How to Cure Chronic Pelvic Pain

51 Tips for Dealing with Endometriosis

51 Tips for Dealing with Endometriosis

Do you have Endometriosis? Do you think you do, but aren’t sure? Are you having a hard time learning to cope? 51 Tips for Dealing with Endometriosis can help.

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Treating Your Endometriosis

Health researcher, Shelly Ross is the author of Treating Your Endometriosis and in her remarkable eBook, she will walk you through practical methods to successfully control and manage endometriosis once and for all. In this eBook Shelly does a wonderful job in showing you how to get your body to function as nature intended, a very important aspect if you are trying to get pregnant and suffer from endometriosis. Learn how a few simple changes in your diet can dramatically reduce your endometrial implants from spreading. You will also find more information on nutritional supplements, stress reduction techniques, best exercises to reduce endometriosis symptoms, and much, much more!

Treating Your Endometriosis Overview

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Endometriosis Bible & Violet Protocol

The Endometriosis Bible & Violet Protocol is a comprehensive guide to understanding and treating Endometriosis and Endometriosis and Pregnancy. The author, Zoe Brown, has. suffered from Endometriosis and has also been cured of it's devestating consequences. She is dedicated to helping other women trying to cope with endometriosis and pregnancy. symptoms. The e-guide contains 303 pages which cover all fundamental information about endometriosis that can helps you pinpoint the root causes of your endometriosis condition and abolish typical symptoms of this problem. Zoe Brown also uncovers that connection between some specific foods and endometriosis. She also guarantees that most of you do not acknowledge 70-80% of the facts presented in her program.

Endometriosis Bible & Violet Protocol Overview

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Approach to acute pelvic pain with a positive pregnancy test

In a female patient of reproductive age, presenting with acute pelvic pain, the first distinction is whether the pain is pregnancy-related or non-pregnancy-related on the basis of a serum pregnancy test. B. In the patient with acute pelvic pain associated with pregnancy, the next step is localization of the tissue responsible for the hCG production. Transvaginal ultrasound should be performed to identify an intrauterine gestation. Ectopic pregnancy is characterized by a noncystic adnexal mass and fluid in the cul-de-sac.

Approach to acute pelvic pain in nonpregnant patients with a negative HCG

Acute PID is the leading diagnostic consideration in patients with acute pelvic pain unrelated to pregnancy. The pain is usually bilateral, but may be unilateral in 10 . Cervical motion tenderness, fever, and cervical discharge are common findings. B. Acute appendicitis should be considered in all patients presenting with acute pelvic pain and a negative pregnancy test. Appendicitis is characterized by leukocytosis and a history of a few hours of periumbilical pain followed by migration of the pain to the right lower quadrant. Neutrophilia occurs in 75 . A slight fever exceeding 37.3 C, nausea, vomiting, anorexia, and rebound tenderness may be present. E. Endometriosis usually causes chronic or recurrent pain, but it can occasionally cause acute pelvic pain. There usually is a history of dysmenorrhea and deep dyspareunia. Pelvic exam reveals fixed uterine retrodisplacement and tender uterosacral and cul-de-sac nodularity. Laparoscopy confirms the diagnosis.

Endometriosis

Steroids produced by the ovary stimulate uterine endo-metrial cells. In endometriosis, cells that have escaped from the uterus grow in the peritoneal cavity, resulting in clinical symptoms that include tumors, obstructions, painful menses, and disrupted GI tract function. In women the incidence of endometriosis increases with age and has been estimated to be 10-20 in young reproductive women and up to 35 in women with menstrual difficulties. Endometriosis in captive colonies of female rhesus monkeys can occur in relatively high incidence ( 26 ). The causes of endometriosis appear to be varied and range from surgery to radiation exposure (Fanton and Golden, 1991). One of the major issues of endometriosis, especially in rhesus macaques, is diagnosis at a treatable stage of the disease. As observed by a number of laboratories, endometriosis is difficult to diagnose until relatively advanced (Rippy et al., 1996). Use of indicators, such as plasma levels of CA-125, have been examined as a...

Common presenting symptoms

Common presenting symptoms in Australian practices are presented in Table 1.1 , 5 where they are compared with the United States of America. 6 The similarity is noticed but the different classification system does not permit an accurate comparison. In the third national survey of morbidity in general practice in Australia 5 the most common symptoms described by patients were cough (7.5 per 100 encounters), throat complaints (4.7 per 100), back complaints (3.8 per 100) and skin symptoms (3.6 per 100). In addition very common presentations included a check-up (13.6 per 100) and a request for prescription (8.8 per 100). McWhinney lists the ten most common presenting symptoms from representative Canadian and British practices but they are divided between males and females. 7 For males in the Canadian study these symptoms are (in order, starting from the most common) cough, sore throat, colds, abdominal pelvic pain, rash, fever chills, earache, back problems, skin inflammation and chest...

The Real World of Health Policy

WHEREAS The term dioxin refers to a group of chemicals that includes furans and biphenyl compounds (the most well-known dioxin being 2,3.7.8-TCDD), and dioxin is a potent human carcinogen and an endocrine-disrupting chemical affecting thyroid and steroid hormones, scientifically linked to endometriosis, immune system impairment, diabetes, neurotoxicity, birth defects, testicular atrophy and reproductive dysfunction and

Gynecologic problems

Endometriosis is present in approximately one-third of women undergoing laparoscopy for CPP and is the most frequent finding in these women. Typically, endometriosis pain is a sharp or crampy pain. It starts at the onset of menses, becoming more severe and prolonged over several menstrual cycles. It is frequently accompanied by deep dyspareunia. Uterosacral ligament nodularity is highly specific for endometriosis. Examining the woman during her menstruation may make the nodularity easier to palpate. A more common, but less specific, finding is tenderness in the cul-de-sac or uterosacral ligaments that reproduces the pain of deep dyspareunia. Medical Diagnoses and Chronic Pelvic Pain Endometriosis, advanced and or with dense bowel adhesions

Clinical evaluation

Endometriosis should be considered in any woman of reproductive age who has pelvic pain. The most common symptoms are dysmenorrhea, dyspareunia, and low back pain that worsens during menses. Rectal pain and painful defecation may also occur. Other causes of secondary dysmenorrhea and chronic pelvic pain (eg, upper genital tract infections, adenomyosis, adhesions) may produce similar symptoms. Differential Diagnosis of Endometriosis Generalized pelvic pain B. Infertility may be the presenting complaint for endometriosis. Infertile patients often have no painful symptoms. C. Physical examination. The physician should palpate for a fixed, retroverted uterus, adnexal and uterine tenderness, pelvic masses or nodularity along the uterosacral ligaments. A rectovaginal examination should identify uterosacral, cul-de-sac or septal nodules. Most women with endometriosis have normal pelvic findings.

Female Reproductive System Disorders

Endometriosis A combination of GLA and EPA is better than placebo in relieving the symptoms of endometriosis according to one placebo-controlled study. Of those in the treatment group, 90 reported relief of symptoms compared with 10 of those in the placebo group (Horrobin 1990).

Abdominal Wall and Umbilicus

Secondary carcinoma commonly due to either gastrointestinal or gynaecological cancer involvement, can be by direct spread at presentation or because of a subsequent metastatic recurrence. The former is not infrequently seen with a perforated bowel cancer and the inner layers of the abdominal wall may be dissected off separately or in continuity with it. The latter tends to be encountered as an intramural nodule or deposit with a previous history of bowel resection and is often amenable to diagnosis by clinical FNAC. Classically secondary carcinoma (colon, ovary, breast) can present as an umbilical deposit (Sister Mary Joseph's nodule) which is also a site for hernias, endometriosis or fistula due to persistence of an embryonic structure, e.g., the vitellointestinal duct or urachus. These result in umbilical protrusion, cyclical menstrual haemorrhage or serous discharge respectively. A persistent urachal remnant may be attached to the dome of the urinary bladder potentially acting as a...

Pelvic factor infertility

Pelvic factor infertility is caused by conditions that affect the fallopian tubes, peritoneum, or uterus. Tubal factor infertility is a common sequela of salpingitis. Appendicitis, ectopic pregnancy, endometriosis, and previous pelvic or abdominal surgery can also damage the fallopian tubes and cause adhesion formation. 2. Endometriosis is another condition involving the peritoneal cavity that is commonly associated with infertility. Uterine abnormalities are responsible for infertility in about 2 of cases. Examples of uterine abnormalities associated with infertility are congenital deformities of the uterus, leiomyomas, and intrauterine scarification or adhesions (Asherman's syndrome). 3. The mainstay of treatment of pelvic factor infertility relies on laparoscopy and hysteroscopy. In many instances, tubal reconstructive surgery, lysis of adhesions, and ablation and resection of endometriosis can be accomplished laparoscopically.

Differential Diagnosis

Left Lower Quadrant Diverticulitis, intestinal obstruction, colitis, strangulated hernia, inflammatory bowel disease, gastroenteritis, pyelonephritis, nephrolithiasis, mesenteric lymphadenitis, mesenteric thrombosis, aortic aneurysm, volvulus, intussusception, sickle crisis, salpingitis, ovarian cyst, ectopic pregnancy, endometriosis, testicular torsion, psychogenic pain. Right Lower Quadrant Appendicitis, diverticulitis (redundant sigmoid) salpingitis, endometritis, endometriosis, intussusception, ectopic pregnancy, hemorrhage or rupture of ovarian cyst, renal calculus. Hypogastric Pelvic Cystitis, salpingitis, ectopic pregnancy, diverticulitis, strangulated hernia, endometriosis, appendicitis, ovarian cyst torsion bladder distension, nephrolithiasis, prostatitis, malignancy.

Infections in Females

In women, chlamydial infections may cause pelvic inflammatory disease, tubal infertility, chronic pelvic pain, and ectopic pregnancy. Chlamydial infection may also be linked to cervical cancer (Koskela et al., 2000). Chlamydial and gonococcal infections may increase susceptibility to and transmission of HIV in both men and women (Plummer et al., 1991).

Pelvic Inflammatory Disease

Pelvic inflammatory disease (PID) represents a spectrum of infections and inflammatory disorders of the uterus, fallopian tubes, and adjacent pelvic structures. PID may include any combination of endometritis, salpingitis, tubo-ovarian abscess, oophoritis, and in its more extreme manifestation, pelvic peritonitis. One out of every 10 women will have at least one episode of PID during her reproductive years. At least one-quarter of women with PID will have major complications, including infertility, ectopic pregnancy, chronic pelvic pain, tubo-ovarian abscesses, and or pelvic adhesions.

Results and Discussion

The (CA)n region near the promoter or in the first intron ofa gene affect its promoter activity (10). Indeed, a 1.75 relative risk is not high enough, but reveals a significant role of CA repeats among other BC risk factors, i.e., other genes, gene-gene interactions, and gene-environment interactions. ERp. genetic variant interactions with known BC risk factors may provide new insights into BC etiopathology. Finally, a possible relationship of ERp. polymorphism with other E-dependant diseases (endometriosis, fibroma, and atherosclerosis) should be considered.

Clinical Presentation

Clinical features related to ovarian pathology are often non-specific and, in general with ovarian neoplasia, symptoms occur late in the course of the disease when the tumour has often spread beyond the ovary. Symptoms related to ovarian tumours include swelling or a feeling of fullness in the abdomen or pelvis, the presence of an abdominal mass, irregular uterine bleeding and abdominal or pelvic pain. There may be associated ascites, especially with ovarian malignancies, but also with some benign neoplasms such as fibromas. With ovarian endometriosis, pain and swelling may fluctuate depending on the stage of the menstrual cycle. In younger patients, ovarian pathology may be discovered during the course of investigations for infertility. Ovarian pathology may also be discovered incidentally during abdominal or pelvic imaging or as a result of an

Clinical Investigations

Serum CA-125 measurements an increase in serum CA-125 may be an indicator of ovarian malignancy. However, modest or even marked elevation of serum CA-125 may occur in many non-neoplastic diseases or non-ovarian neoplastic diseases, this serum marker being relatively non-specific. CA-125 is produced by mesothelial cells, and conditions which involve the peritoneal cavity with its lining of mesothelial cells are especially liable to result in an elevated serum CA-125. These conditions include ascites, endometriosis, peritoneal tuberculosis and disseminated non-ovarian neoplasms. Laparoscopy this may be indicated in certain conditions, e.g., suspected endometriosis. Biopsy can be performed at laparoscopy.

Nonneoplastic Conditions

Endometriosis the ovary is the most common site of endometriosis, which is defined as the presence of endometrial tissue, usually both glands and stroma, outside the uterus. Most common in the reproductive age group, but occasionally encountered in postmenopausal women, the symptoms are protean and varied. Patients may present with a palpable abdominal mass, abdominal or pelvic pain, dysmenorrhoea, dyspareunia, irregular uterine bleeding or infertility. Endometriosis within the ovary may take the form of an endometriotic cyst. These can be single or multiple and are often bilateral. They generally have a thick fibrous wall which is yellow to brown in colour with a ragged internal surface. The cyst contents are typically brown fluid which may be inspissated, giving rise to the term chocolate cyst of the ovary. Rarely, tumours can arise within ovarian endometriotic cysts and these usually take the form of a thickened area within the wall. Endometriosis within the ovary may also be...

Neoplastic Conditions

Mucinous, endometrioid and clear cell adenocarcinomas may have an alternative pathogenesis. For example, K-ras mutations are found in mucinous adenocarcinomas and these may develop from pre-existing borderline mucinous neoplasms, unlike serous adenocarcinomas which are thought to arise de novo. Endometrioid and clear cell carcinomas can be associated with endometriosis in the ipsilateral or contralateral ovary or elsewhere in the pelvis, and it is clear that a proportion of these neoplasms arise from endometriosis, sometimes from atypical endometriosis. Since the preferred theory for the development of endometriosis is retrograde menstruation, it is interesting that tubal ligation is protective for the development of endometrioid and clear cell carcinomas but not for other morphological subtypes. Endometrioid neoplasms may coexist with similar tumours in the endometrium in up to 25 of cases. The ovary is a common site for metastatic carcinomas. The most common primary sites include...

Sequelae and Limitations of Chemoradiotherapy for Squamous Cell Anal Cancer

Late complications associated with radiation and chemotherapy can adversely affect the QOL of patients. Grade 3-4 complications occur in 10 to 19 of patients (17,20,27,29,45,46). Frequent late effects of chemoradiotherapy include chronic diarrhea, dysuria due to proctitis, chronic pelvic pain, fractures and sexual dysfunction (27,45,47). Complications of the anal canal occur in 15 to 30 of patients and include anal necrosis, stenosis, fistulae or ulceration, and anal incontinence (particularly if there was sphincter involvement by tumor). The incidence of radionecrosis in patients treated with BRT is 2 to 9 (48-50). In general, treatment-related anorectal complications require APR or colostomy in 3 to 6 of patients (39,40,44). In a retrospective study of 144 patients treated with radiation and chemotherapy, factors contributing to late toxicity included anatomical tumor extent and delivered dose of radiation. Patients receiving < 39.6 Gy had a 7 complication rate, while those...

Contraindications And Precautions

There are no known contraindications for the flower head extracts. Concentrated isoflavone extracts should only be used by people with oestrogen-sensitive cancers under professional supervision because of the possible proliferative effects. Additionally, people with conditions that may be aggravated by increased oestrogen levels, such as endometriosis or uterine fibroids, should use this herb under professional supervision only. Short- or long-term use of red clover tea or flower head extract is not thought to be associated with any adverse reactions and its use is considered safe. Concentrated red clover isoflavone extracts may have subtle oestrogenic activity and little is known about drug interactions or long-term use. As a result, they should not be used by people with oestrogen-sensitive tumours or conditions that may be aggravated by increased oestrogen levels such as endometriosis, unless under professional super-

Physical Examination

Differential Diagnosis Nephrolithiasis, appendicitis, cystitis, pyelonephritis, diverticulitis, salpingitis, torsion of hernia, ovarian torsion, ovarian cyst rupture or hemorrhage, bladder obstruction, prostatitis, prostate cancer, endometriosis, ectopic pregnancy, colonic obstruction, carcinoma (colon, prostrate, cervix, bladder).

What Does the Term Dyspareunia Mean

In 1874, Barnes (1) coined the term dyspareunia. He felt that it would be a convenient way of summarizing the different conditions underlying painful intercourse just as 'dyspepsia' is used to signify difficult or painful digestion, we want a word to express the condition of difficult or painful performance of the sexual function (p. 68). Although the usefulness of the term dyspepsia is a matter of some controversy (2), the diagnosis of dyspareunia has not been seriously challenged and is still used by all major classificatory systems, such as the DSM-IV-TR (3) and the ICD-10 (4). The lack of specificity of the word dyspareunia is evidenced by the growing number of overlapping terms (e.g., vul-vodynia, vulvar vestibulitis syndrome, dysesthetic vulvodynia, vestibulodynia) denoting presumed disease entities. The majority of these terms originate from a recent renewed interest in painful vulvar conditions. Even prior to this increased interest, the term dyspareunia was often used...

Classification Of Pain

Ureters by an abdominal mass may cause severe flank pain. Local tumor extension or pelvic metastasis is likely to cause visceral pelvic pain whereas visceral abdominal pain may arise from metastatic disease in abdominal organs or para-aortic nodes. Afferent impulses from abdominal organs are transmitted via the celiac plexus and splanchnic nerves although innervation of these structures is less dense than in the peripheral tissues. The resulting pain is deep and poorly localized pain, frequently described as squeezing and cramplike. Referred pain, if present, is experienced in the somatic der-matome that corresponds to the nerve plexus that is involved. Symptoms of nausea and diaphoresis, which are mediated by the sympathetic nervous system, may also accompany this type of pain. Opioid analgesics do provide some relief although patients may experience medication side effects before satisfactory analgesia is achieved. In this case, sympathetic plexus blocks including the superior...

Omentum and Peritoneum

Peritoneal inclusion cysts relatively common, solitary or multiple and should be distinguished from lymphangitic cysts (cytokeratin negative endothelial lining) and well-differentiated multicystic peritoneal mesothelioma. The latter is rare, occurring on the surfaces of the uterus, ovary, bladder, rectum and pouch of Douglas with potential for recurrence and invasion locally into retroperitoneum, bowel mesentery and wall. Some have a previous history of surgery, endometriosis or pelvic inflammatory disease.

Female Reproductive System

Endometriosis is the presence of endometrial glands in abnormal locations (e.g., ovary, uterine ligaments, pelvic peritoneum), causing infertility, dysmenorrhea, and pelvic pain. 5. Dysmenorrhea is excessive pain during menstruation. It is commonly associated with endometriosis and an increased level of prostaglandin F in the menstrual fluid.

Management

When endometriosis or pelvic adhesions are discovered on diagnostic laparoscopy, they are usually treated during the procedure. Hysterectomy may be warranted if the pain has persisted for more than six months, does not respond to analgesics (including anti-inflammatory agents), and impairs the woman's normal function.

Medical treatment

Progestins are similar to combination OCPs in their effects on FSH, LH and endometrial tissue. They may be associated with more bothersome adverse effects than OCPs. Progestins are effective in reducing the symptoms of endometriosis. Oral progestin regimens may include once-daily administration of medroxyprogesterone at the lowest effective dosage (5 to 20 mg). Depot medroxyprogesterone may be given intramuscularly every two weeks for two months at 100 mg per 4. Danazol (Danocrine) has been highly effective in relieving the symptoms of endometriosis, but adverse effects may preclude its use. Adverse effects include headache, flushing, sweating and atrophic vaginitis. Androgenic side effects include acne, edema, hirsutism, deepening of the voice and weight gain. The initial dosage should be 800 mg per day, given in two divided oral doses. The overall response rate is 84 to 92 percent. Medical Treatment of Endometriosis

Medical references

I once annoyed an obstetrics registrar by using my handheld in front of him. The consultant had asked me to wait outside his clinic while he was dealing with a sensitive case. My short attention span soon had me rooting for my machine. Given the patient's history, I started reading about endometriosis. The registrar saw me and suggested that I do some work. I replied that I was, but he just thrust an information leaflet on contraception in my direction. I thanked him for this and said I would read it as soon as I had finished the chapter. Two minutes later, he was back and more annoyed that I was ''not doing work''. I was now presented with a leaflet on fertility. It was the leaflet on endometriosis that broke me and I asked him why he insisted on this. He said clinic was no place for a ''Game Boy'' and that I should be doing some work. He calmed down after seeing my handheld's chapter on endometriosis.

Psychologic effects

A woman who is sexually assaulted loses control over her life during the period of the assault. Her integrity and her life are threatened. She may experience intense anxety, anger, or fear. After the assault, a rape-trauma syndrome often occurs. The immediate response may last for hours or days and is characterized by generalized pain, headache, chronic pelvic pain, eating and sleep disturbances, vaginal symptoms, depression, anxiety, and mood swings.

General approach

While her usual GP was on holiday she consulted a locum, complaining of pelvic pain and in great distress. She was referred to the local gynaecologist. At the hospital, where she saw a succession of junior doctors, various medications were tried to no effect, and eventually a hysterectomy was performed. The patient then complained that her pain had actually got worse. A psychiatric referral followed, and a diagnosis of somatization disorder was made, but the patient refused to engage in any form of psychological treatment and spoke of suing the gynaecologist.

Diagnostic workup

The tumor marker CA 125 may assist in evaluation. Sustained elevation of CA 125 levels occurs in more than 80 of patients with nonmucinous epithelial ovarian carcinomas but in only 1 of the general population. Levels of CA 125 in serum also may be elevated in patients with conditions such as endometriosis, leiomyomata, pelvic inflammatory disease, hepatitis, congestive heart failure, cirrhosis, and malignancies other than ovarian carcinomas. In postmenopausal patients with pelvic masses, CA 125 levels in serum greater than 65 U mL are predictive of a malignancy in 75 of cases.

Chronic Prostatitis

Thirty men with category Ilia or lllb chronic pelvic pain syndrome received either placebo or quercetin 500 mg twice daily for 1 month. Sixty seven percent of the treated subjects had at least a 25 improvement in symptoms, compared to 20 of the placebo group. In a follow-up, unblinded, open-label study, 17 additional men received the same dose of quercetin (combined with bromelain and papain to enhance absorption) for 1 month. The combination increased the response rate from 67 to 82 (Shoskes et al 1999). The anti-inflammatory, antioxidant and

Ovaries

Crus Clitoris

A functional cyst is a physiologically and hormonally active cyst that has not yet involuted. There are three types follicular cyst, corpus luteum cyst, and theca lutein cyst (caused by elevated levels of (3-human chorionic gonadotropin). Clinical findings include sudden, extreme pelvic pain, especially in an adolescent girl. Functional cysts usually resolve spontaneously.

Adverse Effects

Bleeding is the major adverse effect of bivalirudin and occurs more commonly in patients with renal impairment. Injection site pain has been reported in individuals given sc bivalirudin (Fox et al., 1993). Mild headache, diarrhea, nausea, and abdominal cramps have also been reported (Fox et al., 1993). In the Hirulog Angioplasty Study (HAS) (now known as the Bivalirudin Angioplasty Trial BAT ), the most frequent adverse effects included back pain, nausea, hypotension, pain, and headache. Approximately 5-10 of patients reported insomnia, hypertension, vomiting, anxiety, dyspepsia, bradycardia, abdominal pain, fever, nervousness, pelvic pain, and pain at the injection site (Bittl et al., 1995 Sciulli and Mauro, 2002) (Table 3).

Patricia Harrison Md

Several common pain syndromes are more likely to arise in patients with advanced germ cell tumors. These syndromes are caused by direct tumor invasion in the pelvis or as a result of distant metastasis.8 Pelvic pain may arise from tumor recurrence locally, and abdominal pain may arise with the involvement of para-aortic lymph nodes or hepatic metastasis whereas chest pain may signify mediastinal metastasis or the presence of a mediastinal extragonadal germ cell tumor. When neural structures are invaded, pain will be severe and neuropathic in nature. It is important to understand the etiology of the pain that is described as the success of therapy will depend on accurate assessment and the implementation of appropriate analgesics. This may include pharmaco-logic or interventional therapy.

Week 1 Days

Conjoined Twins Diagram

3- Ectopic pregnancy is most commonly seen in women with endometriosis or pelvic inflammatory disease. 5- An ectopic tubal pregnancy presents with abnormal uterine bleeding and uni-lateral pelvic pain, which must be differentially diagnosed from appendicitis, an aborting intrauterine pregnancy, or a bleeding corpus luteum of a normal in-trauterine pregnancy.

Invasive Therapy

Intravenous Injection Via Heparin Block

Sympathetic plexus or ganglion blocks are indicated if pain is predominantly visceral.46 Blocks of the superior hypogastric plexus are intended to relieve pelvic pain due to malignancy or radiation-induced cystitis or enteritis.4748 A network of sympathetic nerves lies anterior to the fifth lumbar vertebral body (Figure 26-2). At that level, it is a retroperitoneal bilateral structure that innervates the pelvic viscera via the hypogastric nerves. The block is performed with the patient in the prone position, and needles are inserted 5 to 7 cm from the midline bilaterally at the level of the L4-L5 spinous interspace. The needles are directed under computed tomography (CT) or fluoroscopic guidance until they reach the position of the plexus (see Figure 26-2, B). A diagnostic or prognostic block can be performed with 6 to 8 mL of 0.25 bupivacaine whereas injection of a neurolytic agent such as alcohol or phenol will give a prolonged block. The sacrococcygeal plexus or ganglion impar can...

The masquerades

If the patient has pain anywhere it is possible that it could originate from the spine so the possibility of spinal pain (radicular or referred) should be considered as the cause for various pain syndromes such as headache, arm pain, leg pain, chest pain, pelvic pain and even abdominal pain. The author's experience is that spondylogenic pain is one of the most under diagnosed problems in general practice. A checklist that has been divided into two groups of seven disorders is presented (Tables 15.4 and 15.5). The first list, 'the seven primary masquerades', represents the more common disorders encountered in general practice the second list includes less common masquerades although some, such as Epstein-Barr mononucleosis, can be very common masquerades in general practice.