro-tuberous ligament but also in a canal structure during their passage along the posterior lateral face of the 'ischium.
The pain is also positional, more on a hard seat here, relieved on the toilet seat. Patients feel like they are sitting on their bones. The pain is described in a paramedian territory, extending from the ischium, laterally towards the gluteal fold and the posterior aspect of the thigh, medially towards the labial region or the scrotum, even the genitocrural groove. Paramedian endo-ischial pain is reported in 80% of cases.
When these criteria are present, the diagnosis is confirmed by a test anesthetic block along the posterior cutaneous nerve of the thigh. This test, to be usable, must be carried out under indisputable conditions of realization and evaluation. The treatment also combines decompression surgery, always as part of a comprehensive care such as for pudendal neuralgia.
Bone pain:
Pain in the bone framework is common in perineal pain. They probably result from locoregional hypersensitization. Their diffuse character is in favor of a vegetative origin. At this level, a desensitization test approach can go through the impar ganglion.
Coccygodynias
This is a nosological framework that we will discuss more particularly. The functional complaint is coccygeal pain caused when sitting and more particularly when pressing on the coccyx. We also find, in many patients, an exacerbation of pain when getting up from a sitting position. More rarely, pain is also found when standing and walking. These latter characteristics would result from a myofascial component involving the muscles inserting on the coccyx (the ischiococcygeal head of the elevator ani, the gluteus maximus and the anal sphincter).
In chronic forms (beyond 3 months), these pains result in 60% of cases either from a bone spine or from anterior or posterior dislocation or from hyper mobility in flexion of the coccygeal parts. The thorns are congenital and often appear as a result of weight loss. Dislocations are favored by repetitive strain injuries to the coccyx due to loss of sagittal rotation of the pelvis. Overweight or a loss of spinal mobility (arthrodesis) are contributing factors. The remaining 40% include 15% of the beginning form of true dislocation or hypermobility, approximately 25% of the “referred” reactive pain of pelvic, perineal or spinal origin. We find more rarely microcrystalline pathologies, real spondylarthrosis
interbody. The therapeutic approach must once again be comprehensive without neglecting the psychological repercussions of these lesions. A myofascial component must be sought and treated. The infiltration improves 60 to 80% of patients. It is repeated if the improvement lasts more than a month.
In our practice we couple it to an impar ganglion infiltration. The search for locoregional desensitization makes it possible to reduce the number of non-responders to infiltrations and to increase their effectiveness. Radiofrequency is more and more proposed before moving towards surgery. The surgical intervention allows the resection of the identified element, at the origin of the pain (spine, coccyx). It lasts about 20 min. It allows an improvement of more than 50% of pain in 80% of cases. The main risk, infectious, is currently well controlled by a specific antibiotic prophylaxis protocol.
Figure 4: coccygeal hyper-mobility in flexion: standing (left) sitting (right)
Figure 5: X-ray in sitting position: posterior dislocation (left), coccygeal spine (right)
Complex pelvic pain syndrome:
The definition was detailed at the start of our presentation. Roughly speaking, it integrates any chronic pelvic pain that is not strictly localized to an organ or to a systematized neurological territory.
The frequency of associated vegetative signs, (here: sensation of intracavitary foreign bodies, cold buttocks, post-defecation, voiding, ejaculatory, coital pain), the often neuropathic expression of pain.
The absence of obvious or treatable causes leads us to a therapeutic strategy aimed at modulating nociception (pain pathways). This can be done at the periphery or at the medullary level.
A specific assessment with organ specialists must exist in the patient's journey. Baseline imaging of the spine and the painful area may be performed depending on the context. The dismemberment of the painful picture makes it possible to set up the diagnostic project (imaging, infiltration tests, specialized consultations, ...) and therapeutic with the aim of local desensitization (local topic infiltration, nerve block, under radio or under scanner, skin stimulation outpatient, physiotherapy), systemic desensitization (oral medication, ketamine infusion, psychological treatment) with sometimes potentiation by the combination of the 2 during a short hospital stay.
Peripheral stimulation is frequently used with results. The skin electrodes can be placed on the internal face of the ankle, to modulate the sensory perineal afferents (cutaneous territory of the S3 root), or loco-dolenti. You have to try both methods. In the absence of efficacy, or when the effect is present, but the skin electrodes become too restrictive, an epidural stimulation test can be proposed.
The improvement observed may lead to implantation of the device.
We insist on the fact that this approach is considered in patients:
- insufficiently relieved by general (medicinal) and local (physiotherapy, topical topical) treatments for 1 year.
- on pain that can be described as sequellar. It is meaningless and can be deleterious if it substitutes for or precedes specific treatment of an underlying causal lesion. The evolution of anesthesia techniques, and the low invasiveness of the technical gesture make it possible to carry out this test with the participation of the patient. The electrode is then placed in an epidural, at a height generating stimulation in the painful area, guided by the patient. The patient is evaluated after 10 days of testing in his usual environment:
- coverage of at least 80% of the painful area
- Pain reduction of at least 50%
The most recent studies show that the duration of the pain can be a factor of poor prognosis. Therefore, this approach should at least be discussed after the first year of pain development. An evaluation, within the framework of a pain unit, must be carried out and allow the early identification of the patients who may benefit from it.
Figure 6: Medullary cone stimulation for intractable chronic perineal pain
CONCLUSION
Currently, comprehensive care is essential in the context of chronic pain and particularly for pelvic pain. The dismemberment of the neurological, bone and muscular components and their integration into a nosological framework that includes the dimension of hypersensitization, facilitate a better understanding of the pain reported by our patients. A large part of this progress results from the dialogue (gynecologist / gastroenterologist / proctologist / visceral surgeons / perineal physiotherapist and psychologist,…) which is developing more and more in our activities.