Downregulating the Dorsal Horn

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Beyond the Abstract - Chronic pelvic pain syndromes: Clinical, urodynamic, and urothelial observations

by Charles W. Butrick, MD
Wednesday, 29 July 2009

BERKELEY, CA (UroToday.com) - Patients with pain can present with various symptom complexes that include interstitial cystitis, vulvodynia, irritable bowel syndrome, myofascial pain or various causes of dyspareunia but when carefully evaluated, the majority have very similar findings. No matter what their primary complaint might be over 70% of patients will have hypertonic pelvic floor dysfunction and/or pain as well as a component of at least one visceral pain syndrome such as interstitial cystitis (the most common), chronic pelvic pain or irritable bowel syndrome.

Given what we know about visceral pain syndromes it should not surprise us that the majority of patients with chronic pain have multiple pain generators and we must aggressively look for each of these pain generators. It is only through the identification and treatment of each of these pain generators that we can expect to down regulate the dorsal horn and help these patients and their allodynic manifestations of their pain disorders. This study points out that therapeutic anesthetic cocktails are very helpful in the majority of patients no matter what their chief complaint would be thus the urothelium must be evaluated as a possible pain generator in the majority of our patients with pelvic pain.

Finally, the clinician must be aware that five to ten percent of patients that present with urinary incontinence or pelvic organ prolapse may also have a chronic pain disorder that must be identified and treated prior to any surgical intervention. Many of our patients learn to accept chronic pain, pain with intercourse, or urinary frequency because they have had these problems for many years so that when they present with a problem such as stress incontinence or prolapse their pain disorder will often be overlooked unless this unfortunate patient has a postoperative exacerbation of her pain problems.

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In this respect, we all need to be aware of the information available on pain wind-up:

http://en.wikipedia.org/wiki/Pain_wind-up