Ask The Expert

Question from Katherine: Unusual Pelvic Pain Dear Dr. Toub,
I have an unusual type of pelvic pain. I had a cesarean section 6 years ago this September. I have been having severe abdominal pain now for the last six months. My physician said that he can see a staple still left in the incision from my cesarean. The wound has been infected all of this time. My doctor would only give me ointment. He will not do anything further. I have gained 41 lb. in the last six months and my stomach is very bloated. I am not sure if this is due to feeling sick all of the time or could the infection be spreading?

Answer from Dr. Toub: It is unusual to gain so much weight over 6 months, and it is also unusual to have a wound that is infected for so long without any major illnesses. I would suggest that the remaining staple be removed and your doctor might consider getting an ultrasound or some other imaging study of the wound to see if there might be a fluid collection underneath. Given the feeling of being bloated and the weight gain, I would consider a pelvic ultrasound as well to evaluate the uterus and ovaries to make sure there are no enlarging fibroids or ovarian cysts. If your doctor is not amenable to considering any of this, you might want to seek out a second opinion-any reasonable physicians should be willing to make such a referral. Good luck, and thank you for your e-mail!

David Toub, M.D.

  Question from JD: Pelvic Congestion I am 32 and have been experiencing pelvic pain, a shooting pain on either side of my abdomen for several years. The pain occurs mainly the week before my period is to begin. These pains last for 3-4 days, at different degrees of intensity. I have been on birth control for years. My primary care doctor felt that it was endometriosis, after a pelvic and abdominal ultrasound showed nothing. My gynecologist seemed to agree and performed a laparoscopy. This showed no signs of endometriosis, although I have a slightly tipped uterus and enlarged blood vessels. My gyn. put me on continuous birth control for the past 3 months to determine if taking my period out of the picture would alleviate the pain. I got the pain twice in one month and I spotted every day for a whole month. I was on LoOvral. When I went to see her this week she said I should try Depo Provera to take the Estrogen out of the picture. I am not at a point in my life where I want to have a baby so I want to be on some type of birth control but I am not sure if this is the right option. I am taking a month off from all of it to see how I feel after a month of no "drugs" and getting my period.

My gyn. has called this pelvic congestion but I don't know what that really means or what the best way to treat it is. I read a lot about endometriosis and I know my symptoms are not that severe but they sound similar. Do you have any ideas on what this could be or if Depo Provera is the right move for me at this point?

Thank you for any insight you may have.

Answer from Dr. Toub: Depo probably can't hurt, but it may not help either, especially if birth control pills had no beneficial effect on your symptoms. That makes a hormonally-affected process like endometriosis less likely, and the fact that laparoscopy was negative is also consistent with this not being endometriosis. Sometimes there can be other things going on (adenomyosis, for example, in which cells from the uterine lining grow into the muscle layer of the uterus--this is not the same as endometriosis) that can be helped with hormonal manipulation, which is why your doctor might be thinking of trying depo. At the very least, it is a non-invasive way to try to treat pelvic pain, so it may be worth the shot depending on how both you and your doctor feel.

As far as pelvic congestion---I admit that I personally am not much of a believer in this condition, although data supporting both sides of the issue go back and forth. The studies are mainly anecdotal rather than controlled studies, so it is hard to say whether or not it does or does not exist. My arguments against it are that one can see engorged pelvic veins in women without pelvic pain, and most pregnant women have extremely dilated and congested pelvic veins for several months yet don't have disabling pain (apart from the usual pain of fetal movement and the enlarging uterus). My skeptical side makes me wonder if pelvic congestion was not created as a diagnosis many many years ago in order to explain many cases of chronic pelvic pain, since all of us physicians altruistically want to be able to tell patients that we understand their condition when, in truth, we may not. Again, it's my nature to be skeptical about medical issues where there is no reproducible, controlled data.

Obviously it is hard to make specific recommendations over the Internet without the benefit of a detailed history and exam, but some things your doctor might consider is a trial of pain medicine, an MRI scan to evaluate your uterus for possible adenomyosis or some other condition, a trial of depo provera (which can be helpful for treating adenomyosis), a trial of a GnRH agonist, and even a referral to a multidisciplinary pain center. There are a lot of possibilities and things to look into, so it is not at all hopeless!
Good luck, and thank you for your e-mail!

David Toub, M.D.  

Question from NECA225: Abdominal Adhesions I was told before that I have abdominal adhesions. I saw a new gyn. and he told me I needed a hysterectomy. I have had this problem for many years and had laparoscopy done twice since 1986. A few years ago, I was told I had it again and that it was also on my bladder. They said couldn't remove it because it was on the bladder. Years went by and recently it got worse. My lower abdomen is in a lot of pain and when I have sexual intercourse it is very painful during and after. I can not find my doctor anywhere and I am afraid to trust just anyone. Can you please give me some information on this and also help me find a doctor near me. I live in New York City. Thank you very much.

Answer from Dr. Toub: It is my policy to not provide specific referrals online, since that can lead to conflicts of interests, etc. However, there are a lot of physicians in NY, many of whom would suggest courses of action other than hysterectomy. It may be that hysterectomy is appropriate for your situation, but you might ask your doctor about attempting to treat your pain medically, as well as even a repeat laparoscopy to remove adhesions. Given that you have had laparoscopies before for this problem, it is understandable that your doctor might be hesitant to repeat it; but a hysterectomy may or may not necessarily be helpful. He/she should be able to suggest a second opinion with another physician, preferably one who is very experienced with pelvic pain. If not, you could approach any of the major medical centers in NYC for gynecologists who specialize in pelvic pain and its management. There might also be one or more Pain Centers, in association with an anaesthesiology dept., that could be of benefit (for example, if your pain is strictly midline, a presacral block might be appropriate depending on the opinion of the anaesthesiologist). In any event, there may be other options unless something in your history or physical exam excludes all alternative therapies. Good luck, and thank you for your e-mail!

David Toub, M.D.  

Question from Abbye: Deep Burning Sensation Dr. Toub,
I'd appreciate any suggestions or information you can give me. Six months ago I delivered a baby. I was scheduled for a C-section but went into an early, rapid labor and ended up delivering vaginally. I had level 4 tears, an episiotomy and a catheter after not being able to urinate for 10 hours. Upon returning home, I noticed a deep burning sensation, with a slight pinching feeling somewhere in the vulvar region. I've come to believe it's at the "northern" end, closer to the clitoris/urethra than the vagina. I have had many courses of oral and vaginal medications for UTI and they helped briefly. Also I was given Metro-gel, a medication for atypical yeast and Premarin for atrophic vaginitis. I'm entering my 6th month of postpartum pain and have become extremely debilitated to the point where I can no longer take care of my family and can barely walk. I have seen a neurologist who can not tell me if this could be nerve damage and if I would recover. I tried a low dose of Elavil but had a reaction to it, so I have nothing for pain. This burning has spread into my buttocks and my inner thighs feel somewhat puffy and rub together so my walking pattern has changed. Whenever I lay down, at any point in the day and in any position the burning intensifies dramatically. I live in State College, PA and my doctors are very limited here. I am functioning at about 10% of my normal energy level and cry every day. Please feel free to provide any information to me.

Thank you for caring enough to read this.

Answer from Dr. Toub: It is hard to say for certain without an examination, etc. but the first thing that comes to mind is some form of "vulvodynia" or chronic vulvar pain syndrome. The symptoms you describe and the onset after delivery are a little unusual, making me also wonder about some trauma that was incurred during delivery. Elavil can be useful for vulvar pain syndromes, but obviously this is not the best treatment for you. In any event, it is probably going to be helpful if you are referred to someone who has some expertise in vulvar pain syndromes, and these tend to be concentrated in larger cities than State College, unfortunately. Ask your doctor about possible referrals in the Philadelphia or Pittsburgh areas (I'm not personally aware of gynecologists in Hershey who is particularly expert in this area, although they may exist). There is a lot that can be done, but a definitive diagnosis first has to be made, and the diagnosis remains a bit unclear from the description. Good luck, and thank you for your e-mail!

David Blair Toub, M.D.  

Question from RubyRed: An Operation To Improve Sex I saw an article printed in the Ladies Home Journal in November 1995, by Dr. Janice Bacon, Associate Professor of OBGYN. at The University of South Carolina in Columbia. It was a short article on an operation that can improve your sex life. Dr. Bacon said the procedure was relatively simple and involved pulling the levator muscles closer together after stretching and tearing from childbirth. I have asked many physicians and nobody knows what the doctor is talking about. Please help with any information.

Answer from Dr. Toub: I am skeptical of any surgical procedure that is purported to "improve your sex life." There have been others who have performed all sorts of operations on the vagina for that purpose, most often with disastrous results. First of all, this operation is generally only indicated at this time for women who need to have their perineal body (the connective tissue between the vaginal introitus and the anus) reconstructed after it has been injured from childbirth. In such patients, there is typically only a small distance between the vagina and the rectum and patients may experience fecal incontinence if the rectal sphincter is not intact. The operation involves performing an episiotomy more or less, but is much more complex and risky than a median episiotomy done during childbirth. I'm not sure that there have been any controlled prospective trials demonstrating the effectiveness of this operation in improving sexual function, nor is there any reason in my opinion to take a healthy woman to the OR and subject her to surgery without a proven indication. Furthermore, no study that I'm aware of has demonstrated any correlation between the size of the vaginal outlet and orgasmic function. Many women who have had multiple vaginal deliveries may have an enlarged introitus, and it does not impact on their sexual pleasure. So while I respect Dr. Bacon's efforts, until such work has been shown to be beneficial and with minimal risk to the patient, I would not recommend this to anyone at this time unless it is part of an investigational study with appropriate informed consent and patient protections. Thank you for your e-mail!

David Blair Toub, M.D.  

Question from WM: Hysterectomy For Ovarian Cysts Eight years ago, I had a laparotomy for severe endometriosis and cysts on both ovaries. At the time, there was some concern over whether the cysts were malignant, but the pathology reports showed no malignancies. One of the cystic masses removed was the size of a large grapefruit. Fortunately, my surgeon saved my ovaries (my uterus was normal). I was put on birth control pills for 3 years to control endometrial buildup. However, I discontinued them when I developed numerous uterine fibroids. The longest measurement of my uterus is now 11 cm. I am periodically observed by ultrasound. I once again have ovarian cysts that are growing on both ovaries. My doctor feels that the only solution is a total hysterectomy with bilateral. salpingo-oophorectomy. His main concern are the ovarian cysts; he says that there is no way to tell without surgery if they're endometriomas or cancer. Even if the cysts are not malignant, he says that conservative surgery would not be the best choice because of adhesions, and the fact that the endo returned after the last extensive surgery. I would like to add that I have never had any pain, and I am not in any pain now, although the doctor finds it hard to believe. Does this kind of surgery seem like the only option here? I would not be able to take HRT right away, because it could cause any remaining endo tissue to grow. How will this effect my heart, etc.? Other than heavy bleeding, I don't feel as if anything is wrong.

Answer from Dr. Toub: As far as the fibroids go, they were unrelated to the use of birth control pills. If the fibroids are not causing symptoms, there is probably not much of a compelling reason to treat them, via hysterectomy or any other method. As far as the cysts, I would not automatically assume they are endometriomas, although ultrasound and/or MRI can often help to determine if they are most likely endometriomas. Many radiologists can give a reasonable degree of accuracy in diagnosing endometriotic cysts on the ovary, and doppler ultrasound can also be helpful in determining how likely these cysts are to be malignant. It is not foolproof, but if an experienced radiologist feels that these cysts are consistent with endometriosis, and a doppler ultrasound reveals a low probability for malignancy, then at least it is more likely benign than not (again, not 100% certain!). Still, if these are endometriomas, they generally should be removed, but under certain circumstances it can be acceptable (so long as the patient is fully informed of all the risks and can undergo close follow-up) to observe asymptomatic cysts and try to shrink them a bit with hormonal agents or GnRH agonists (lupron, synarel, zoladex, etc.).

Surgery may still be indicated, and depending on the ultrasound findings your doctor may be absolutely correct to suggest surgical intervention at this time. However, that does not necessarily mean removal of the ovaries is required-the cysts could be evaluated with laparoscopy and removed, preserving the ovaries as your surgeon did previously. There is certainly a risk that one or more ovaries might have to be removed, depending on what is found at the time of laparoscopy, but at least there is the intent of trying to preserve one or both ovaries if possible, along with the uterus. As far as the concern about adhesions-it is true that even laparoscopic surgery can produce adhesions (although generally much less so than a laparotomy incision) but that is also true when performing a hysterectomy and removing both ovaries-any surgery can produce adhesions, so I'm not sure I understand the logic.

I would recommend a second opinion (which is always a good idea when contemplating definitive treatment for endometriosis) from someone experienced with endometriosis and laparoscopic treatment. Again, all of the above is my own opinion, and I do not have the benefit of the imaging results, physical exam, full history, etc. that your own doctor has. Based on specific data available to your own doctor, hysterectomy and removal of the ovaries may be absolutely appropriate, but based on my limited data, I do think alternative plans of action may be available. Again, this is where a formal second opinion would be extremely valuable, and any reasonable physician would be quite willing to refer a patient for another opinion. I view it as almost standard operating procedure in such situations. Good luck, and thank you for your e-mail!

David Toub, M.D.  

Question from Terra:Chronic Pain Dear Dr. Toub;

I am 22 and I have no health insurance. My periods have always been irregular. Lately there's been pain during sex. An internal, sharp, almost burning pain. There's no problem with lubrication or yeast infection, it doesn't even happen all the time. Recently, the pain was overwhelming. I spent a couple hours in the morning in pain. It feels like gas, but hurts more and is located very low in the abdomen. When I returned to bed, a wave of fever, nausea and almost delirium over came me. I laid on the floor fearing that I'd faint. I woke up a 1/2 an hour later and the pain was a faint ache, but returned a few hours later. The pain is getting worse all the time, sometimes without sex, but usually aggravated by it. Can you help? Any suggestions?

Terra 

Answer from Dr. Toub:  The best advice I can give is to suggest that you be seen by a gynecologist or primary care physician, or go to the nearest emergency room the next time one of these episodes takes place. There are a number of possible reasons for your pain, ranging from endometriosis and bladder problems (such as interstitial cystitis or a urinary tract infection) to things that could be much more serious (even chronic appendicitis). The fact that you are without health insurance is irrelevant. The only way to start to figure out what is going on in your case is to be fully evaluated. And again, if your pain again becomes very severe, I would strongly recommend going to an emergency room. I would not want someone to delay seeking appropriate attention for this level of pain. I would also recommend that you have a Pap smear to be on the safe side, since abnormal vaginal bleeding can be a sign of cervical dysplasia in some cases (precancerous cells within the cervix). Good luck, and thank you for your e-mail!

David Toub, M.D.

  Question from Mary: Hysterectomy for Chronic Pelvic Pain Hello,
I hope you can help or at least steer me in the right direction. I have had pelvic pain for two and a half years. I have had procedures done for ovarian cysts, endometriosis, ovarian vein embolization and finally in late November, a vaginal hysterectomy. I have begun to experience the pain again. It has always been limited to my right side. It begins about where my ovary is and radiates down my groin area into the back of my leg. My gyn. has recently taken over for another doctor and is swamped with patients. He does not seem to have the time to deal with me or anyone else beyond the typical exam. I am very frustrated. I am used to leading a very active life. I have been greatly impaired by all of this pain. I believed the hysterectomy would be the end to my pain. I cannot help but feel that I had the hysterectomy for no reason. Please, help to find someone to address this. Thanks for your time.

Mary

Answer from Dr. Toub:  No surgical or medical procedure, including hysterectomy, is "guaranteed" to abolish chronic pelvic pain. There are a number of possibilities for your pain even after a hysterectomy (pelvic adhesions being one of them). I would suggest you find someone else in your area with whom you might obtain a second opinion-any reasonable doctor should be amenable to having one of their patients seen elsewhere for a second opinion. If possible, a gynecologist who is experienced with chronic pelvic pain or who is part of a multidisciplinary pain center would be optimal. At this point, I would be reluctant to recommend surgery unless other methods do not work, or there is a high likelihood of success with surgery. Good luck, and thank you for your e-mail!

David Toub, M.D.

  Question from Debby: Bladder Adhesions? I have undergone 3 laparoscopies this year and 1 major surgery for adhesions formed after my hysterectomy. in May 1998. My last laparoscopy was in July and major surgery in June. I am now having a lot of pain when I urinate. It is not a burning pain and I don't have a fever. It is a pain that is very severe in the morning and is there every time I go to the bathroom. The pain is worse as I am finishing. I don't feel the urge to go a lot and have seen any blood. Could this be adhesions on my bladder? What doctor should I go see for this?

Debby

Answer from Dr. Toub: It is unlikely to relate to any adhesions on the bladder, since the bladder is fairly insensitive to adhesions The first thing that comes to mind is a urinary tract infection, which is not at all uncommon after surgery. A simple urine culture can rule this in or out, and you should definitely contact your doctor for a possible antibiotic prescription if he/she thinks it is appropriate. Another possibility is interstitial cystitis, but it is a bit lower on my list since it tends to be more of a chronic problem, whereas your description seems to indicate that this just started happening after surgery. There are other possibilities, like bladder spasm, but UTI is the first thing to address. Again, your doctor should be helpful in this regard and should be consulted as soon as possible. Good luck, and thank you for your e-mail!

David Toub, M.D.  

DISCLAIMER: The above represents material for educational and discussion purposes only. The material provided should NOT be used for diagnosing or treating any health problem or condition. It is NOT a substitute for consultation with and advice from qualified healthcare providers. If you have or suspect you have a health problem, consult a qualified healthcare provider. The author and any other party involved in the preparation or dissemination of the material presented are not responsible for any errors or omissions in the material provided above, or any results obtained from the use of such material.