The Endometriosis Summit's Mentor and Friend, Dr. Maurice K. Chung, RPh, MD, joins the blog this week. Dr. Chung is an absolute pioneer in pelvic pain, preaching to the world that there are multiple generators of pain in the pelvis when someone has endometriosis. He is the Director at Mercy Regional Center of Excellence for Endometriosis, Pelvic Pain & Urogynecology in Canton, Ohio, and Clinical Professor of Obstetrics/Gynecology at the University of Toledo School of Medicine. Dr. Chung has served as President to multiple societies including SLS and IPPS. He is the founder of the "evil twins" concept of painful bladder syndrome and endometriosis being present together. He is also an amazing friend and, along with his World Team of Pelvic Pain experts fantastic conference companions, Pelvic Pain would be no where without Dr. Chung and it is an honor he has joined our blog. He writes:
The pelvic neural network is complex and interconnected, with multiple factors that affect the expression of pelvic pain. For my patients whose pelvic pain is related to endometriosis, the central focus of treatment begins with complete laser excision, removing the initiating source. This minimally invasive surgery does not damage adjacent tissue, thus preserving the ovaries (and fertility) while mitigating pain. In addition to this essential procedure, I take a multi-step approach to addressing all contributing sources of pain throughout the pelvis.
What Causes Pelvic Pain?
A study of women’s pelvic pain showed that 30% of cases were related to the bowel, 30% involved the bladder, 20% were musculoskeletal, and 20% could be attributed to the reproductive organs.1-3 As a gynecologist, I can’t just focus on the reproductive organs, knowing that they only account for 20% of pelvic pain cases. When a patient has pelvic pain, I evaluate all the potential sources, even if another practitioner has already made a diagnosis.
Patients with endometriosis often have interstitial cystitis (IC), or bladder pain syndrome, pudendal neuralgia, and pelvic myofascial pain syndrome. Some physicians diagnose them with pelvic floor dysfunction and order physical therapy. In my approach, I identify all the sources of pain and treat them individually. First, I evaluate the urinary system and ask patients questions that could point to IC. Next, I evaluate the pelvic floor muscles and the nerves that innervate those muscle groups. To gauge potential bowel pain, we discuss symptoms such as diarrhea, constipation, dietary changes, or a previous diagnosis of gluten sensitivity, irritable bowel, or inflammatory bowel.
Treating All Sources of Pain
Once I understand the source(s) of my patient’s pain, I explain the total picture of pelvic pain as a neighborhood. The endometriosis is a burning house. If some of the neighboring houses (the bladder, muscles, nerves, or bowels) are burning as well, then they add more fuel to the fire. The neighborhood is burning hotter and out of control. We can’t put out the fire by just treating one house – we need to treat the whole neighborhood. Here’s how we do that:
Endometriosis is a complex and painful disease, but a combination of laser excision and a systematic approach to other common sources of pelvic pain has been very effective for my patients. Three months after excision surgery, 80-90% of my patients have at least 50% less pain, and it continues to decrease as the pelvic network quiets down. We could not achieve these results by treating endometriosis as an isolated problem – we need to address the pelvic pain as a whole.
1. Zondervan KT, et al. Patterns of diagnosis and referral in women consulting for chronic pelvic pain in UK primary care. Br J Obstet Gynaecol. 1999 Nov;106(11):1156-61.
2. Howard FM. Chronic pelvic pain. Obstet Gynecol. 2003 Mar;101(3):594-611.
3. Chung MK, Chung RP, Gordon D. Interstitial cystitis and endometriosis in patients with chronic pelvic pain: The "Evil Twins" syndrome. JSLS. 2005 Jan-Mar;9(1):25-9.