PPOD Case Report 10

PPOD Syndrome Diagnoses: bilateral inguinodynia (chronic inguinal pelvic pain), suprapubic neuralgia (superficial suprapubic pain), vaginodynia (pain in the vagina), urinary difficulty, urinary sluggishness, urinary retention (inability to completely empty the bladder), stress urinary incontinence (loss of bladder control with coughing, sneezing, straining, etc.), obstipation (intractable constipation), chronic flatulence (intestinal gas), dyspareunia (pelvic pain with intercourse), anorgasmy (loss of ability to achieve orgasm).

A 52-year-old woman was seen for the complaints of low back and right leg pain. She reported that 10 years earlier she was involved in an automobile accident at which time she injured her low back, right hip and right knee. As a result of her injuries she underwent a total knee replacement, however she had continued to experience ongoing intermittent low back, right knee and right lower extremity pain since that time. She noted that at 14 years of age, because of recurring abdominal pain, cramping, constipation and diarrhea she underwent enterologic evaluation and had been diagnosed with ulcerative colitis and diverticulitis. She was prescribed medication and dietary modification for these complaints, however these measures failed to provide any significant relief of her symptoms. Approximately 5 years prior to being seen, her enterologic (bowel) function deteriorated and she began to experience severe ongoing constipation which prevented her from being able to evacuate her bowels any more frequently than once every 8-10 days, and then, only with the aid of high doses of laxatives supplemented by enemas. In addition, pronounced ongoing flatus had begun to occur. As a result of her severe bowel dysfunction she began to eat only sparingly in an attempt to minimize her abdominal discomfort and avoid the potential of developing fecal impaction. Approximately four years later, 12 months prior to being seen, while working as a house cleaner, she developed recurrent low back pain which gradually intensified over the course of several weeks. As her back pain increased she noticed the onset of pain in the right inguinal region. Continuing to work, her back pain gradually became more severe. As it did, her right inguinal pain became more intense and she additionally began to experience suprapubic and left sided inguinal pain. She underwent evaluation for these complaints, initially by her family doctor and subsequently by her gynecologist. However, after a complete work-up, no abnormalities could be identified. She was prescribed medication for pain and advised to return should her condition change. Over the next few of months, she began to experience burning pain within the vagina and a loss of normal sensory perception of the external genitalia. Intercourse which had been painful became more severe, and because of her accompanying sensory impairment she had lost the ability to achieve orgasm. During this same period of time, she additionally began to experience symptoms of urologic dysfunction consisting of a decrease in urinary frequency which was accompanied by a loss of the normal urge or desire to void, and the inability to completely empty the bladder. She stated that instead of emptying her bladder every couple of hours, she would void only 1-2 times per day. Furthermore, despite being unable to completely empty the bladder she also developed the paradoxical state of being unable to maintain normal bladder control when coughing, sneezing or straining. Additional urologic evaluation at that time was unable to account for any of her complaints, nevertheless, a bladder suspensory surgery had been recommended in an attempt to restore urinary continence. She agreed to undergo the procedure, but, decided to postpone her surgery until things had slowed sufficiently at work for her to easily take the time off. It was during this time that I had seen her for her back and leg pain complaints. At the time of her evaluation, she revealed multiple findings indicative of the mechanically induced pelvic pain and organic dysfunction syndrome. After her first few treatments she experienced a distinct increase in her back, pelvic and leg pain. However, by the end of her first week of care, she was aware of improving bladder function. After the second week of treatment, she was no longer experiencing urinary incontinence while coughing or sneezing and she was able to empty her bladder with greater ease. Furthermore, although it had been eight days since the last time she had evacuated her bowels, for the first time in many years, she was able to evacuate with greater ease and without the need of a chemical stimulant or laxative. By the end of the third week of care her bladder function had normalized and bowel function continued to improve. She was able to evacuate her bowels with great ease and without the use of any chemical stimulant or laxative every 1-2 days. Furthermore, she reported that her gas problem had disappeared as well. In addition, she was aware of a distinct reduction in the intensity of her pelvic and vaginal pain. Although she had not engaged in intercourse since initiating treatment she stated that she was aware of improved genital sensory perception. By the end of the fourth week of treatment she stated that intercourse was now pain free, and although she had not achieved orgasm she was aware of a distinct improvement in genital sensory perception. After two more weeks of treatment, she reported that the ability to achieve orgasm had returned. As a result of her improved bladder function and restored urinary control she canceled her planned bladder suspensory surgery as it was no longer needed.

Comment: Although she had been seen for evaluation and treatment of her back and leg pain complaints, which at the time had progressed in severity to keep her from being able to work and maintain her household responsibilities, as is usually the case she had no suspicion that any of her pelvic complaints were, in any way, related. At the completion of her treatment however, happy with the improvement of her back and leg symptoms, it was the resolution of her severe, ongoing and unrelenting bowel dysfunction that gave her the greatest satisfaction.