Step-by-Step model to Treat Chronic Pelvic Pain of a Vascular Origin
Rick Kennedy is the CEO of The Center for Vascular Medicine based here Greenbelt, Maryland and a practicing PA.
Rick Kennedy transcribed presentation explaining the Chronic Pelvic Pain Diagnosis & Treatment
So, if a patient presents to us with a chief complaint, non-cyclical pelvic pain that’s been ongoing, that’s chronic, it’s been ongoing for greater than 6 months, the first thing we’re going to ask is whether or not they’ve had a Ob-GYN (Gynecological) evaluation. And we will complete our evaluation, but before we propose any treatment options we will insist that that patient should have a thorough gynecological evaluation to rule out any other causes of pelvic pain.
Once we’ve done that and we are sure that there are no primary causes that need to be addressed by the Ob-GYN (Gynecological) first, again we assess the patient very much based on what we call the history of the presenting illness - the symptoms that have been occurring and the things like the duration and the quality, just like we talked about before, the things that bring on this pain, the things that make it better.
And once we’ve determined that a treatment plan that we can put together, a treatment plan that will help improve the quality of the life of the patient, we do that. And it would typically involve some more specific diagnostic imaging, probably in the form of ultrasounds. And then moving on to the procedures we’ve talked about with regard to venography, which is passing of the x-ray dye through the veins and taking x-ray pictures, the intravascular ultrasound, which is passing an ultrasound probe inside the vein to give us a three-dimensional, really a perfect view of the morphology, or the shape, and the areas of concern inside the vein that we may need to address.
And then addressing that with a couple of different forms of treatment, specifically potentially venoplasty or venoplasty plus venous stenting. So the procedure itself is about a 30-45 minute procedure. We introduce needles into the groin veins if you will, or the leg veins close to the groin. In terms of pain, we do give a local numbing medicine there and it’s probably not much more painful than just getting a needle injection. And once that has happened a lot of that local pain is taken care of.
At that point, not a lot of discomfort is really going to be experienced until we get a little bit further down in the treatment process. You know, the first part of the process is to inject the x-ray dye and take x-ray pictures of the veins in the abdomen, or in the pelvis. The second step, again, is the intravascular ultrasound, which is the introduction of the probe through the needle, so again there’s no discomfort for the patient. This is completely painless. It allows us to image 360 degrees inside the vein. And again those two things are pretty painless.
When you look at the anatomy as we get into talking about balloon venoplasty and venus stenting when you look at the anatomy, particularly if we’re treating the left side of the left leg vein if you will, the left pelvic vein, when we inflate the balloon or when we place the stent, in many cases to the spine. And so, as a result of that, there can be some back pain that occurs during and immediately after the procedure.
We talk about this ahead of time with our patients. We provide different conservative options as well as some medication options to control that pain. And again in our experience, this is only temporary pain and it’s pain that’s not going to last more than 7 or 10 days and can really be managed for the most part using heat in the form of heating pads or just simply using Tylenol. And other than that, as I said, 30 to 45-minute procedure we do have you recover 2-3 hours afterward to ensure that you’re stable and that there’s no bleeding and you’re able to go home safely.
And as I said the one thing to be aware of is that there probably will be some back pain, but it’s something that is easily controllable and it’s only temporary. So, the stents that we use now are approved by the FDA, they’re what’s called nitinol stents, and this technology, this stenting technology, while a little bit newer in the vein is not new to us in medicine in that we’ve been using it in the coronary arteries for many many years and have a lot of good experience about how these things behave. It is a permanent implant, but what’s fascinating about it is once it’s placed inside the vein, the vein quickly will heal over it and make it so that it becomes part of the wall of the vein.
So it is permanent. You want it to be permanent and you want it to isolate itself to the wall of the vein, which is exactly what’s going to happen, it’s what your body’s going to do. And that allows it to continue to, essentially hold open that vein, reestablish the outflow or the drainage of the legs and the pelvis, and really that’s what improves the symptoms. So, these are permanent implants.
We have now fairly long-term data about what we call stent patency, the ability for the stent to stay open. It is sort of a memory metal, so even if over time it starts to become a little bit more narrow than it should be we do always have the option of going back and doing balloon venoplasty again to bring it back to its original shape and size. You know, again, in summary, these are devices that we’ve been using in the vasculature for many years and we understand pretty well how they behave and have had a really good experience with them.
Summary of the Diagnosis & Procedure (if necessary) of Chronic Pelvic Pain of a vascular origin.
1) Ultrasound - Transabdominal non-invasive ultrasound similar to a pregnancy sonogram of the abdomen.
2) Venography - X-Ray of the veins to vein any narrowing of the vein.
2) IVUS - Probe to see inside of the vein (3D image) to confirm findings. Minimally-invasive to view inside of the vein.
4) Venoplasty - A balloon is placed to open the vein in the narrowing region.
5) Venous stent - A stent is placed to keep the vein open and improve blood circulation.