Chronic pelvic pain of unknown origin may be caused by loose uterosacral ligaments failing to support pelvic nerve plexuses - a critical review

Abstract

Introduction: Chronic pelvic pain of unknown origin (CPPU) affects the quality of life (QoL) of up to 20% of women. The 2005 Cochrane Review, based on randomized controlled trials (RCTs), stated that the pathogenesis of CPPU is poorly understood and its treatment is empirical and ineffective. Totally ignored were the high cure rates from uterosacral ligament (USL) repair, the principal subject of this review.

Material and methods: We carried out a review of literature on USL causation, diagnosis, and treatment of CPPU, selecting only the literature relevant to USL.

Results: The first mention of CPPU being caused by lax USLs was in the pre-WWII German literature by Heinrich Martius. In 1993, CPPU was described as one of the 4 pillars of the posterior fornix syndrome (PFS- CPPU, urgency, nocturia, abnormal bladder emptying). Cure/improvement of CPPU was reported by widely geographically separated surgical groups using squatting-based pelvic floor exercises and by shortening and reinforcing USLs with tension tapes, literally a reverse transvaginal tape. Patients can potentially be cured either by native tissue ligament repair or in older women a posterior sling can be tested using a speculum test or even menstrual tampons.

Conclusions: This technology, based on USL pathogenesis, which can be tested for potential cure, non-surgical or surgical, offers hope for women for a condition previously considered incurable. Chronic pelvic pain, bladder and bowel incontinence occur in predictable symptom groupings, which are associated with apical prolapse. USL repair, whether native tissue or (preferably) using a posterior sling has the potential to improve clinical practice, QoL for women and open new research directions.

Keywords: Allen-Masters syndrome; Integral Theory; chronic pelvic pain of unknown origin; overactive bladder; pelvic floor disorders; posterior fornix syndrome.

Figure 1

EAU Guideline Chronic Pelvic Pain, 2016. Source: Messelink B. Perspective Pelviperineology. 2017; 36: 67-70 (published with permission).

Figure 2

The Pictorial Diagnostic Algorithm – co-occurrence of pain with bladder and bowel symptoms with USL damage. The size of the bar correlates broadly with the site and probability of symptom causation. The posterior zone (red rectangle) indicates the symptoms associated with uterosacral (USL) ligament looseness. These occur in predictable groupings (red rectangle). The main ligaments are indicated in capital letters: PUL ‘pubourethral ligament’, (front ligaments); ATFP ‘arcus tendineus fascia pelvis’, CL ‘cardinal ligament’ (middle ligaments); USL ‘uterosacral ligament’, PB ‘perineal body’ (back ligaments).

Figure 3

The Pelvic Symptom probability pyramid – Symptoms occur in predictable groupings. The relationship of symptoms within this grouping of 611 patients who had cardinal/uterosacral ligament laxity is expressed as a pyramid. Published with permission of the authors Liedl et al. [34].

Figure 4

Pathogenesis of chronic pelvic pain. The ganglions of Frankenhauser and the sacral plexuses are supported by uterosacral ligaments (USL) at their uterine end. ‘L’ indicates ligament laxity. The posterior directional forces are weakened and cannot stretch the USLs sufficiently for them to support the nerves. The nerves may be stimulated by gravity, by the prolapse, or by intercourse to fire off and be perceived as pain by the cortex. Published by permission from the Pelviperineology Journal [11].