Chronic Pelvic Pain Flashcards
Sensory Innervation of PFD
Direct: genitalia
Indirect: to adjacent regions - abdomen, thighs, may refer pain to or have referred pain from one of these structures
Motor function of PFD
Direct: PFM
Indirect: to adjacent regions = abdominals thighs, trigger points may cause motor disturbances and may refer pain to adjacent structures
Visceral referral:
- visceral and somatic afferent nerves converge on the same dorsal horn transmission cells within the spinal cord
- as a result, visceral dysfunction may manifest as somatic pain
- somatic difficulties may result in visceral dysfunction
Sensory Nerves in PFD:
- Iliohypogastric
- ilioinguinal
- genitofemoral: two branches = genital and femoral
- femoral: anterior and posterior divisions
- lateral femoral cutaneous
- posterior femoral cutaneous
- obturator
- pudendal: perineal, rectal, and dorsal nerve to the clitoris/penis
Branches of Femoral Nerve
Anterior:
- intermediate femoral cutaneous nerve
- medial femoral cutaneous nerve
- nerve to pectineus
- nerve to sartorius
Posterior:
- branches to each quadricep muscle
- saphenous nerve
What results from lateral femoral cutaneous nerve compression?
meralgia parasthetica - a disorder characterized by tingling, numbness, and burning pain in the outer side of the thigh.
Nerve injuries: Motor Nerve Damage Signs
- muscle weakness
- Painful cramps or fasciculations (uncontrolled visible muscle twitching)
- muscle atrophy
- Bone degeneration
- changes in skin, hair, and nails (can also occur with sensory or autonomic nerve fiber loss)
- loss or reflexes
Nerve injuries: Sensory Nerve Damage Signs
- Decreased ability to feel vibration, touch; stocking glove ‘numbness’
- decreased proprioception and/or coordination
- decreased pain receptors or hyperesthesia (burning severe pain from over-sensitized pain receptors)
- decreased temperature perception
Nerve injuries: Autonomic Nerve Damage Signs
- changes in blood pressure leading to dizziness, hypotension
- inability to sweat/heat intolerance
- loss of bladder control
Pathophysiology of Nerve Injury: Neurapraxia (First Degree)
- involves local blockage of the nerve impulse but no actual damage to the axon resulting in slowed or stopped nerve conduction velocity
- EMG = normal above and below level of injury
- prognosis: resolution of symptoms occurs within few days or weeks
Pathophysiology of Nerve Injury: Axonotmesis (second degree)
Second Degree:
- the neural tube remains intact while one or more axons within experience damage
- Resolution occurs via Wallerian degeneration; portions of the nerve distal to the lesion die - nerve must regenerate from the point of injury
- Mechanisms = prolonged neurapraxia, trauma (crush, compression, contusion), childbirth (pudendal, obturator nerves)
EMG = denervation changes in affected muscles and in cases of reinnervation, MUPs are present
- Prognosis: recovery takes weeks to months; the farther the target tissue is from the lesion, the longer the healing time. (human axon growth rates can reach 2mm/day in small nerves and 5mm/day in large nerves)
Pathophysiology of Nerve Injury: Axonotmesis (3rd degree)
Third Degree:
- Endoneural tube not intact; regenerating axons may not reinnervate original motor and sensory targets
- nerve regeneration progress monitored with advancing tinel sign -> as nerve regenerates, the tinel’s sign will be found further along the path of the nerve
- Mechanism: more severe injury than second degree
- EMG = denervation changes with fibrillations in affected muscles and MUPs present in cases of reinnervation
- Prognosis = poor recovery in lesions that require more than 18 months to reach target muscle
Pathophysiology of Nerve Injury: Fourth Degree
4th degree:
- The Neural Tube and the axons within are completely interrupted
- scarring at site of nerve injury precludes axons from advancing distal to level of nerve injury
- Positive Tinel Sign at the level of injury that does not advance beyond that level
- MOI: severe contusion, stretch, laceration injuries
- EMG = denervation changes in affected muscles; no MUPs
- Prognosis = generally poor; original functino of the axon may be altered - sensation recovered in an abnormal pattern - altered target muscle firing pattern; can result in complete loss of motor, sensory, and autonomic function; require surgical intervention to restore neural continuity and permit axonal regeneration and motor/sensory reinnervation; mixed recovery, even with surgery - most motor recovery occurs within 3-6 months
Pathophysiology of Nerve Injury: Fifth Degree injury
Fifth Degree:
- complete transection of the nerve
- EMG: same as 4th degree
- prognosis: requires surgery to restore; mixed recovery possible
Nerve Entrapment - nerve being relatively fixed to the bony skeleton:
- the spinal cord
- origin branches
- where nerve takes large turns to change direction
- at the skin/in a scar
- where the nerve pierces a muscle
- where the nerve passes through a ligament
