Marc Possover, MD - Beyond Endometriosis: Why Neuropelveological Expertise Is Essential to Understand Pelvic Pain

So yes, thank you so much. So in 20 minutes it's clear I will be not able to make a lecture and to explain everything of neuropeviology. But once again, I want to make a little bit on high level lecture on neuropeviology. And that is something you discussed, as you discussed before, why neuropephological expertise is essential to understand pelvic pain. The first thing we have to understand in neuropeviology is that when a patient is coming with pain in your office, it's always because nerve involve. Always, always, always. Because an endometriologist is not going through the body to the brain and tells the brain information, "I have pain." The nerve aren't doing that. So the question is endometriosis or any other pathology in the pelvis? A nerve sanctric disease? Yes, always. Every time when you feel pain, every time when you feel a sensation, a burning pain, a phantom pain, even simply sensation, it's linked with a nerve always.

And that is what you have to keep in mind. And that is a problem in gynecology. We're dealing with patient with chronic pelvic pain, with dysmenorrhea, dyspareunia, infertility. And as a gynecologist, we are doing one dealing with organ-based medicine. So we say you have pain. We will do a laparoscopy. We'll do a surgery. And that is a reflex. It's a classical reflex in gynecology. And as you say several times, I completely agree with you. In my consultation in neuropelvology, how many times I see patient got several surgery and it's always the same. Patient have still pain. And then you see the patient we always found the best surgeon. We have an incredible ego as the gynecologist. The other one was not radical enough. It was not good enough, but you come in my office, you will see I'm the best surgeon on the world. And it's always like that.

And then the patient are still staying home with the pain. One patient asked before, but what are you doing when the patient have pain? And to say, "Yeah, that is central sensitization. That is not enough because you have to do some things. You cannot say, if central sensitization, I will disconnect your brain, go home." But in gynecology, we are asking the wrong question. That is a problem. We are asking, where do you have pain? And once the patient said, "Is it my pelvis?" Okay, pelvis on the right is appendix, it's an ovarian. On the left is maybe the bowel. In the lower abdomen is the uterus is ovarian. And of course, today, pain mean endometriosis. It's more or less always like that. And endometriosis is only one of the cause of the possible cause. So we have in neuropelvilogy, we are not asking, where do you have pain?

We try to understand which nerve generates the pain and bring the pain information to the brain, because that is pain. And you have plenty of nerve in the pelvis. You cannot say, "Okay, you have nerve pain. Never bring the information of pain. Like in gynecology, I will do a laparoscopy. I will check. I will go on the left. On the right, I will see if I will find something to remove." No, you cannot deal like that in a neuropeviology in nerve surgery. You have plenty of nerve ... Oh, sorry for that. You have plenty of nerve in the pelvis. And from the neuropelvical neurological point of view, you have the somatic and the visceral pain. There are two different system, nerve system that brings the information of pain to the brain. And in neuropathology, that is the first question. If the patient is suffering from visceral pain, it make no sense to go to the seatic nerve and to explore the theortic nerve.

On the other hand, if the patient is suffering from a somatic nerve pain, it make no sense to remove the uterus because the reuterus will undo the removal of the uterus will use even more neurogenic disorder and mostly patient will develop even more pain. The neuropathic pain plus on the top, the phontom pain. That means exactly like the guy after the leg amputation will say, "I have a stump pain and I have phontom pain. I have the feeling my foot is painfully." Patient will experience exactly the same. The patient will start to have stump pain mean dysmenorrhea. And of course, when a patient report about pain during antercourse, it's always because you have recurrence of endometriosis or because you have some neuroma there and we try to perform a surgery. If a patient in front of pain after leg amputation, the treatment is not to perform a rare amputation and one again and one again.

No, you have to try to find what is the cause. And just by the way, from the neuropelvical point of view, what's held very well is to inject the vaginal cuff after hysterectomy with buttocks. If you can block the visceral nerve that way, you can treat the pain without need for any surgery.

Something is wrong. Yes. So I told you in gynecology in medicine in general, we base our diagnosis on organ. We are dealing with organ-based model of medicine. If the patient, for the same pain, if the patient is coming to the gynecologist, it will be an issue of the uterus, of the ovarian, of the tube, it will be endometriosis. For the same pain, if the patient is going to the urologist, it will be an issue with the blood. I will perform a cystoscopy, and usually the urologist will come with a diagnosis, "Oh, you have chronical sites. You have to get antibiotic for the coming three weeks." And if it don't work, during the next consultation, the urologist will tell you that you have an antithesial situation, mean you have something we cannot do anything for you. You have your pay, go home. It's a long time I saw you.

And if the patient is going to the colorectal surgeon, you will say, "Yes, you have MRI, you have a fistula, you have an ipertonia of the rectum. I will inject buttocks, whatever." In any case, any doctor will try to understand the pain in his area, in his specialty, but I'm not thinking that pain, once again, is a neurological signal. And the patient before who said, "Yeah, but if I have central sensitization and I have pain, what can you do? " My experience, my daily work and I'm dealing with neuropathylogists in 20 years, is the answer is easy. This patient will be left alone, fully alone. She will get maybe a lot of painkillers. She will get a lot of side effect and at some point she will end it in the hand of a psychologist or if even a thick out and everybody will tell you, "Come on, you got 10 surgery, the best surgeon performs the surgery, you must be crazy." And that is the way of most of the patient of endometriosis.

So to say you got a great surgery is a perfect excision, no residual lesion, and you have still pain. Of course, we learn patient can have a lot of pain even with a little bit endometriosin and some patient have a huge amount of endometriosis have a little bit pain. For me, from the neuropaviology point of view, when a patient underwent several surgery and she has still pain, the diagnosis is wrong. It's simple like that. The diagnosis was wrong and the diagnosis probably not endometriosis. And in 95% of my patient I see my consultation neuropeliology is exactly like that. So neuropelviology begin with a different question. Which nerve brings the information of pain to the brain? And you see on the picture on the right, you have plenty of nerve and all nerve are mixed. That means all nerve contain efferent and afferent fibers. So when we are talking for an issue with the nerve, the symptom number one is the pain, but the same nerve has efferent fibers.

That mean when you have an issue with the nerve, you will have always a dysfunction of some pelvic organ. It could be the bladder, it could be the uterus. We were talking about that before. It could be the tube. And from the neuropelvilogical point of view, it's exactly what you have to look for. You have to see the combination of symptom. In gynecology, when you have 50 minutes to spend with a patient, once she said pain, you will think maybe you will make sonography, but in the coming 10 minutes, you will say, "We'll do a laparoscopy for suspicion of endometriosis." We don't want to hurt too much complaint for the patient. If the patient is coming with, "Yes, and I have pain on the left. I have pain on the right. I have pain in my shoulder. I have pain in the tip of my nose.

I have this issue and sometime I'm falling down." It's too much for us gynecology. You said pain is enough for me to go in the wall and to do laparoscopy and neuropelogy is exactly the contrary. The more information you will get, the more you will know exactly within the pelvis where it's the problem. And once again, neuropeliology is not the mentality of gynecologist. Let's do a laparoscopy and let's see. You cannot simply explore the nerve. We are much too arrogant as gynecology to try to understand that because if you think for all of the pain in the body, there are two specialty, too disciplined dealing with pain. You have the neurologist, you have the neurosurgeon, and then you have the symptom doctor like pain doctor. And we think that with an endoscope, we will be able to fix the issue. No, neuropelvilogy don't work like that.

You have to have a full assessment of the sensory symptom of the motor dysfunction, all motor dysfunction, and of course the visceral organ disturbance. The second thing, you have to be aware that in neuropelvilogy pain or when you have an irritation of a nerve, the patient will always feel the pain at the end of the nerve. That mean if it's the nerve of the vulva, the patient will feel the pain in the vulva. Even if the issue is in the pelvic, in the spinal cord or even in the brain. For example, I had vulvar pain. I like this topic because more of the patient will vulvar pain are coming to the gynecology. "Oh yeah, you have an affection. I will give you some topics. I will give you some medication for that. " You see the patient three weeks later, "Oh, it's not getting better." Or, "I will give you a little bit cartison and sometime volvodemia is clear.

It's a psychological issue. Probably you had any sexual issue when you was a kid, something like that. It's always going in this direction." Why? In neuropaviology, vulvodia, vulvar pain mean an information coming from the vulva that will reach the brain. And then the most difficult is to understand which nerve brings this information to the brain. Is that the genital branch of the genitofemoral nerve? Is that the dorsal nerve of the clitoris, the penatal nerve, the endopelvic portion of the pudental nerve, the sacral plexus, or even the central nerve system. And of course, the central sensitization is able to create pain as well. And that is a big deal in neuropelvilogy to found where is the problem, which on all this nerve and in which location within the pelvis creates the information of pain and brings the informational pain. One of the speaker did said before, in endometriosis, when you fix the endometriosi, you will fix the pain.

No, it's not like that. It's definitively not like that. So the real challenge in neuropevilogy is once again to know which nerve, in which location is involved in the pain, is central versus peripheral when you are in the pelvis is visceral or somatic or maybe both. It's a plexus or an hypogastric plexus, hypographic nerve or sacral plexus. And for example, in neuropelvilogy, we are dealing a lot with a lot of pain with buttocks. Is the lesion below or above the pelvis? Below the pelvis, you can use botox above. You can not use the blabotox. And then you have to know it's a neurogenic or non-neurogenic lesion. Neurogenic mean you have axonal damage. If a patient have an axonal damage and you do a laparoscopy, you will find a damaged nerve. You will be not able to do anything. You need this information before you go in the wall.

It's an irritation or damage. You was talking before about suturing of the nerve, suturing of a nerve, even with a 90. It's nice when you have a cutting in the wall and you want to repair directly. But if you see the patient 10 days later, the patient in between have developed a valiant degeneration. That means the distal part of the axon will die. It make even no sense to do a laparoscopy and to reconnect the nerve. All this information you need. If damage on the nerve is within the nerve or outside the nerve, endometrial, the sacral plexus will surround the nerve. Ondometrus of the sciatic nerve start to develop within the nerve. And then I go one step above. It is at the level of the upper or the lower motor neuron within the spinal cord. All these answers, this question have to be answered before you do something.

And with the dysfunction, exactly the same. Patient is coming. She report, "I'm going 30 times per day on the toilet. I need to pee." So for most of us, we'll say, "Okay, you have a bladder infection. I send you home with some antibiotic." Then the next time, the next consultation don't work, you will say, "It's an hyperactivity and OAB. I will give you some anticolinergic." But the most frequent cause for urgency frequency is not hyperactivity in young patient, but hyper sensitivity mean not an ipier activity of the bladder, but an ipier activity of the nerve of the bladder. And before we were talking, somebody was speaking about thresh urinary and continent psoriasis, but it could be also a bladder deep endometriosis. It could be a lazy bladder, which is a very, very consequence of our surgery for deep endometriosis. Once again, I remember you that the hypogratis nerve have nothing to do with avoiding function of the bladder, but avoiding function of the rectum, the pelvic splant nickname in shells of the bladder function.

And of course, when patient is going several time per day on the toilet, the diagnosis number one is IC.

It's like pelvic chronic pelvic pain syndrome. It's like vulvodynia coccidonia that undiagnosed with say blah, blah, blah. It mean only you have a stamp on your face that you have a syndrome, nobody can help you go home and stay home with your pain. That is a reality for this patient. So second, very, very important. In neuropelvilogy, disease always have a cause. There is always a cause. You will never say there is something on the neck, but nobody knows what. Tame show us this morning a beautiful picture of a vascular treatment and described for 20 years ago, the first time vascular treatment compression of the sciatic nerve by gluteal nerve. The question is why? Why not other patient? We found now that more than 60% of these patients are affected by Elodonos syndrome. Elodonzo syndrome, I'm a cardiovascular surgeon. It's a vascular disease. And these patient have usually atopical and delayed vessel that will compress the nerve.

So you cannot say hypsicosomatic in neuropeliology, you have always found a cause. And that is the reason why in neuropevilogy, the consultation take time. In my office, I'd need between one and two hours to make the diagnosis. And even when you have a great radiologist, we will describe everything in the pelvis. With a neurological examination, you will be not even able to say you have probably a schwannoma or non-dometry of the ciatic nerve, but in which part of the ciatic nab, how deep within the sciatic nerve. The neurological examination and history patient history is the most accurate preoperative diagnosis, much better at everything. And in my opinion, sonography with dopa is even better at MRI. In any case, you need the full patient history. You need to find a cause. You can found cause like patient as a kid was ice king, fell down on the coccyx, got a hematoma over the year development scar tissue.

And 30, 40 years later, she start to develop coccygodinia or pudatal pain. That is how neuropelvilogies work. And now it's my pleasure and my obligation is my duty. To say that within the eyes and the internal society of neuropelvilogy is not now everybody who one can call himself neuropelvilogist. We have clear consensus and guideline on neuropelvilogy. Who can say, "I am a neuropeviologist. I have the knowledge, I have the train, I have the volume of patient to tell myself a neuropeliology." We have a certification now in neuropeviology level and level two, level three, and we have clear guideline you can see on the wrong page. And now when the patient say answer, "But if you have pain, what are you doing?" The answer was, "Yeah, we have multidisciplinary team." When I'm really honest, I don't believe in multidisciplinary team. For the patient, usually mean I will go on the left, on the right, at the end, she will sit home alone.

I believe that one guy have to understand everything in the patient. And in patient with pain, we can use painkiller, a painkiller mean treatment for the rest of the life with a lot of side effect, but I want to introduce the bioelectronic medicine because we cannot just decompress the nerve. We have never took cartonel, but we can use neuromodulation. And that is the key. Gynecologists have some point to understand that we can use the nerve. We can use electricity even to control pain on a nerve by using neuromodulation. And that is the future in pain medicine. And there is knowledge, there is clear ... It's obvious that when, for example, you have stimulation of the vagus nerve, you will unpack at the level of the cells, and you will have a decrease of the alpha TNF factor, mean less inflammation and less pain. So yes, with neuromodulation, in body neuromodulation, bioelectronic meditine, for sure we will be able to treat part of the symptom of the endometriosis.

If we will be able to avoid even the development of endometriosis by stimulation, the parasympathetic nerve system, and then to reduce the sympathetic nerve system, we will see that in the future. But for sure, no bioelectrodic medicine will be part of the treatment and will be a part of the treatment, not just of the pain, but endometriosis as well. That is the next generation of medicine. And a gynecologist will have to be aware that it will not come in the coming 20 years. It's already there, definitive there. So technology is there. Thank you very much for your attention. And just if you see on YouTube, I'm doing a lot of lecture for education of patient. Education of patient is the most important, exactly how we are doing education of patient for endometrials. Neuropelvis, that is the key. Thank you.