Everything I learned about pelvic pain from my first appointment with Dr. Abdelmalak

Here is a more comprehensive report of my first appointment with Dr. Abdelmalak in the Pain Management department at the Cleveland Clinic.

The most important thing I learned from Dr. Abdelmalak

I'm putting this first because it is the most important thing I learned from Dr. A., and I feel like everyone in the world should know this.

At the end of my appointment, I asked Dr. A. why food influences my pain.  "Is it just inflammation?" I asked.

"No," he said.  "And I'm glad you reminded me about that."  He said that pain with urination and pelvic pain that changes depending on the food you eat are both symptoms that indicate you're at risk for developing interstitial cystitis.  In other words, they are as metabolic syndrome is to diabetes: a state that, if it persists, is highly likely to develop into a full-blown disease.

Here is why this is so important: interstitial cystitis is terribly debilitating.  Pain is a uniting symptom, but almost all people who have interstitial cystitis also have urinary frequency and/or urgency.  These symptoms can be extremely debilitating, limiting where the person can go and how long she can concentrate, sending the person to the bathroom fifty times a day, and sometimes forcing the person into disability.

There have been occasions when I have had symptoms of a urinary tract infection -- urinary urgency and even blood in my urine -- without having an actual infection, but thankfully, such episodes have been very rare.  I want to make sure that those episodes don't start occurring more frequently, and according to Dr. A., the primary way to fight it is to change my diet.

When I look back over the years leading up to the onset of my chronic pelvic pain, I recall episodes when sugar, for example, would cause a tingling or pinching sensation in or around my urethra.  At the time, I just thought, "You dummy, you're eating stupid things.  Stop it."  But now I realize that those episodes were precursors to the pain that is with me today.

A couple notes related to the bladder:
- I had my (horrifyingly painful) cystoscopy performed at the same hospital with lidocaine in the area, no anesthesia, which I've now learned -- from the doctors in pain management -- is not standard practice at the hospital.  Maybe things have changed in the five or so years since I had my cystoscopy, but hydrodistention of the bladder is usually necessary to observe physical evidence of interstitial cystitis, and it can only be performed under anesthesia.
- The polyps in my urethra that the urologist said were normal are apparently not normal, or at least not according to Dr. Abdelmalak.  Note: Dr. A. originally trained as a urologist, so he has footing to dispute other urologists' claims.

The pudendal nerve

But there is a wider diagnosis at hand, according to Dr. A. After giving me a verbal tour of the pelvis from the skin on inward, he described the nerves that innervate the pelvic area.  There are the ilioinguinal nerve, the genitofemoral nerve, the superior hypogastric nerve.  But he settled on the pudendal nerve -- familiar on this blog.

He held his arms and said they represent the pudendal nerve as it runs down through each butt cheek and up either side of the groin.  He stretched out his index, middle, and ring fingers, tucking his pinkies and thumbs in.  The ring finger, he said, represents the branch of the pudendal nerve that innervates the anus and perineum.  The middle finger represents the branch that innervates the vestibule (outside of vagina) up to the anterior wall of the urethra (most forward part).  The index finger represents the branch that innervates the clitoris.  (These branches go to different places in men, obviously, but there are still three branches.)

"The pudendal nerve is the most important nerve in the body," Dr. A. said after describing it.  If something goes awry with it, he said, it makes your life hell.  All these basic body functions become painful or otherwise corrupted -- urinating, having a bowel movement, having sex.  You can't sit, your movement is restricted, you can't talk about it with anyone because it's in a private area of the body.  Dr. A. pointed to other areas on his body where if one nerve fails, another one compensates for it -- the face, the arm, the leg.

But I was skeptical.  The most important nerve in the body?  What about the sciatic nerve, which I think is the nerve that allows you to stand up?  What about nerves that provide sensation in the face, or those that allow you to swallow?  But while my mind was practicing devil's advocacy, I was simultaneously elated to hear a doctor take my pelvic pain so seriously.  If he thinks it's the most important nerve in the body, he's the doctor I should be seeing.

The examination & confirmation of diagnosis

Up until this point, Dr. A. had not examined me physically.  But now he had me sit up on the examination table, legs dangling, while he pressed different points on my body and asked if I felt pain.  The head, neck, back, arms, legs.  He tested the strength of my arms and legs, having me push his hands this way and that.

He had me lay on my back to examine my abdomen.  He pushed several different points before starting in on my lower abdomen.  He pressed left to right in the area below my belly button, hip to hip, asking if I felt pain.  No pain.

Then he pressed low on my left pantie line, and I jerked up from the table.  The pain radiated out to my bladder, clitoris, and urethra like a painful swelling, and I suddenly felt like I was going to pee all over the table.

"Okay, so pain there," Dr. A. said.  "That's the genitofemoral nerve."  He pressed the center of that area, the part that generally hides behind your underwear, the area that is right over your bladder.  Pain there, but not as bad as the left side.  He pressed the right genitofemoral nerve, and while I felt pain, it wasn't like the left side.

Then he and the Fellow who was with him stepped out of the room so I could take off my underwear and get comfortable under a blanket for an internal examination.  No stirrups, thank goodness.  I just lay back on the table with my knees slightly bent.

The internal examination was of course awful, all of it.  But it provided absolute confirmation that I have pudendal neuralgia.

The doctor first examined the outside of my pelvis.  My butt cheeks bounced back, or something -- I really have no idea what happened here -- which he says means my muscles are good.  He touched the surface of my vulva, and while I had pain in certain areas -- including the clitoris -- it wasn't even close to the pain that radiated from the genitofemoral nerve.

Then the internal exam.  He pulled down at six o'clock on the vestibule.  Ripping, tearing pain.  He pushed on the anus.  Some pain.  He pushed on the bladder.  Bad pain.  Then he sought the pudendal nerves, first the right one.  I tensed up.  "Relax so I can reach it," he said.  "Relax," the nurse said.  I relaxed my butt, clenched my fists, and nearly screamed when he pushed on the pudendal nerve.

"Now the left side," Dr. A. said.  He found the pudendal nerve on the left side and pushed.  Again, searing pain.  "Is it as bad as the right side?"

"I don't think so," I said.

He pushed the right nerve again.

"Yes, that one hurts more."

He removed his finger and said we were done, but by now all the colors of the pain were sliding over my vision and I was crying.

"Are you okay to concentrate?  Do you need me to leave?"

"No, I'm fine," I said.  The nurse rushed Kleenex to me.  "The pain is just scary."

Where did it come from?

Dr. A. says I have pudendal neuralgia as well as genitofemoral neuralgia.  He is betting the pudendal neuralgia is bilateral, but he thinks the genitofemoral neuralgia is on the left side only.

"Why do I have pain coming from two different nerves?" I asked him at the end of the appointment.  "I thought neuralgia was usually due to injury to a single nerve."

"There are a number of possible causes," he said.  He listed several, and I found I qualified for two -- sitting for long periods of time and having repeated urinary tract infections.  Both were happening leading up to the sudden onset of my pain in the fall of 2006.  At that point, I had been sitting at a desk job for three years -- which is certainly not a long time, but if a person is prone to such neuralgia, maybe it is -- and I had had two urinary tract infections in the previous six months, as well as a lifelong history of UTIs going all the way back to when I had just finished potty training.

The treatment

Dr. A. prescribed a multifaceted treatment:
- Taking Gabapentin, working up to 300mg three times a day
- Taking Cymbalta, 30mg a day
- A bilateral pudendal nerve block performed with fluorscopy? which I had never heard of before
- A genitofemoral nerve block performed with ultrasound

And here is the BEST part, the part that sold me on Dr. A.'s sensitivity to pudendal neuralgia.

"Have you done physical therapy?" he asked me.

"Yes," I said.  "But I only got one session in before my insurance expired."  This was several years ago.

"What did you do?"

I showed him a few movements the physical therapist suggested.

"And did she work on the inside?"

"Yes," I said.

He used his thumb to massage my arm firmly.  "Like this?"

"Yes."

"If you can't stand me poking your pudendal nerve for one second, how are you going to stand this kind of therapy?"

BAM -- the sky was clear.  Internal physical therapy is a mainstay of pelvic pain therapy.  Everywhere I turn, I read about someone doing pelvic-floor therapy.  But here Dr. A. had hit the nail on the head, the reason why I have resisted the idea of such therapy from the get go.

[As a side note, I have done some muscle training on my own at home, lying on my back and resting my finger on my perineum (which doesn't hurt for me) so I can sense how tense my pelvic muscles are and remind them to relax.  For me, this has been a great non-invasive way to understand the habits of my pelvic muscles.]

"Instead, for pelvic pain, I like to recommend aqua therapy," Dr. A. said.  "That way you can get exercise and movement without putting stress on your body."

Woo-hoo!  What a great idea.  This guy is totally in touch.  The whole appointment bowled me over.

"And if you're too afraid to be seen in a bathing suit and you don't want to tell me that now, just sit in a warm bath every day at home for fifteen minutes," he said.

Dr. Abdelmalak himself

Dr. Abdelmalak is an amazing doctor.  Little things he said and did throughout the appointment made it so much better than any other appointment I've had about my pelvic pain.  Here are a few, in case you're curious:

- He spent five minutes telling me how the appointment would go before he began
- He made sure I understood the underlying mechanics of the body
- He told me repeatedly that he is the GPS, but I know my body better than he does, so if I see a shortcut in my treatment, I should take it
- He also told me repeatedly that sometimes patients don't speak up at appointments, and he gave me alternatives in case I wasn't voicing a concern (such as the bathtub alternative above).  No other doctor I've had has observed that patients sometimes don't speak up during appointments, while I've read report after report from patients about how they failed to speak up about a concern during a doctor's appointment
- The whole appointment lasted over an hour.  I felt throughout it that I was important, that Dr. A. and the pain-management department took me seriously and cared about my well-being, that I was worth spending time on.

And at the end of the appointment, Dr. Abdelmalak told the Fellow, who was completely new to the department, "Now you know everything there is to know about pelvic pain.  You should pay her!"  It was funny, and I was happy to be a case study for the Fellow, but above everything, it validated that my diagnoses are on the spot.  My pelvic pain is a quintessential case.  I BELONG SOMEWHERE.

A final word

At the outset of the appointment, after I described my pain to Dr. A., he said to me, "People think of pelvic pain like they think of an injury.  You get a shot, or you do something else, and you're cured.  But it's not like that.  Pelvic pain is a disease."

My skepticism kicked in immediately.  My pelvic pain didn't originate from an infection, and it isn't like cancer or diabetes or any other condition that I have understood to be a disease.  To me, it's always been idiopathic -- arising from unknown origin.  It's been a collection of symptoms, not a physiological dysfunction of defined cause.

But Dr. A. showed me over the course of my appointment that he is extraordinarily knowledgeable about pelvic pain, and the other staff in the pain-management department praised him to me during my interactions with them.  So while I don't understand his reasoning yet, I am taking his word for it.  And I have come away with the understanding that pelvic pain will be a long-term if not permanent issue in my life.

My view of life shifted radically over the past few months, even prior to Dr. A.'s assertion that pelvic pain is a disease.  But that, I guess, is for another post.