Hello, designguru-ga!
I can certainly understand you frustration and anguish over the
daily, debilitating, chronic pain that should have cleared up after
successful pelvic surgery. I can also understand your desire (and your
doctor's) to wean you off daily doses of morphine. Unfortunately,
after researching this issue, the conditions that underlie
inflammatory pelvic conditions often do not have an easy resolve.
Medical forums are full of individuals who have recurring pain and
numerous operations after pelvic surgeries. It is of utmost importance
that you realize you are NOT alone in continuing to feel pain after
surgery. Unfortunately, I cannot tell you whether the continued pain
you are experiencing is normal for your particular condition, or
abnormal.
Whether your continued pain is due to a recurring infection,
adhesions or scarring, or another condition altogether is an answer
only a medical expert can provide. As you are aware, the GA terms of
service are not a substitute for medical advice. Nor should any
researcher attempt to diagnose your condition or provide surgical
recommendations. Therefore, the best I can do is provide information
that you may use as you continue to seek some continued healing and
relief from your continued pain. Again - you are NOT alone in this!
Medical situations involving cysts and tubo-ovarian abscesses are
very specific to each individual. There are different underlying
conditions, different stages of abscesses and varying types of
surgical treatments. You have obviously sought out the opinions of a
variety of doctors since your surgery. Considering the fact that your
doctors have assured you that the abscess is gone, and they have
likely assessed you for recurring infection and diagnosed a negative
result, it sounds as if you may, in fact, be dealing with some
scarring, or adhesions. It is encouraging that two of the doctors you
have consulted have recommended an exploratory procedure to determine
whether scar tissue is causing your continued pain. Encouraging
because it provides an avenue of hope. I do understand why your
general surgeon has asked you to wait. The medical literature does
highlight the possibility that correcting adhesions unnecessarily can
contribute to further scarring. Your surgeon may be encouraging you to
bear with it a bit longer to discover if the pain from possible
adhesions will dissipate with time. However, if pain persists, surgery
is often warranted. It is also not uncommon for women who have had a
bout with Pelvic Inflammatory Disease, including abscesses, to
experience chronic, recurring pelvic pain. If this turns out to be the
case, then the alternative therapies should hold particular importance
for you.
==
Before referring you to information concerning adhesions/scarring in
the pelvic region, I have included some articles about tubo-ovarian
abscesses.
Read "Tubo-Ovarian Abscess." eCureME.
http://www.ecureme.com/emyhealth/Pediatrics/Tubo-Ovarian_Abscess.asp
Read "Severe Pelvic Infection and Infertility," by Frederick R.
Jelovsek MD. Women's Diagnostic Cyber.
http://www.wdxcyber.com/ninfer08.htm
==
This next article is definitely not written for the laymen and will
require some concentration :)
Read "PELVIC INFLAMMATORY DISEASE - TUBO-OVARIAN ABSCESS," by Mehmet
R. Genc, MD and William J. Ledger, MD. Medical Online Review and
Database.
http://www.snowtigermed.com/cgi-local/viewarticle.pl?doc=20000216165007
Some excerpts:
"The term pelvic inflammatory disease (PID) attempts to cover a wide
range of clinical syndromes. Women with this diagnosis include those
seriously ill with tubo-ovarian abscess (TOA) who require operative
intervention, encompassing either drainage or removal of the pelvic
organs."
"Hospitalization of women with presumed PID is recommended if... 6)
the patient has tubo-ovarian abscess;..."
** Please scroll down to the section on "Tubo-Ovarian Abscess" and
read the article in it's entirety for some good background.
==
Please also read the section on "Ovarian and tubal surgery" in the
following article:
"Surgical Treatment for Chronic Pelvic Pain," by James E. Carter, MD,
Ph.D. OBGYN.net
http://www.obgyn.net/displayarticle.asp?page=/cpp/articles/carter_pt2_0699
ADHESIONS AFTER SURGERY
=======================
Adhesions can be a very common and extremely painful result of
surgical interventions of the pelvis. The existence of the
"International Adhesions Society" and the "UK Adhesions Society"
should be indication enough that this is a very real and painful
problem affecting many patients who are expected to be "pain free"
after surgery.
Some Background Articles:
"Pelvic Adhesive Disease (Adhesions)--Hidden Scars Take Their Toll,"
by GERARD M. DiLEO, M.D., F.A.C.O.G. From "Pelvic Pain--Causes &
Treatment." 1998 http://www.gynob.com/pelpain.htm
"Whenever anyone has any surgery there is scarring. The only scar the
patient sees is on the outside, but there are healing phenomena at
work on the inside as well, resulting in internal scarring
(adhesions). As a gynecological surgeon, much pelvic surgery I do is
actually abdominal. Adhesions are an expected result, but fortunately
there are usually no noticeable effects. Occasionally, however, a
patient will present with pain from adhesions, the result of bowel or
its fatty tissue sticking to pelvic or other abdominal organs,
limiting the normal flexibility of their function. For instance, when
feces or gas pass an area in the intestinal tract kinked or narrowed
due to the distorting affects of adhesions, this area can become
inflamed or painful."
"There are several ways to treat the pain from adhesions. The best way
is to just wait it out, because most symptoms will fade away over
time. The main advantage in waiting is that surgery, a quick way to
treat the adhesions by actually cutting these internal scars, freeing
up the stuck structures, can actually lead to further adhesions. But
sometimes surgery is the only answer."
"When pain becomes so continuous or frequent that the patient can't
enjoy any quality of life--exercise, sex, recreation, or work--and
analgesics are being increased such that the patient is at risk for a
narcotics problem, surgery needs to be offered. This is usually a
joint decision between doctor and patient. The patient knows what she
is feeling, and the doctor must be sure that all conservative options
have been considered. Laparoscopy, placing a lighted tube into the
navel, has been used in recent years to treat adhesions surgically.
Laser and other specialized laparoscopic instruments can be used to
break up the areas of internal scarring, restoring normal anatomy. The
good thing about the laparoscope is that laparoscopy itself seems to
cause very little adhesion formation."
"When the adhesions are unusually severe or when important structures
are involved, making an actual incision appropriate, attention is
usually paid to meticulous technique, since most adhesions seem to
develop due to tissue damage. It seems the actual healing process
causes the adhesions; the damaged tissue seeks to seal itself off by
joining to other sites. Two preventatives that have been used in the
past are Hyskon and Intercede. Hyskon is a sugary substance left as a
puddle in the abdomen, the internal tissues forced to slide around so
they can't stick. Intercede is a cloth-like absorbable substance.
Wrapped around traumatized structures, it converts to a gelatinous
barrier to protect the tissue. These two and other techniques have had
mixed success in preventing adhesions, so some doctors routine use
them, others have discontinued using them."
==
"The severe consequences of Adhesion Related Disorders" on the AKAS website:
http://www.adhesions.org.uk/index2.shtml
* Click on "What are Adhesions."
Some excerpts follow:
"Pelvic Adhesions are bands of fibrous scar tissue that form in the
abdomen and pelvis, usually after surgery. Adhesions connect organs
and tissue that are normally separate, ovaries, fallopian tubes,
bladder or bowel can be affected. Adhesions can also lead to a variety
of severe complications including chronic pelvic pain, infertility and
bowel obstruction."
"Adhesions start forming almost immediately after surgery as part of
the normal healing process to repair raw tissue. Unfortunately In the
process some organs/tissues become "stuck" to adjacent tissues and
thus cause pain."
"Adhesions also develop as normal tissue responds to some form of
injury.In many cases these Adhesions are painless and the patient
never knows she has them, while in other cases they cause a sharp,
pulling type of pain, or pain with intercourse or bowel movements."
...
"Adhesions are believed to cause pelvic pain by tethering down organs
and tissues. It is not unusual for several organs to be adhered to
each other, causing traction (pulling) of nerves. Nerve endings may
also become entrapped within a developing Adhesion causing severe
pain. Also if the bowel becomes obstructed, distensions will cause
pain.
Please read article in entirety.............
CHAT AND MESSAGE FORUMS
========================
Both the "International Adhesions Society" and the "UK Adhesions
Society" have websites where you can exchange messages and chat with
others who are experiencing pain after pelvic surgery. I read through
many of the messages and I am can say with confidence that you are NOT
ALONE!!!
Click on the Message Board and Chatroom links on the UKAS website:
http://www.adhesions.org.uk/index2.shtml
Message Forum at International Adhesions Society
http://www.adhesions.org/forums/message.htm#search
==
Dr. Andrew S. Cook has an excellent question and answer site about
pelvic pain that I urge you to visit. Although a good deal of his
expertise revolves around endometriosis, he is also an expert in
pelvic pain issues.
About Dr. Cook
http://www.pelvicpain.com/askdoctor.html
Please see the following questions and answers about Adhesions.
http://www.pelvicpain.com/askdoctor_QA.html#adhesions
* Please pay particular attention to the types of Adhesions (Vascular
adhesions are the most likely to cause continued pain months after
surgery)
If you would like to submit a question to Dr Cook, please visit the following page:
http://www.pelvicpain.com/askdoctor_topic.html
==
A very comprehensive, multi-page article on Pelvic Pain is available
on the iVillage website. It cover causes, surgeries, a variety of pain
medications and alternative treatments. Please read it for a very good
overview! Don't forget to click the link at the bottom of each page to
read further.
"Pelvic Pain." Written by: Editorial Staff of the National Women's
Health Resource Center
http://www.ivillagehealth.com/library/nwh/content/0,,215912_542484,00.html#top
Some excerpts from the treatment section:
http://www.ivillagehealth.com/library/nwh/content/0,,215912_542486,00.html
"Surgery may be recommended to remove endometriosis, adhesions and
fibroids, correct physical abnormalities or to remove a diseased or
damaged uterus and ovaries. Surgery has disappointing results and is
almost never the only treatment or even the best treatment."
* Laparoscopy is recommended for both diagnosis and treatment,
although there is no evidence that it accomplishes either. During the
procedure, sites of endometriosis and adhesions may be destroyed by
laser beam or electric current or cut out. Microscopic endometriosis
or endometriosis in tissues too deep to be seen may be missed by
laparoscopy."
* A laparotomy is a more invasive surgical procedure that involves an
abdominal incision. It's used to remove endometriosis, adhesions,
ovarian cysts or hernias that can't be removed by laparoscopy."
* A hysterectomy is the surgical removal of the uterus. It may be a
reasonable treatment for chronic pelvic pain when the uterus is
affected by adenomyosis."
Various other therapies may be helpful alone or in combination with
conventional treatment:
* relaxation and breathing techniques to reduce stress and anxiety
* stretching exercises, massage therapy and biofeedback to reduce
muscle tension in the pelvic floor, hips and low back that can cause
or enhance pelvic pain
* physical therapy to improve posture, gait and muscle tone
* cognitive behavioral therapy that includes various pain-coping strategies
* electronic nerve and muscle stimulation (TENS) to relax tight
muscles, reduce spasms, and relieve painful trigger points
* psychological and emotional counseling to treat depression and
counseling and participation in support groups to strengthen coping
skills
****
"To summarize, be patient. The chronic nature and complexity of pelvic
pain may require multiple treatment strategies and the right
combination for you may take some time. Your pain may not be totally
relieved, but in most cases it should be able to be reduced to a
tolerable level and your ability to engage in normal activities
restored. A combination of conventional and alternative therapies may
work best for you. Counseling and support groups can help you to keep
a positive attitude during treatment. Meanwhile as research continues
on the possible causes of chronic pelvic pain, improved drug
treatments and less invasive surgical techniques are being developed."
MORE ABOUT ALTERNATIVE THERAPIES
=================================
A variety of physical and alternative therapies that can be useful in
treating chronic pelvic pain due to various conditions have been
summarized by the Sunnybrook and Women's Pelvic Heath Center. I don't
know if similar facilities exist near you, but I suggest exploring
methods that might help you to find the means to deal with the
continued pain UNTIL you can resolve the issue medically, if that is
warranted.
Please see the treatments outlined on the following site. (Scroll down the page)
http://www.sunnybrookandwomens.on.ca/programs/generic.cfm?dept=64&secID=429&conID=1293&page=5#section6
==
Since tubo-ovarian abscesses can follow pelvic surgery or be a
symptom of advanced Pelvic Inflammatory Disease, the following
suggestions on the University of Maryland Medicine site are worth
exploring. Aside from surgery intervention, the website mentions the
following alternative therapies to help in healing PID:
http://www.umm.edu/altmed/ConsConditions/PelvicInflammatoryDiseasecc.html
Nutrition
---------
"Eat whole foods such as fresh vegetables, whole grains, and essential
fatty acids (nuts, seeds, and cold-water fish). Avoid sugar, refined
foods, and saturated fats (animal products, especially dairy)
"Potentially beneficial nutrient supplements include the following.
Vitamin C (1,000 mg three to four times per day)
Zinc (30 mg per day)
Selenium (200 mcg per day)
Vitamin E (400 IU per day)
B-complex (50 to 100 mg, especially folic acid 800 mcg per day)
Vitamin A (25,000 IU one to two times per day) or beta carotene
(50,000 IU one to two times per day)
Bromelain (500 mg three times per day between meals)
Anti-inflammatory oils (for example, flax, borage, evening primrose)
1,500 mg two to three times per day
Acidophilus (one capsule with meals)
Herbs
------
"Herbal remedies may offer relief from symptoms. Herbs are generally
available as dried extracts (pills, capsules, or tablets), teas, or
tinctures (alcohol extraction, unless otherwise noted). Dose for teas
is 1 heaping tsp. per cup of water steeped for 10 minutes (roots need
20 minutes).
"For acute infection, combine half parts of yarrow (Achillea
millefolium), pasque flower (Pulsatilla pratensis), marigold
(Calendula officinalis), and poke root (Phytolacca americana) with one
part each of coneflower (Echinacea purpurea) and goldenseal root
(Hydrastis canadensis). Take 30 to 60 drops tincture every two to four
hours. Use caution with poke root.
"For chronic infection, combine equal parts of coneflower, goldenseal,
licorice root (Glycyrrhiza glabra), myrrh gum (Commiphora molmol),
wild indigo (Baptisia tinctoria), and red root (Ceonothus americanus).
Take 30 drops tincture two to three times per day.
Turmeric (Curcuma longa, 500 mg three times per day). Use with
bromelain to enhance anti-inflammatory effects."
Acupuncture may also be helpful.
POSSIBLE NEUROPATHIC PAIN ORIGIN
=================================
Although the following abstract deals with persistent pain following a
hysterectomy to combat a tuboovarian abscess, it may still be a
possible consideration:
"Neuropathic uterine pain after hysterectomy. A case report." Chavez
NF, Zweizig SL, Stewart EA. J Reprod Med. 2003 Jun;48(6):466-8.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12856521&dopt=Abstract
BACKGROUND: Neuropathic pain arises when there is damage to or
dysfunction of the nervous system. Diabetic neuropathy, postherpetic
neuralgia and phantom limb pain are common types of neuropathic pain.
It is not commonly recognized in gynecologic practice.
CASE: A patient underwent a hysterectomy for a tuboovarian abscess and
underlying endometriosis. Despite maximal dosing with conventional
pain medications, she continued to have significant pain that had not
been present following prior surgeries. Use of low-dose amitriptyline
successfully treated the pain, with no sequelae.
CONCLUSION: Persistent pain following gynecologic surgery that does
not respond to conventional therapy may have a neuropathic origin.
Attention to appropriate history and physical examination may lead to
an increase in the diagnosis of neuropathic pain in gynecology
patients. This may have implications for persistent pain in other
gynecologic diseases.
ADDITIONAL READING
==================
"Trigger Point Injections for Chronic Pelvic Pain." The International
Pelvic Pain Society
http://www.pelvicpain.org/pdf/trigger.pdf
Please click on the link for the article, "Peripheral neuropathies
presenting as CPP" found on the International Pelvic Pain Society
Website:
http://www.pelvicpain.org/resources_physician.asp
Provider Directory from International Pelvic Pain Society (simply
press the search button)
http://www.pelvicpain.org/findmd.asp
Links from Women's Health - Pelvic Pain
http://www.healthcyclopedia.com/women's-health/conditions-and-diseases/pelvic-pain.html
==
Finally, you have asked whether you should seek another medical
opinion. There is certainly nothing wrong with doing so. If I were in
your shoes, I would try to find a comprehensive diagnostic and
surgical center dealing specifically with pelvic inflammatory diseases
- most preferably within a top-notch medical facility. This way, you
can have the advantage of a variety of specialists consulting about
your specific condition. I don't think a second follow-up ultrasound
from another physician is out of the question, either. And yes, aside
from the alternative therapies provided above, a visit to a top-notch
pain specialist to help you wean off the morphine is an important
facet to your recovery.
Again, I can only imagine how discouraging this must be for you after
leading such a healthy and active life. However, as the iVillage
article stresses, please try to be patient. Pelvic pain can have
complex origins. Stress and anxiety will only hinder your recovery.
I wish you the very best. If I can help further, please don't hesitate to ask.
Sincerely,
umiat
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