pain generators

Patients who have chronic pain rarely have pain originating from just one problem. A classic example would be endometriosis. When patients have the severe menstrual cramps that are associated with endometriosis it will quickly evolve to include many other problems. One-step in this evolution involves the pelvic floor muscles becoming tight and tender. This results in a feeling of pressure like the patient needs to urinate all the time. Often as menstrual cramps continue to be a problem intercourse becomes uncomfortable and even tampons become uncomfortable. Patients will develop centralized pain in up to 87% of patients who are diagnosed (laparoscopy with biopsy is how the diagnosis of endometriosis is made) and as this occurs patients will often develop problems with bowels including constipation and/or pain with bowel movements. The basic management requires that each of these problems is identified and treated. The evidence is quite clear that if the only thing done is to remove the endometriosis with surgery approximately half the patients will have persistent pain because of the other pain generators that have developed and never been treated. In the example I have given the patient needs treatment of her endometriosis, her pelvic floor pain, her IBS, and her central sensitization