FAQ: What your Urologist should know.
she...@edp.net
Hi again,
Really hope that this time this comes through. A little fibrofog on
this end!
Sheryl
she...@edp.net
What Your Urologist Should Know
You have seen patients with fibromyalgia and myofascial pain
syndrome, and will see more. They are both very real medical
conditions, and both very different, although often confused. They
may be the answer to some of your "challenging" patients.
Fibromyalgia is a systemic neuroendocrine condition with,
among other things, a disrupted adrenal-hypothalamus-pituitary
axis. It is nonprogressive (although it may seem so),
nondegenerative, and noninflammatory. It is responsible for diffuse
body-wide pain, tender points that hurt but don't refer pain, and
sleep disturbances.
Chronic myofascial pain syndrome (MPS) is a musculoskeletal
chronic pain syndrome. It is nonprogressive (although it may seem
so), nondegenerative and noninflammatory. It is composed of many
Trigger Points (TrPs), which refer pain and other symptoms in very
precise, specific patterns. It seems progressive because each TrP
can develop satellite and secondary TrPs, which can form secondaries
and satellites of their own. With treatment of the TrPs and
underlying perpetuating factors, however, these TrPs can be
"reversed" and minimized or eliminated.
When occurring together, what I call the "FMS/MPS Complex"
forms. This is a condition of interconnected symptom spirals that
get increasingly worse until the spiral is interrupted. For
example, the pain causes muscle contraction which causes more pain
which causes more contraction, etc. The patient can sometimes have
muscles that are like cement, due to myofascial splinting.
Two excellent medical texts are available on MPS,
"Myofascial Pain and Dysfunction: The Trigger Point Manual Vol. I
and II" by Janet G. Travell M.D. and David G Simons M.D. The second
volume is important to you, as it deals with lower body TrPs. This
chapter is but an introduction to them. The Manuals show the
referred patterns, tell what causes them, and how to relieve them.
Many symptoms a neurologist sees are from FMS, but there are
specific symptoms of FMS/MPS that should put up a red flag.
There is a type of insomnia called Compulsive Urination
Insomnia that I've found very common in FMS/MPS Complex. Most
people urinate before they go to bed. There is usually a small
amount of urine left in the bladder. We have hypersensitive nerve
endings, and can feel the pressure, so we get up and go again. We
are conscious of how hard it is for us to get some sleep, and we
don't want to take a chance on being wakened in the night by
having to go again, so whenever we wake (sometimes with every alpha
intrusion, we take a trip to the bathroom. This can happen over 30
times a night. Lidocaine ointment on the urinary opening will stop
some of the sensitivity, but first be check for a possible yeast or
low-grade bacterial infection.
There are many medications to help FMS/MPS, as well as
physical therapy modalities that are effective in defusing the TrPs
of myofascial pain syndrome.
Irritable bladder, bowel: This can be due to the pyramidalis,
multifidi,
and abdominal TrPs, as well as yeast overgrowth in the
gastrointestinal tract. I have found that TrPS in the upper rim of
the pubis adds to the irritability and spasm of the genital-urinary
tract. This is as least part of the reason so many of us have
urinary frequency. Not only is the bladder hypersensitive, it won't
hold as much. In addition, we can't empty the bladder totally.
There is also a trigger point that can form high on the adductor
magnus, about an inch from the join of trunk to leg. Often you
will be able to feel a taut band of TrPS in this region. This
refers a diffuse soreness and pain throughout the pelvis, which can
mimic PID, prostate trouble, and other visceral conditions
I have a theory that we also can lose bladder elasticity, as the
myofascia
in that area tightens and "splints" the stressed muscles. This is also
a
common occurrence as we age. It just can happen earlier for those of
us
with FMS/MPS. Fortunately, there are often ways to reverse this
process.
Often, in cases of irritable bladder and bowel, the lower internal
oblique
muscle and possibly lower rectus abdominus are involved.
Burning or foul-smelling urine: This is fairly common, and also
occurs with guaifenesin treatment for FMS reversal. It can mimic a
urinary infection.
Impotence Occurring Secondary to Myofascial Trigger Points: This
information is taken directly from "Myofascial Pain and
Dysfunction: The Trigger Point Manual Volume II" by Janet G.
Travell M.D. and David G. Simons M.D., and references are to that
volume.
Both the bulbospongiosus and ischiocavernosus muscles enhance
erection of the penis. These muscles can develop TrPs. The
bulbospongiosus essentially wraps around the corpus spongiosum of the
penis, which is the central erectile structure through which
the urethra passes. The anterior and middle fibers of the
bulbospongiosus and ischiocavernosus muscles contribute to
erection by reflex and voluntary contraction that compresses the
erectile tissue of the bulb of the penis and also its dorsal vein.
Contraction of the ischiocavernosus muscle maintains and enhances
penile
erection by retarding the return of blood through the crus penis.
TrPs
in the bulbospongiosus muscle can cause impotence (page 118). TrPs in
scar tissue produced by surgical incision are well known (page 121).
TrPs in the pelvic floor muscles are sometimes activated by surgery
in the pelvic region (page 121).
The piriformis is a major intrapelvic muscle which is a frequent site
of TrPs.
Entrapments are numerous. The nerves and blood vessels that pass
through
the greater sciatic foramen along with the piriformis are subject to
en
trapment (page 187). Exiting the pelvis along the lower border of the
piriformis are the pudendal nerve and blood vessels. The pudendal
nerve
innervates the bulbocavernosus, ischiocavernosus, and sphincter
urethrae
membranacea muscles and the skin and corpus cavernosus of the penis.
Innervation of these structures is essential to normal sexual function
(page 191). "Patients may complain of...sexual
dysfunction...impotence
in the male" (page 192). "Pudendal nerve entrapment may cause
impotence
in men" (page 194). The piriformis TrP is most commonly found with a
complex of other TrPs (page 203). This is a complex area with
multiple
layered muscles and opportunities for entrapment. After a surgical
procedure, such as a hernia repair, a regimen of stretches can often
help prevent adhesions and TrPs.
Pain during coitus can be caused by TrPs in the surrounding
muscles. Sharp, shooting pain is most often caused by piriformis
entrapment of the pudendal nerve.