In the pain clinic, we often encounter patients who often stammer, look around, and whisper when asked to describe their condition, and sometimes even the doctor cannot hear them clearly. After careful questioning, we learn that the disease they are suffering from is perineal pain syndrome. Perineal pain syndrome is a group of syndromes with no organic lesions and unknown causes of severe pain in the vaginal opening, clitoral root, labia, urethra and surrounding tissues.
The authors named this syndrome perineal pain syndrome. Patients are often reluctant to talk to their family or friends about their disease, finding it difficult to talk about it and unwilling to go to the hospital, thus delaying treatment and complicating the pain. Perineal pain is often caused by cancer or chronic painful diseases in the pelvic area, and the sensation of the perineum is innervated by rich sympathetic and somatic nerves.
It is one of the more difficult pain disorders to treat clinically, with the following common causes.
I. Chronic pelvic pain syndrome
(a) Psychogenic chronic pelvic pain: dull pain, persistent episodes, often pain upon awakening, episodes when there are psychosocial factors, inconsistent pain sites and nerve distribution, no radiating pain, metastatic changes and diffuse, maintaining the same pain for years and years, not triggering or increasing pain after examination, and occurring when dealing with interpersonal relationships.
(ii) Organic pelvic pain: pain is sharp, spastic, intermittent, can occur at any time, can be awakened by pain during sleep, radiates along the nerve distribution pathway, has typical pressure points, develops or improves quickly or becomes more intense, arises or intensifies after manual examination, is not affected by emotions.
Etiology
1, gastrointestinal system constipation, irritable bowel syndrome, enteritis, intestinal diverticulitis;
2, urinary system urethritis, cystitis;
3, nerve, muscle ~ skeletal system pelvic floor tension myalgia, pear-shaped myositis syndrome, ventral hernia, rectus abdominis tendon sprain, myofasciitis;
4. Reproductive system: inflammation of reproductive organs, pelvic cysts, uterine fibroids, deformities of the reproductive tract, history of previous pelvic surgery, endometriosis, adenomyosis, pelvic stasis syndrome, cervical canal obstruction, residual ovarian syndrome.
Treatment
A multidisciplinary and comprehensive approach is required, including surgery, medication (gabapentin), physical therapy, psychotherapy, and diet therapy. The goal of treatment is to relieve pain, improve function, and eliminate psychological barriers, but the treatment is not effective in those with long duration of disease
Descending perineum syndrome (DPS)
It is a pelvic floor disease, due to various causes of pelvic floor muscle degeneration and dysfunction, the patient’s perineum position is low in the quiet state, or during forceful defecation, the perineum descends more than the normal range, and the clinical manifestation is export constipation or fecal incontinence. In recent years, with the widespread use of fecal imaging, the number of reports on perineal descent syndrome has increased.
Perineal descent syndrome is a concomitant lesion of endorectal impaction or rectal prolapse. The main symptoms include a feeling of incomplete stool, anal swelling, difficulty in defecation, increased frequency of stool, pain in the perineum, partial sexual incontinence, some patients have a history of applying various laxatives, a few have mucus and blood stools, and a swelling prolapsing from the anus after defecation or walking.
Three, chronic prostatitis
The common symptoms can be summarized in the following five categories:
(1) urinary discomfort may appear frequent urethral burning, pain can be radiated to the head of the penis; early morning urethral orifice mucus mucus and pus secretion, cloudy urine or white flow after stool; serious end urinary hematuria and urinary difficulty or urinary retention.
(2) Local symptoms Posterior urethra Discomfort in the perineum and anus, with a feeling of pressure or fullness, especially when squatting or defecating.
(3) Radiation pain The prostate or seminal vesicles are richly innervated by sympathetic nerves, when inflammation occurs, the internal tension of the gland increases, which can stimulate the sympathetic nerves and cause metastatic low back pain, which can radiate to the penis, testicles, scrotum, groin, perineum, abdomen, thighs, buttocks, rectum, etc.
(4) Sexual dysfunction Chronic prostatitis can cause loss of libido or loss of ejaculation pain, blood sperm, premature ejaculation, impotence, seminal emission and infertility. Treatment with drugs and warm water sitz baths, etc.
IV. Pubic Nerve Compression
Also known as pubic canal syndrome, it is a rare cause of chronic pain where the pubic nerve located in the pelvis is truncated or compressed. The pain is significant and worsens when sitting. Other symptoms include genital numbness, erectile dysfunction, fecal incontinence and urinary incontinence. Typical pain is caused by sitting, relieved by standing, and disappears by lying down or sitting on a stool.
If perineal pain is related to posture, it suggests ductal syndrome, which is the most valuable diagnostic basis. In addition there is the problem of urinary and fecal incontinence. It needs to be differentiated from the more common chronic prostatitis/chronic pelvic pain syndrome or interstitial cystitis. Causes Pregnancy or accidents or incidental surgical accidents. Anatomic abnormalities can lead to PNE due to fusion of the pubic nerve into other anatomic structures or entrapment between the iliac nodes and the iliac sphenoid ligament.
Strenuous and prolonged bicycle riding, especially with an improperly shaped or positioned bicycle seat, can eventually thicken the iliac nodes and iliac spinal ligaments, which can trap the pudendal nerve between them and lead to PNE. treatment options include behavior modification, physical therapy, analgesics, pudendal nerve sealing, surgical nerve release, and the latest high-frequency pulse therapy.