- Email: [email protected]
Presacral Sympathectomy for Intractable Functional Uterine Pain*
PRESACRAL SYMPATHECTOMY FOR INTRACTABLE FUNCTIONAL UTERINE PAIN':' EDWARD G. WATERS, M.D., P.A.C.S., JERSEY CITY, N. J. N DISCUSSING even briefly any form of medical or surgical therapy for
functional pelvic pain, which in most instances means uterine pain, an exIposition of the supposed etiology of the condition is obligatory, for the treatment of this distressing disturbance is not solved by the exhibition of a few drugs, the manipulation of organs, nor necessarily the eradication of certain pain tracts. In this connection, a casual acquaintance with ethnographic history through uncounted ages is illuminating, for it depicts the psychic blight under which menstruating women lived in primitive and medieval society. Now we are somewhat better informed on the physiology and pathology of menstruation. But without proper and due consideration of its psychological aspects, it is impossible to understand completely this fundamental evidence of femininity. Of the various disturbances associated with menstruation, dysmenorrhea is patently the mo.."'t common and most important of the functional alterations. 'rhe investigation of the cause of dysmenorrhea clearly involves as a first pro-cedure a most thorough gynecologic examination. This will serve to determine whether or not the pain is really functional. All too often, however, will minor disturbances in the pelvis be found which by no stret{'h of the imagination, other than that of an eager surgeon, could possiby serve as a cause for the expressed pain. Nor do some of the occasional good results from surgical management of uterine malposition, asymptomatic ovarian cysts, cervical erosions, etc., justify the assumption that they were curative specifically for the pain of which the patient had been relieved. In many instances, they are merely the psychological placebos which relieve the psychogenic pain and often are only as long lasting as a placebo may be. Let one but review the operating schedules on the gynecologic wards of twenty years ago with those of today and note how time and experience have dealt with displacements of the uterus as causes for female pelvic pain, or whatever else the patient complained of. 'rhe same applies to cervical stenosis. Congenital failure of development or infantile uterus, follicular cysts of the ovary, and a variety of other conditions, are given as causes for dysmenorrhea. At present, endocrine deficiencies of one type or another, or all types put together, are assumed as etiological factors. If the physician is sufficiently observant, experienced, and honest, and has sustained enough disappointments in therapy, he inevitably recognizes the psychoneurotic side of dysmenorrhea. The more he knows of conditioning factors and psychological trauma of the patient's early girlhood and adolescence, the more will he consider her psychological •Presented before the Society of Surgeons of New Jersey, Jan. 31, 1945.
235
rather than IH:r g·yn<'<·olug'i<· poist'. .\ llillll to tind an~· basi(· pntlwlog-ie or a11almni•· dumg-•• in tlH: Ul!'J'Ils with llll~- tlq.!'l't't: ui' !'OilSisl!'lW,V in !hi• I'xperieJH't· has shown not defini1d~ pain pt·ofhwing. entities IH'('PSi'i1t·il~' responsive lo medil·nd~'i'. lt i~-1 1h(• t·••sponsin· ot· I'('iH'I ing; agPnt to ouh•r disturham·es. and it i;; th;· 1·iolnHT of the reaetion whieh \\'P :,;et:k t.iJ <·ontrol by snrgery, mtlwr than ''ratli•·ntion of lh!' initiatiH!-! disonkr. My attitud<' toward tlw utiliu1tion ol' presaeral sympHtht•etom.'c for d.nnnenon·heu i:; enmpar-ahk to tlwt just t>xpressed. l reg-m·d it as n means or :sevPring the paths of pain ful uteri11e stimuli, no matter how prochwed, and in spite of thr· admitted fll'olJ .. ability that it i;;; oJ'ten a painful ps;n·hosomat.ie disorder ot ps,\'f•hogell ic· origin. Nor do I t'XJH'CI that 11w operation will prenmt m•eessaril,v the tt·ansf!'I'l'lH'(' of an emotional eonfli<·l tu another organ m· organ-gToup with the d('n•lopmt•nt of symptoms, tlw Plmt·aeter of whi(•h a r·e dq1elldent upon the or·gan lll'lll'osis ellgend<•r·(·~l. ( 'ertain alterations of mc•ustrnation may he t•xplaiw·d hy the af'tiun ol' tlw een1ral reg·ulating meeh:misltl ill 1ht· brain and nwdulla oblongata Px;•rting; eontrol on the autouotni(• regulating nwehanisnt of 1It<' h.'T'og·asttic· (g'<'llital) ph'xus. ( Parenthetieally, the assoeial ion of l't.lllt rol ma.v he hel1 er tmdt•rstood h.' teealling that to he found hetwet>n tlw olfaetory and gPrlital ot·g-mls of the dog.) OhYiousl~', howe\'l'l', ;nwh alterations eannot IH· painful if tlw twin-Nn·r·.dng Yis<•eral afferent fibers an• dividhl. Howt>ver. it will. in ('HJ'I'i'ully sdeeted (·ases, \'veutuate in a eessation of uterine pain and an e1·adieation ol' pain fixation tu a fundamental and eeeUJTt'111 ph~·siologi<• JH'(}('e~, ot· one lrss periodie or
'hwt•
antieipated in form.
\VATERS:
PRESACRAL SYMPA1'HECTOMY FOR UTERINE PAIN
237
The innervation of the uterus is both by the sympathetic and parasympathetic systems. The motor fibers arise above the sixth and probably in the fourth dorsal segments of the cord, reaching the sympathetic chain by way of the white mmi communicantes and traveling thence by the sympathetic plexuses to reach the uterus. Section of the cord at that level by injury or by high spinal or caudal anesthesia abolishes uterine contraction. This fact has been demonstrated and employed clinically to completely arrest premature labor contractions. Labor stops and the patient may be carried to term.
~-ig.
1.-Cros,; section of approximately one-fourth of a resected plexus shows eight s>·mpathetic fibers of major size. (X 75.)
This autonomic mechanism is counteracted by the parasympathetic fibers of the sacral division, for when the influence of the latter is abolished by sacral anesthesia, there is cervical relaxation and an increase in tone and force of uterine contractions, but no alleviation of pain. Obviously, the sacral parasympatheties carry no uterine pain sensations, although the pain of dilatation of cervix and vagina is relieved. Anesthesia involving the eleventh and twelfth thoracic segments causes complete cessation of uterine pain without impairing uterine contractions. It is thereby demonstrated that the centripetal fibers transmitting painful uterine stimuli pass to this level. These sensory afferent fibers travel with the sympathetic nerves, and will be fbund in the superior hypogastric (presacral) plexus (Fig. 1). It is evident therefore, that removal of the presacral plexus will arrest painful stimuli from the uterus, without materially altering those from cervix or upper vagina. The fibers carrying these pain sensations are regarded as special visceral afferents anatomically and functionally distinct from the sympathetics
238 with \vhieh the~- travel, sinrt• thr~y arF poo1·l.'· m~·r!linatt>d. nud ;·o11nw to thi! ;•t!l'd with ll() ganglion symq.Jst• hefon• t•nlt•J·ing· th<· poslerioJ· spinal l'J' of l!.'anglia \YPI'C found. T11is is not ill aer•ord with the rommonly held opinion that tlwn· 'll'i! no g-anglia. in tlw JH'PHrus vi11 th1• ganglion of Fr~tnkenhiius\!r, pl'PSH(·J·al sympathectomy will not obliterat<~ tfw funet ional rwltoJ· d'fr<·t ivrness of tlw ::;ympathetic nerve supply. 'l'hcoretieally. therefore. uh•l'in(• pain n·lief without marked motor alteration may he expr:r'tecL It is likt>wisP appat'ent that the cffeetiveness of a pre:-;a<'J'al rc:-;eetion may lw a<·<·m·at.Pl.'· Jn·esag-ed h.v inducing a sympathetic. bloek at the Pleventh and hn•lfth dorsal st;gments. where thP spceial uterine afferents ent<'r the dorsal roots with the sympatlw1 ie r·bai11. 'rhe following ease:-; are seleeted from a largPI' !i.Toup. Th•~.\- an• prescntt:d because they illustrate in their ease histories innoeuou:-; assotiated patholog~·, constitutional inadequacy, symptom t.r:an~fm·, anrl prrvions useless operations and hormone therapy. The pain relief after pn:sa<•ral s~·mputheetomy IS un· questionably ascribable to thorough rPmoval of tlw plt'Xlls in ~·nwlt ('ases. l'AsE
J.-Patient singlP, aged Ul yean'.
::-iurgkal hibtory:
::\Ia~toid
operation,
w:n
and 194:2.
.\pp<'n•le•·tomy awl removal oi
two ovarian <'yst~, 1942. Chief ·~omplaint: r;even; dysmenorrlwa sine<• OllHf•t .,{ ft.m. PXtremely ~evere for· pa~t six monthR, and in no wh-f' relieved by the operation
Examination and. oper·ative right parao(iphoron.
finding~:
N'otlring ex<:ept an innoi'UOUK
linw-~ized e~·st
of the
Operation, .Man·h, 1!H4: CyHI wa,; removPd, utnroRa<:ral ligmrwntH shortened wit I< Pagcnsteeher suture. A presaeral sympathcrtomy was then performed. The first menstruation occurred ,;ix weeb after operation with ulJ~olntely no pain. However. ,inee thi>< girl had enure~i~ for year" at night, pRychoanaly:;i.K was recornml'nded, but thi~ wa~ not mnried out. She has had no pain with her perimls Hillce tlw operation, hut. h,,Ji,vPB l~t•r enure~is is worse. 'fhi~ nUt~' well represent a symptom transfpr.
GAShi 2.·--White, welhleveloped woman, 2iJ .'·ears ohL married iive yenrs lmt separat,•d. Nothing· of importarwe in the past Chi<'f eomplainl: HPvt're oysnwnonh;;u for nin<' y•·an<, benuuing progressivt>ly nneessitating the lo>~ of three to five days from hn work C'ach month.
wor~P,
Previous treatment: Various typ<'~ of douches, one dilatation and curettage, one cervical dilatation, repeated injections of variou~ types of hormones. an associated with severe pain, nausea, and vomiting, and she was desperate for relief.
WATERS:
PRESACRAL SYMPATHECTOMY FOR UTERINE PAIN
239
On Aug. 1'7, 1943, under 100 mg. of spinal anesthesia, a presacral sympathectomy was "arried out, accompanied by an incidental appendectomy. Both tubes were ma rkedly thick· ened at the cornual end with typical isthmica nodosa present. These were not touched. Except for one spell of pain with a left sacroiliac strain and sciatica in June, 1944, the patient has been well and free of all menstrual pain since the operation.
Fig. 2.-Presncra l (hypogastric)
~Ym!'athe tic
n erve fiber with distin c t gan-lion cells.
( X160.)
Fig. 3.--A complete ganglion showing numerous n e rve cells, r e moved with the p r esacral (hypogastric) plexus. It is not commonly admitted tha t suc h ganglia exist in thiR a r ea. (X 384. l
240 C.\SE ::.·-\\"hite~ \\'(-'11-de\'eloped \\·onutJJ
;{;) yearr', tHttn'!t>d
:-'l>.
.n~:Jr;-.,
~n pl'UJo;'lUHH·i;':->.
~een }:[a~·.
i!-1·:1-:-L l'rPYiou:-- ;.;.urgif•.al l)Xperh:n~'P;·'· all for d,\':-
t•onl plaint~
Seven~
dy.snwuorrhea
I'V~~J- :-:inn:~
pat ieut ;.;tarh'd ; '.)
l1H'11:-
rua t P a i t lH-·-
ag·t· of I :1 y(~ar:-:. 1H\;•owing: War ...:, t·au,:.;,iog· t~otnplPti• pt·:;~tnd ion foy
t wen.t,Y
four io forty-eight hom'" ni'iPr its onset. ~~ ... <'X}l<'tieneed 11<1 J'<"lit•f fnllmvin~ 111<' >'tn.!;ieal l'l'o eedm·p, mentiono•ol abov<'. ::\u phyKi<'al lindil!~' uf intPro•,;t. ihP ult•t·us h<•ing srmtll. :!llt<'fir•x••·L and probably tuulenl<"VP)operl. Treattw•nt: ~Jw wa~ tn•ait>d with l':triilu~ nJt•di,.afitm> and hol'l!Jillit·' for ihre•• tnonthH without n~li<•L itl .lanuary. IH4+, au opnation wa' dOlil' in wJti,·h there' werr• nr' pathologi' dolit' ll'ilh <·•nuph•tt· r•!~e··fion "r all tltp Het'\'t~~hParin~- ti:-;stH• in 1'11( iuteriljH•.' I l'igorw. .\n itH·idr•nta! npp< 1 nlh·~·tofllY wn;-; ul~o 1
perform<'< I.
The patient lwgan to Hlt'IJH!ruatt• J'our
afl<'r tlu· opt•ration, lthilt· iu bed iu th" ~he lws hPPll followed h• dat
hospital, without bPing awan• tlf tlw onHet of lwr Jlow. report is that slw lm,; been ••omplctely reli<•wtl of ]Hii!l. ~<"'Pitt ~OHH· 1 \\·hat Htnn-· profui4e than fonnel'ly.
HPr ouiy notation is rhat her periods
Conclusions l•'unetional uterine pain l'ommordy reprt•sents a psydwsomati<• disord(•t· Psyehotlwnq>,v offers lllot't' promise than t'OI'l'Petion of eoexistent bnt eompletPly innoeuous findillgs ol' nlinur pelvic pathology
affixt•d to tlw predominant ombh'm of femininity.
When other treatment is inadequate, the pain may he effeetivPl,Y relievt~o hy JH't'sacral sympatheetomy. In patiPilL~ with apparent emotional instability
References Fr.enwut-Hmith, .\f.: New England .1. Med, 226: i\1;), 1!!4:!. Wittkower, E., am! Wilson, A.'!'.: Brit. :VL .J. 2: .)Sfi, Hl-+0, Novak, ;r., and Hamirk, M.: Ztschr. f. Gel•urt~h. lL H,,·niik. 96: Wetherell, P. 8.: .J. A . .\L A. 101: 12\J;), l!l:l:l . .Taboulay, 1\L: Lynn mCd. 90: 102, 18fJ!1. Adson, A. W., and .\fasson, .L C.: .L A. l\1. A, 102: 986, 1!134. Flothow, P. G., and Rwift, H. W.: Am .•T. 1-<;·ehol. 22: fl(l, Hl41.
:;:;{!1,
l!l:!\1.
functional pelvic pain, which in most instances means uterine pain, an exIposition of the supposed etiology of the condition is obligatory, for the treatment of this distressing disturbance is not solved by the exhibition of a few drugs, the manipulation of organs, nor necessarily the eradication of certain pain tracts. In this connection, a casual acquaintance with ethnographic history through uncounted ages is illuminating, for it depicts the psychic blight under which menstruating women lived in primitive and medieval society. Now we are somewhat better informed on the physiology and pathology of menstruation. But without proper and due consideration of its psychological aspects, it is impossible to understand completely this fundamental evidence of femininity. Of the various disturbances associated with menstruation, dysmenorrhea is patently the mo.."'t common and most important of the functional alterations. 'rhe investigation of the cause of dysmenorrhea clearly involves as a first pro-cedure a most thorough gynecologic examination. This will serve to determine whether or not the pain is really functional. All too often, however, will minor disturbances in the pelvis be found which by no stret{'h of the imagination, other than that of an eager surgeon, could possiby serve as a cause for the expressed pain. Nor do some of the occasional good results from surgical management of uterine malposition, asymptomatic ovarian cysts, cervical erosions, etc., justify the assumption that they were curative specifically for the pain of which the patient had been relieved. In many instances, they are merely the psychological placebos which relieve the psychogenic pain and often are only as long lasting as a placebo may be. Let one but review the operating schedules on the gynecologic wards of twenty years ago with those of today and note how time and experience have dealt with displacements of the uterus as causes for female pelvic pain, or whatever else the patient complained of. 'rhe same applies to cervical stenosis. Congenital failure of development or infantile uterus, follicular cysts of the ovary, and a variety of other conditions, are given as causes for dysmenorrhea. At present, endocrine deficiencies of one type or another, or all types put together, are assumed as etiological factors. If the physician is sufficiently observant, experienced, and honest, and has sustained enough disappointments in therapy, he inevitably recognizes the psychoneurotic side of dysmenorrhea. The more he knows of conditioning factors and psychological trauma of the patient's early girlhood and adolescence, the more will he consider her psychological •Presented before the Society of Surgeons of New Jersey, Jan. 31, 1945.
235
rather than IH:r g·yn<'<·olug'i<· poist'. .\ llillll
'hwt•
antieipated in form.
\VATERS:
PRESACRAL SYMPA1'HECTOMY FOR UTERINE PAIN
237
The innervation of the uterus is both by the sympathetic and parasympathetic systems. The motor fibers arise above the sixth and probably in the fourth dorsal segments of the cord, reaching the sympathetic chain by way of the white mmi communicantes and traveling thence by the sympathetic plexuses to reach the uterus. Section of the cord at that level by injury or by high spinal or caudal anesthesia abolishes uterine contraction. This fact has been demonstrated and employed clinically to completely arrest premature labor contractions. Labor stops and the patient may be carried to term.
~-ig.
1.-Cros,; section of approximately one-fourth of a resected plexus shows eight s>·mpathetic fibers of major size. (X 75.)
This autonomic mechanism is counteracted by the parasympathetic fibers of the sacral division, for when the influence of the latter is abolished by sacral anesthesia, there is cervical relaxation and an increase in tone and force of uterine contractions, but no alleviation of pain. Obviously, the sacral parasympatheties carry no uterine pain sensations, although the pain of dilatation of cervix and vagina is relieved. Anesthesia involving the eleventh and twelfth thoracic segments causes complete cessation of uterine pain without impairing uterine contractions. It is thereby demonstrated that the centripetal fibers transmitting painful uterine stimuli pass to this level. These sensory afferent fibers travel with the sympathetic nerves, and will be fbund in the superior hypogastric (presacral) plexus (Fig. 1). It is evident therefore, that removal of the presacral plexus will arrest painful stimuli from the uterus, without materially altering those from cervix or upper vagina. The fibers carrying these pain sensations are regarded as special visceral afferents anatomically and functionally distinct from the sympathetics
238 with \vhieh the~- travel, sinrt• thr~y arF poo1·l.'· m~·r!linatt>d. nud ;·o11nw to thi! ;•t!l'd with ll() ganglion symq.Jst• hefon• t•nlt•J·ing· th<· poslerioJ· spinal l'
J.-Patient singlP, aged Ul yean'.
::-iurgkal hibtory:
::\Ia~toid
operation,
w:n
and 194:2.
.\pp<'n•le•·tomy awl removal oi
two ovarian <'yst~, 1942. Chief ·~omplaint: r;even; dysmenorrlwa sine<• OllHf•t .,{ ft.m. PXtremely ~evere for· pa~t six monthR, and in no wh-f' relieved by the operation
Examination and. oper·ative right parao(iphoron.
finding~:
N'otlring ex<:ept an innoi'UOUK
linw-~ized e~·st
of the
Operation, .Man·h, 1!H4: CyHI wa,; removPd, utnroRa<:ral ligmrwntH shortened wit I< Pagcnsteeher suture. A presaeral sympathcrtomy was then performed. The first menstruation occurred ,;ix weeb after operation with ulJ~olntely no pain. However. ,inee thi>< girl had enure~i~ for year" at night, pRychoanaly:;i.K was recornml'nded, but thi~ wa~ not mnried out. She has had no pain with her perimls Hillce tlw operation, hut. h,,Ji,vPB l~t•r enure~is is worse. 'fhi~ nUt~' well represent a symptom transfpr.
GAShi 2.·--White, welhleveloped woman, 2iJ .'·ears ohL married iive yenrs lmt separat,•d. Nothing· of importarwe in the past Chi<'f eomplainl: HPvt're oysnwnonh;;u for nin<' y•·an<, benuuing progressivt>ly nneessitating the lo>~ of three to five days from hn work C'ach month.
wor~P,
Previous treatment: Various typ<'~ of douches, one dilatation and curettage, one cervical dilatation, repeated injections of variou~ types of hormones. an
WATERS:
PRESACRAL SYMPATHECTOMY FOR UTERINE PAIN
239
On Aug. 1'7, 1943, under 100 mg. of spinal anesthesia, a presacral sympathectomy was "arried out, accompanied by an incidental appendectomy. Both tubes were ma rkedly thick· ened at the cornual end with typical isthmica nodosa present. These were not touched. Except for one spell of pain with a left sacroiliac strain and sciatica in June, 1944, the patient has been well and free of all menstrual pain since the operation.
Fig. 2.-Presncra l (hypogastric)
~Ym!'athe tic
n erve fiber with distin c t gan-lion cells.
( X160.)
Fig. 3.--A complete ganglion showing numerous n e rve cells, r e moved with the p r esacral (hypogastric) plexus. It is not commonly admitted tha t suc h ganglia exist in thiR a r ea. (X 384. l
240 C.\SE ::.·-\\"hite~ \\'(-'11-de\'eloped \\·onutJJ
;{;) yearr', tHttn'!t>d
:-'l>.
.n~:Jr;-.,
~n pl'UJo;'lUHH·i;':->.
~een }:[a~·.
i!-1·:1-:-L l'rPYiou:-- ;.;.urgif•.al l)Xperh:n~'P;·'· all for d,\':-
t•onl plaint~
Seven~
dy.snwuorrhea
I'V~~J- :-:inn:~
pat ieut ;.;tarh'd ; '.)
l1H'11:-
rua t P a i t lH-·-
ag·t· of I :1 y(~ar:-:. 1H\;•owing: W
t wen.t,Y
four io forty-eight hom'" ni'iPr its onset. ~~ ... <'X}l<'tieneed 11<1 J'<"lit•f fnllmvin~ 111<' >'tn.!;ieal l'l'o eedm·p, mentiono•ol abov<'. ::\u phyKi<'al lindil!~' uf intPro•,;t. ihP ult•t·us h<•ing srmtll. :!llt<'fir•x••·L and probably tuulenl<"VP)operl. Treattw•nt: ~Jw wa~ tn•ait>d with l':triilu~ nJt•di,.afitm> and hol'l!Jillit·' for ihre•• tnonthH without n~li<•L itl .lanuary. IH4+, au opnation wa' dOlil' in wJti,·h there' werr• nr' pathologi
perform<'< I.
The patient lwgan to Hlt'IJH!ruatt• J'our
afl<'r tlu· opt•ration, lthilt· iu bed iu th" ~he lws hPPll followed h• dat
hospital, without bPing awan• tlf tlw onHet of lwr Jlow. report is that slw lm,; been ••omplctely reli<•wtl of ]Hii!l. ~<"'Pitt ~OHH· 1 \\·hat Htnn-· profui4e than fonnel'ly.
HPr ouiy notation is rhat her periods
Conclusions l•'unetional uterine pain l'ommordy reprt•sents a psydwsomati<• disord(•t· Psyehotlwnq>,v offers lllot't' promise than t'OI'l'Petion of eoexistent bnt eompletPly innoeuous findillgs ol' nlinur pelvic pathology
affixt•d to tlw predominant ombh'm of femininity.
When other treatment is inadequate, the pain may he effeetivPl,Y relievt~o hy JH't'sacral sympatheetomy. In patiPilL~ with apparent emotional instability
References Fr.enwut-Hmith, .\f.: New England .1. Med, 226: i\1;), 1!!4:!. Wittkower, E., am! Wilson, A.'!'.: Brit. :VL .J. 2: .)Sfi, Hl-+0, Novak, ;r., and Hamirk, M.: Ztschr. f. Gel•urt~h. lL H,,·niik. 96: Wetherell, P. 8.: .J. A . .\L A. 101: 12\J;), l!l:l:l . .Taboulay, 1\L: Lynn mCd. 90: 102, 18fJ!1. Adson, A. W., and .\fasson, .L C.: .L A. l\1. A, 102: 986, 1!134. Flothow, P. G., and Rwift, H. W.: Am .•T. 1-
:;:;{!1,
l!l:!\1.