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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.
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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.
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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.
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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.
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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 ...