Pelvic Congestion Syndrome

Pelvic Congestion Syndrome or Pelvic Venous Congestion Syndrome is not a "go-to" diagnosis for pelvic pain (including vestibulodynia), but it can mimic many of the symptoms. It is having varicose-like veins in the pelvis that are causing pelvic pain. The kinds of doctor one might consult would be an interventional radiologist, a physiatrist or physical medicine doctor who has a pelvic specialty, a vascular doctor, or maybe a urogynecologist (this would be the kind of doctor easiest to find.)

From this website: Pelvic Venous Congestion Syndrome

For some women, the cause of their pelvic pain is a condition known as pelvic congestion syndrome (PCS). It may go undiagnosed simply because physicians are often unfamiliar with it or fail to look for it.

Symptoms

• Pelvic pain or aching around the pelvis and lower abdomen 
• Dragging sensation or pain in the pelvis 
• Feeling of fullness in the legs 
• Worsening of stress incontinence 
• Worsening in the symptoms associated with irritable bowel syndrome 

Pain is usually commonest symptom and present for over 6 months duration. The pain is usually on one side but can affect both sides. The pain is worse on standing, lifting, when you are tired, during pregnancy and during or after sexual intercourse. The veins are also affected by the menstrual cycle/hormones and therefore the pain can increase during the time of menstruation. The pain usually is improved by lying down.

Causes of pelvic congestion syndrome 

Pelvic congestion syndrome occurs when varicose veins develop around the ovaries, similar to varicose veins that occur in the legs. Then:
The valves in the veins no longer function normally.
This causes blood to back up.
The veins become engorged or “congested,” which can be very painful.

Treatment for pelvic congestion syndrome 

Treatments for PCS include:
Hormonal medications
Embolization, a minimally invasive catheter procedure to “plug” the varicose vein

The term is easily google-able. It is something you consider when nothing else seems to make sense.

Predictors of Vestibulitis

What makes developing vestibulitis more likely?

The journal article "Medical and Physical Predictors of Localized Provoked Vulvodynia" by Nina Bohm-Starke discusses predictors of localized provoked vulvodynia, a.k.a. vestibulitis).
http://onlinelibrary.wiley.com/doi/10.3109/00016349.2010.528368/abstract;jsessionid=4E60EAF10EE04E4F1BC811DD8028FBF5.f01t04

Localized = in the vestibule rather than the vulva as a whole
Provoked = the pain is associated with penetration (by a tampon, or penis, or...)

Predictors:

• trauma to the vestibular mucosa develops greater pain sensitization in the peripheral and central nervous system (I discuss this in my "Pain is a Loop" post);
• greater pain perception
• proliferation of mast cells in the vestibule
• pelvic floor muscle dysfunction
• concurrent bodily pain in other areas of the body
• history of hives (2.5 times more likely)
• bacterial vaginosis*
• genetics - allele 2 of the IL-1beta gene in 40% of women versus 25% control; reduced capacity of TNF-alpha production in response to microbes with polymorphism of the mannose-binding lectin gene; fair skinned women; and when there is polymorphism of the melanocortin-1 receptor (MCIR) gene
• hormones (read article for greater depth), with birth control thought to be a significant precursor according to Andrew Goldstein. 

*Although bacterial vaginosis is a predictor, human papillomavirus (HPV) and herpes simplex are not. Yeast infections are probably not a predictor, the article says. Studies that have been done on vestibulitis and yeast infections have all used "self-report" rather than judged by a clinician which undermines those studies.

This is written in 2010, and, as the author states, there were not enough high quality studies to review so these predictors are hypotheses, but have not been repeatedly confirmed.

3-D Image of the Pelvic Muscles and Ligaments

The Pelvic Floor in 3-D:

1. Pelvic Floor Muscles: https://www.youtube.com/watch?v=P3BBAMWm2Eo
2. Pelvic Floor Ligaments (1/2): https://www.youtube.com/watch?v=Bf_sr2qRRWs
3. Pelvic Floor Ligaments (2/2): https://www.youtube.com/watch?v=Bf_sr2qRRWs

Anatomy of the Clitoris

Notice that even if you can't take direct clitoral touch, you can still get clitoral stimulation because the clitoris extends quite a lot on each side, located between the labia majora and minora.

A fun little video that's a drawing. Watch first to get oriented before...
https://www.youtube.com/watch?v=YhoSUoZ_uJ0

A cadaver video that shows the same area (it's not super-gross given it is a cadaver):
https://www.youtube.com/watch?v=h5Y7do2z-Dw

More on Pelvic Anatomy

These are much more complex than the other two posts and may make your brain hurt. They focus on the muscles and fascia that sit above the pelvic diaphragm:
http://www.youtube.com/watch?v=49yeRmj3cIo
http://www.youtube.com/watch?v=7fZfpNJHQTM

What is Your Pelvic Diaphragm? The "Sling Thing" They Always Talk About

If you have wondered what the "pelvic diaphragm" or "sling" that books refer to, here is a video by the same excellent youtube poster about nerves

Why am I Constipated?

Okay, not a subject generally discussed, but here goes. Constipation is a common occurrence when you have vulvodynia.

My first theory:
Your pelvic muscles are tight and clamp down on the your large intestine. The poop sits there and dries out, forming dark pellets that don't move easily to the rectum. When it does get to the  rectum it sits there again, refusing to come out. This is because in both the large intestine and the rectum, peristalsis, smooth muscle movement that propels poop forward, can't work optimally. Your poop gets stuck.

My second theory:
People with vulvodynia can have have up-regulated "fight or flight" nervous systems. This shuts down the gastrointestinal track's normal functioning, including peristalsis. A wiki excerpt on the sympathetic nervous system follows at the end of this blog entry.

Note that my first and second theories can co-exist and both are, in my opinion, viable explanations for why someone with vulvodynia is constipated. So what to do? Here it gets gross. Read the next blog.


From Wikipedia on "Fight or Flight"

Sympathetic nervous system

Main article: Sympathetic nervous system

Promotes a "fight or flight" response, corresponds with arousal and energy generation, and inhibits digestion.

• Diverts blood flow away from the gastro-intestinal (GI) tract and skin via vasoconstriction.
• Blood flow to skeletal muscles and the lungs is enhanced (by as much as 1200% in the case of skeletal muscles).
• Dilates bronchioles of the lung, which allows for greater alveolar oxygen exchange.
• Increases heart rate and the contractility of cardiac cells (myocytes), thereby providing a mechanism for the enhanced blood flow to skeletal muscles.
• Dilates pupils and relaxes the ciliary muscle to the lens, allowing more light to enter the eye and far vision.
• Provides vasodilation for the coronary vessels of the heart.
• Constricts all the intestinal sphincters and the urinary sphincter.
• Inhibits peristalsis.
• Stimulates orgasm.