I’d like to welcome you to the Pelvic Pain and Organic Dysfunction Syndrome Blog. As implied by its name, this forum has been established to prompt discussion and disseminate information and awareness about a little known and routinely misdiagnosed disorder called the mechanically induced Pelvic Pain and Organic Dysfunction (PPOD – pronounced “pea pod”) syndrome. It’s impetus has sprung from the stark realization that an almost universal lack of awareness of this condition has contributed, in no small way, to significant ongoing confusion and untold suffering by many millions of men and women who have had to endure the devastating effects of chronic pelvic pain and various disturbances of bladder, bowel, gynecologic and sexual function that frequently accompany it. Because this forum exists for you, individuals with an interest in learning more about this disorder, I’d like to take you back to the beginning and initiate our discussion by recounting my introduction to the PPOD syndrome and share with you how an unexpected clinical encounter led to a life time of study of an extremely complex and fascinating condition. After this introduction, I will also describe some of the characteristics and features of some of the most common symptoms that develop in the PPOD syndrome patient. It is hoped that these initial comments will not only provide you with some measure of insight for a problem that has perhaps, until now, defied clinical explanation and symptomatic treatment, but, also, serve as a stimulus to solicit your involvement in discussion which will undoubtedly add to a greater understanding of this disorder for us all.
Very early on in my career, in fact, while I was still a student at Palmer College of Chiropractic in Davenport, Iowa, I had the opportunity to attend a symposium and presentation on the treatment of mechanical disorders of the lumbar spine. At that meeting, in presenting an overview of some of the early investigative work that had been done on mechanical disorders of the lumbar spine, reference had been given to a handful of reports that had been published a number of years earlier, in which a smattering of isolated symptoms of pelvic organ dysfunction had been related to the presence of a mechanical disorder of the low back. Although the existence of accompanying symptoms of pelvic organic dysfunction in patients with back pain was not in any way unusual or even noteworthy in and of itself, what was of interest is that some of these individuals had reported improvement in response to their treatment in unexpected ways. Surprisingly, some of these patients had experienced significant improvement while others a complete resolution of symptoms of chronic pelvic pain, as well as a handful of disturbances of pelvic organ function, ostensibly in response to the successful treatment of their accompanying back problem. While this alone was noteworthy, in some of these cases the response seemed even more consequential by the fact that the accompanying pelvic problems had been of a chronic and recalcitrant nature, and had failed to respond to intensive local treatment of a urologic or gynecologic nature. It was these particular references that caught my attention.
Being, at the time, a chiropractor in training, I was extremely interested in finding all the research and corroborative data I could that spoke to the basic chiropractic premise; that mechanical disorders of spinal origin, by giving rise to secondary neurological impairment, could cause disturbances of an organic nature (organ function). Prior to this time, the only reference I had been aware of regarding an association between a mechanical disorder of the low back and any type of disturbance of pelvic organ function had been in the context of an acute cauda equina syndrome, a rare condition usually caused by a massive disc herniation resulting in severe bladder and bowel paralysis and associated incontinence. Being curious about these findings, I wrote the citations down and after returning to school went to the library to see if I could find any of the articles referenced at the meeting. After a short search I had been able to obtain copies of several of the studies which were mentioned. One such reference, which at the time was a very difficult read for me, was that of a collection of cases from a Scandinavian doctor who had highlighted the clinical features and examination findings of a group of patients that he had seen over a two and a half year period of time. The emphasis of his work had been on trying to refine the method of diagnosing nerve root compression syndromes by physical examination procedures to improve the identification of patients suffering from back and sciatic pain as a result of disc herniation.
At the time, the state of diagnosis and treatment of certain types of spinal conditions was fraught with much confusion and uncertainty. While disc herniation as a cause of low back and leg pain had first been reported nearly 30 years earlier, there had not yet been the development of imaging procedures, such as CT scans and MRIs, sophisticated enough to accurately reveal soft tissue problems of this type. Although plain X-rays, which were the standard of the day, could demonstrate the presence of fractures and various disease states of the bony structures, soft tissue abnormalities such as a disc herniation could not be seen. The closest one could get to visual confirmation of a disc problem causing nerve root compression, and hence leg pain, was with the use of a myelogram, an X-ray procedure enhanced with dye injected into the spinal column which in some cases would reveal an abnormal appearance, ostensibly being caused by a disc herniation. However, because this procedure had a notoriously high error rate, not to mention significant side effects and complications due to the toxicity of the dye used, there was a heavy reliance on the interpretation of a physical examination to identify these patients. However, unlike the rather straightforward exercise of interpreting the results of a blood test or an X-ray, which, if not obviously apparent can be judged against normal parameters, the precise interpretation of a detailed spinal examination, correlating the interaction of abnormal responses associated with aberrant spinal biomechanics, orthopedic stress provocation and neurologic assessment, is a clinical art and skill that is much more complex and takes many years to develop and refine to a level of reliable interpretability. But, because this type of assessment allows for a direct “read” of the patient’s condition in response to maneuvers that challenge the integrity of their physical state, once mastered it can be much more informative and revealing than many of the so called objective testing procedures that are inherently limited by a degree of sensitivity that is dependent upon the discordant interaction of man and machine.
In the processes of refining his diagnostic methods this doctor had identified subtle differences in the clinical presentation and physical examination of some of the patients presenting with back and sciatic pain who additionally suffered from various types of pelvic complaints. At the time, I was unable to understand much of what he had written. The terminology used was completely foreign to anything I had been taught, and the manner in which he had described his cases and examination procedures was very confusing and difficult for me to follow. I quickly found myself totally frustrated and unable to understand the essence of his work. Yet for some reason, despite the frustration and difficulty, something compelled me to persist. That summer I spent much of my free time reading and re-reading the material to try to make some sense out of what was being articulated. Although it wouldn’t be until several years later, after having been in practice for a few years, that I began to completely understand the full significance of what I had been trying to learn, I did manage to grasp a rudimentary mental image of the unique characteristics of the type of patients that were being described. This was extremely fortunate, because had this not occurred, I have no doubt that I would have overlooked any possibility that pelvic complaints might be related to a spinal disorder in the patients I was to later see. But because this sketchy conceptualization had continued to linger in the back of my mind, I later found myself groping to reconstruct the distinctive features of such patients as I contemplated the possibility of an association between severe recalcitrant chronic pelvic pain and longstanding urologic dysfunction in a patient whom I had just begun to treat as a result of a recently acquired spinal injury.
Although at the time I did not possess the level of knowledge or clinical experience to fully comprehend the events I was about to observe, I clearly remember the profound sense of awe I felt when it became clear that 27 years of debilitating pelvic pain and urinary incontinence, which had defiantly persisted in the face of multiple trials of gynecologic and urologic treatment, completely disappeared over the course of several weeks as I treated this patient. While this was my first recognized encounter with such cases, it didn’t take long before I realized that the spinal-pelvic connection and response I had witnessed was far more than an unusual and coincidental occurrence. Over time, as I saw and treated more of this type of patient, I was able to expand on the list of pelvic symptoms that I found to respond to the therapeutic approach that I came to routinely employ in their care. This helped to more completely define the spectrum and parameters of symptoms associated with this disorder. This added knowledge helped me establish a more complete understanding of the various presentations of patients with this condition, and led to the realization that there exists a wide variation in symptomatic presentation from PPOD patient to PPOD patient. In addition, the recognition of a more expanded symptomatic profile, which helped to define the boundaries of the PPOD syndrome, led to additions and refinements in the diagnostic and therapeutic management which served to further enhance the effectiveness of identifying, treating and managing the variant forms of this disorder.
Chronic pelvic pain, the most commonly encountered and single most prevalent symptom of the mechanically induced PPOD syndrome, continues to be one of the true enigmas of medical practice today. In the United States alone, many millions of men and women suffer from the far reaching and devastating effects of this disorder. Far reaching because it can effect people of all ages, and is often times intertwined with disturbances of bladder, bowel, gynecologic and sexual function of an equally enigmatic origin, and devastating because the relentless and intractable nature of the condition has caused untold physical, emotional, psychological and financial ruin. Although there are several disorders that if undetected because of inadequate diagnostic evaluation can cause pelvic pain of a chronic nature, it’s the cases in which no abnormality can be found despite a thorough investigative workup that account for the majority of those with severe, recalcitrant, long term morbidity and physical impairment. These are the cases that interest us, because it is within the realm of the chronic pelvic pain patient without identifiable pathology that the mechanically induced PPOD syndrome patient endures.
From the information gained from the early cases that were instrumental in awakening my awareness to the possibility that an “atypical”, “occult”, or “asymptomatic” mechanical disorder of the spine might be responsible for the production of chronic persistent pelvic pain, to later, more severe and recalcitrant cases which served as a testament to the effectiveness of the diagnostic and therapeutic protocols used to identify and treat these patients, it is hoped that this blog and accompanying website will provide a deeper understanding of this disorder by serving as a vehicle to explore the many facets of the mechanically induced PPOD syndrome.
James E. Browning, D.C.