Chronic pelvic pain of "unknown origin" in the female

Abstract

The remit of this review is confined to the experimental scientific works and surgeries based on the Integral Theory Paradigm (ITP). Chronic pelvic pain (CPP) is a major societal problem which is said to occur in up to 20% of women. The pathogenesis of CPP of "unknown origin" is said to be unknown and CPP is said to be incurable. According to the ITP, however, CPP is said to be mainly caused by the inability of loose or weak uterosacral ligaments (USLs) to mechanically support visceral nerve plexuses (VPs), T11-L2 and S2-4. These fire off de novo impulses, interpreted by the cortex as pain coming from the end organs. CPP, when it occurs simultaneously in multiple pelvic sites, is associated with uterine/apical prolapse (often minimal) and bladder symptoms such as overactive bladder (OAB), nocturia, retention. This combination of symptoms was described in 1993 as the "posterior fornix syndrome" (PFS). As such, CPP when associated with the PFS, is potentially curable by surgical repair of USLs. However, patients with CPP generally complain only of one symptom, CPP. This is known as the "Pescatori iceberg" effect. Other PFS symptoms are "under the surface" and must be sought out by direct questioning. The diagnostic algorithm is helpful in locating other associated symptoms. Definitive diagnosis of CPP, caused by USL laxity, is immediate alleviation of pain by mechanical support of USLs by using the speculum test or by tampons in the posterior fornix. Treatment of CPP can be non-surgical, by strengthening USLs by squatting exercises, supporting USLs mechanically with tampons or USL surgery. Coexisting bladder symptoms are (variously) improved or cured. URL for CPP https://www.pelviperineology.org/volume/36/issue/3.

Keywords: Chronic pelvic pain (CPP); speculum test; uterosacral ligaments (USLs); visceral nerve plexuses.

Figure 1

Diagnostic algorithm. The rectangle represents the co-occurring symptoms of the “Posterior Fornix syndrome”. CPP and nocturia are uniquely caused by USL laxity and are cured or improved by repair thereof. Reused from Petros P (5). The female pelvic floor function, dysfunction and management according to the Integral Theory. 3^rd ed. Heidelberg: Springer Berlin; 2010. With permission from Peter Petros; retains ownership of the copyright. PUL, pubourethral ligament; EUL, external urethral ligament; ATFP, arcus tendineus fascia pelvis; CL, cardinal ligament; USL, uterosacral ligament; PB, perineal body; CPP, chronic pelvic pain.

Figure 2

A “simulated operation” relieves pain and urge by supporting USL. Left: 3D view of the PUL and USL attachments to the pelvic brim. “L”, USL laxity. A gently inserted speculum mechanically supports lax USLs and pelvic visceral nerve plexuses “VP”. The test, if successful, decreases afferent pain and urge impulses; the patient reports lessening of pain in multiple sites (11), for example, “B”, “R”, “M” (right image). Co-occurring urge is also often relieved by speculum support of urothelial stretch receptors “N”. Right: 3D view of pelvic organs. The VP comprises sympathetic plexus “SP”, and parasympathetic plexus “PS”. The yellow lines represent visceral nerves to and from the end organs. M (muscles) V (vagina/vulva), B (bladder), R (rectum). “G” force of gravity acting on “VPs”. (left figure) Reused from Petros P (5). The female pelvic floor function, dysfunction and management according to the Integral Theory. 3^rd ed. Heidelberg: Springer Berlin; 2010. With permission from Peter Petros; retains ownership of the copyright. (right figure) Reused from (12). Copyright 2022, with permission from Karger. PCM, pubococcygeus muscle; PUL, pubourethral ligament; ATFP, arcus tendineus fascia pelvis; USL, uterosacral ligament; CL, cardinal ligament;LP, levator plate; LMA, conjoint longitudinal muscle of the anus.

Figure 3

Pescatori iceberg applied to CPP. The iceberg numbers show symptom prevalence, latent symptoms below the waterline. All symptoms derived from the validated ITSQ. Reused from (6). Copyright 2017, with permission from Pelviperineology. ODS, obstructive defecation syndrome; SUI, stress urinary incontinence; FI, fecal incontinence; CPP, chronic pelvic pain; ITSQ, Integral Theory Symptom Questionnaire.

Figure 4

Chronic pelvic pain varies widely with time. A daily graph over a 3-month period by a 67-year-old woman, scoring CPP on a 0–10 VAS. Note wide fluctuation in pain intensity, as previously stated by patients (15). Reused from Petros P. Private Collection, with permission from Peter Petros; retains ownership of the copyright. CPP, chronic pelvic pain; VAS, visual analogue scale.

Video S1

Video abstract.

Video S2

Pain summary powerpoint.