Neuropelveology

Neuropelveology is a recent development in medicine, founded and conceived of by Dr Marc Possover of Zurich, Switzerland.   It is a field concerned with the diagnosis of injuries and dysfunctions of the pelvis nerves, and treatment of symptoms caused by them.

Problems that fall within the neuropelveologic disease state include:

* Pelvic pains caused by endometriosis directly affecting pelvic nerves

* Chronic urinary dysfunction (spasticity, pain with urination)

* Fecal incontinence, urinary retention

* Neuropathic pelvic pain

* Pelvic mononeuropathies such as Pudendal Neuralgia, Meralgia Paresthetica, and genitofemoral nerve dysfunction.

In many ways, the field a Neuropelveology is a rediscovery of knowledge that every physician learned in their first and second year of medical school, and a reapplication of that lost knowledge to understand why women and men have pelvic neurologic pain and dysfunction.

For example, a woman may complain of pain in her left lower quadrant.  A non-neuropelveologic approach might be to do a laparoscopy and look directly for endometriosis or something else in the left lower quadrant that might be causing this pain.  If there is endometriosis and that is the problem, the excision surgeon would remove it and the patient would improve.  The problem with approach is that not all pain is from endometriosis, and furthermore, not all pain is coming from the location where the pain is felt.  

 

A neuropelveologic approach would be more precise:

  1. First, we would determine if this pain is being carried by somatic or autonomic nerves, based on the character of the pain.

  2. Second, we would do a detailed neurologic exam, and hope to identify the actual nerves that are carrying this pain.

  3. Third, we would do a physical exam, and determine if this pain can be replicated by pressure on specific nerve areas.

  4. Fourth, we might do imaging or targeted nerve blocks to narrow down exactly where along a particular nerve pathway there may be a problem.

Armed with this knowledge, we would now develop a treatment plan that might involve specific physical therapy, target blocks, targeted botox injections, hernia repair, electrical neurostimulation, or neurolysis surgery.

In effect, we are trying to use a very deep knowledge of neuroanatomy and neurofunction to narrow our diagnosis, and ultimately create a more specific treatment than "we are going to go in there and remove the endometriosis and see what happens".

Case Studies

CASE 1 - A woman has been dealing with cyclic pain just under her central chest (epigastric area) for over 10 years.   A previous surgery had been done for endometriosis which was helpful in relieving pelvic pain, but her cyclic epigastric had become crippling for several days a month.  She had seen 8 physicians, none of which had figured out why she had pain.  The gastroenterologist thought it must be her stomach and did a endoscopy and colonoscopy, and found nothing.  She was told there was nothing wrong with her bowels.  A general surgeon took out her gallbladder, since that is in the same location as her pain.  That did nothing. She had seen experts in endometriosis, who felt that her endometriosis had been fully excised.  She was very frustrated.

In our office, we did a thorough history and determined based on her description of her pain (dull, aching pain in the general upper abdomen) that she had a visceral pain.  That meant her pain was being carried by autonomic sympathetic nerves, not somatic nerves.   We then considered the location of the pain, which was in the area of the superior mesenteric and celiac plexus, an autonomic plexus of nerves that carries signals from the cecum, ascending colon, transverse colon, some of the small bowel, and stomach.  

 

Based on this info we knew the pain had to be coming from one of those organs. Given that the pain was cyclic, it was probably related to her previous severe pelvic endometriosis.

 

Armed with this knowledge, we did a very careful laparoscopy.  In this surgery, we found a very subtle change in the surface of the cecum, and noticed that the cecum was too firm.  Knowing that this organ was likely the source of the pain, we performed a ileo-cecectomy (removal of the cecum and a small portion of small bowel).   Once the organ was removed and opened on the path table, we found a huge mass of endometriosis within the cecal wall.    The patient recovered from surgery and had total and immediate relief from her cyclic epigastric pain.

This case demonstrates how a knowledge of neurofunction and neuroanatomy can lead to a direct diagnosis of a condition that had been difficult to understand without that knowledge.   We were happy to have been able to help with this difficult problem!

CASE 2 - A woman presents with endometriosis pain and a history of endometriosis.  As part of her pain, she feels a shocking sensation along the lateral aspect of her leg that is cyclic in nature.  

At physical exam, she has paresthesia / hyperesthesia along the distribution of the lateral femoral cutaneous nerve. 

At surgery, endometriosis is removed from the pelvis.  The peritoneum overlying the lateral femoral cutaneous nerve was normal, and lacking preoperative suspicion we would have left it undisturbed.

Nerve dissection was undertaken along the lateral aspect of the psoas muscle, up the lateral-most aspect of the inguinal ligament.  The lateral femoral cutaneous nerve is dissected, and in doing so a sub-peritoneal focus of fibrosis is found along its path, which is resected, releasing the nerve.

Several months after surgery, the patient reports complete resolution of her lateral thigh tinging and pain.

In all likelihood, removal of the visible endometriosis alone would not have improved her lateral thigh pain.  it is only by a careful history that we knew to look for the area of disease along the nerve.  This is neuropelveology at work.

Neuropelveology at NWEPS

Dr Fogelson is one of just a handful of physicians in the US who has completed formal training in Neuropelveology through ISON, the International School of Neuropelveology.  He completed the Level 1 Training in 2019, and in early 2020 will complete the Lvl 2 training as well.  

Dr Fogelson uses the knowledge gained from Neuropelveologic training in every case, as he believes that this augments our ability to provide the best possible surgical and non-surgical care.

Over time, we will expand the neuropelveologic procedures that we can offer.  As such procedures are technically challenging, we limit what we offer to what we believe we can presently provide that is safe and effective for our patients, which will no doubt expand over time.   There are definitely cases that we feel are best handled directly by Dr Possover in Zurich, or one of the few more experienced neuropelveologic surgeons in Europe.  

 

At present we work with the following conditions:

 

  • Pudendal Neuralgia diagnosis and treatment (surgical and non-surgical) in women.

  • Pudendal Neuralgia, consultative services only, in men.

  • Meralgia Paresthetica (Lateral Femoral Cutaneous Nerve entrapment / neuropathy)

  • Abdominal wall nerve pain (ilioinguinal, iliohypogastric nerve dysfunction)

  • Genitofemoral nerve entrapment

  • Obturator and Sciatic nerve vascular entrapment / endometriosis (selected cases only)

  • Pelvic nerve root entrapment / endometriosis (selected cases only)

  • Undiagnosed pain syndromes with potential neuropelveologic origin

503-715-1377

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© 2018-2020 Nicholas Fogelson, MD / Northwest Endometriosis and Pelvic Surgery