Multifocal Nature of Chronic Pelvic Pain

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Larry Demco, MD: "This is Dr. Demco reporting from the AAGL Conference here in San Francisco. It's my honor to talk to the Head of the Pelvic Pain Society, Dr. Perry from Birmingham. Dr. Perry, welcome to San Francisco. I understand the Pelvic Pain Society is improving here and you've got a conference coming up. Could you tell us a little bit about that before we get into the interview?"

C. Paul Perry, MD: "Thank you for that opportunity, Dr. Demco. We are going to have our annual meeting in San Diego in August of next year. The date and the information will be both on OBGYN.net and also on the link to our website, and that's http://www.pelvicpain.org." 

Larry Demco, MD: "Speaking of pelvic pain, this is quite an issue. I know in my practice up to approximately 40% of all our gynecological patients have one pelvic pain or another. Give us a little idea of the scope of pelvic pain and how we think it might be involved with more disease with more organs." 

C. Paul Perry, MD: "It's estimated that at least ten million women in the United States suffer from chronic pelvic pain, and the tragedy of that is of those ten million probably only about three million really seek proper treatment. There are a number of reasons for that discrepancy. One is that sometimes women are just told the pain is all in their head and they just give up. Another is they may find it difficult in trying to reach someone who has expertise in the area. Chronic pelvic pain is very complex; it is a multifocal disease and usually with pain that lasts for six months or longer. We're not talking about a simple cause and effect, we're talking a multiorgan involvement."

Larry Demco, MD: "It's interesting you say that because I'm sure most patients and most family doctors always think there's one cause for pain, and if we could find that one cause we'll eliminate the pain totally. How do you want to expand on that concept? Do you think that's relevant with today's knowledge or do you think that maybe we're barking up the wrong tree with that?"

C. Paul Perry, MD: "I really think that whole concept of the parsimony of one disease and one symptom goes by the wayside when you're dealing with chronic pain. The reason why that happens is because pain is a function of intensity and duration, and it causes some side effects in the spinal chord itself, which can cause the pain to spread to other organ sites. Very commonly we see patients start out with endometriosis, let's say, or pelvic congestion and then develop other symptoms if they're not controlled such as interstitial cystitis, functional bowel disease, vestibulitis, and other problems like pelvic floor myalgia. In fact, it's the rule rather than the exception when somebody hurts for six months that you don't have multifocal origins of their pain."

Larry Demco, MD: "There's a debate whether this is the same disease surfacing in the bladder, the bowel, and in the peritoneum like endometriosis versus a syndrome like what you're talking about. What are your views on both?"

C. Paul Perry, MD: "I do think it's probably the same disease, for instance, we now believe that things like vestibulitis and interstitial cystitis - what we call a neuro inflammatory process - is if someone has pain for a long period of time they actually have a sensitization and an up regulation of the dorsal horn receptor cell of the spinal chord. That receptor cell actually causes pain transmission in reverse down the nerve fibers that actually innervate, let's say, the bladder or the vestibule, and when that happens that produces allodynia. That's the allodynia that we see with a Q-tip test when we're checking for vestibulitis or the changes in the mucosa of the bladder. As we're learning more and more about pain, we're learning more and more that the autonomic nervous system is more of a grid than it is just a function of cartesian - one response and one stimulus type of nervous system. So it's viewed as a grid; if one area is touched, the whole area is effected to some degree." 

Larry Demco, MD: "Many people think that pelvic pain can be treated effectively but only for a short period of time. What do you think about that?"

C. Paul Perry, MD: "Again, I think it's a matter of duration and intensity. The longer someone hurts and the more intense they hurt, the more difficult it is to down regulate those changes in the spinal chord but there are two very important concepts. I believe one is we can prevent chronic pelvic pain syndrome and the way we do that is we find these young women that are hurting very early with severe dysmenorrhea and other pain that have been ignored or told that it's natural and find out the pain focus in them and get the pain generators under control. I think those folks down the road would develop into a chronic pelvic pain patient, which is probably the most difficult patient that we see. When there are multiorgan systems involved, when there's pelvic floor myalgia, vestibuli, function of bowel disease, and all these other components you have to accurately identify each one of the components and get each one of the components under control. Most of us did get that in training and most of us weren't shown how to do that but it's definitely possible to do a better job than we're doing today. That's why we would like to see more people join the International Pelvic Pain Society because we have a multidisciplinary organization that has gynecologists, urologists, anesthesiologists, psychologists, and neurophysiologists that come together. We're learning from one another in a way that helps us to relate these heretofore thought unrelated problems, and the more progress we make, the more we're able to apply it to our patients that are suffering and the better results we're going to get."

Larry Demco, MD: "I think with this summation that the importance of the Pelvic Pain Society getting these people together is a messages that has to be sent to not only people with chronic pelvic pain for a long time but the adolescents and the patients with pain. I'd like to thank you very much for spending time here with us and all the success. I hope to see you at the Pelvic Pain Society meeting in August."

C. Paul Perry, MD: "My pleasure, Dr. Demco."

Larry Demco, MD: "Take care."