POSTOPERATIVE CHRONIC PAIN AND BLADDER DYSFUNCTION - WINDUP AND NEURONAL PLASTICITY - DO WE NEED A MORE NEUROUROLOGICAL APPROACH IN PELVIC-SURGERY

Purpose: Cases of combined symptoms of dysfunctional voiding and assoc iated pelvic discomfort are difficult diagnostic and therapeutic chall enges. Surgical solutions not uncommonly fail to relieve those symptom s. We determine why these symptoms persist postoperatively. Materials and Methods: Four cases of ureteral injury during gynecological laparo scopic procedures for pelvic/menstrual pain are presented. The cases a re reviewed for their severity and similarity in presenting symptoms, complications and long-term consequences. Results: In all cases light pain symptoms and/or dysfunctional voiding problems that existed befor e the initial surgery escalated severely after corrective pelvic surge ry. Conclusions: There are established neurophysiological mechanisms t hat would explain the observed increase in pain after surgical manipul ation of the pelvis. Windup and changes in neuronal plasticity are dir ect consequences of wounding and/or neural injury to the central nervo us system. These principles are important for surgeons to appreciate d ue to the impact they can have on the outcomes of surgery. Blocking th e sensory input into the spinal cord, inherent to every surgical proce dure, through use of local anesthetics, that is preemptive anesthesia, before creation of a wound provides the greatest protection against e scalation of symptoms. Thorough evaluation of all patients before pelv ic surgery is recommended to identify high risk groups (preexisting pa in, voiding syndromes).