Perineal pain is a pain syndrome of the somatic and sympathetic systems. Patients often have malfunctioning of the perineum and are associated with varying degrees of psychological disorders and even depressive manifestations. The pain in this area is difficult for patients to talk about, limiting them to discuss their symptoms with their physicians, who often do not know enough about these pains clinically, leading to difficulties in diagnosis and treatment.
Etiology.
Although there is a high prevalence, the etiology of perineal pain remains unclear, and there is no clear evidence of a causal relationship between certain fixed factors and the onset of perineal pain. Possible etiologic factors include a history of chronic perineal disease, a history of perineal surgery, anatomically related causes, and psychological disorders.
1. Previous history of chronic disease of the perineum:
Possible etiological factors range from benign causes (such as chronic prostatitis, chronic proctitis, chronic urinary tract infection, cystitis, perineal abscess, chronic anal fistula, urinary incontinence, chronic constipation, etc.), malignant causes (such as prostate cancer, chronic cancer of the pelvic organs, etc.), rectal prolapse, prostatitis, etc.
2. History of perineal surgery:
Common perineal surgeries causing perineal pain usually include obstetrical and gynecological surgeries, anal and intestinal surgeries, urological surgeries, etc.
3.Anatomical related causes:
(1) Pubic nerve compression card: the pubic nerve is formed by the anterior branch of the S2-4 sacral nerve, exits the pelvis to the buttocks via the inferior foramen of the pear-shaped muscle, circles across the sciatic spine, crosses the small sciatic foramen to the sciatic rectal fossa, and proceeds anteriorly in the pubic nerve canal, where it divides into three anterior and posterior branches-penile, dorsal clitoral nerve, perineal nerve, and anal nerve. The entire sciatic spine is the same area where the pubic nerve is likely to be compressed. The ventral aspect of the pubic nerve can be entrapped by the sacrospinous ligament and the dorsal aspect by the sacral tubercle ligament. Similarly, entrapment can occur in the falciform region of the sacral tubercle ligament, the pubic nerve canal, at the foraminal fascia, and in the area of the pear-shaped muscle.
(2) Spine-related diseases: such as sacral canal cysts, lumbar disc herniation (and have low back pain, increase abdominal pressure to make perineal pain worse) patients.
4.Psychological factors :
People who have experienced mental and physical abuse are more likely to suffer from chronic perineal pain. Many cases are difficult to reveal their clear etiology in clinical etiological analysis, including comprehensive consideration of obstetrics and gynecology, urology and anorectal surgery, and underlying structural abnormalities have been considered but there is little objective evidence, so perineal pain is often considered a manifestation of psychological disorders.
5. Spontaneous :
Its origin and pathophysiological mechanism are unknown, causing difficulties in clinical evaluation and treatment, which is known as chronic spontaneous perineal pain.
Pathophysiological mechanism:
Possible reasons are that this area includes different and mixed somatic tissue structures, viscera and autonomic nerves that can affect the bladder and control bowel function as well as sexual function. A variety of factors including inflammation, autoimmunity, chemical inflammation, immune system dysfunction, urethral disorders, and pelvic floor muscle tension may be the mechanism.
Symptoms.
The clinical presentation of perineal pain is complex, with acute or chronic manifestations that affect both quality of life and sexual function in patients of all ages. Because of the lack of clear clinical evidence confirming the patient’s complaints, the presentation is usually not fully understood by the physician, which also contributes to the fact that patients with perineal pain are often not understood. Chronic, refractory perineal pain manifests as perineal pain that worsens in a sitting position. Other symptoms include urinary incontinence, frequency, urgency, constipation, painful stools, and sexual dysfunction, as well as perineal pain that manifests as spontaneous vulvar, prostate, and testicular pain, spontaneous anal, rectal, and anal raphe syndromes, and urethral syndromes. Although the manifestations of perineal pain are diverse, they all share the common feature that the pain is in one or two areas of distribution of the pubic nerves. Anxiety and depression are the two most common concomitant symptoms.
Diagnosis.
Nantes criteria (the Nantes criteria).
① pain in the area of distribution of the perineal nerves.
(ii) Significant worsening of the pain in a sitting position.
③Patients’ sleep is not affected by pain at night.
④ pain without objective sensory disturbance.
⑤ Pain is reduced under the Diagnosis|Sheng pubic nerve block.
Treatment.
1.Medication :
Such as non-steroidal anti-inflammatory drugs, tricyclic antidepressants, anticonvulsants and narcotic analgesics, anticholinesterase drugs, etc.
2.Nerve block and minimally invasive treatment:
Local nerve block methods include: chemical relaxation, radiofrequency ablation, etc.
Another: odd nerve ganglion destruction shows its superiority. The destruction of pain and sympathetic sensation in the perineal region provided by the odd ganglion has shown beneficial effects in patients with chronic perineal pain. Diagnostic chordal ganglion blocks using local anesthetic drugs can confirm the effectiveness of the disruption.
3. Surgical procedures:
Surgical nerve decompression of the pubic area has a success rate of 50% to 60%.
4.Other:
Including physical therapy, psychotherapy, aerobic exercise, etc.