End Fatigue

Pain Down Under

Vulvadynia, Proctalgia Fugax and Interstitial Cystitis

Proctalgia Fugax

This is the name for literally "a pain in the behind." The pain can be experienced in the anal area or up inside the rectum. It often can feel like an even deeper pain when in the pelvic muscles. There are several considerations to look at:

Is the pain coming from the anal area itself? If so, touching the anal area or putting ones lubricated finger gently inside the anal area can elicit or reproduce the pain. When this is the case it is worth looking for hemorrhoids, anal fissures or inflammation in the rectum if the pain is reproduced by going less than an inch or two into the rectum. For hemorrhoids, it is important to treat constipation, using Anusol HC (as opposed to plain Anusol) in cream form if pain is on the outside or suppositories if pain is on the inside can be helpful. The hemorrhoids or pain may also be aggravated by diarrhea or poor digestion. If the food burns as it comes out of the rectum, this often reflects malabsorption of sugars and carbohydrates. When these are not absorbed properly, the bacteria will utilize them and make acidic by-products from them. If this is the case, one should cut back on sugar, decrease carbohydrates, and try different kinds of digestive aids including the pancreatic enzymes which can be found at a health food store (Amylase, etc.). A trial of Betaine HCL (which is a form of hydrochloric acid or stomach acid) may also help improve digestion with the acids being well absorbed long before they get to the rectum. These can be tried to see whether they help. It is also helpful to use moist towelettes (e.g., Tucks) when wiping after a bowel movement. If you have anal fissures, using a small amount of nitroglycerin cream on the area can also be very helpful. This would need to be obtained by prescription from your physician. I will note that nitroglycerin, in whatever form, can cause headaches or a drop in blood pressure—so use only the amount you need and start with a tiny amount the first time (e.g., 1/2 a pea size). These side effects usually go away with time and the dose can be increased if needed. Interestingly, nitroglycerin can often improve symptoms of Fibromyalgia in general, so you may get beneficial side effects as well.

Once one has had rectal pain it is not uncommon for people to keep the rectal sphincter muscle very tight in response to the pain. As is the case with any muscle that is kept tight, this can lead to pain in its own right. When you are on the commode, see how far you can relax your anal/rectal muscles without anything coming out. You will probably be amazed at how much extra tension is kept in these muscles. It is good to get in the habit, throughout the day, of releasing the muscles as much as you can (of course while staying continent). Symptoms can also be helped by sitting in a sitz bath. This can be made by filling your tub several inches high with comfortably warm to hot water and squatting in the water so that the warm water circulates on the anal area and soothes it and helps it to heal. I would consider using the medication Elavil (Amitriptyline)—10 to 25mg at bedtime. Several weeks on this it can often alleviate the pain considerably, as can Neurontin—(900 to 3600 mg a day).

If the pain is coming from higher up in the rectum in a male, one can use his finger to check up inside. Feel for a rounded area on the front part of the rectal wall near the end of your finger when the finger is all the way in. Normally, pushing on it will cause you to feel like you have to urinate. It should, however, not be painful. If it feels boggy when you push on it, or is painful—especially if it reproduces your pain—you may have a prostatitis as a major cause of your FMS/CFIDS/ME. In this situation, especially if you have urinary urgency with low volumes or burning when you pass water, I would use Cipro 500 to 750 mg twice a day or Doxycycline 100 mg twice a day (both are antibiotics) for six weeks. After six weeks stop the antibiotics. If your symptoms have improved and then recur when you stop the antibiotics, continue to take six-week courses of antibiotics until they stay gone. If they didn't improve with the first course of antibiotics switch to the other antibiotic. This may be very helpful treatment for you. A few cautions: Do not use Doxycycline that is expired or out of date. This is one of the few times that an expired prescription can cause you harm or kill you. Also do not take magnesium within 4 to 6 hours of taking Cipro or it will block the absorption of the Cipro. As Cipro is quite expensive (Doxycycline is cheap) it is even more important to not lose any of the absorption. Take the Cipro first thing in the morning and the last thing at night and take the Magnesium in the middle of the day while you are on the Cipro. On either of these antibiotics it is critical that you be on Nystatin and a low sugar diet to prevent yeast overgrowth. Otherwise you will initially feel better and then you will get worse and worse with the antibiotics. The Nystatin dose would be 500,000 unit tablets—2 tablets 2 to 4 times a day. I would note that coffee can aggravate the symptoms of Prostatitis.

If your symptoms of Prostatitis do not respond to the antibiotics, your condition may be what is known as "Prostadynia." This is pain in the prostate where no bacterial infection can be isolated. It may come from fungal overgrowth, constant tightening of the muscles in the pelvic region, or other unknown causes. Fortunately it often improves with the overall treatment of the FMS/CFIDS/ME process. Once again though, it is important to remember to release your anal/pelvic muscles whenever you are aware that they are tighter than they need to be. If you have a discharge from your penis (not during ejaculation—but first thing in the morning before you urinate) see your doctor and have a culture done to make sure that there is no sexually transmitted disease present.

Vulvadynia

Vulvadynia is a process which is often also very uncomfortable for patients. It is felt as pain in and around the vulvar/vaginal area—either constantly or with intercourse. It is sometimes brought on by touch or contact, but may also occur as a constant discomfort even without any touching. Vulvadynia seems to fall into several sub-groups:

A.	Neuropathic—this is pain from a nerve injury and will often feel stinging, burning or electric shock-like. The pelvic exam is usually normal in these cases.
B.	Inflammatory—this sometimes is associated with a ring of redness around the inner vulva and may be associated with some unknown infection or other inflammatory process in that tissue. For this subset, some physicians are recommending surgical incision of a small strip of tissue in a circle around the vulva. I would not do surgery until other approaches have been tried.
C.	Muscular—this comes again from pain in the pelvic muscles. Sometimes one can find the muscle which feels like a tight band and can reproduce the pain by pressing on that muscle. It also can sometimes come from muscles deep in the pelvic area and be referred to the vaginal/vulvar area.

To treat these problems I would begin with using the medication Elavil (Amitriptyline)—10 to 25 mg at bedtime. Several weeks on this can often alleviate the pain considerably. If this is not effective within 6 weeks I would switch to or add Neurontin in a dose of 100 to 600 mg 3 to 4 times a day. Magnesium can interfere with the absorption of Neurontin and therefore should be taken several hours away from the Neurontin (in a single dose during the day) while on the Neurontin. This Magnesium and Neurontin interaction is suspected—but I have not seen it be an actual problem in day-to-day life. You should know if the Neurontin is going to help within a few days of being on a given dose. Start slowly with the Neurontin and work your way up to see what dose is needed. If there is no effect at 2800 mg a day, taper it off. If it helps, one can go as high as 5000 mg a day or higher. If the Neurontin is either poorly tolerated or ineffective, it is worth a trial of Dilantin (an anti-seizure medication) 100 mg 3 to 4 times a day. All of these are prescriptions and should be discussed with your physician.

In addition, be sure that any infections that are present—especially fungal infections which can be a common trigger for this disease—are treated. If you have some drops of urine that seem to burn the area when they come out, have your doctor check the pH (acidity) of your urine. If it is less than 7 then your urine is acidic and it might be worth discussing ways to alkalinize your urine with your physician. For more information contact the National Vulvadynia Association (301-299-0775).

Interstitial Cystitis (I.C.)

This is a condition where people have discomfort in the bladder area and a constant sense of urine urgency and frequency—usually with burning on urination. It is normal in this disease to have some urinary urgency and frequency and this generally goes away or ceases to be an issue after treating the disease. When it is very severe however and is a major focus of your discomfort, you may have Interstitial Cystitis. There are a number of theories about the cause of IC.

A.	One theory is that the coating that lines the inside of the bladder wall and protects the cells is gone and therefore the cells become very vulnerable.
B.	Another theory is that yeast overgrowth (which then becomes aggravated as the symptoms mimic bladder infections—resulting in ongoing or recurrent antibiotics which may cause more harm than good). In these cases the anti-fungal treatments with Sporanox or Diflucan often need to be continued upwards of 12 to 18 months.
C.	That the muscles that attach to the pubic bone (that's the bone all the way at the bottom of the abdomen) can cause a sense of urine urgency with small bladder volumes when they are in spasm. This usually does not cause the burning on urination. Spasm of the other deep muscles in the pelvis can also contribute to this sensation.
D.	Food allergies have been implicated and there are a number of common foods that are considered to be the major culprits.
E.	Excess oxylate production has been proposed. In this case, changing the diet and adding certain supplements one can reverse this process. If your I.C. is severe, add in your supplements one each week or slower as some may aggravate the I.C. If the Malic Acid does this, take the Magnesium Glycinate by itself. Your doctor may be able to help you adjust your supplements as well.