PPOD Case Report 15

PPOD Syndrome Diagnoses: bilateral inguinodynia (chronic inguinal pelvic pain), suprapubic neuralgia (superficial suprapubic pain), coccygodynia (coccygeal pain), proctalgia (rectal pain), pelvic floor myalgia (para-anal pain), urinary frequency, urinary urgency, total urinary retention (loss of ability to empty bladder), overflow urinary incontinence (urinary loss due to excessive bladder filling), recurring lower urinary tract infections (bladder infections), excessive flatulence (intestinal gas), fecal incontinence (loss of rectal control), spontaneous uncontrollable bowel discharge, atrophic vaginitis (vaginal spotting), recurrent spontaneous miscarriage (loss of pregnancy).

A 53-year-old woman was seen for long-standing complaints of bladder, bowel, gynecologic and sexual dysfunction. She presented wearing diapers for long-standing urinary and fecal incontinence. She reported that although she was unable to recall the specific sequence of their onset, bilateral inguinal, suprapubic, coccygeal, para-anal and rectal pain all had their onset during childhood. Despite the persistence of these symptoms, they were not evaluated at that time. At 19 years of age, she married and over the next four years had become pregnant on four separate occasions. Each pregnancy had been accompanied by vaginal bleeding and all were terminated in a spontaneous miscarriage occurring between the third and fifth month of gestation. During this time, recurring and persistent bladder infections had begun to occur. At about 23 years of age she became pregnant for the fifth time. During this pregnancy vaginal bleeding recurred, however, recumbency and activity limitation allowed her to carry the pregnancy to term at which point a normal baby girl was born. Her next two pregnancies, although complicated by a breach presentation and toxemia respectively, resulted in the cesarean delivery of baby boys. Her eighth and final pregnancy was complicated by bleeding abnormalities and ended in a spontaneous miscarriage at three months of gestation. Although she had been evaluated on numerous occasions during her pregnancies, no specific cause could be identified for her recurring miscarriages. About one year later, because of ongoing chronic pelvic pain and continued vaginal bleeding, a hysterectomy was performed. Although her bleeding abnormalities were resolved, pelvic pain continued to persist unchanged. Approximately 11 years later, which was about 15 years prior to being seen, she had injured her low back while working in a nursing home. Treatment consisting of ultrasound and physical therapy gradually resolved her complaints over a six month period. During this episode of back pain however her pelvic pain had increased and urological disturbances consisting of frequency, urgency and stress urinary incontinence began to occur. Over the next several years low back pain had periodically recurred and gradually became accompanied by bilateral lower extremity pain and numbness. During this time her urinary incontinence had decidedly worsened. As a result, a urological consultation was obtained and this culminated in a bladder suspensory surgery. However, rather than improving the situation her urological dysfunction became more severe, taking the character of total urinary retention with secondary overflow incontinence. She stated that during this time she had become aware of a loss of bladder, rectal and perineal sensory perception so that she was unaware of bladder and rectal filling, and could not feel when urine was dripping from her bladder and flowing over her perineum. As a result, she was trained in self catheterization techniques which had to be performed every 3-4 hours to empty her bladder. She catheterized herself for approximately 5 years at which point, because of ongoing frustration and inconvenience, she discontinued the procedure altogether. Over this period of time, her bowel dysfunction had become more severe and resulted in ongoing anorectal or fecal incontinence, excessive flatulence, sharp severe rectal pain and intermittent episodes of spontaneous uncontrollable bowel discharge occurring from 2 to 6 times per day. Because of the severe and continuous nature of her bladder and bowel dysfunction, she required the ongoing use of diapers. Approximately one year later, she developed vaginal spotting as a result of what was attributed to be atrophic vaginitis. Several months of using intravaginal estrogen creams however, proved to be of no help, and as a result, she discontinued the use of her creams altogether. A pelvic examination at about this same period of time, revealed the presence of a cystocele and rectocele which were judged to be the probable cause of her bladder and bowel dysfunction. However, no specific treatment had been recommended or performed and she continued to suffer ongoing bladder, bowel and gynecologic dysfunction. Upon her PPOD syndrome examination, there was clear evidence of the mechanically induced pelvic pain and organic dysfunction syndrome. Treatment resulted in a progressive improvement of her complaints. After two weeks of care, her low back, inguinal, para-anal, coccygeal and rectal pain at all diminished. In addition, her anorectal or fecal incontinence had lessened. After approximately 3 weeks of treatment she began to note a return of bladder filling sensory perception with the ability to voluntarily pass small amounts of urine. Although she could not completely empty her bladder, she could stop urine flow in midstream by contracting her pelvic floor musculature. Her spontaneous uncontrollable bowel discharges had lessened in frequency and were accompanied by periods of returning sensory awareness of rectal filling and the ability to maintain rectal control. After six weeks of care, low back, lower extremity and all pelvic pain (inguinal, suprapubic, coccygeal, para-anal and rectal) had all but resolved. Bladder and bowel sensory awareness and control had returned to normal. She had fully regained the ability to voluntarily empty her bladder and she was able to replace diaper dependency with ordinary panty liners needing changing only one or two times per day.