Pelvic Pain 3

Article three - covering interstitial cystitis, pain from the ovaries, and ovarian remnant syndrome.

Pain from the bladder - interstitial cystitis

When we talk about cystitis we usually mean bacterial cystitis which is the medical term for a bladder infection. In this, bacteria get into the bladder, multiply and irritate the lining of the bladder. A bladder infection is easily treated with antibiotics which kill the bacteria.

The word cystitis means inflamed bladder, it does not say what caused the infection. Interstitial cystitis (IC) is different from bacterial cystitis. The bladder wall is inflamed but there is no infection. Antibiotics do not help because there is no infection.

Interstitial cystitis is not well understood. What is known is that it can cause long-term pelvic pain and that it is more frequent in women with endometriosis. Men can get interstitial cystitis, but it is ten times more common in women.

Although interstitial cystitis is not a bacterial infection, women with IC often develop more bladder and urinary tract infections (UTI) than other women. Any interstitial cystitis symptoms usually become worse during and after a urine infection.

It is not known why, but women with IC often also have irritable bowel syndrome (IBS), fibromyalgia, vulvar vestibulitis (a painful area near the opening of the vagina), migraines or allergies as well as their IC. This makes the pain of IC complicated to diagnose and treat. There is no association between fibroids and IC.

Like endometriosis, many women with interstitial cystitis and uterine fibroids suffer pain for years before the correct diagnosis is made. This is very distressing. Interstitial cystitis, endometriosis, fibroids, fibroid pain and the diagnosis of pelvic pain are receiving more medical attention now. There have been significant improvements in the way that interstitial cystitis is treated, and it is diagnosed much more frequently now than in the past.

The pain and symptoms of interstitial cystitis

The pain of IC may be a burning pain, a shooting pain, a pressure feeling, a lower abdominal discomfort, or a spasm. The pain is felt in the pelvis, in the bladder itself or in the urethra (the tube which carries the urine out of the bladder). Commonly the pain worsens as the bladder fills and improves as the bladder empties.

There are usually other bladder symptoms such as frequency (wanting to pass urine frequently), urgency (needing to go pass urine urgently), and nocturia (having to get up to pass urine at night). Sexual intercourse may be painful, especially in positions that put pressure on the bladder.

The pain may be worsened by sex, periods, foods that are high in acid or potassium. Stress does not cause IC, but it can certainly make it worse.

Diagnosis of interstitial cystitis

There is no one good test for IC. It is what doctors call a “clinical diagnosis”. This means that if the symptoms fit and no other cause for the symptoms is discovered, then the diagnosis of IC is made. In order to exclude other causes of pain you may need the following:

  • One or ideally several urine tests to rule out a urine infection, or the presence of cancer cells. If there are white cells in the urine but no infection, then it is important to check for Chlamydia infection.
  • A bladder diary, which records how much urine you pass, and how frequently you pass urine over a few days.
  • An ultrasound scan of the kidney, pelvic organs and bladder.
  • A review by a urologist to check that other conditions are not present.
  • A cystoscopy, which is a short operation, or examination, where a telescope is passed through the urethra into the bladder. A cystoscopy looks at the inside of the bladder.

A cystoscopy in women with IC usually looks normal, but can be useful to exclude other conditions such as endometriosis inside the bladder (rare) or other causes of bladder infection such as bladder stones or rarely bladder cancer.

Treatment of interstitial cystitis

There are probably several types of IC which are presently placed together in one group. It is therefore not surprising that no one type of treatment helps everyone. For some women, changes in their diet are sufficient to manage their symptoms, while other women require the expertise of a urologist who specialises in the treatment of kidney and bladder conditions to try various treatments until an effective one is found. As the treatment of IC becomes more sophisticated and more is learned, satisfactory treatments will become individualised more successfully for IC sufferers.

It is usually a matter of trying a number of different therapies with your doctor until an effective one is found. No therapy works for everyone and is it unusual for one treatment to continue working indefinitely. Fortunately, about 10% of women recover spontaneously. The treatment options include:

  • Dietary changes. Avoid drinks and foods that are high in potassium, acid or caffeine such as citrus juices (including cranberry juice), fizzy drinks, tea, coffee or alcohol. Also avoid foods and beverages containing artificial sweeteners, and foods containing hot peppers and spicy foods. The ideal fluid to drink is water.
  • Drink the right amount of fluid for you. This can mean drinking more water to dilute the urine and avoid bladder irritation, or drinking less, if the extra fluid aggravates your symptoms. About two litres of water a day suits most women.
  • Stress reduction and exercise. Interstitial cystitis is not due to stress, but stress seems to make it worse. Treatment suggestions include: meditation, hypnosis, massage and relaxation therapies. Hot or cold packs placed between the legs, warm baths, wearing loose clothing/belts and cotton underwear may help.
  • Bladder retraining. Learning to hold on longer is worthwhile. A physiotherapist who specialises in continence can advise on bladder retraining and strengthening the pelvic floor muscles.
  • Amitriptyline. This is a tricyclic antidepressant, which when taken in low doses can help to treat urgency, frequency and pain.
  • Pentosan polysulphate sodium (Elmiron). This is a tablet containing a glycosaminoglycan, which protects the lining of the bladder from irritation. The dose is 100mg three times a day. It has been found to help around 40% of IC sufferers, but may take up to six months to work. The possible side-effects include dyspepsia, diarrhoea, headache, rash, reversible hair loss and occasionally abnormal liver function tests. Because Elmiron is an anticoagulant some patients have reported they bruise more easily. In some cases, patients are asked to stop Elmiron before any major surgical procedures in order to reduce the likelihood of bleeding.
  • Other medications. These include anti-histamines such as hydroxyzine (Atarax), H2-antagonists like cimetidine, Resiniferotoxin, Botox injections into the bladder wall, anti-spasmodic drugs like oxybutynin (Ditropan) and tolteradine (Detrusitol).
  • Hydro-distension of the bladder. During this procedure the bladder is over-filled with saline (salty water) under a general anaesthetic, to stretch the bladder wall. After the bladder has been stretched in this way about 90% of women with IC will have a special pattern of bleeding within the bladder wall. After this procedure approximately 60% of women will have less IC symptoms in the months following.
  • Bladder instillations. These are drugs that are mixed with fluid and placed inside the bladder. They settle the bladder irritation. Examples include: dimethyl sulfoxide (DMSO), bacillus of calmette-guerin (BCG-Tice), sodium oxychlorosene (Chlorpactin), steroids e.g. Sterile triamcinolone acetonide suspension USP (Kenalog), heparin sodium, hyaluronic acid (Cystistat) and local anaesthetics (Lidocaine).
  • Transcutaneous Electrical Nerve Stimulation (TENS). A TENS machine has been found to help some women.
  • Sacral nerve neurostimulators. These devices stimulate the bladder electrically. They are implanted in the buttock and stimulate the nerves to the bladder.
  • Urethral dilatation. This is rarely used these days.
  • Major surgery. Surgery to remove part of the bladder is rarely necessary, unless all else has failed and symptoms are very severe.

First aid treatment for a painful bladder

If there are occasions when your bladder pain or urgency comes on rapidly, try drinking 500 ml of water mixed with 1 teaspoonful of bicarbonate of soda. Then drink 250 ml of water every 20 minutes over the next few hours. If the symptoms persist, try paracetamol (acetaminophen) or ibuprofen. If no improvement occurs, have a urine test for infection and only take antibiotics if an infection is present.

Pain from the ovaries

Anything that stretches or ties down an ovary can lead to ovarian discomfort or hurt. Ovaries are important and sensitive organs and they do not like being stretched or tied down.

What type of pain is ovarian pain?

This depends on whether or not the pelvis is otherwise normal, or whether there is a pelvic condition aggravating one or both ovaries.

If the pelvis looks normal, a woman neither is pre-menopausal and not pregnant, nor is taking the contraceptive pill, normal ovulation pain is common. This may be a deep ache on one or other side of the lower pelvis lasting from a few hours to a day, that happens each month almost exactly 14 days before a period arrives. Because the ovaries usually take it in turns to ovulate, normal ovulation pain swaps sides most months. If one of the ovaries has been removed, then the ovary that remains will ovulate each month, and the pain will be on the same side each month. Not all women with a normal pelvis get ovulation pain.

If a woman has a pelvic condition, such as endometriosis or adhesions, affecting an ovary, then the pain will last for longer, and be more severe in the months when it is that ovary’s turn to ovulate. Anything that ties down the ovary makes ovulation pain worse, because the ovary is not free to change size and shape freely. The pain will still be worst around ovulation time, but may bother a woman at other times of the month too. If both ovaries are affected, then the ache will affect both sides of your pelvis.

Functional ovarian cysts and ovarian remnant syndrome cause slightly different types of ovarian pain.

Treatment of normal ovulation pain

  • Do nothing. Ovulation pain is not dangerous.
  • Take anti-prostaglandin medications, such as NSAIDs like ibuprofen, mefenamic acid and diclofenac. Prostaglandin chemicals are released at ovulation, so these medications are particularly effective, especially if they are taken before the discomfort is too severe.
  • Take the combined contraceptive pill. The combined contraceptive pill stops ovulation.
  • Use a progestogen only contraceptive like Implanon.

Functional ovarian cysts

These are cysts that form as part of the function of the ovary. It is normal for small, round fluid-filled cysts to develop from time to time in women who are neither pregnant nor taking the contraceptive pill. Most are not painful, but some are.

If they do cause discomfort or hurt, it is a constant ache, felt most of the time on one side of the pelvis. It may last a few weeks or a few months but ultimately resolves spontaneously. Because functional cysts may produce hormones, periods can become irregular and some women develop tender breasts. If the cyst ruptures, there is a sudden hurt that goes away a few hours later. Functional cysts do not cause long-term discomfort so they are rarely confused with endometriosis.

Ectopic Pregnancy

Important: There is another condition that may cause a sudden pain in one side of the lower pelvis, irregular periods and breast tenderness. This is an ectopic pregnancy. An ectopic pregnancy is a pregnancy in the fallopian tube rather than in the uterus. It is a dangerous condition and is easy to confuse with a functional cyst. If you are in any doubt see your doctor without delay. A good quality pregnancy test (ideally a blood test) is usually positive in a woman with an ectopic pregnancy and negative with a functional cyst. Ectopic pregnancies are notoriously difficult to diagnose, and if there is any suspicion of this diagnosis, hospital investigation with an ultrasound and a laparoscopy are essential. Missing an ectopic pregnancy can be disastrous.

Diagnosis of a functional ovarian cyst

An ultrasound scan will show up a cyst that looks like a round small balloon filled with clear watery fluid. It should measure less than 5 cm in diameter and have no solid pieces inside it. If the cyst has ruptured, then the ultrasound may be normal or show up a small amount of fluid in the pelvis and a pregnancy test is negative. An ultrasound will also diagnose other pelvic problems such as uterine fibroids.

Treatment of functional ovarian cysts

  • Do nothing. Most functional cysts resolve spontaneously in two or three months. It may be a good idea to have a repeat ultrasound three months later to confirm that it has disappeared.
  • Start the contraceptive pill. This may not remove the cyst, but it will prevent more functional cysts in the future.
  • Have a laparoscopy with removal of the cyst. This is only necessary if your doctor is uncertain which type of cyst it is, or if the pain is severe or cannot be managed. Even if the cyst is removed, this does not prevent other cysts from forming.

Ovarian Remnant Syndrome

This syndrome describes a pelvic mass or pain in a woman who has had both her ovaries (and often her uterus) removed in the past. A small piece of an ovary has been left behind unintentionally the surgical procedure. This remaining fragment of ovary has become larger and painful. This usually happens in women who have had a lot of pelvic surgery in the past and as a consequence have had many adhesions in their pelvis. The gynaecologist who performed the operation did not intend to leave behind any ovary at all, but scar tissue or endometriosis made removing the ovary difficult. In time, even a tiny fragment of ovary can respond to hormones produced by the pituitary gland and enlarge or make cysts.

Symptoms of ovarian remnant syndrome

Ovarian remnants cause pain that is felt on one side of the pelvis. In younger women, the pain is worst about once a month, when ovulation would have occurred, but in older women, it can cause chronic discomfort or pain. Not all ovarian remnants cause hurt, but those that do, start to cause problems within a few years of surgery.

Diagnosis

The description of the pain is the most useful way to point to a diagnosis of an ovarian remnant. The diagnosis can be confirmed by:

  • A blood test for estrogen or FSH. If both ovaries have been removed, and a woman is not taking HRT then a blood test should show low estrogen levels and a high level of FSH (a hormone produced by the pituitary gland at the base of the brain). If the estrogen levels are normal or the FSH is low then it is likely that a small piece of active ovary is left.
  • An ultrasound scan may reveal a cyst in the pelvic cavity that has formed in the remaining ovarian remnant.
  • A laparoscopy. During a laparoscopy the ovarian remnant appears like a white, often cystic patch of scar tissue. There is a drug, called clomiphene that can be taken before surgery to make the ovarian remnant larger and easier to locate.

Treatment

Any treatment that removes the ovarian remnant or makes it less active will help the pain. These options include:

No treatment. At menopause the remnant will become less active, just as a normal ovary does, and the pain may well improve.

Medication to make the ovarian remnant less active. The options that usually help are: the contraceptive pill, a GnRH analogue (e.g. goserelin – Zoladex) or a continuous progestogen medication.

An operation to remove the ovarian remnant. This surgery can be tricky because most remnants are small and trapped within scar tissue. They lie close to the ureter (tube from kidney to bladder), which can be easily damaged during surgery. The good thing about this treatment is that removing the remnant usually makes the pain resolve.

Radiotherapy. This is a treatment that is usually used to treat cancers. It is rarely used these days.

Pain from pelvic veins - ovarian vein syndrome and pelvic congestion syndrome

...continued in this article: Pelvic Pain 4