Letter written by an ER doc
Posted: Sun May 08, 2011 1:02 am
An ER doc wrote this in response to a discussion he listened to on ano rectal pain in the ED. Thankfully, there are doctors out there who "get it".
Dear Dr. ___________________
In the April 2011 EMRAP you featured an interesting discussion with Dr. XXXX and Dr. ZZZZ, a colorectal surgeon and faculty at USC. I found the discussion on acute rectal pain interesting and I want to comment and add some important considerations to the differential diagnosis. A family member of mine developed pudendal neuralgia and pelvic floor dysfunction, a rather rare, yet debilitating condition that often presents in the ED. When the condition is acute, if diagnosed appropriately with correct referral, this condition can be treated and the path to chronic widespread pain may be averted. Pudendal neuralgia /pelvic floor dysfunction affects women more than men, although it was first described in French cyclists, and termed “cyclists syndrome”, “bicycle seat neuropathy”, and often in men, is misdiagnosed as chronic non-bacterial prostatitis. The condition can present with severe widespread pelvic pain, or localized pain to the s2-4 distribution, and in men, penile pain, perineal pain, and rectal pain. Often the pain is described like a “foreign body “ in the rectum or vagina. A cardinal symptom is excruciating pain with sitting, and it is often relieved with sitting on a toilet seat. Patients will often describe weakened urine stream, urgency frequency and constipation.
This condition often affects young people who are active athletes: cyclists, runners, horseback riders, weight lifters and gymnasts. Other individuals affected are people who work in jobs that require prolonged sitting, such as IT professionals, and truck/taxi drivers. Women who have had traumatic birth injuries, frequent UTI’s, and painful intercourse should all be considered at risk for PN/PFD if they present with the above symptoms. Patients who have inflammatory bowel disease are also at risk for PN/PFD. Those affected are 2/3 women, and 1/3 men. Men will complain of ejaculatory pain and erectile dysfunction, and women will often complain of clitoral pain, perineal pain, and sometimes experience persistent sexual arousal. Burning stabbing pain is often described and they experience allodynia, and are unable to even tolerate wearing underwear and anything but loose clothing. The pain can become widespread, centralized, and chronic.
I draw this to your attention because since I have learned more about the scope of pelvic floor dysfunction and pudendal neuralgia, I have diagnosed several cases in the ED and made appropriate referrals. I have seen patients who are bounced back and forth to urologists and other physicians, treated with multiple courses of antibiotics for "chronic prostatitis" with no benefit, and end up in the ED feeling hopeless and in severe pain without anyone having considered this diagnosis. Many urologists and OB-Gyn's, and most primary care physicians are not aware of this condition, and it sometimes requires extra time to educate the patient as well as their physicians about this possible diagnosis. Of course this diagnosis is not made until other diagnoses such as PID, acute prostatitis, pelvic and rectal tumors, etc. have been ruled out.
There are physical therapists who exclusively treat pelvic pain in both men and women. Physical therapy is the starting point for treatment, and if PT fails to progress, other measures such as nerve blocks can be done. Pudendal nerve blocks are diagnostic in purpose. Many patients are referred to pain management specialists for chronic pain management. Although there are surgeons who specialize in pudendal nerve decompression surgery, the surgery is rather controversial and the outcomes concerning. This condition has the potential to be extraordinarily disabling, and many patients end up with a disability diagnosis. If we can at least have this diagnosis on our radar, and appropriately refer for a PT evaluation, we can potentially intervene before a widespread chronic pain
Dear Dr. ___________________
In the April 2011 EMRAP you featured an interesting discussion with Dr. XXXX and Dr. ZZZZ, a colorectal surgeon and faculty at USC. I found the discussion on acute rectal pain interesting and I want to comment and add some important considerations to the differential diagnosis. A family member of mine developed pudendal neuralgia and pelvic floor dysfunction, a rather rare, yet debilitating condition that often presents in the ED. When the condition is acute, if diagnosed appropriately with correct referral, this condition can be treated and the path to chronic widespread pain may be averted. Pudendal neuralgia /pelvic floor dysfunction affects women more than men, although it was first described in French cyclists, and termed “cyclists syndrome”, “bicycle seat neuropathy”, and often in men, is misdiagnosed as chronic non-bacterial prostatitis. The condition can present with severe widespread pelvic pain, or localized pain to the s2-4 distribution, and in men, penile pain, perineal pain, and rectal pain. Often the pain is described like a “foreign body “ in the rectum or vagina. A cardinal symptom is excruciating pain with sitting, and it is often relieved with sitting on a toilet seat. Patients will often describe weakened urine stream, urgency frequency and constipation.
This condition often affects young people who are active athletes: cyclists, runners, horseback riders, weight lifters and gymnasts. Other individuals affected are people who work in jobs that require prolonged sitting, such as IT professionals, and truck/taxi drivers. Women who have had traumatic birth injuries, frequent UTI’s, and painful intercourse should all be considered at risk for PN/PFD if they present with the above symptoms. Patients who have inflammatory bowel disease are also at risk for PN/PFD. Those affected are 2/3 women, and 1/3 men. Men will complain of ejaculatory pain and erectile dysfunction, and women will often complain of clitoral pain, perineal pain, and sometimes experience persistent sexual arousal. Burning stabbing pain is often described and they experience allodynia, and are unable to even tolerate wearing underwear and anything but loose clothing. The pain can become widespread, centralized, and chronic.
I draw this to your attention because since I have learned more about the scope of pelvic floor dysfunction and pudendal neuralgia, I have diagnosed several cases in the ED and made appropriate referrals. I have seen patients who are bounced back and forth to urologists and other physicians, treated with multiple courses of antibiotics for "chronic prostatitis" with no benefit, and end up in the ED feeling hopeless and in severe pain without anyone having considered this diagnosis. Many urologists and OB-Gyn's, and most primary care physicians are not aware of this condition, and it sometimes requires extra time to educate the patient as well as their physicians about this possible diagnosis. Of course this diagnosis is not made until other diagnoses such as PID, acute prostatitis, pelvic and rectal tumors, etc. have been ruled out.
There are physical therapists who exclusively treat pelvic pain in both men and women. Physical therapy is the starting point for treatment, and if PT fails to progress, other measures such as nerve blocks can be done. Pudendal nerve blocks are diagnostic in purpose. Many patients are referred to pain management specialists for chronic pain management. Although there are surgeons who specialize in pudendal nerve decompression surgery, the surgery is rather controversial and the outcomes concerning. This condition has the potential to be extraordinarily disabling, and many patients end up with a disability diagnosis. If we can at least have this diagnosis on our radar, and appropriately refer for a PT evaluation, we can potentially intervene before a widespread chronic pain
