Lower Back and Pelvic Issues Pelvic and vaginal symptoms Many women who report lower back pain may also experience pelvic pain, groin pain, sensations of numbness and/or pain in and around the vagina. Often times these symptoms are not reported because the patient does not think they are related, they may feel uncomfortable discussing it or the doctor does not think there is a link. There are a number of causes that often are not considered in the evaluation. These conditions will often cause lower back, buttock and leg pain or exacerbate underlying back disease slowing or confounding treatment. Tilted uterus A tilted uterus is a normal variant of the uterine position within the pelvis but has mechanical consequences. It will typically reflect pain to the back in the pre-menstrual and early menstrual phases. The swelling of the uterine wall will send messages to the spinal cord that shares space with other nerves that feed the lower back region. There is information overload at those levels of the spinal cord causing a painful response in the lower back. These symptoms are transient but can be disabling in some cases one full week of every month. Fibroid tumors Fibroid tumors when large enough will take up enough space to cause pressure and sends signals back to the spinal cord via nerves that share space on the cord that then spill over information sending signals to the lower back. They are generally more symptomatic at the pre-menstrual and onset of the menses. When large enough they are a continual source of referred pain to the back. Prior gynecologic or abdominal surgery The same issues that affects the body in the case of spinal surgery affect this region; The issue of scar tissue. Scar tissue grow uncontrolled, it is mechanically inferior to normal tissue and is neurologically hypersensitive resulting in a lower threshold to pain fibers firing. Scar tissue in this region can slowly strangulate the bowel leading to ongoing constipation in the early years and entrapment of other uterine structures including blood vessels and nerves. Inguinal hernias or prior hernia repair failures Hernias are often associated with males because they are easily seen and diagnosed. Women have them as well but they are not obvious and take a specific diagnostic test to clearly prove they are present. Ongoing groin discomfort may be misinterpreted especially in the case of female athletes. The groin has an important relationship to the mechanical function of the lower black and will cause great distress to the lower back. Tarlov/sacral cyst formation This condition was originally diagnosed by Dr. Tarlov in the 1940’s and is still misunderstood and its clinical importance underappreciated. In brief it is a fluid filled cyst like other cyst but is not an isolated structure like other cysts. It is really an inappropriate term in this region. Really the covering or sheath of the nerve has a weakness leading to a ballooning of tissue. The sheath is continuous with the rest of the spinal cord with is bathed by the pulsing circulation of the spinal cord fluid known as cerebro spinal fluid. This outcropping of tissue places undue pressure on the nerves often mimicking a classic sciatic nerve pain. This pain will often travel into the buttock, back of the thigh knee, calf and foot. These cysts occur almost always in the top two segment of the tailbone and in my experience always women unrelated to age or child bearing. I have several theories as to why but it is a more technical academic discussion. These are only diagnosed on MRI and are often not even remarked on by radiologists and thought of as clinically irrelevant by other experts.. Nothing could be further from the truth. These can be the direct and only cause in some cases for the patient’s symptoms. There are also often symptoms of bladder dysfunction including burning. Some women suffering with interstitial cystitis could have this as a primary or contributing factor. Diagnosis and conservative treatment are available. In some cases surgery may be required but very few surgeons are experienced in this approach. The Japanese have been most innovative in this area. Pudendal nerve entrapment The pudendal nerve is a small branch that traces back to larger spinal nerves located at the base of the spine and top of the pelvis. This nerve travels deep in the pelvis near the sit bone also called the ischium. This nerve also supplies sensation to the vaginal region. Irritation to the tailbone or sit bone either by direct blunt trauma, birthing or long term sitting and chronic lower back disease can also fire up the pudendal nerve. The diagnostic to reveal its involvement requires injection to the nerve via the vagina. In some severe cases surgical intervention may be required to free the nerve.

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