INTRODUCTION

Expert opinion, (one example is the British Journal of Urology), regularly states that chronic pelvic pain (CPP) has no known pathogenesis or cure.¹ Such statements are challenged by data from the posterior fornix syndrome (PFS) paradigm “PFS”, (co-occurring CPP, urge, frequency, nocturia (now “OAB”), abnormal bladder emptying/retention) caused by uterine/apical prolapse (even of minor degree), and cured by native uterosacral ligament (USL) repair² (see rectangle, algorithm, Figure 1). Nor is CPP “incurable”. There are copious data of CPP cure by USL laxity, when part of the PFS paradigm (Video 1).^2-13

Lax USLs as cause of CPP was reported for the first time in the German literature in 1938 by Heinrich Martius,¹⁴ and independently for the first time in the English literature by Peter Petros 60 years later, in 1996.³ In a laparoscopically controlled trial, Petros reported 70% cure of CPP at 12 months by native tissue USL plication. He also reported relief of CPP in 50% of women with ring pessaries.³ Petros hypothesized that CPP originated from inability of lax uterosacral ligaments to support visceral nerve plexuses. These fired off afferent impulses which were interpreted by the cortex as pain originating in the end organ, Figure 2.

DIAGNOSIS

CPP of unknown origin requires co-occurrence of urge or emptying symptoms (see rectangle, diagnostic algorithm, Figure 1. The speculum test, Figure 2, mechanically supports the USLs, and therefore, the visceral plexuses (VP).¹⁵

Uterosacral ligament causation for CPP is easily tested. The speculum test, when it works, relieves multiple pain sites simultaneously. As such, it is a predictive test for cure of CPP by USL repair.

The definitive test for USL causation of CPP is the Bornstein test, local anesthetic (LA) injected transvaginally into the proximal end of USLs. LA anaesthetizes the VPs, and relieves multiple pain sites simultaneously.

TREATMENT

“Repair the structure and you will restore the function”- Integral Theory.

Younger women with CPP are potentially curable by USL native tissue plication.³ Older women have collagen deficiency and require a posterior sling or wide-bore polyester plication of USLs (Video 2).