Treating chronic pelvic pain
However, you’ve come to the right place, because Dr. Nezhat specializes in treating chronic pelvic pain caused by numerous gynecological, genitourinary, gastrointestinal, rare congenital reproductive disorders, as well as post-surgical and obstetric complications. As a result of his extensive experience treating even the rarest and most difficult cases, Dr. Nezhat has been able to help countless patients who had gone from post to pillar for years, searching for answers but finding none.
Step 1: Best Medicine in the World? Listening
Contrary to today’s soaring hyperbole, modern technology is often no match for the ancient art of listening. Therefore, the first step in assessing your chronic pelvic pain is simply listening attentively to your concerns. Of course, these days it seems like everyone is so rushed that they don’t have time to just listen anymore. However, Dr. Nezhat will encourage you to take your time and provide even the smallest details about your symptoms, even those that may seem unimportant.
And, as Carl Jung recognized nearly 100 years ago, valuing a patient’s own perceptions is equally crucial. For example, some disorders, like neurogenic bladder, may be caused by a complication from a previous laparotomy or childbirth. Yet, many patients report that their concerns about new, post-surgical symptoms were sometimes downplayed or dismissed altogether. In contrast, Dr. Nezhat knows that it’s critical to investigate all potential causes of chronic pelvic pain, particularly those that the patient herself believes may be relevant.
The initial analysis will also include:
– reviewing your past medical records and history
– assessing your medication history, including use of vitamins, herbs and/or supplements
– an analysis of how you sit, stand, and walk is also part of the initial work-up
Step 2: Abdominal and Pelvic Exam
A general physical, as well as an abdominal and pelvic exam are also part of your first evaluation. Living in such a high-tech, postmodern world, it’s sometimes easy to forget that the old-fashioned abdominal and pelvic exam can prove surprisingly effective in pinpointing a diagnosis. For example, finding extreme tenderness at the rectovaginal septum or indurations in the uterosacral ligaments during digital palpation often suggests endometriosis, while a boggy (sponge-like) and enlarged uterus, combined with diffuse tenderness, may indicate adenomyosis.
The abdominal and pelvic exam will also include:
– an external examination of your abdominal area that includes gently pressing on various areas all over your lower and upper abdomen and pelvic area and asking you to explain where you feel pain
– an internal pelvic exam inside of the vagina, uterus, and rectum in order to map internal pain points, as well as look for anything that seems unusual
– an external abdominal ultrasound can help detect some disorders, such as masses in the pelvic area
– an internal transvaginal ultrasound can help visualize some (but not all) abnormalities of the lower pelvic region
– a color doppler ultrasound is also utilized because it’s very effective for performing a pelvic blood flow analysis and mapping vascularization patterns in your uterus, which can help rule out certain conditions like adenomyosis or endometrial cancer
– a Pap smear, to rule out cervical dysplasia (precancerous growths), cervical cancer, cervical endometriosis, and check the overall health of your cervix
Step 3: Other Imaging Tests
Although pelvic exams by a specialist can actually be highly predictive for some disorders, other imaging tests are sometimes required to help narrow the diagnosis. For example, adenomyosis is often misdiagnosed as diffuse fibroids. However, these conditions look quite different at ultrasound, with adenomyosis typically featuring asymmetrically thickened endometrium, combined with diffuse vascularization, numerous tiny cyst-like cavities, and increased echogenicity. Likewise, even laparoscopy can sometimes fail to detect certain conditions, like type IV and V rectovaginal fistulas, making imaging tests and procedures like rectograms critically important if such fistulas are suspected.
Assuming there are no contraindications, the most common imaging tests include:
– high resolution CT scan of the pelvis, which might help visualize abnormal growths, adhesions, or abnormalities of organs, bones, muscles, or connective tissues (ligaments, tendons, cartilage)
– magnetic resonance imaging (MRI) of the pelvis with oral contrast, which uses a magnetic field and pulses of radio wave energy to create pictures of organs, bones, and other anatomical structures
– Voiding cystourethrogram calls for taking an x-ray of your bladder during urination to assess the shape and function of your bladder
– Other urodynamic analyses are available to test whether bladder spasms, for example, are causing pelvic pain
– high resolution computed tomography (CT) urogram uses X-rays to create pictures of the kidneys and urinary tract
– A sonohysterography may be necessary to check for uterine septums, submucosal fibroids, endometrial polyps, hernias, and fistulas, which are not always detected by conventional means, such as ultrasound or a physical exam.
– A hysterosalpingography is another X-ray test that involves injecting a special contrast solution (radio-opaque dye) into the uterus and fallopian tubes, which may allow certain abnormalities to be detected
– rectogram and barium enema studies are helpful to confirm the presence of a type IV or V fistula
ONE IMPORTANT CAVEAT: IMAGING TESTS OFTEN CANNOT DETECT ENDOMETRIOSIS!
Please note, however, that endometriosis is rarely detected using these imaging technologies, which is why a laparoscopy must be performed in order to definitively diagnose endometriosis.