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Chronic, nonmalignant pain syndromes of the perineal area have been well described in the medical literature dating back to the last century. However, the etiology of these focal pain syndromes is poorly understood. The patient who is experiencing pain in the perineal area is often embarrassed, because these areas of the body are considered taboo in our society. These pain syndromes are frequently under-reported and under-recognized.

Patients with these pain syndromes often have seen a variety of specialists in different subspecialties—including urologists, gynecologists, gastroenterologists, proctologists, and internists—and despite an extensive evaluation, no specific etiology has been found in the majority of cases. Not surprisingly, many of these patients are frustrated, because they have suffered from chronic pain for many years, but the disease has not been “given a name” and the pain is not controlled. It is important to recognize that these focal chronic pain syndromes of the perineal area do exist. The etiology of these pain syndromes is not known, and a specific secondary cause can be identified in a minority of patients. Although these patients often are depressed, rarely are these pain syndromes the only manifestation of a psychiatric disease. Currently available treatment strategies are empirical, only. Although complete cures are uncommon, effective treatment modalities exist to lessen the impact of pain and offer reasonable expectations of an improved functional status.

The intent of this chapter is to first give a brief overview of the current knowledge of the neurobiology of the perineal area, and then to review the clinical characteristics and treatment strategies of the different perineal pain syndromes.

The perineum is a highly specialized area of the body, responsible for carrying out a host of basic biologic functions, including defecation, micturition, copulation, and reproduction. The display of these diverse functions relies on precise nervous system control, coordinated with endocrine and other local control mechanisms. Compared with other areas of the body, there has been fairly little research on the neuroanatomy, neurophysiology, and neuropharmacology of the perineum. The complexity of the perineum in carrying out many different specialized functions has largely been considered to account for the slow progress in our understanding of the neurobiology of this area. The fact that these areas of the body often are considered taboo in our society also may account for the scarcity of research on this topic.

A detailed review of the neurobiology of the pelvic floor is provided by Burnett and Wesselmann.1 Briefly, the innervation of the perineum is served by both components of the autonomic nervous system, the sympathetic and parasympathetic divisions, as well as the somatic nervous systems2,3 (Figs. 36-1 and 36-2). Sensations from the pelvic floor are mainly conveyed via the sacral afferent parasympathetic system, with a far lesser afferent supply from afferents traveling with the thoracolumbar sympathetics.4 However, sensations of the testis and epididymis may predominantly involve thoracolumbar afferents.4 Somatic efferent and ...

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