04/11/2013 // Concord, CA, USA // Vaginal Mesh Website // Greg A. Vigna M.D., J.D. // (press release)
There is little help in the way of literature that provides guidance to women who suffer from chronic pelvic pain. Not only is the literature sparse, it is inaccurate. Most literature on pelvic pain, in fact, pays little attention to the nerves in the pelvis. From my review of the literature, most articles completely ignore the pelvic nerves as the source of pain in the female pelvis. Pelvic pain secondary to nerve injury has become increasingly recognized by the medical community as a pain generator in the pelvis because of the frequency of documented nerve damage in the transvaginal mesh population.
A recent article titled the “Clinical manifestations and diagnosis of myofascial pelvic pain syndrome in women” that I recently read in a usually very reliable medical journal completely omits the nerves in the pelvis as a source of pain. It is my belief the physicians should think of myofascial pain syndrome as either ‘primary myofascial pain’ that arises from the muscles themselves or ‘secondary myofascial pain’ that is referred from other pain-generating sources. Patients who have received the transvaginal mesh suffer with myofascial pain which may in fact be primary or secondary. The nerve is the pelvis must be considered as a source of secondary myofascial pain in the transvaginal mesh patient. There is risk of compression of the pudendal nerve from the arms of the transvaginal mesh. There may also be damage to any of the three terminal branches of the pudendal nerve during the procedure itself independent of the mesh caused by the traction on the vagina during the transvaginal approach of placing the mesh.
Medical providers must be aware that both primary myofascial pain and secondary myofascial pain may occur at the same time and the issues of neural compression should not be blindly ignored. By recognizing both primary and secondary myofascial pain, a clinician is more likely to be successful in managing the pain caused by the vaginal mesh says Dr Greg Vigna, a medical doctor and founder of TVM.LifeCare123.com that operates a Vaginal Mesh Complication resource.
The medical journal “Up to Date” describes myofascial pelvic pain syndrome (MPPS) “as a disorder in which pelvic pain is attributed to short, tight, tender pelvic floor muscles, usually with hypersensitive trigger points.” These trigger points when pressed will cause pain that radiates. The article describes that the pain may occur in the pelvis, vagina, vulva, rectum, or bladder. “Up to Date” describes MPPS as having urinary symptoms such as pain, frequency of urination, and a sensation of incomplete emptying. Other described symptoms include a sensation of rectal fullness and pain with sexual intercourse.
“Up to Date”, in its description of the differential diagnosis, fails to acknowledge nerve compression as a contributor or cause of myofascial pain. Contrarily, pudendal neuralgia does exist. The pudendal nerve arises from the spine (S2-4), enters the pelvis and has three terminal branches. These terminal branches can be damaged together, or in isolation by a variety of problems, including the transvaginal mesh procedure. The symptoms of pudendal neuralgia are well described. Pain is predominately while sitting, anorectal pain, sexual dysfunction, and in severe cases, incontinence. There may be frequency with urination, sensation of incomplete emptying of both bowel and bladder, and pain with sexual intercourse. These symptoms can mirror the symptoms of MPPS as described above. The nerve damage that occurs in pudendal neuralgia may be the actual cause of the myofascial pain in which case, I would regard the myofascial pain as secondary (to the nerve damage).
When a clinician is trying to determine if myofascial pain is from the muscles itself (primary) or if referred from the nerves (secondary) diagnostic and therapeutic injections may be useful. If the myofascial pain evident during a clinical exam of a new patient does not improve with physical therapy, botox, and/or local medications such as vaginal valium, the clinician must explore other pain generators for the myofascial pain such as from the nerves. A clinician should then consider diagnostic and therapeutic nerve blocks of either the pudendal nerve itself or any one of the three terminal branches based on the particular symptoms the patient describes. This is done to clarify the actual pain generator for the myofascial pain. Once the pain generator is identified, then surgical decompression can be considered.
The primary vs. secondary myofascial pain that I am discussing is not a new concept, but one that is well described in rehabilitation literature. When clinicians who care for patients with pelvic pain begin analyzing the pain generators and begin treating myofascial pain as primary or secondary, then there may be a viable solution to the suffering caused by the transvaginal mesh complications.
Interested in previous articles on Life Care Planning For Mesh Patients With Chronic Pain, click here.
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