How do contractions and labor pains feel? Moms share their experiences with intense cramps, tightening, pounding, stabbing, and burning sensations during childbirth.

The Varying Experiences of Labor Pain

The only way to truly understand what labor feels like is to experience it firsthand. But for first-time mothers, this can be a daunting prospect. In a survey of nearly 1,000 BabyCenter readers, one thing became clear: labor is different for every woman, with pain ranging from mild to extreme.

Some women described their labor as relatively painless, using terms like “irritating but not unbearable” or “close to painless, thanks to all the training and prep work I did during pregnancy.” On the other end of the spectrum, others reported “excruciating pain” and felt “like [they] were being run over by a train.”

Even for those who received epidurals, the results were mixed. While some found the epidural effectively managed their pain, others still felt “the pressure of each contraction and the pain from the crowning.”

Contractions: Cramping, Tightening, and More

Many moms likened the contractions to an extreme version of menstrual cramps, with the cramping radiating from the top of the stomach down to the pubic area. Others compared the pain to “gas pains times a thousand” or “a horrible cramp that started in [their] back and radiated into [their] stomach.”

Beyond just cramping, some women described the contractions as a “tightening” sensation, like their “entire stomach was tightening down into a painful little ball” or “someone was grabbing all the skin in [their] back and pulling very slowly until it was tight, then holding it for a minute and releasing.”

Pounding, Stabbing, and Burning Sensations

For some, the labor pain was more akin to a pounding or punching feeling, with one mom saying it felt “like being hit with something really hard.” Others experienced a more sharp, stabbing pain, with one likening it to “being impaled on a hot fireplace poker.”

Several moms also reported a burning sensation, particularly during the crowning stage. As one mom explained, “During crowning there was a definite burning sensation, but I did tear, and that made it feel so much better, believe it or not.”

The Often Overlooked Back Pain

While we tend to associate labor pains with the abdomen, some women experienced the most intense pain in their backs. As one mom shared, “I had terrible back pain. I didn’t have any contractions in my stomach like you see in the movies.”

Another mom echoed this sentiment, saying, “It felt like a really bad backache that radiated down my legs.”

Unique Sensations and Experiences

In addition to the more common descriptions, some moms had truly unique experiences with their labor pains. One mom used the words of Forrest Gump to describe it, saying, “Labor is like a box of chocolates, you never know what you’re going to get.”

Another mom compared the contractions to “charley horses in your lower abdomen,” while yet another felt like “someone was squeezing [her] insides as hard as they could.”

Preparing for the Unknown

Despite the wide range of labor experiences shared by these moms, one thing is clear: there is no one-size-fits-all description of what labor feels like. The pain can vary greatly, even for the same woman across multiple deliveries.

While hearing from those who have been through it can provide valuable insight, the only way to truly know what your labor will feel like is to experience it yourself. The best approach is to remain open-minded, trust your body, and lean on the support of your healthcare team and loved ones throughout the process.

Embracing the Unpredictable Journey of Childbirth

Labor is an immensely personal and unique experience for each woman. While some may find it relatively painless, others may face excruciating sensations. Regardless of the specifics, the journey of childbirth is one filled with both challenges and profound moments of strength and triumph.

By understanding the diverse range of possible labor experiences, expectant mothers can better prepare themselves mentally and emotionally for the unpredictable nature of this transformative event. Whether it’s cramps, tightening, pounding, or something entirely unique, the shared experiences of these moms serve as a reminder that there is no “right” way to give birth – only the path that is uniquely your own.

What does labor feel like? Moms describe

The only way to truly find out what labor feels like is to experience it – a bit of a catch-22 for first-timers who want to know what they’re in for!

We did the next best thing and asked nearly 1,000 BabyCenter readers to tell us about their own labor experiences. No one can predict what your labor will be like, but hearing from those who have been there can help you get familiar with the possibilities.

Labor is different for everyone

Our survey results made one thing clear: Labor is different for every woman, with pain ranging from mild to extreme. Even the experience of labor after epidural varied widely. One mom used the words of Forrest Gump to describe it: “Labor is like a box of chocolates, you never know what you’re going to get.”

Some women described labor as relatively painless:

“My pain was irritating but not unbearable.”

“My contractions felt like muscle spasms and weren’t very painful. “

“At first I didn’t know I was in labor and thought I needed to have a bowel movement. By the time we got to the hospital, I was at 10 centimeters. It hurt, but it wasn’t that bad.”

“It was close to painless, thanks to all the training and prep work I did during pregnancy.”

Others reported severe pain:

“I had excruciating pain.”

“The pain was all-encompassing.”

“I felt like I was being run over by a train.”

“I begged my hubby to throw me out of the car on the way to the hospital, it hurt so bad.”

Women who got epidurals had mixed results:

“I was induced and got my epidural early, so I only felt minor contractions. It was all fairly easy!”

“I had period-like cramps until I got an epidural. Then I just waited.”

“The epidural didn’t get rid of everything, like I had hoped. I felt the pressure of each contraction and the pain from the crowning.”

“Painful, until I got the epidural! It saved my life!”

“I still felt most of the pain, even after the epidural was in. “

Cramping

Many moms told us that their contractions felt like an extreme version of menstrual cramps, while others compared them to cramps from gas, the stomach flu, or a charley horse.

“My contractions were like menstrual cramps on steroids.”

“The cramping went from the top of my stomach down to my pubic area.”

“It was like gas pains times a thousand.”

“A horrible cramp that started in my back and radiated into my stomach.”

“Very painful cramping and tightening that started at the top of my uterus and spread downward and through my back.”

“Strong menstrual cramps that came and went. They would start low and radiate up my belly and around into my lower back.”

“Like the cramps you get with a really bad stomach flu, but they last longer!”

“Labor feels like charley horses in your lower abdomen.”

Tightening

Several women described the contractions as a “tightening” sensation rather than cramping.

“It felt like my entire stomach was tightening down into a painful little ball. But the contractions were not unbearable at all.”

“I literally felt my uterus muscles tightening.”

“The contractions felt like my whole body was clenching.”

“It was like someone was grabbing all the skin in my back and pulling very slowly until it was tight, then holding it for a minute and releasing.”

“I had tightening all over my belly, radiating into my lower back and rectum.”

“It felt like someone was squeezing my belly every two or three minutes.”

“It was like someone was squeezing my insides as hard as they could.”

Pounding

Some women described labor as more of a pounding or punching feeling.

“Having contractions felt like being hit with something really hard.”

“Each contraction felt like getting punched in the stomach – the type of punch that knocks all the air out of you.”

“It was like getting punched in the back and the stomach at the same time, but only when the epidural wore off.”

Stabbing

In some cases, the labor pain was decidedly more sharp than dull.

“It felt like I was being impaled on a hot fireplace poker.”

“It was like someone took a serrated knife and stabbed me in the top of my stomach slowly, slowly sawed downward to my pubic bone, and then stopped for a few minutes and started all over again.”

“It felt like a knife going through my cervix.”

Burning

Several moms felt a burning sensation during the contractions and crowning.

“I was expecting the contractions to feel like intense menstrual cramps, but it felt more like burning.”

“I felt a burning pain that spread across my lower abdomen and then slowly eased up as a contraction ended.”

“During crowning there was a definite burning sensation, but I did tear, and that made it feel so much better, believe it or not.”

Back pain

We tend to think of labor pains as occurring in the abdomen, but for some, the pain is in the back.

“I had terrible back pain. I didn’t have any contractions in my stomach like you see in the movies. “

“It felt like a really bad backache.”

“It felt like a Mack truck running over my spine over and over again.”

“It felt like a knife in my back with every contraction. I was literally trying to get away from my own back.”

Pain in other areas

Legs, hips, and the rectal area were also fair game for pain.

“I had rectal pain with each contraction from the very beginning.”

“I had an hour of labor before my epidural was placed with really bad cramping along my upper thighs.”

“It felt as though a 400-pound man was pressing down on each hip.”

“I felt sharp aching in my hips.”

“It felt like someone was stabbing me in the butt and hips from the inside. I had no pain in my back or tummy.”

Waves

Labor certainly isn’t a trip to the beach, but many women described the wavelike effect of contractions.

“Each contraction felt like a wave of pain that rose, peaked, and fell.”

“I could feel each contraction coming on, building and building, then peaking and coming down. When the contraction was over, I felt completely fine.”

“I had very intense waves of pain, coming right on top of one another.”

Pressure

Lots of women felt pressure, even before the pushing stage. The most common analogy used to describe the sensation? All decorum aside, think having to poop.

“After the epidural, it just felt like so much pressure. I was surprised that it felt like I had to have a bowel movement rather than pressure in the vagina.”

“You feel like you want to poop really bad, and there’s some pressure pushing down.”

“It felt like a big poop, to be completely honest.”

“When my contractions started, I thought I had to have a bowel movement.”

“I felt extreme pressure on my rectum.”

“I had lots of pressure in the groin area.”

“I had extreme pressure on my tailbone and vagina.”

“It felt like I had to take a giant poop! Honestly! The pressure was insane!”

“Transition made me feel like I had to move my bowels. “

“When the contractions were beginning, before they really hurt, it just felt like I had to go to the bathroom!”

Pushing

Many women described pushing as a relief, while others found it painful.

“There is a ton of pressure, and once you start pushing it hurts so bad to stop.”

“My contractions were manageable but the rectal pressure was intense! It was relieving to push and incredibly relieving to push him out.”

“Pushing felt awful, like I was constipated times a hundred and trying to push a baby out of my butt!”

“Pushing was great because I could finally do something.”

“I felt contractions during pushing that were pretty bad, but the pushing made them stop hurting.”

“I had deep waves of intense pain up until I was able to push. Then the pain became part of the background noise, as though I was in an altered state.”

Connected, or not, with the body

While some women felt very present in their bodies during labor, others felt separated.

“I felt like I was not in control of my body.”

“My body wanted to take over and do its own thing.”

“It felt like an out-of-body experience.”

“I was stuck between agony with my contractions, ecstasy when I sneaked a push in, and feeling like I was trying to stop a freight train (trying not to push when the urge was there). I have never been more in my body.”

“It was very calm. I was working with my body and felt very empowered.”

“I felt like my body knew what to do, and I went with the flow. I think being fearful contributes to the pain level a lot. As the fear lessened, the pain became less grueling.”

Exhaustion

They don’t call it labor for nothing. Moms definitely acknowledged how much work was involved.

“It was very consuming. I was unable to think of or do anything else after contractions started.”

“It was a lot of physical work, kind of like doing weight training at the gym with heavy weights.”

“If I could describe it, I would say it was the hardest work I have ever done in my life. “

“It was exhausting. I hadn’t eaten, so I had very little energy and had to be on oxygen for about half my labor.”

“The pushing made time fly, but at the same time really exhausted me in a way that I wasn’t prepared for.”

The sunny side of labor

Even if your own piece from that box of labor chocolates turns out to be considerably less than tasty, remember that childbirth has a definite sunny side, as celebrated by many BabyCenter moms.

“It was the most beautiful pain I’ve ever felt.”

“It was amazing. Painful, yes, but I could see (with a mirror) my baby coming out!”

“I was cracking jokes between contractions. I had a blast and was not afraid.”

“It felt natural, like my body was meant to do it and I should just let it happen.”

“It was painful, of course, but it was a different pain. I had never really felt pain with a purpose. Somehow knowing the end result and that it was normal made it easier to bear.”

“Emotionally, it was amazing. Many people say the pain disappears once your child is in your arms, and they’re right!”

What to Expect Before, During, & After Labor

Contractions are a normal part of pregnancy and occur when the uterine muscle tightens and flexes, just like flexing any other muscle. In the end, uterine muscle contractions are what will help you in labor, pushing your baby down the birth canal and out into the world (woohoo!). But to many, decoding the activity of the uterine muscle can be confusing, especially when it comes to the telling the difference between non-labor and labor contractions. Even within those categories, there are still different types of contractions to prepare for.

Let’s break down six types of contractions you can to expect to feel before, during, and after labor.

1. Braxton Hicks:

Your everyday contraction.

Named after an English doctor, Braxton Hicks contractions are essentially “warm up” contractions. They are totally normal and usually start in the second trimester. Often you will feel a quick hardening or tightening of the uterus, usually felt in the front. Dehydration or exertion can bring them on. You may feel more of them at night, especially after a long day.

Just a gentle reminder again, these little twinges are normal and no reason to grab the hospital bag and run out the door.

2. Early labor contractions:

Go time… but not quite yet.

These contractions may be slightly uncomfortable and feel like mild to moderate menstrual cramps. Usually, they’re intermittent and variable, seven to ten or even twenty or more minutes apart. You may be able to sleep or do other activities while experiencing them.  To help figure out if you’re experiencing early labor contractions or Braxton Hicks, you can start timing contractions and look at the pattern.

When you are in early labor, you should aim to stay home as long as possible. Ask your partner to help you create a space to rest through early labor, with low lights and a calm vibe. If that’s not your thing, trying to distract yourself with other activities (like walking, cooking, or watching a favorite TV show or movie) is a good idea, too.

3. Active labor contractions:

Now it’s go time.

Things are picking up in active labor, with contractions coming closer together, from about 4-5 minutes apart and lasting around 30 seconds to a minute. This is usually when your doctor or midwife suggests it is a good time to head to your chosen place of birth—when contractions are strong, regular, and progressing (getting closer together). Most people experience these types of contractions as painful, in both the front and back of the uterus.

You may need more emotional reassurance or help with comfort measures during this time.

4. Transition contractions:

Baby on the way.

Transition is the time when the cervix changes from 8-10 centimeters. It’s often the hardest and most difficult part of labor, the time when people say “I can’t do this!”. Transition contractions are long (up to two minutes) and strong, with short breaks in between. Often, they are accompanied by large amounts of pressure in the vagina and rectum. During transition, you may experience shaking, vomiting, chills, and the need to vocalize. 

It’s common for people not to want to be touched or talked to very much during transition, but if you do want support, encouraging words from your partner and strong counter pressure on your back can make a difference.

5. Pushing contractions:

Here comes baby!

During the pushing stage, you will most often feel a strong expulsion sensation with (and sometimes between) contractions, a feeling very much like having to poop. It’s not uncommon for contractions to slow down quite a bit during this time, allowing rest in between. Some people say it feels good or pressure-relieving to push during these contractions. 

Pushing is pretty darn physically taxing so ask for whatever support you need. Your partner can support you during pushing with lots of encouraging statements like “You’re doing great” or “You are so strong”. They could also hold one of your legs as you push. It’s also helpful to have water, cool washcloths, lip balm or other small things available to stay comfortable.

6. Post-birth contractions:

Yes, uterine contractions happen after birth, too.

Not only are contractions needed to expel the placenta immediately after the baby, but the uterus will continue to contract after birth, as it returns to its pre-pregnancy size (this is called involution). Breastfeeding can trigger post-birth contractions, as well. Known as after-pains, they are at their strongest two to three days after birth. This is totally normal!

Just like during labor, stay calm and remember that you can (and will!) get through this.

Enjoy those newborn snuggles. You certainly earned them!

Signs of Labor – FamilyEducation

How your body prepares and tricky false labor

As labor approaches, your body starts to prepare itself for the task ahead and you may notice various physical symptoms and signs that labor is about to start. Not every woman experiences labor in the same way, and certain signs can occur either before labor starts or during labor.

The following article and video will take you through the signs and symptoms of labor.

Common physical symptoms

Toward the end of your pregnancy, you may experience a sensation of building pressure or cramping in your pelvic or rectal area. This pelvic cramping can feel very similar to monthly menstrual cramps. A dull pain in your lower back that comes and goes is common too. You may also notice an increase in heartburn (acid reflux) and gassiness. Unless you have a high-risk pregnancy, there is no need to go to the hospital or call your doctor if you experience any of these symptoms in the later stages of your pregnancy.

Your emotional state

This is a time of waiting and many women busy themselves with household tasks. These bursts of activity are often thought to be instinctual, as the mother prepares the home for the new arrival, referred to as “nesting.” The anticipation of what will happen during labor can give rise to a mixture of emotions, from fear and anxiety to excitement and impatience. Women may feel fearful about how much pain they will feel or how uncomfortable they will be with bodily functions. Nothing can prepare you fully for how you will feel in labor, but the more you understand about pain relief options beforehand, the more confident you will feel about your ability to manage. It’s also thought that by being informed and prepared, you are likely to reduce your anxiety during labor, which in itself can enable you cope better with the pain of contractions.

Braxton Hicks’ contractions

One of the most common symptoms of approaching labor is an increase in the strength and frequency of Braxton Hicks’, or practice, contractions (see False labor), which may be occurring up to four times an hour. The purpose of these practice contractions is to prepare your uterus to deal with real labor contractions so that labor progresses smoothly. Some women find Braxton Hicks’ relatively painless, while others find these practice contractions fairly uncomfortable, especially if the baby is quite low and contractions cause increased pelvic pressure.

Apart from the level of pain, one of the main ways to distinguish Braxton Hicks’ from real contractions is that Bracton Hicks’ are irregular and they fade away, whereas labor pains occur at regular intervals and gradually become stronger, more intense, and closer together. The other main difference between Braxton Hicks’ contractions and real ones is that, unlike Braxton Hicks’, real contractions cause your cervix to dilate, which indicates that labor is beginning.

No one is sure exactly what triggers labor, but it seems the process varies with each species.

In sheep, a drop in progesterone signals the start of labor. In mice, babies release proteins to signal their maturity, which in turn triggers labor. In humans, little is known about the signals that start labor although there are many theories. Studies suggest that the production of hormones such as corticotrophin-releasing hormone (CRH) by the uterus and placenta may play a role. It’s also thought that an increase in pro-inflammatory substances known as cytokines may be involved. Whatever the trigger, it’s likely that the onset of labor involves a biological communication between your baby and your body to indicate that your baby is ready to be born.

As you approach labor, you will experience irregular contractions; these will increase in strength and regularity as labor progresses.

Common Conditions – After Delivery – Obstetrics – UR Medicine Obstetrics & Gynecology

Common Conditions

Constipation

Normally, bowel movements will resume within the first few days following your baby’s birth. Constipation can occur after having a baby. If you experience postpartum constipation, here are a few suggestions:

• 
  Drink at least eight to ten large glasses of fluid a day.
• 
  Try eating prunes – they are a natural mild laxative.
• 
  Get plenty of rest every day.
• 
  Drink warm liquids each morning.
• 
  Eat foods such as bran, fruits, green vegetables and whole grain cereals and breads.
• 
  A mild laxative or fiber supplement can be used if other measures do not work.
• 
  Call your health care provider if you do not have a bowel movement by the third or fourth day after having your baby.

Hemorrhoids (Piles)

A hemorrhoid is a painful swelling of a vein in the rectum. After having a baby – especially after a vaginal delivery – many women develop hemorrhoids. Symptoms include pain, rectal itching, bleeding after having a bowel movement, or a swollen area around the anus.

How to treat:

• 
  You can use a sitz bath (a basin filled with warm water) or a bath to soak yourself in warm water. This will help hemorrhoids to shrink. Do this two to four times a day.
• 
  Apply witch hazel to the hemorrhoids to soothe. Keep the witch hazel cool in the refrigerator, then apply with cotton balls.
• 
  Sit on a pillow or waffle cushion to relieve pressure on the rectum. Sitting in a rocking chair or recliner may also be more comfortable than sitting in a straight chair.
• 
  Hemorrhoid creams, ointments, suppositories or sprays are available over-the-counter and can produce short term relief. Your health care provider can recommend a brand that is best for you.
• 
  Increase dietary fiber and your intake of fluids. This will help to prevent constipation.
• 
  You may be prescribed a stool softener, and this may take a few days to work. Drinking extra water will also help keep your stools soft.
• 
  If the pain does not go away within a few days, contact your health care provider for further assistance.

Vaginal Bleeding

Every woman experiences postpartum discharge – or lochia – following the birth of a baby. Initially, the bleeding will be bright red with a few small clots – similar to a heavy menstrual period. This should last only through the first week. Over the first two to six weeks following birth, the color will turn from bright red, to pinkish brown then fade to cream or white.

In the hospital, your nurses will provide you with sanitary pads. During your hospital stay, you may want to leave your nicer lingerie (panties and nightgowns) at home, in case you experience any leaking.

This bleeding usually stops in three to six weeks. At home, continue to use sanitary pads, and be sure to wash your hands after changing your pad. DO NOT use tampons douches or powders – these may introduce bacteria to your healing uterus and cause infection.

After delivery of the baby, you will be given a peri bottle (plastic bottle) to squirt warm water over your perineum (area of the opening to your vagina) to keep it clean. This not only keeps the area clean, but can also be very soothing following a vaginal birth and/or episiotomy. Fill your peri bottle with comfortably warm water, and use after each time you use the restroom. Squirt the water from front to back, then gently dry yourself (also from front to back). Take a shower or tub bath every day, using soap and water. Do not use bubble bath during this healing time.

Report heavy vaginal bleeding (soaking more than one pad per hour), large clots, a foul odor, or unusual abdominal tenderness to your health care provider.

Postpartum Blues (or “Baby Blues”)

The birth of a baby is a joyful and happy time, but for various reasons, many women (60-80%) experience a mild and temporary form of depression commonly referred to as the “Baby Blues. ” Possible triggers include the sudden hormonal changes following delivery, the stress and lack of sleep that occur while caring for a newborn.

Symptoms of the Baby Blues usually appear within the first week or two following delivery, and may last for several weeks following. Symptoms include: feelings of tiredness; mood swings; feelings of loss, frustration or anger; unexplained weeping; irritability; inability to sleep.

How should you deal with these feelings? First, try to get some help with the baby and some rest. Many mothers find these feelings go away after adequate rest. Share your feelings with your partner, and find a friend or family member to talk to as well. Most of the time, the main thing you need is a hug and a shoulder to cry on.

If you do not feel better within a few weeks, or if you are concerned about the way you are feeling, be sure to call your health care provider.

Postpartum Depression

While many women will experience Postpartum Blues (“Baby Blues”), in some women these feelings of depression will persist – Postpartum Depression (PPD). If these feelings persist or worsen, medical attention is needed to help you get through this time.

Some symptoms of PPD are similar to the Baby Blues, but become more intense. Other symptoms include: insomnia; persistent sadness; lack of interest in nearly all activity; anxiety; change in appetite; persistent feelings of guilt; thoughts of harming oneself or the baby.

You or a family member need to be aware that sometimes the feelings of guilt will keep some mothers from admitting that they are depressed. Partners or other family members may need to be the ones to contact your health care provider.

So how do you know when the baby Blues have become PPD, and you need to seek medical attention? Contact your health care provider:

• 
  If you or your family suspect that you are experiencing postpartum depression;
• 
  If the “Blues” do not seem to go away two to three weeks following delivery, or feelings seem to intensify;
• 
  If you do not want to be with your baby;
• 
  If you become so angry or frustrated that you worry that you may harm yourself or your baby;
• 
  If you are overeating or not eating at all;
• 
  If you are having increased difficulty coping with everyday frustrations;
• 
  If you are experiencing little satisfaction and enjoyment with motherhood.

Colonic Motility Dysfunction – Colonic Motility

The colon is the last major organ in the gastrointestinal tract. Therefore, it plays a critical role in regulating the frequency of defecation and consistency of stools. The two primary symptoms of colonic motility dysfunction are altered bowel habits (constipation, diarrhea) and intermittent abdominal cramping. Additional symptoms include straining, urgency, feeling of incomplete evacuation, passage of mucus, bloating or feeling of abdominal distension, and postprandial exacerbation of symptoms. The following sections discuss the symptoms of specific motility disorders affecting the colon, the motor correlates of these symptoms, and the cellular and molecular mechanisms of dysfunction, following a brief discussion of how physiological or pathologic motor activity produces the sensation of abdominal pain.

Irritable Bowel Syndrome

The prevalence of IBS is about 11% to 14% in the general population in North America [248–250]. About 70% of IBS patients consulting physicians in Western countries are females [251]. Rome II criteria define IBS as having abdominal pain/discomfort along with at least two of the following three features. (1) Defecation relieves pain/discomfort. (2) Onset of pain associates with an abnormal frequency of stools (more than three times per day or fewer than three times per week). (3) Onset of pain associates with a change in the form of the stool [252]. Additional supportive symptoms in IBS patients include straining, urgency, feeling of incomplete evacuation, passage of mucus, bloating, feeling of abdominal distension, and postprandial exacerbation of symptoms. Altered colonic motor function may result in constipation (constipation-predominant IBS [IBS-C]), diarrhea (diarrhea predominant IBS [IBS-D]), or alternating constipation and diarrhea IBS (IBS-C/D). In addition, recent studies show that about 10% to 25% of patients develop the symptoms of IBS after an episode of severe or prolonged enteric inflammation (postinfectious IBS [IBS-PI]).

Diarrhea-Predominant IBS

In addition to intermittent abdominal cramping, IBS-D patients have one or more of the following symptoms: (1) more than three bowel movements per day, (2) loose (mushy) or watery stools, and (3) urgency of defecation.

Colonic Motor Dysfunction in IBS-D Patients

IBS-D patients presenting with abdominal pain and diarrhea show a several-fold increase in the frequency and amplitude of spontaneous GMCs, compared with healthy controls [22]. Several of the GMCs in IBS-D patients result in defecation during manometric recordings, indicating urgency. The transit time of radiopaque pellets from the cecum to defecation in these patients was several-fold faster than in controls [22]. About 90% of the GMCs in patients were associated with the sensation of intermittent short-lived abdominal cramping. Diarrhea usually occurred after breakfast, and cramping subsided after defecation. The GMCs in the healthy cohort did not produce the sensation of abdominal cramping. The intensity of RPCs (measured as area under contractions) in IBS-D patients was not different from that in healthy controls, except in the descending colon, where it was greater.

The above findings demonstrate a primary role of motility dysfunction—an increase in the frequency and amplitude of GMCs-in generating the symptoms of diarrhea, urgency and abdominal cramping in IBS-D patients. These findings also show that RPCs may have little role in the induction of these symptoms. As indicated earlier, RPCs are essential in frequent and regular turning over of fecal material, thus allowing uniform and extensive exposure of the fecal material to the mucosa for absorption of water and electrolytes. However, rapid propulsion by increase in the frequency of GMCs deprives the fecal material of adequate exposure to mucosa, resulting in loose stools. IBS-D patients do not have impaired absorptive function.

The above group of patients experienced daily symptoms of abdominal bloating, cramping, urgency, and frequent bowel movements ranging from 4 to more than 15 per day for more than 6 months. Therefore, these patients represent cases of moderate to severe IBS-D. The classification of IBS-D patients by Rome III criteria is liberal [253]. As a result, studies that select patients by strict Rome II or Rome III criteria find an increase in the frequency of GMCs in IBS-D patients, which may not reach statistical significance [39]. The colonic transit in a wider population of IBS-D patients is faster than in controls [254–261] but not as much as in patients of the above study with severe symptoms of IBS-D [22]. However, the association between frequent GMCs and faster propulsion and sensation of abdominal cramping with most GMCs in IBS-D patients is present in almost all studies. The relief in abdominal cramping following a bowel movement is due to the lack of a stimulus in the distal colon to generate GMCs.

As shown in , a significant increase in the amplitude of GMCs in IBS-D patients by itself should be enough to increase compression of the colon wall to above the nociceptive threshold. However, a subset of IBS-D patients show hypersensitivity to colorectal distension by a balloon [247, 262–267], which would increase the susceptibility of inducing abdominal cramping by GMCs (see ).

FIGURE 38

The ingestion of a meal stimulates GMCs in IBS-D patients (B), but not in healthy control subjects (A). The amplitude of GMCs in IBS-D patients is more than twice that of healthy controls.

Take-home Messages

1. The frequency and amplitude of GMCs increase significantly in IBS-D patients.

2. These increases relate to the severity of symptoms of abdominal cramping and bowel movements per day.

3. The increase in the amplitude of GMCs by itself may be sufficient to induce the sensation of abdominal cramping in IBS-D patients. Concurrent visceral hypersensitivity exaggerates this sensation.

4. The relief of abdominal cramping may relate to reduction in the incidence of GMCs following defecation.

5. However, if a GMC occurs in the absence of feces in the sigmoid colon, it might initiate an urge to defecate, giving the sensation of incomplete evacuation.

Constipation-Predominant IBS, Slow-Transit Constipation, Idiopathic Constipation, and Constipation Due to Pelvic Floor Dysfunction

According to the Rome II criteria, IBS-C patients present with one or more of the following symptoms: (1) fewer than three bowel movements per week, (2) hard or lumpy stools, (3) straining during bowel movements, and (4) intermittent short-lived abdominal cramping. The patients with IBS-C differ from those with other subtypes of constipation primarily by the absence of abdominal cramping. However, this discrimination is not absolute: non-IBS-C constipated patients may also have abdominal cramps, albeit less frequently. This section discusses all subtypes of constipation together. This does not imply that constipation in different subtypes has the same etiology or that it is manageable by a common approach. The discussion of the subtypes of constipation together highlights the overlapping motor dysfunctions that lead to straining, hard stools, and fewer than three stools per week.

The severity of constipation and types of symptoms differ widely among patients within the same classification. This heterogeneity has resulted in inconsistent findings among clinical studies, which makes it difficult to formulate hypotheses for mechanistic studies.

Colonic Motor Dysfunction in IBS-C, Slow-Transit Constipation (STC), Idiopathic Constipation, and Pelvic Floor Dysfunction (PFD) Patients

The amplitude and frequency of GMCs in IBS-C, STC, idiopathic constipation, and PFD patients are less than half of those in normal subjects; in severe cases of constipation, GMCs are totally absent or scarce [203, 268–272]. The suppression of GMCs in constipation may be pancolonic or confined to the distal colon. Ambulatory 24-hour recordings from STC patients show depression of the overall contractile activity of the colon throughout the day. These patients also show suppression in normal increase of colonic motor activity after awakening in the morning [271].

The frequency and amplitude of GMCs in the colon of patients with constipation due to pelvic floor dysfunction do not differ from those in normal subjects [272]. However, the GMCs are noticeably absent or reduced in frequency when patients feel the urge to defecate (). The urge to defecate in these patients may come from the accumulation of feces in the sigmoid colon or rectum due to RPCs. In the absence of GMCs propagating to the rectum, the descending inhibition and the propulsive force for defecation are absent in constipated patients. Hard straining may not be enough to push feces against the closed internal and external anal sphincters. Additional structural impairments in the pelvic floor function may exacerbate the difficulty in stool expulsion in some patients.

FIGURE 39

GMCs are notably absent, fewer in number, or do not propagate up to the rectum prior to and at the time of defecation in patients with obstructed (pelvic floor dysfunction) defecation. In the absence of a driving force for expulsion of feces and descending (more…)

Pelvic floor dysfunction in constipation may partly be due to impaired motility function of the sigmoid colon. The internal anal sphincter relaxation depends on descending inhibitory signal generated by GMCs propagating up to it. In addition, strong compression by GMCs generates the afferent signal (urge) to relax voluntarily the puborectalis muscle and external anal sphincter. The decrease in the frequency and amplitude of GMCs in constipated patients would compromise both aspects of pelvic floor function. Additional abnormalities in enteric neuromuscular function or in autonomic nerves regulating the puborectalis and external anal sphincter may worsen constipation in these patients. We do not know whether abnormalities in GMCs and impairments in pelvic floor regulation occur independently or whether one leads to the other. Rectal motor complexes are absent in some constipated patients, indicating enteric neuromuscular dysfunction ().

FIGURE 40

The rectal motor complexes were nearly absent in a patient with constipation. (Reproduced with permission from Waldron, DJ, Gut, 31: 1284–1288, 1990 [498]. )

The total incidence of RPCs measured as area under contractions in constipation is variable; it depends on the severity of constipation. The area under contractions in patients with normal colonic transit, with moderately slow transit, or in patients with IBS-C is higher than that in healthy controls [273]. Note that these data, obtained by a wireless capsule, have less fidelity than those obtained by manometric tube. Another study, using the manometric method of recording, found that the area under contractions in slow-transit constipation is less than that in healthy subjects throughout the day (). It is worth noting that, in the absence of GMCs or a reduction in their frequency, colonic propulsion occurs primarily by propagating RPCs. Therefore, having more RPCs does not necessarily mean that propulsion will be faster. Propulsion is faster only if the incidence of propagating RPCs increases. These data are not available. However, as noted earlier, the contribution of RPCs to colonic propulsion is relatively minor. They may influence the consistency of stools by regulating the intensity of turning over of luminal contents.

FIGURE 41

Twenty-four-hour mapping of total colonic motor activity (area under contractions) in slow-transit constipation patients. The total colonic motor activity is suppressed in constipated patients throughout the day. Note that the increases in motor activity (more…)

Take-home Messages

1. The amplitude and frequency of GMCs decrease significantly in constipated patients.

2. The severity of constipation relates to the intensity of suppression of GMCs.

3. The suppression of GMCs in the sigmoid colon will impair pelvic floor function, adding to the severity of constipation.

4. There is no consistent change in the parameters of propagating or nonpropagating RPCs in any type of constipation.

5. Diagnosis of motility disturbances in IBS-D, IBS-C, slow-transit constipation, idiopathic constipation, and obstructed defecation could be made simply by analyzing the frequency of GMCs over 24 hours, their amplitude, duration, distance of propagation, and point of origin in the whole colon. These analyses do not require a computer program. Ambulatory recordings with solid-state transducers would provide more physiological data.

6. GMCs are a reliable biomarker of both primary symptoms of IBS: altered bowel habits and abdominal cramping.

7. The Rome criteria to subdivide IBS patients into different groups are subjective and symptom based. They have not received universal acceptance after three revisions. A mechanism- based criterion, using 24-hour recordings of GMCs, might be more objective. The inclusion of objective criteria would spur mechanistic studies followed by development of therapeutic agents to normalize dysfunctional proteins.

Alternating Constipation/Diarrhea IBS

The symptoms of patients with IBS-C/D alternate randomly between those of IBS-C and IBS-D. We do not know the precise motor patterns during the two opposite conditions of motility function. However, one can extrapolate from what we know about the motor patterns in IBS-C and IBS-D patients that the frequency of GMCs fluctuates from one extreme to the other in IBS-C/D group: when the frequency is above normal, diarrhea results; when it is below normal, constipation results.

Postinfectious IBS

Clinical observations show that a subset (about 10% to 25%) of the subjects exposed to enteric infections in an individual or community setting go on to develop predominantly the symptoms of IBS-D [274–280]. Two major risk factors predispose individuals to developing postinfectious IBS symptoms following an enteric infection: (1) enteritis lasting more than 3 weeks significantly increases the risk for developing IBS-PI over a duration lasting less than 1 week and (2) the presence of comorbid psychiatric disorders or a lifetime history of anxiety and depression at the time of infection increases the risk of developing IBS-PI. The longer duration of enteritis reflects severity of inflammation [275]. The psychosomatic disorders represent dysregulation/impairment of the central nervous system and hypothalamus-pituitary-adrenal (HPA) axis [276, 281]. While motility recordings from these patients are not available, their motility dysfunction is likely similar to that in IBS-D patients.

Take-home Messages

1. Spontaneous variations in the frequency and amplitude of GMCs from one extreme to the other in IBS-C/D patients suggest that environmental conditions (diet, stress, somatic activity) affect their regulatory mechanisms.

2. These observations speak against a genetic (mutation, polymorphism) role in motility and sensory dysfunctions in IBS. The genetic dysfunctions are stable.

3. The persistence of IBS-D-like symptoms in IBS-PI patients is likely due to epigenetic changes in genes encoding proteins of the regulatory mechanisms. Epigenetic changes in gene expression are sensitive to the cellular microenvironment.

Cellular and Molecular Mechanisms of IBS and Other Types of Constipation

Our understanding of the cellular mechanisms of motility dysfunction in functional bowel disorders (FBD) is limited, largely due to the unavailability of neuromuscular tissues from these patients and the paucity of animal models that mimic salient features of these disorders. However, clues from clinical and animal studies suggest potential cellular mechanisms. The following sections highlight the insights obtained from these studies and from recently available models of IBS-D.

Smooth Muscle and Enteric Neuronal Dysfunction

Impaired Gastrocolonic Response.

Clinical studies show that the increase of motor activity— including the incidence of GMCs—in the sigmoid colon following ingestion of a meal is significantly greater in IBS-D patients than in healthy controls [22]. IBS-D patients also show an exaggerated response to exogenous CCK-8 [22]. The greater increase of GMCs after a meal in IBS-D patients associates with faster postprandial transit than in healthy subjects [259]. By contrast, the increase of postprandial colonic motor activity is significantly less in constipated patients than in healthy controls [269, 271, 282–286]. Antral distension by a balloon and duodenal instillation of lipids mimic the gastrocolonic response by increasing tone in the distal colon [287]. The increase in colonic tone by either stimulus is impaired in patients with slow-transit constipation [287].

The parasympathetic nerves mediate the gastrocolonic response to ingestion of a meal. The parasympathetic nerves synapse on nicotinic receptors on the excitatory and inhibitory motor neurons. Accumulating evidence shows that the physiologic stimulation of parasympathetic nerves by ingestion of a meal [22] or experimental electrical stimulation enhances colonic motor activity by release of ACh from excitatory cholinergic motor neurons in the myenteric plexus [42, 44, 215, 288]. Although the postprandial increase of plasma CCK after ingestion of a normal meal in healthy subjects is not enough to stimulate colonic motor activity [208], duodenal instillation of lipids and pharmacologic doses of CCK stimulate colonic motor activity [22, 208]. CCK acts on presynaptic interneurons or directly on motor neurons to release ACh and stimulate colonic contractions, while atropine blocks the contractile response to CCK in human colonic circular muscle strips [22]. Exogenous CCK stimulates GMCs in healthy volunteers as well as in IBS-D patients [22]. However, the number of GMCs stimulated by CCK is several-fold greater in IBS-D patients than in healthy controls, indicating greater and prolonged release of ACh from the cholinergic motor neurons in these patients. These findings suggest that the exaggerated motor response in IBS-D patients may be due to enhanced synthesis/release of ACh at the neuroeffector junction, slow hydrolysis of ACh at the neuromuscular junction, or sensitization of excitation-contraction coupling in circular smooth muscle cells (see Figures 10 and 11).

Findings in patients with constipation are just the opposite of those in IBS-D patients. The contractile response to ACh in circular muscle strips from idiopathic chronic constipation patients is significantly less than that in normal strips from patients with normal colon transit [289]. Interestingly, the muscle strips from constipated patients also show smaller contractile responses to electrical field stimulation (EFS). EFS induces in vitro contractions by releasing ACh from the cholinergic motor neurons. These findings suggest that the impaired colonic motor function in constipated patients is due to a reduction in the expression of ChAT, synthesis or release of ACh, or a defect in excitation-contraction coupling in circular smooth muscle cells. A decrease in the evoked release of ^3Hcholine confirms the defect in the activity of cholinergic neurons in constipated patients [290].

An impairment in excitation-contraction coupling in smooth muscle cells follows from the finding that the contractile response to edrophonium chloride—a short acting choline esterase inhibitor—is significantly lower in slow-transit constipation patients than in healthy controls [291]. ACh accumulation at the neuromuscular junction acts directly on muscarinic M₃ receptors to stimulate smooth muscle contractions. Smooth muscle dysfunction in idiopathic chronic constipation patients is evident from the inability of cathodal current to generate spikes, which suggests impairment of Ca_v1. 2b (L-type) calcium channels [292].

Constipated patients also display subclinical autonomic and sensory neuropathy [293, 294]. These observations may explain the hyposensitivity to colorectal distension in some constipated patients.

Abdominal Cramping/Pain.

About 70% to 90% of patients with different subtypes of IBS report intermittent short-lived abdominal cramping/pain [254, 295]. The perception of pain occurs in the higher centers of the brain when they receive signals from a noxious stimulus from the periphery. Noxious signals reach the higher centers due to an unphysiological condition in the periphery, such as inflammation, amplification of a physiological signal during its transmission to the CNS (visceral hypersensitivity), or impaired supraspinal processing. IBS patients do not have any organic abnormality such as inflammation. Consequently, visceral hypersensitivity and supraspinal processing have received much attention in understanding the etiology of abdominal cramping in IBS patients.

Patients’ recognition of visceral feelings—initial sensation, urge to defecate, and pain—in response to phasic or ramp distensions of a balloon in the colorectal area are used to determine the level of visceral sensitivity. Using this approach, some studies reported that about 90% of IBS patients have visceral hypersensitivity to colorectal distension [263, 296]. These investigators have proposed visceral hypersensitivity as a biomarker of IBS. However, they could not relate most symptoms of IBS to visceral hypersensitivity. They also suggested, without any scientific evidence, that visceral hypersensitivity is the source of motility dysfunction in IBS patients. The concept was that the amplified afferent signals reflexively send aberrant efferent signals to the colon to cause motility dysfunction [297–299]. In proposing these hypotheses, the investigators ignored an important fact: visceral hypersensitivity or impaired central processing does not by itself induce the sensation of pain; a peripheral signal is required.

Numerous other studies show that on average, only about 50% (range, 20% to 80% [300]) of IBS patients show visceral hypersensitivity [254, 267, 295, 301, 302]. The visceral hypersensitivity hypothesis does not explain abdominal cramping in normosensitive patients [265, 295]. In fact, none of the symptoms of IBS adequately distinguish hypersensitive from normosensitive patients [295]. This hypothesis also does not explain which reflexes alter motility function in response to visceral hypersensitivity, which alterations in colonic contractions they produce, or how the same reflexes cause diarrhea in some patients and constipation in others. This hypothesis ignores the wealth of knowledge we have about the regulation of contractions by smooth muscle cells and enteric neurons, the types of contractions they generate, and the specific functions of those contractions. Several publications have challenged this simplistic hypothesis of visceral hypersensitivity alone as the basis of IBS symptoms [300, 303].

It is noteworthy that the symptom of abdominal cramping usually follows alterations in bowel habits. In addition, repetitive high-pressure mechanical sigmoid stimulation develops hyperalgesia in normosensitive IBS patients [304–306]. GMCs that strongly compress the colon wall send afferent signals similar to those of distension of the wall by a balloon. Therefore, an increase in the frequency of GMCs could be one of the factors inducing visceral hypersensitivity.

A unifying hypothesis, based on accumulated basic science and clinical data, is that GMCs are the source of abdominal cramping. Visceral hypersensitivity, if present, worsens the sensation of abdominal cramping. explains the sensation of abdominal cramping with and without visceral hypersensitivity. First, the afferent signals generated by a GMC in health are below the nociceptive threshold (), so they do not cause the sensation of abdominal cramping. The amplitude of GMCs increases more than twofold in IBS-D patients [22]. The afferent signals they generate are noxious (). Each GMC may induce the sensation of abdominal cramping; however, concurrent visceral hypersensitivity will exaggerate the pain [295, 301]. shows a scenario in which abdominal cramping is entirely due to visceral hypersensitivity. In this case, a GMC of normal or below-normal amplitude will induce the sensation of cramping. The intensity of pain will relate to the degree of hypersensitivity.

There is no evidence that the nociceptive threshold decreases to levels where the afferent signals generated by RPCs become noxious. Were this to happen, patients would feel a continuous sensation of pain, because RPCs are always present somewhere in the colon. By contrast, GMCs occur only a limited number of times per day, even in IBS patients who have more. Therefore, abdominal cramping occurs intermittently and only for the duration of a GMC.

illustrates another scenario in which abdominal cramping may occur with or without visceral hypersensitivity. Impairment of descending inhibition prevents relaxation of the receiving segment ahead of it. Receptive relaxation decreases in some IBS patients [247]. In this situation, the afferent signals due to ballooning of the receiving segment will add to those of the GMCs to become a noxious signal. This is likely to happen when impairment of descending inhibition prevents relaxation of the internal anal sphincter as the GMC is attempting to push feces through for defecation or when voluntary relaxation of the puborectalis muscle and the external sphincter are impaired. Another potential scenario is when a GMC attempts to push fecal material past compacted stool in constipated patients ().

FIGURE 42

GMCs in the ascending colon of a severely constipated patient. Each GMC induced a discrete sensation of pain. The recording ports were 12 cm apart. According to the authors, a kink in the manometric tube located distal to the bottom port stimulated these (more…)

Take-home Messages

1. About 90% of IBS patients report intermittent short-lived abdominal cramping. However, only about 50% of these patients have visceral hypersensitivity.

2. Visceral hypersensitivity does not correlate well with most symptoms of IBS.

3. GMC is the stimulus from the periphery that sends perceptible signals to the CNS. At higher amplitudes of GMCs, these signals are noxious and produce the sensation of abdominal cramping/pain that lasts for the total duration of a GMC.

4. Concurrent visceral hypersensitivity and/or failure of descending relaxation enhance the afferent signals generated by a GMC. When this happens, normal-amplitude GMCs produce the sensation of cramping/pain.

5. The frequency of GMCs relates to the symptoms of diarrhea and constipation in IBS patients. A significant increase in GMC frequency causes diarrhea, while a significant decrease causes constipation.

6. The frequency of GMCs may serve as a biomarker of IBS subtypes.

Stress.

Stress is an adaptive physiological response of living systems to real or perceived life-threatening situations. This response begins in the CNS. The release of corticotrophin-releasing hormone (CRH) from the paraventricular nucleus of the hypothalamus is an early and essential step in the stress response [307]. The central release of CRH and other mediators, such as arginine vasopressin (AVP), stimulate the neuroendocrine system comprised of autonomic neurons and the HPA axis, which modulate the adaptive and maladaptive responses of peripheral organs in a stress- and cell-type-specific manner. Nontranscriptional mechanisms largely mediate the immediate and short-term effects of acute stress. For example, acute stress releases norepinephrine in the amygdala and hypothalamus to sharpen focus and attention [308]. It also increases the heart rate and blood flow in preparation for the “fight-or-flight” response [309].

The HPA axis and the sympathetic nervous system show subtle alterations in IBS patients in the resting state and after stressors [310–321]. Acute psychological as well as physical stress modestly stimulate colonic motor activity. Animal studies show that hypothalamic release of CRH and vagal nerves mediate the stimulation of colonic motor function by acute stress [322–324].

Acute stress modestly reduces the thresholds to colorectal distension in IBS patients relative to normal subjects, presumably due to baseline alterations in the HPA axis and the autonomic nervous system [310, 325, 326]. However, we do not know the cause-and-effect relationship between individual mediators of stress and transient sensitization of visceral afferents.

The effects of acute stress are transient, lasting more or less for the duration of the stressor. Clinical studies show that chronic stress, as opposed to acute stress, precipitates/relapses or exacerbates the symptoms of IBS [327, 328]. This is not surprising, because stress targets some of the same physiological functions already impaired in IBS patients, i.e., altered motor function and visceral hypersensitivity to motor events in the colon.

The mechanisms by which chronic stress relapses or exaggerates the symptoms of IBS are not investigable in patients due to ethical considerations and lack of availability of neuromuscular tissues. Animal studies show that heterotypic or homotypic intermittent chronic stress (HeICS and HoICS, respectively) induces visceral hypersensitivity in rats that persists after the stress is over by the following mechanisms [329, 330] ().

FIGURE 43

Cartoon showing the mechanisms of HeICS-induced visceral hypersensitivity to colorectal distension (CRD) in relation to the well-established elements of the stress response. Step 1: Stress releases CRH and angiotensin vasopressin from the paraventricular (more…)

1. Chronic stress releases CRH and angiotensin vasopressin from the paraventricular nucleus in the hypothalamus.

2. CRH and arginine vasopressin stimulate the locus ceruleus/norepinephrine system. In parallel, CRH releases adrenocorticotropic hormone from the pituitary, which releases corticosterone from the adrenal cortex.

3. Activation of the greater splanchnic sympathetic preganglionic neurons releases norepinephrine from the chromaffin cells in the adrenal medulla into the blood stream [331, 332]. The increase in plasma norepinephrine persists for several hours [333].

4. Norepinephrine enhances the expression of NGF in the colon wall.

5. NGF complexes with trkA receptors, and the complex transports retrograde to the thoracolumbar DRG [334].

6. NGF/trkA complex in the DRG sensitizes the ion channels.

7. Hypersensitization of these ion channels amplifies the afferent signals in response to colonic distension/compression to increase perception. This sensitization occurs in the absence of a detectable inflammatory response in the muscularis externa or in the mucosa/submucosa.

Based on the topology and phenotypes of afferent nerve endings in the colon wall [245–247, 335, 336], an increase in NGF in the muscularis externa mediates the induction of visceral hypersensitivity by HeICS, whereas an increase in NGF in the mucosa/submucosa mediates an altered physiological response to digesta in the lumen.

The systemic upregulation of norepinephrine by HeICS also enhances the reactivity of colonic circular smooth muscle cells to ACh in muscle strips as well as in single isolated cells, resulting in an increase in colonic transit and pellet defecation, producing diarrhealike conditions in rats [333] (). Adrenalectomy, but not the depletion of sympathetic neurons by guanethidine, blocks these effects. Corticosterone, CRH, or vagal nerves do not mediate these effects.

FIGURE 44

Effects of HeICS on colonic smooth muscle contractility and motor function. (A) The contractile response to ACh in colonic circular muscle strips increased significantly at 4 hours and 8 hours after 9-day heterotypic intermittent chronic stress protocol (more…)

Norepinephrine enhances expression of the pore-forming α_1C1b subunit of Ca_v1.2b channels in circular smooth muscle cells, which increases Ca²⁺ influx in response to ACh [173] (see Figure 11) to enhance the amplitude of contractions and hence colonic transit. These effects peak at about 8 hours after the last stressor and return to baseline by 24 hours [333]. These findings show that prolonged upregulation of plasma norepinephrine by chronic stress remodels the cellular regulatory mechanisms, resulting in organ dysfunction. Similar remodeling occurs in CNS neurons and cardiac muscle cells [337–340]. Acute chronic stress does not induce these effects. By contrast, HoICS induces hyperalgesia in rats that lasts up to 40 days [330]. The prolonged effects of chronic stress in animal models is consistent with clinical observations that the symptoms of IBS improve with the resolution of major life stressors.

Take-home Messages

1. Chronic, rather than acute, stress in animal models produces prolonged motor dysfunction and visceral hypersensitivity.

2. Chronic stress precipitates/exaggerates the symptoms of IBS.

3. Sustained increase in plasma norepinephrine following chronic stress makes a major contribution to the development of visceral hypersensitivity and altered motor function.

4. Increase in the expression of NGF in the colonic muscularis externa mediates the induction of visceral hypersensitivity by norepinephrine.

5. The retrograde transport of NGF/trkA complex sensitizes the colon-specific DRG neurons.

Early-Life Trauma and IBS

Retrospective studies show that prenatal, infant, or childhood trauma predisposes to developing the symptoms of IBS at an early age, which continue in adulthood [341–350]. Animal models of neonatal trauma support the hypothesis that early-life trauma results in visceral hypersensitivity to colorectal distension and/or motility dysfunction in adulthood.

Mechanical or chemical irritation in neonates results in persistent sensitization of the spinal afferents and visceral hypersensitivity to colorectal distension in adulthood [351]. Maternal separation of neonatal rats induces allodynia and hyperalgesia in adulthood by enhancing expression of NGF in the colon wall [352, 353]. In this model, the proliferation and degranulation of mast cells increase the expression of NGF, which mediates hypersensitivity to colorectal distension. The maternally separated rats also show heightened response to acute water avoidance stress.

A randomized double-blind placebo-controlled study found little improvement in symptoms of IBS- PI patients by prednisone treatment [354]. Therefore, it is not clear whether neonatal maternal separation represents a model of IBS or IBD. Regardless, we do not know yet the epigenetic mechanisms, described later, that underlie colonic motor dysfunction and visceral hypersensitivity in response to adverse early life experiences.

Neonatal inflammation on postnatal day 10 (PND 10) significantly enhances the mRNA and protein expression of the α_1C-subunit of Ca_v1.2 (L-type) calcium channels, Gα_q, and the regulatory myosin light chain kinase (RLC₂₀) in adulthood [355]. The enhanced expression of each of these cell-signaling proteins favors increased reactivity to ACh (see Figure 11). As a result, the contractile responses of single smooth muscle cells and of circular smooth muscle strips from affected rats are greater than those from control rats. The faster colonic transit and greater pellet output in these rats simulate the diarrhealike conditions of IBS-D patients.

The neonatal insult in these rats also enhances the VIP content of muscularis externa and plasma concentrations of norepinephrine. The motility dysfunction in adult rats who received neonatal inflammatory insult occurs in the absence of any inflammation or structural damage. Of note, a similar inflammatory insult in adult rats does not result in enhancement of smooth muscle reactivity to ACh or faster colonic transit [355].

Note that there is seldom a perfect animal model of human disease. However, these models closely mimic specific features of IBS and their regulatory mechanisms. They are indispensable in identifying the underlying mechanisms of organ dysfunction, allowing for testing of hypotheses in humans and development of therapeutic agents.

Take-home Messages

1. Neonatal psychological and inflammatory insults induce visceral hypersensitivity and motor dysfunction in adulthood.

2. The maladaptive effects of chronic stress on gut function—altered motor function and visceral hypersensitivity to motor events in the colon—are the same as those that characterize IBS patients. However, the mechanisms by which chronic stress exaggerates these effects in IBS patients may be different from those that underlie abnormal functions without stress.

Impaired Enteric Reflexes

Balloon distension in in vitro experiments in the intact human colon stimulates contractions above and relaxation below it [47]. The ascending stimulation—mediated by the release of ACh—is blunted in the colon of slow-transit patients [287], which agrees with other findings that the synthesis and/or release of ACh and the excitation-contraction coupling are impaired in constipated patients. However, the descending relaxation—mediated by NO—is not different between slow-transit constipation patients and healthy controls, suggesting a normal function of inhibitory motor neurons. In vitro findings in muscle strips from patients with idiopathic chronic constipation support the notion that their nitrergic neurons are functioning near normal [292]. The normality of inhibitory neuronal function, however, may not be universal in constipation. One study found enhanced NO-induced and ATP-induced relaxation in a group of idiopathic chronic constipation patients [289].

Take-home Message

Impaired release of ACh proximal to the site of balloon distension confirms the defects in the synthesis/release of ACh and/or excitation-contraction coupling in smooth muscle cells in slow-transit patients.

Impaired Smooth Muscle Excitation-Contraction Coupling in Slow-Transit Constipation

The prevalence and severity of slow-transit constipation are higher in females than in males [356, 357]. Alterations in cell-signaling proteins of excitation-contraction coupling in smooth muscle cells in response to progesterone partly explain this disparity. Progesterone acting on its nuclear receptors regulates the expression of some G proteins (Gα_q and Gα_i3) negatively and others (Gα_s) positively [358–360]. Progesterone levels in females with slow-transit constipation are normal. However, due to genetic/epigenetic abnormality, these patients overexpress progesterone B (PGR-B) receptors on colonic smooth muscle cells. As a result, transcription and protein expression of Gα_q decrease, while those of Gα_s increase. The suppression of Gα_q reduces the binding of ligands such as ACh and CCK to their respective receptors coupled with this G protein, resulting in reduction in smooth muscle contractility in response to ligands (). The contractile response to diacylglycerol and KCl, which bypass the Gα_q protein, remains intact, indicating normality of the rest of excitation-contraction coupling (see Figure 11). Incidentally, progesterone concurrently suppresses the expression of COX-1 and enhances that of COX-2 [359], decreasing the generation of thromboxane A₂ (TxA₂) and prostaglandin F2α (PGF₂α) and increasing the expression of prostaglandin E₂ (PGE₂). PGF2α and TxA₂ contract smooth muscle cells, while PGE₂ inhibits these contractions. However, the contribution of these pathways in spontaneous colonic motor function is unknown.

FIGURE 45

The shortening of single isolated smooth muscle cells obtained from normal controls and from patients with chronic constipation. The cell shortening in response to agonists CCK, ACh, and GTPγS was smaller in tissues from constipated patients than (more…)

Take-home Message

Upregulation of progesterone B receptors in smooth muscle cells in the human colon explain the higher incidence of slow-transit constipation in female patients.

Role of ICCs

Some reports found a deficiency in the volume of ICC throughout the colon of patients with slow-transit constipation [99, 361–364]. However, these publications did not establish a cause-and-effect relationship between the reduction in the volume of ICC and patient symptoms, disorders in colonic motor activity, or its regulatory mechanisms. According to numerous clinical studies cited above, the slow transit in these patients is primarily due to the reduction in GMCs. There is no evidence that ICC regulate GMCs, which occur independently of slow waves. A recent study has demonstrated that ICC do not mediate the neuronal input to smooth muscle cells [365]. The normal function of inhibitory nitrergic motor neurons in descending inhibition is additional evidence that reduction in the volume of ICC in constipated patients does not mediate neuronal input to smooth muscle cells [79, 365]. The RPCs regulated by slow waves play a relatively smaller role in slow-transit constipation. However, the slow waves do not show a defect in in vitro recordings from the colonic smooth muscle cells of slow-transit patients [292]. The slow-wave frequency and its spatial organization are not different between IBS patients and healthy controls under resting conditions and after stimulation with a meal or neostigmine [366].

Take-home Messages

1. The volume of ICC is decreased in the colon of slow-transit constipation patients. However, there is no evidence that this decrease causes motility dysfunction or visceral hypersensitivity.

2. Both the frequency of slow waves and nitrergic neuronal function are normal in these patients.

Role of Alterations in the Expression of Neuropeptides in the Myenteric Plexus and Structural Damage to Enteric Neurons and Smooth Muscle Cells

Several immunohistochemical, radioimmunoassay, and ultrastructural studies have identified abnormalities in enteric neurons and smooth muscle cells in tissue from IBS patients [367–374]. Most of these studies are on tissues obtained from severely constipated patients undergoing colonic resection. Disappointingly, these findings are often divergent; some show a positive change, some show a negative one, and others find no change in the same parameter, such as damage to neurons containing a certain neurotransmitter or global damage to neurons [357]. This is partly due to the qualitative nature of analysis in these methods and the heterogeneity of tissues and observations at the microscopic level. Another major limitation is the absence of efforts to establish a cause-and-effect relationship between the findings and functional impairment. These approaches have been very helpful in identifying the cause of a disease when the defect is simple and confined to one type of cell, such as aganglionosis in Hirschsprung’s disease. However, these approaches seem to be of limited use in complex diseases like IBS.

Epigenetic Dysregulation

Over the past three decades, discoveries of gene mutations that cause or contribute to simple Mendelian diseases, such as sickle cell anemia, hemophilia, and cystic fibrosis have been reported [375–377]. However, the search for gene mutation that causes complex diseases, such as diabetes, most cancers, asthma, inflammatory bowel disease, and functional bowel disorders has largely been unsuccessful. Complex diseases exhibit an inheritable component but do not follow Mendel’s laws. For example, discordance of monozygotic twins reaches 30%–50% in diabetes, 70% in multiple sclerosis and rheumatoid arthritis, and 80% in breast cancer [378]. Differential environmental factors during fetal and neonatal development usually account for discordance of monozygotic twins. The simple diseases following Mendel’s laws begin predominantly before puberty [379], whereas complex diseases tend to appear later in life and may exhibit more than one peak of increased risk of onset [380]. The simple diseases progressively worsen after onset, whereas complex diseases, such as major psychosis, inflammatory bowel disease, functional bowel disorders, and rheumatoid arthritis, exhibit relapses and remissions. Epigenetics plays a prominent role in cancer and autoimmune and inflammatory diseases [381–386].

The inherited genetic code is identical in all cell types in an organism, with the exception of a few, such as the gametes [387]. During ontogeny, epigenetic mechanisms set the transcription rates of each gene in the genome ranging from complete silence to full activation, imparting phenotype to each cell. The transcription rates of different genes are set for survival of the fetus and the neonate as well as for optimal responses of the cells to their microenvironment of hormones, neurotransmitters, growth factors, and inflammatory mediators in adulthood. However, if the fetus (indirectly through the mother) or the neonate is exposed to psychological or inflammatory stress, the transcription rates of genes vulnerable at the time of insult may be set at abnormal levels, ensuring current survival but leading to abnormal cell function in adulthood, causing a complex disease. This is known as Barker’s hypothesis [388] or neonatal/fetal programming.

Epigenetic regulation during neonatal inflammatory or psychological stress can modify gene expression by post-transcriptional histone modifications and by DNA methylation.

Posttranslational Histone Modifications.

DNA is packaged tightly into a highly organized and dynamic protein-DNA complex called chromatin. The basic subunit of chromatin is the nucleosome, which contains about 146 bp of DNA wrapped twice around an octomer core of four histones (two molecules each of histones h3A, h3B, h4, and h5) in a 1.65 left-handed superhelical turn [389–392] ().

FIGURE 46

Nucleosome is the smallest unit of chromatin. On the left, the packing of the first few nucleosomes is tight so that the transcription factors do not have access to the DNA wrapped around these nucleosomes. Acetylation of the N-terminal histone protein (more…)

Normally, the histone proteins are positively charged and form tight electrostatic associations with negatively charged DNA, which results in tight compaction of chromatin and inaccessibility of the DNA to transcription factors and transcriptional machinery. The N-terminal tails are the main sites of posttranslational modifications including acetylation, methylation, phosphorylation, citrullination, sumoylation, ubiquitination, and ADP-ribosylation by enzymes, and this affects their function in gene regulation [393]. Acetylation, one of the most widespread modifications of histone proteins, including h3B, h4, and h5, occurs on lysine residues in the N-terminal tail and on the surface of the nucleosome core as part of gene regulation [394]. The addition of an acetyl group to histone proteins reduces their positive charge to form a more relaxed configuration with DNA, which allows the transcription factors and transcriptional machinery access to their recognition sites on the promoters of specific genes to induce transcription.

The opposing actions of histone acetyltransferases (HATs) and histone deacetylases (HDACs) control the acetyl group turnover. The HATs are present as part of large protein complexes and act as transcriptional coactivators. The deacetylases (HDACs) are recruited to target genes via their direct association with transcriptional activators and repressors, as well as their incorporation into large multiprotein transcriptional complexes [383]. Together, these two classes of enzymes account for the coordinated changes in chromatin structure that carry out its functions [395, 396]. The balance between the actions of these enzymes is a key regulatory mechanism for gene expression and governs numerous developmental processes and disease states [383]. Lysine acetylation is associated with active gene expression and open chromatin. h4K9ac and h5K16ac are two histone modifications often associated with euchromatin. Chromatin immunoprecipitation (ChIP) assay shows that neonatal colonic inflammation significantly increases the association of RNA polymerase II (RNAP II) with the core promoter region of the Cacna1c gene in adulthood, which would increase the transcription rate of this gene ().

FIGURE 47

RNAP II interaction with the Cacna1c core promoter is markedly elevated in the colonic muscularis externa of adult rats subjected to neonatal inflammation. Freshly obtained full-thickness rat colon tissues were immersed in warm, carbogenated Krebs solution (more…)

Methylation of lysine and arginine residues can occur in histones h4 and h5, in the mono-, di-, or tri-methylated form [397]. Depending on the site and type of histone, the methylation pattern will result in a different transcriptional outcome. Methylation of h4K9, h4K27, and h5K20 links generally to heterochromatin formation, whereas methylation of h4K4 and h4K36 associates with transcriptionally active regions. Di- and tri-methylation of histone h4 lysine 4 (h4K4me2 and h4K4me3) are hallmarks of chromatin at active genes [398].

DNA Methylation.

Covalent addition of methyl groups, catalyzed by enzymes known as DNA methyltransferases (DNMTs), modifies DNA to alter gene transcription. DNA methylation occurs at specific dinucleotide sites along the genome, cytosines 5′ of guanines (CpG sites). About 40% to 50% of the protein-coding genes have GC-rich sequences in their promoter regions, known as CpG islands, and about 70% to 80% of all CpG dinucleotides in the genome are methylated [399]. DNA methylation affects the correct temporal and spatial silencing of gene expression during development and during disease processes such as tumor progression [400]. The methylation of CpG islands restricts the access of transcription factors to the promoter region, thereby suppressing transcription of the targeted genes [401].

Four members of DNA methylation transferases (DNMTs) regulate DNA methylation in mammals. DNMT1 has a high affinity for the hemimethylated form of DNA, maintaining the constitutive methylation status of the DNA [402]. DNMT2 does not have a DNA-binding domain, and its role in DNA methylation is unknown [403]. By contrast, the roles of DNMT3a and DNMT3b in regulating DNA methylation in oncogenesis and in response to stressors are well established [402].

Genetics

Functional bowel disorders do not have the traits of genetic diseases. Genetic alterations (mutations and polymorphisms) inherited from parents or mutations due to environmental factors once acquired are irreversible. Mutations in a gene may produce a wrong protein or no protein at all; polymorphisms may produce a variant protein. The functional effects of mutations and polymorphisms are stable.

By contrast, the severity and types of symptoms in functional bowel disorders vary, arguing against a genetic component [404, 405]. The symptoms of altered bowel function in IBS-C/D patients switch from one extreme to the other. Acute events such as stress precipitate/exaggerate the symptoms of functional bowel disorders [328]. All these characteristics of functional bowel disorders suggest fluctuating expression of proteins causing dysfunction, a result of epigenetic regulation rather than genetic variance. Epigenetic mechanisms, discussed above, can alter the expression of target proteins in target cells, such as smooth muscle cells and afferent neurons, in response to changes in their microenvironment.

Take-home Messages

1. Epigenetic regulation modifies the expression of selective genes in cells following changes in their microenvironment.

2. If the changes in microenvironment occur during the vulnerable stages of fetal and neonatal development, the changes in expressions of selective genes may persist into adulthood to cause complex diseases, such as IBS.

3. The relapsing/recurring changes in symptoms of IBS do not make them candidates for genetic mutations/polymorphisms.

Inflammatory Bowel Disease

Inflammatory bowel disease (IBD), comprised of ulcerative colitis and Crohn’s disease, is a chronic, idiopathic, and relapsing inflammation of the gut. Ulcerative colitis usually begins in the rectum/distal colon and progresses orally. Crohn’s disease usually begins in the terminal ileum but may extend to other areas of the gastrointestinal tract, especially the colon (Crohn’s colitis). The two types of IBD are clinically, immunologically, and morphologically distinct. In spite of differing etiologies, the primary symptoms of both types of IBD (diarrhea, abdominal cramping, and urgency of defecation) are strikingly similar. Stools of ulcerative colitis patients are bloody and contain mucus.

IBD patients present with motor diarrhea (diarrhee motrice), frequent nonwatery stools [406]. The daily frequency of unformed stools is about five times per day in mild to moderate pancolitis and four times per day in mild to moderate distal colitis. These numbers increase with severity of colitis. About 80% to 90% of pancolitis patients show urgency and nocturnal defecation, and 30% have incontinence [407]. About 80% of these patients report incomplete evacuation. Paradoxically, about 20% to 30% of pancolitis and distal colitis patients pass hard stools [407]. The total gut transit in ulcerative colitis patients is not different from that in healthy controls [408]. However, the proximal colon shows stasis while the rectosigmoid colon shows rapid propulsion, which counteract each other to produce normal whole colon transit [409–412].

Motility Dysfunction in Colonic Inflammation

Limited data are available from manometric recordings in ulcerative colitis patients due to the risk of perforation; much less is available from Crohn’s colitis patients. However, the disturbances in small intestinal motor activity in Crohn’s disease are similar to those seen in the colon of ulcerative colitis patients [413]. Much of our understanding of motility dysfunction in both types of IBD has come from animal models of inflammation.

Studies in IBD patients and in experimental models show that inflammation suppresses RPCs and tonic contractions, at the same time enhancing the frequency of GMCs [19, 166, 409, 414–416]. The degree of suppression of RPCs and increase in the frequency of GMCs are independent variables, but each correlates with the intensity of inflammation and clinical symptoms [166, 409]. The stimulation of GMCs and suppression of RPCs are most intense in the inflamed part of the colon. However, inflammation in one part of a gut organ can reflexively alter motility function at distal locations [417], which means that colitis in the distal colon may suppress RPCs in the middle and the proximal colon.

The above motility dysfunctions explain most of the observed clinical symptoms in IBD patients.

Note that most studies of ulcerative colitis have recruited patients with mild to moderate colitis. Patients with severe colitis are likely to have more intense motility dysfunction, as judged by inflammation in experimental models.

In one group of patients with moderate colitis, the frequency of GMCs increased about twofold over that in healthy controls [39]. The increased frequency of GMCs produces frequent mass movements. The concurrent suppression of RPCs facilitates distal propulsion of luminal contents. The GMCs that propagate up to the rectum or the distal sigmoid colon stimulate afferent signals to generate urges to defecate as well as causing descending relaxation of the internal anal sphincter in preparation for defecation. A strong GMC propagating to the rectum can result in involuntary defecation (fecal incontinence). It is noteworthy that even though the frequency of GMCs increases in colonic inflammation, it still occurs no more than 10 to 15 times per day in moderate colitis. The frequent rapid propulsion by GMCs reduces the contact time of fecal material with the inflamed mucosa to reduce absorption of water and electrolytes. In addition, the concurrent suppression of RPCs reduces the mixing and turning over of fecal material to reduce its total exposure to the mucosa. Together, these two factors result in unformed, but not watery, stools. Note that the degree of stool softness depends on the intensity of inflammation, which stimulates GMCs and suppresses RPCs.

The GMCs compress the colon wall very strongly because of their large amplitudes (>100 mm Hg). Excessive occurrence of GMCs causes hemorrhages, thick mucus secretion, and mucosal erosions in experimental models [418]. These lesions explain the bloody stools with mucus characteristic of ulcerative colitis. While the GMCs are also the driving force for diarrhea in IBS-D patients, their mucosa is not inflamed and fragile as in ulcerative colitis patients. So while IBS-D patients have diarrhea, they do not have bloody stools. The higher frequency of GMCs propagating up to the rectum in the inflamed colon induces frequent bowel movements in ulcerative colitis patients (motor diarrhea).

In a canine model of moderately severe acute pancolitis, the frequency of GMCs increased more than 10-fold [166]. About half of these GMCs propagated to the sigmoid colon, resulting in uncontrollable defecation (urgency). The rest occasionally expelled gas and caused tenesmus, which may result if a GMC generates the urge to defecate in the absence of any stool in the rectum. The false urges caused by GMCs in an empty distal colon may also generate the sensation of incomplete evacuation. These symptoms and abnormal motility cease on recovery from inflammation.

About 20% of ulcerative colitis patients pass hard stools [407], giving the perception that they are constipated. The ascending colon in colitis patients shows stasis, while the sigmoid colon shows rapid transit [408]. Concurrent manometric recordings from the ascending and sigmoid colons of these patients are not available. However, on a speculative note, stasis in the ascending may result if inflammation in the sigmoid colon reflexively suppresses both RPCs and GMCs in the proximal colon, thus prolonging stool transit and forming hard stools. However, when these hard stools reach the inflamed sigmoid colon, the frequently occurring GMCs propel them rapidly, so that the passing of hard stools gives the impression of constipation.

One study in patients with inactive Crohn’s ileitis reported suppression of small intestinal RPCs and stimulation of GMCs [413]. These effects are similar to the colonic motor dysfunction seen in ulcerative colitis patients. Animal models of ileal inflammation confirm these findings [419]. Ileal inflammation suppresses RPCs in the ileum as well as proximal to it, extending up to the stomach. Many of the GMCs stimulated by ileal inflammation propagate up to the terminal ileum. The animals are visibly uncomfortable during the passage of an ileal GMC. The frequency of bowel movements increases several-fold due to ileal inflammation [419]. Spontaneous GMCs in the ileum occur primarily in the interdigestive state [6]. However, in ileal inflammation, they also occur after a meal, resulting in rapid emptying of undigested food and bile from the ileum into the colon.

The increase in the incidence of GMCs in the ileum, by itself, cannot induce frequent defecation. Colon involvement is necessary. Animal studies show that many GMCs originating in the ileum propagate to the colon, causing uncontrollable defecation if they propagate to the sigmoid colon [420]. Furthermore, postprandial GMCs occurring during ileal inflammation rapidly transfer undigested chyme into the colon, which increases its osmotic load to suppress RPCs and stimulate colonic GMCs [149]. In an animal model of ileal inflammation, a collection cannula located distal to the inflamed segment of the ileum collected copious discharge of mucus with fresh blood [419]. These data indicate that an excessively high incidence of GMCs in the inflamed ileum likely causes the severe hemorrhage seen in some Crohn’s disease patients [421, 422].

Take-home Messages

1. Increase in the frequency of GMCs and suppression of RPCs characterize colonic motor dysfunction in IBD patients.

2. Frequent mass movements by GMCs cause diarrhea and urgency.

3. A difference between IBS-D and IBD patients is that RPCs are suppressed in IBD patients but not in IBS-D patients.

4. Strong compression of the colon wall with inflamed mucosa by GMCs causes hemorrhage. Hemorrhage does not occur in IBS-D patients because their mucosa is not fragile.

Visceral Hypersensitivity in IBD

The sensation of pain in IBD patients is generally located in the lower abdomen and rectal areas. Most information on visceral hypersensitivity in these patients comes from distension studies in the rectum. There are two schools of thought regarding rectal hypersensitivity in IBD patients. One is that the rectum is hypersensitive to balloon distension in patients with moderate colitis, when compared with healthy subjects or patients in remission [408, 414, 423]. These patients present with diarrhea, urgency, feeling of incomplete evacuation, tenesmus, incontinence, and intermittent lower abdominal pain. The rectum in patients with active colitis is less compliant than in controls or in quiescent colitis. The other school of thought is that the rectum is hyposensitive in mild or inactive ulcerative colitis or when active inflammation is in the ileum (Crohn’s disease) [424, 425]. Data from distension studies in the sigmoid colon are not available.

The visceral hypersensitivity that accompanies inflammation is due to the upregulation of neurotrophin growth factor (NGF) in response to the enhanced production of inflammatory mediators in the colon wall [426, 427]. Animal models of inflammation show consistent visceral hypersensitivity, which subsides after inflammation is over [428–432].

Rectal hypersensitivity in moderate to severe inflammation explains the frequent urge to defecate in response to the arrival of smaller volumes of feces in the rectum. The descending inhibition of the internal anal sphincter in response to rectal distension remains intact in colitis patients [408], suggesting that the internal anal sphincter does not obstruct the mass propulsion by a propagating GMC preceding defecation. The perception of pain in these patients is therefore entirely due to strong compression of the colon wall and sensitization of the afferent splanchnic neurons. Colitis patients in remission are relatively free of symptoms because the events precipitating them—excessive frequency of GMCs—are absent. This may happen regardless of whether the afferent sensitization normalizes during remission.

Take-home Messages

Strong compression of the sigmoid colon along with visceral hypersensitivity causes the sensation of intermittent short-lived pain in IBD patients.

Increased expression of NGF in the colon wall mediates visceral hypersensitivity in animal models of colonic inflammation.

Cellular and Molecular Mechanisms

A great deal of our understanding of the cellular mechanisms of motility dysfunction in colonic inflammation has come from animal models of inflammation [433]. The animal models of IBD fairly well replicate the acute inflammatory component of human disease; however, they lack the remission and relapse features. While the animal models have these limitations, they have the advantage of having more or less similar lesions within the study group, and they are free of disease modification by medications. In many cases, the animals serve as their own controls.

Smooth Muscle Dysfunction

Organ bath studies show that circular smooth muscle tissues from human ulcerative colitis [434, 435], Crohn’s disease [436], and their animal models [12, 17, 437–439] are less reactive to ACh than the tissue from respective controls. ACh acts directly on muscarinic M₃ receptors on smooth muscle cells to stimulate contractions. Therefore, the suppression of contractility in inflammation is due, in part, to a defect in the excitation-contraction coupling in smooth muscle cells. Studies in human tissue from ulcerative colitis patients [440] show little change in the characteristics of slow waves. The nitrergic nerves also seem to function normally in tissue from ulcerative colitis patients, which concurs with normal relaxation of the anal sphincter in response to rectal distension [408].

A major abnormality contributing to the suppression of contractility by inflammation seems to be in the excitation-contraction coupling in smooth muscle cells. TNFα and IL-1β, prominent inflammatory mediators, significantly suppress expression of the pore-forming α_1C-subunit of Ca_v1.2b (L-type) calcium channels in human and animal colonic circular smooth muscle cells [62, 177, 441–443]. These inflammatory mediators activate NF-κB, which translocates to the nucleus to suppress transcription of the gene encoding the α_1C-subunit. The suppression of the α_1C-subunit reduces the number of calcium channels in smooth muscle membrane and the calcium influx/inward calcium current moving through them [62, 173]. The inhibition of NF-κB activation, in vivo or in vitro, blocks the suppression of Ca_v1.2 channels to restore cell contractility.

The conventional perception is that inflammation in Crohn’s disease is transmural, while that in ulcerative colitis is limited to the mucosa. This concept might have developed from morphological observations of significant infiltration of white blood cells in the muscle layers of Crohn’s disease but not in those of ulcerative colitis. However, this concept is not consistent with the fact that inflammation in both types of IBD similarly suppresses circular muscle contractility [413, 434–436]. There is no known mechanism by which inflammation confined to the mucosa impairs smooth muscle function, since smooth muscle impairment in inflammation requires local release of inflammatory mediators in the muscularis externa.

Studies on the experimental models of Crohn’s colitis and ulcerative colitis—trinitrobenzene sulfonic (TNBS) acid- and dextran sodium (DSS)-induced colonic inflammations, respectively [433, 444, 445]—show that the inflammatory mediators and their genetic targets to suppress circular smooth muscle contractility differ markedly between the two types of colonic inflammation.

Recent studies in animal models of the two forms of IBD and accumulating clinical findings [446, 447] suggest that inflammation is transmural in both forms of IBD. Crohn’s colitis–like inflammation is due to transmural generation of oxidative stress and peptide inflammatory mediators. The ulcerative colitis–like inflammation is primarily due to transmural generation of oxidative stress. Peptide inflammatory mediators play a minor role in ulcerative colitis–like inflammation. Oxidative stress (H₂O₂) suppresses the Gα_q protein of the excitation-contraction coupling in smooth muscle cells to suppress their contractility. By contrast, cytokines, such as IL-1β, suppress the α_1C-subunit and CPI-17 proteins of the excitation-contraction coupling to suppress circular smooth muscle reactivity to ACh [446].

Both types of inflammation begin with a breakdown of the mucosal barrier, exposing the sterile interior of the colon wall to a pathogenic luminal environment. The breakdown of the mucosal barrier by TNBS results in the translocation of luminal bacteria across the colon wall within 24 hours [448]. TNBS impairs the epithelial barrier function by necrosis. By contrast, Toll-like receptor 4 (TLR4) signaling, which limits bacterial translocation, mediates DSS inflammatory response [449, 450]. DSS arrests the epithelial cell cycle, resulting in apoptosis, impaired proliferation, and weak release of peptide inflammatory mediators [451–453]. DSS inflammation can occur in germ-free or severely-combined-immunodeficiency (SCID) mice [454, 455]. Consequently, bacterial translocation is marginal and confined to the mucosa, indicating its lesser role in DSS inflammation than in TNBS inflammation.

Taken together, aggressive bacterial translocation in TNBS inflammation may underlie the transmural infiltration of immune cells and release of cytokines/chemokines. On the other hand, limited bacterial translocation results in much smaller infiltration of immune cells and release of cytokines/chemokines in the mucosa/submucosa of DSS inflammation. It is noteworthy that TNBS inflammation in the absence of intestinal flora is also primarily mucosal [448]. The differences in the nature of the damage to the epithelium (e.g., apoptosis and necrosis) may underlie the two strikingly different types of inflammatory responses in TNBS and DSS.

Enteric Neuronal Dysfunction

Together with smooth muscle cells, the enteric neurons play an essential role in regulating motility function. They are in the same hostile inflammatory environment as the smooth muscle cells, but their precise role in impaired motility dysfunction in colonic inflammation remains ambiguous. This is largely due to the lack of availability of neuronal cultures until recently [456], the multiple types of neurons containing more than one neurotransmitter, and our limited ability to correlate neuronal abnormality with motor dysfunction. Immunohistochemical studies on inflamed and normal tissues have yielded mixed results [457–461].

Morphological data show that inflammation does not alter the density of neurons innervating circular smooth muscle cells [462]. However, it may impair the packaging, storage, and release of neurotransmitters from the nerve endings of motor and sympathetic neurons [463–465]. Impairment in the synthesis/release of ACh will suppress in vivo motor activity by reduced stimulation of excitation-contraction coupling in smooth muscle cells. Electrophysiological studies show that inflammation in guinea pig colon enhances the excitability of AH neurons and facilitates synaptic transmission in S neurons [466, 467]. However, we do not know yet how these changes relate to the suppression of neurotransmitter release, suppression of RPCs, and the stimulation of GMCs during inflammation.

The number of ICC-MP in the affected areas of Crohn’s disease does not differ from that in controls, whereas the number of ICC-IM decreases and that of ICC-DMP increases [457]. However, recent publications have discounted any role of ICC in regulating motility function [79, 365, 468]. In spite of the changes found in the number of ICCs or damage to their processes, the slow waves and nitrergic inhibition seem to be normal in inflammation, as discussed above.

Take-home Messages

1. Impairment of excitation-contraction coupling in smooth muscle cells due to suppression of key cell-signaling proteins by inflammatory mediators contributes to the suppression of RPCs and tone in the colons of human IBD patients and in animal models of inflammation.

2. Inflammation impairs the release of neurotransmitters from enteric motor neurons.

3. We do not know the cellular mechanisms by which colonic inflammation enhances the frequency of GMCs.

Diverticular Disease

Diverticular disease is prevalent in up to 30% of the population over sixty years of age—about 15% of these patients go on to develop clinical symptoms [469–473]. Clinically, these patients are divided into three categories: asymptomatic diverticular disease, symptomatic uncomplicated diverticular disease, and symptomatic complicated diverticular disease. Some complications of diverticular disease—perforation, fistula, or bowel obstruction—relate to the severity and duration of colitis. The following discussion focuses primarily on asymptomatic and symptomatic diverticular disease patients.

The symptoms of diverticular disease include recurrent abdominal pain in the lower left quadrant and altered bowel habits: diarrhea, constipation, or alternating diarrhea (loose stools) and constipation (hard stools). Additional secondary symptoms are bloating, straining, urgency, incontinence, and mucus and blood in stools [404, 473–475]. These symptoms generally develop in patients over the age of 50 years. Low fiber in the diet is a likely contributor to its higher prevalence in Western counties. However, there is no hard evidence for it. The diverticula form primarily in the sigmoid colon. The severity of the symptoms relates to the degree of diverticulitis [476].

The symptoms of diverticulitis overlap with those of IBD and IBS-D, i.e., abdominal cramping accompanied by altered bowel habits. However, the etiologies of the two conditions may differ to some degree. In IBS-D, inflammation plays little role in the induction of these symptoms. A randomized double-blind placebo-controlled study found little improvement in IBS symptoms in IBS-PI patients by prednisone treatment [354]. We do not fully understand the events leading up to inflammation in IBD patients. However, in IBD, inflammation evenly covers the affected segment. Prednisone treatment is a major therapy in IBD patients. In diverticulitis, the inflammation starts by the translocation of pathogenic fecal material into the diverticula, causing abscess formation. Therefore, in diverticular disease, inflammation occurs in pockets centered on diverticula, and it may be unevenly distributed through the muscle layer. The circular muscle layer in diverticulitis shows hypertrophy and hyperplasia [473, 477, 478].

Colonic Motor Dysfunction in Diverticular Disease Patients

Manometric recordings show a higher incidence of GMCs in the sigmoid colon (and distal to it) in symptomatic diverticular disease patients than in asymptomatic patients or healthy controls. Overall motor activity, quantified as total duration of contractions, is also higher in symptomatic (complicated or uncomplicated) diverticular disease patients than in asymptomatic patients or in normal healthy subjects [476, 479, 480].

Take-home Messages

1. Although, diverticular disease involves inflammation in the diverticula, its symptoms in symptomatic patients are similar to those of IBS-D, i.e., abdominal cramping, diarrhea with loose stools, and alternating diarrhea and constipation.

2. Diarrhea with loose stools is a result of an increase in the frequency of GMCs.

Cellular and Molecular Mechanisms

Pioneering studies in diverticular disease patients proposed that the diverticula form by high outward pressures generated in the lumen [481, 482]. These studies did not identify the source of the pressure. Our current understanding of risk factors for the formation of diverticula are:

1. Strong compression of the colon wall by GMCs can generate high outward pressure.

2. A low-residue diet can create hard stools due to lack of fiber content [483–485].
3. Muscle tensile strength decreases with age [486–492].

4. The sigmoid colon wall near the entry of blood vessels is weaker than at other regions.

Based on these understandings, a potential sequence of events leading to diverticulitis is:

1. A low-fiber diet results in lesser retention of water in feces, causing them to harden.

2. Colonic GMCs occur spontaneously up to about 10 times a day in normal subjects. When a GMC strongly squeezes over a hardened stool pellet, it generates a bulge.

3. Weaker tensile strength of the colon wall increases the risk that the bulge will herniate the colon wall to form a diverticulum. Note that it might take repeated incidents to form a diverticulum.

4. Thereafter, colonic contractions, especially the GMCs, push the pathogenic fecal material into the diverticula.

5. The diverticula do not generate contractions to expel the fecal material.

6. The trapped fecal material starts infection, resulting in an inflammatory response and abscess formation.

7. The continuity of the muscle layers between the diverticula and the unaffected colon spreads inflammation to neighboring smooth muscle cells.

8. Inflammation in muscularis externa causes enteric neuronal and smooth muscle dysfunction to increase the frequency of GMCs as well as induce visceral hypersensitivity.

9. The inflammation that begins in the diverticula becomes transmural [473].

Note that the formation of diverticula by itself does not generate the symptoms of pain and altered bowel habits. The symptoms of intermittent abdominal cramping and altered bowel habits result primarily from the increase in the frequency of GMCs at the site of the inflamed diverticula. The GMCs that propagate to the rectum induce urgency and frequent defecation. As noted earlier [419, 421, 422], frequent GMCs rupture the mucosal barrier in the inflamed colon segment to cause bleeding and exudation of mucus, both expelled with the stool. The stool is loose because frequent mass movements by GMCs reduce its contact time with the mucosa in the sigmoid colon.

Diverticulitis patients show the same phenomena as IBD patients, sometimes passing loose stools, sometimes hard stools. Manometric data during the two conditions are not available. The frequency of GMCs likely fluctuates above and below normal levels to produce alternating diarrhea and constipation.

The amplitude of GMCs in diverticulitis—110 to 120 mmHg [476]—is about the same as that in normal subjects: 115 mmHg [28, 195, 197]. Therefore, pain in these patients is likely due to inflammation-induced visceral hypersensitivity to colorectal distension by a balloon or its compression by a GMC (see ). The sigmoid colon bearing the diverticula and the rectum are hypersensitivity to luminal distension without a change in their compliance [493].

Diverticular disease patients tend to have raised scores on the Hospital Anxiety and Depression scale [494]. Whether a cause-and-effect relationship exists between an increase in anxiety/depression and colonic pain is unknown. However, it seems likely that these patients develop higher anxiety/depression scores following the development of frequent and debilitating colonic pain.

A recent animal study shows that bacterial translocation to the muscularis externa enhances the expression of insulin growth factor-1 (IGF-1) and transformation growth factor-β (TGF-β) in the muscularis externa, causing hypertrophy and hyperplasia, thus thickening the muscle layers [446]. No data are available on changes in the expressions of these growth factors in symptomatic diverticular disease patients. One may speculate, however, that similar changes might induce thickening of muscle layers in diverticular disease patients [477, 478].

Immunofluorescence findings show that inflammation in diverticular disease alters the expressions of several endogenous peptides, including substance P (SP), galanin, neuropeptides K (NPK), pituitary adenylate cyclase–activating peptide (PACAP), and vasoactive intestinal polypeptide (VIP). However, the cause-and-effect relationship between these changes and the symptoms of diverticular disease are unknown. Recent studies in human colonic smooth muscle cells show that VIP regulates transcription of the α_1C-subunit of Ca_v1.2b (L-type) calcium channels in circular smooth muscle cells [173]. The influx of calcium, essential for smooth muscle contraction, occurs through these channels. Therefore, an increase in the expression of these channels enhances calcium influx, the amplitude of contractions, and colonic transit [174, 355]. The twofold increase of VIP in the circular muscle layer of the colon of symptomatic diverticular disease patients might be a contributing factor in the increased frequency of GMCs in diverticulitis.

Recovering From Delivery (for Parents)

Your baby’s finally here, and you’re thrilled — but you’re also exhausted, uncomfortable, on an emotional roller coaster, and wondering whether you’ll ever fit into your jeans again. Childbirth classes helped prepare you for giving birth, but you weren’t prepared for all of this!

What to Expect Physically

After your baby arrives, you’ll notice some changes — both physical and emotional.

Physically, you might experience:

• Sore breasts. Your breasts may be painfully engorged for several days when your milk comes in and your nipples may be sore.
• Constipation. The first postpartum bowel movement may be a few days after delivery, and sensitive hemorrhoids, healing episiotomies, and sore muscles can make it painful.
• Episiotomy. If your perineum (the area of skin between the vagina and the anus) was cut by your doctor or if it was torn during the birth, the stitches may make it painful to sit or walk for a little while during healing. It also can be painful when you cough or sneeze during the healing time.
• Hemorrhoids. Although common, hemorrhoids (swollen blood vessels in the rectum or anus) are frequently unexpected.
• Hot and cold flashes. Your body’s adjustment to new hormone and blood flow levels can wreak havoc on your internal thermostat.
• Urinary or fecal incontinence. The stretching of your muscles during delivery can cause you to accidentally pass urine (pee) when you cough, laugh, or strain or may make it difficult to control your bowel movements, especially if you had a lengthy labor before a vaginal delivery.
• “After pains.” After giving birth, your uterus will continue to have contractions for a few days. These are most noticeable when your baby nurses or when you are given medication to reduce bleeding.
• Vaginal discharge (lochia). Initially heavier than your period and often containing clots, vaginal discharge gradually fades to white or yellow and then stops within several weeks.
• Weight. Your postpartum weight will probably be about 12 or 13 pounds (the weight of the baby, placenta, and amniotic fluid) below your full-term weight, before additional water weight drops off within the first week as your body regains its balance.

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What to Expect Emotionally

Emotionally, you may be feeling:

• “Baby blues.” Many new moms have irritability, sadness, crying, or anxiety, beginning within the first several days after delivery. These baby blues are very common and may be related to physical changes (including hormonal changes, exhaustion, and unexpected birth experiences) and the emotional transition as you adjust to changing roles and your new baby. Baby blues usually go away within 1 to 2 weeks.
• Postpartum depression. More serious and longer lasting than the baby blues, this condition may cause mood swings, anxiety, guilt, and persistent sadness. PPD can be diagnosed up to a year after giving birth, and it’s more common in women with a history of depression, multiple life stressors, and a family history of depression.

Also, when it comes to intimacy, you and your partner may be on completely different pages. Your partner may be ready to pick up where you left off before baby’s arrival, whereas you may not feel comfortable enough — physically or emotionally — and might crave nothing more than a good night’s sleep. Doctors often ask women to wait a few weeks before having sex to allow them to heal.

The Healing Process

It took your body months to prepare to give birth, and it takes time to recover. If you’ve had a cesarean section (C-section), it can take even longer because surgery requires a longer healing time. If unexpected, it may have also raised emotional issues.

Pain is greatest the first few days after the surgery and should gradually subside. Your doctor will advise you on precautions to take after surgery, and give you directions for bathing and how to begin gentle exercises to speed recovery and help avoid constipation.

Things to know:

• Drink 8-10 glasses of water daily.
• Expect vaginal discharge.
• Avoid stairs and lifting until your doctor says these activities are OK.
• Don’t take a bath or go swimming until the doctor says it’s OK.
• Don’t drive until your doctor says it’s OK. Also wait until you can make sudden movements and wear a safety belt properly without discomfort.
• If the incision becomes red or swollen, call your doctor.

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Birth Control

You can become pregnant again before your first postpartum period. Even though this is less likely if you are exclusively breastfeeding (day and night, no solids, no bottles, at least 8 times a day, never going more than 4 hours during the day or 6 hours at night without feeding), have not had a period, and your baby is younger than 6 months old, it is still possible.

If you want to protect against pregnancy, discuss your options with your doctor. This may include barrier methods (like condoms or diaphragms), an IUD, pills, a patch, an implantable device, or shots.

Breastfeeding

You need plenty of sleep, lots of fluids, and good nutrition, especially if you’re breastfeeding. An easy way to stay on top of drinking enough fluids is to have a glass of water whenever your baby nurses. At least until your milk supply is well established, try to avoid caffeine, which causes loss of fluid through urine and sometimes makes babies wakeful and fussy.

If you have any breastfeeding problems, talk to your doctor, midwife, or a lactation specialist. Your clinic or hospital lactation specialist can advise you on how to deal with any breastfeeding problems. Relieve clogged milk ducts with breast massage, frequent nursing, feeding after a warm shower, and warm moist compresses applied throughout the day.

If you develop a fever or chills or your breast becomes tender or red, you may have an infection (mastitis) and need antibiotics. Call your doctor if this happens. Continue nursing or pumping from both breasts, though, and drink plenty of fluids.

Engorged Breasts

Engorged breasts will feel better as your breastfeeding pattern becomes established or, if you’re not breastfeeding, when your body stops producing milk — usually within a few days.

Episiotomy Care

Continue sitz baths (sitting in just a few inches of water and covering the buttocks, up to the hips, in the water) using cool water for the first few days, then warm water after that. Squeeze the cheeks of your bottom together when you sit to avoid pulling painfully on the stitches. Sitting on a pillow may be more comfortable than sitting on a hard surface.

Use a squirt bottle with warm water to wash the area with water when you use the toilet; gently pat dry. After a bowel movement, wipe from front to back to avoid infection. Reduce swelling with ice packs or chilled witch hazel pads. Local anesthetic sprays also can be helpful.

Talk to your doctor about taking an anti-inflammatory drug like ibuprofen to help with the pain and swelling.

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Exercise

Exercise as soon as you’ve been cleared by your doctor to help restore your strength and pre-pregnancy body, increase your energy and sense of well-being, and reduce constipation. Begin slowly and increase gradually. Walking and swimming are excellent choices.

Hemorrhoids and Constipation

Alternating warm sitz baths and cold packs can help with hemorrhoids. It also can help to sit on an inflatable donut cushion.

Ask your doctor about a stool softener. Don’t use laxatives, suppositories, or enemas without your doctor’s OK. Increase your intake of fluids and fiber-rich fruits and vegetables. After your doctor has cleared it, exercise can be very helpful.

Sexual Relations

Your body needs time to heal. Doctors usually recommend waiting 4-6 weeks to have sex to reduce the risk of infection, increased bleeding, or re-opening healing tissue.

Begin slowly, with kissing, cuddling, and other intimate activities. You’ll probably notice reduced vaginal lubrication (this is due to hormones and usually is temporary), so a water-based lubricant might be useful. Try to find positions that put less pressure on sore areas and are most comfortable for you. Tell your partner if you’re sore or frightened about pain during sexual activity — talking it over can help both of you to feel less anxious and more secure about resuming your sex life.

Incontinence

Urinary or fecal incontinence often eases gradually as your body returns to its normal prepregnancy state. Encourage the process with Kegel exercises, which help strengthen the pelvic floor muscles. To find the correct muscles, pretend you’re trying to stop peeing. Squeeze those muscles for a few seconds, then relax (your doctor can check to be sure you’re doing them correctly).

Wear a sanitary pad for protection, and let the doctor know about any incontinence you have.

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What Else You Can Do to Help Yourself

You’ll get greater enjoyment in your new role as mom — and it will be much easier — if you care for both yourself and your new baby. For example:

• When your baby sleeps, take a nap. Get some extra rest for yourself!
• Set aside time each day to relax with a book or listen to music.
• Shower daily.
• Get plenty of exercise and fresh air — either with or without your baby, if you have someone who can babysit.
• Schedule regular time — even just 15 minutes a day after the baby goes to sleep — for you and your partner to be alone and talk.
• Make time each day to enjoy your baby, and encourage your partner to do so, too.
• Lower your housekeeping and gourmet meal standards — there’s time for that later. If visitors stress you, restrict them temporarily.
• Talk with other new moms (perhaps from your birthing class) and create your own informal support group.

Getting Help From Others

Remember, Wonder Woman is fiction. Ask your partner, friends, and family for help. Jot down small, helpful things people can do as they occur to you. When people offer to help, check the list. For example:

• Ask friends or relatives to pick things up for you at the market, stop by and hold your baby while you take a walk or a bath, or just give you an extra hand. Or ask loved ones to drop off a meal.
• Hire a neighborhood teen — or a cleaning service — to clean the house occasionally, if possible.
• Investigate hiring a doula, a supportive companion professionally trained to provide postpartum care.

When to Call the Doctor

You should call your doctor about your postpartum health if you:

• have a fever of 100.4°F (38°C) or above
• soak more than one sanitary napkin an hour, pass large clots (larger than a quarter), or if the bleeding increases
• had a C-section or episiotomy and the incision becomes very red or swollen or drains pus
• have new pain, swelling, or tenderness in your legs
• have hot-to-the-touch, reddened, sore breasts or any cracking or bleeding from the nipple or areola (the dark-colored area of the breast)
• your vaginal discharge becomes foul-smelling
• have painful urination, a sudden urge to pee, or are unable to control urination
• have increasing pain in the vaginal area
• have new or worsening belly pain
• develop a cough or chest pain, nausea, or vomiting
• have bad headaches or vision changes
• become depressed or have hallucinations, suicidal thoughts, or any thoughts of harming your baby

While recovering from delivery can be a lot to handle, things will get easier. Before you know it, you will be able to fully focus on enjoying your new baby.

Chronic Female Pelvic Pain | HealthLink BC

Topic Overview

Is this topic for you?

This topic focuses on pelvic pain that has lasted longer than 6 months. If you have new, sudden pelvic pain, see your doctor as soon as you can. To learn more about new pelvic pain, see the topic Abdominal Pain, Age 12 and Older.

What is chronic female pelvic pain?

Female pelvic pain is pain below a woman’s belly button. It is considered chronic (which means long-lasting) if you have had it for at least 6 months, and it’s not related to pregnancy. The type of pain varies from woman to woman. In some women, it is a mild ache that comes and goes. In others, the pain is so steady and severe that it makes it hard to sleep, work, or enjoy life.

If your doctor can find what’s causing the pain, treating the cause may make the pain go away. If no cause is found, your doctor can help you find ways to ease the pain and get back your quality of life.

What causes chronic female pelvic pain?

Some common causes include:

• Problems of the reproductive system, such as:
• Scar tissue (adhesions) in the pelvic area after an infection or surgery.
• Diseases of the urinary tract or bowel, such as:
• Problems with the muscles, joints, and ligaments in the pelvis, lower back, or hips.

Doctors don’t really understand all the things that can cause chronic pelvic pain. So sometimes, even with a lot of testing, the cause remains a mystery. This doesn’t mean that there isn’t a cause or that your pain isn’t real.

Sometimes, after a disease has been treated or an injury has healed, the affected nerves keep sending pain signals. This is called neuropathic pain. It may help explain why it can be so hard to find the cause of chronic pelvic pain.

What are the symptoms?

The type of pain can vary widely and may or may not be related to menstrual periods. Chronic pelvic pain can include:

• Pain that ranges from mild to severe.
• Pain that ranges from dull to sharp.
• Severe cramping during periods.
• Pain during sex.
• Pain when you urinate or have a bowel movement.
• Pain in certain postures or positions.

Chronic pain can make it hard to sleep, work, or enjoy life. It can lead to depression. Depression can cause you to feel sad or hopeless, eat and sleep poorly, and move slowly.

How is chronic female pelvic pain diagnosed?

At your first visit, your doctor will do a complete pelvic examination to look for problems with your reproductive system. The doctor will also ask questions about your past and present health and about your symptoms. You may have some tests, such as:

Emotional issues can play a big role in chronic pain. Your doctor may ask questions to find out if depression or stress is adding to your problem. You may also be asked about any past or current sexual or physical abuse. It can be hard to talk about these things, but it’s important to do it so you can get the right treatment.

If the first tests don’t find a cause, you may have other tests that show pictures of the organs in your belly. These may include:

You may also have a type of minor surgery called laparoscopy (say “lap-uh-ROS-kuh-pee”). In this surgery, the doctor puts a thin, lighted tube with a tiny camera through a small cut in your belly. This lets the doctor look for problems like growths or scar tissue inside your belly.

Finding the cause of pelvic pain can be a long and frustrating process. You can help by keeping notes about the type of pain you have, when it happens, and what seems to bring it on. Show these notes to your doctor. They may give clues about what is causing the problem or the best way to treat it. And whether or not a cause is found, your doctor can suggest treatments to help you manage the pain.

How is it treated?

If your doctor found a problem that could be causing your pelvic pain, you will be treated for that problem. Some common treatments include:

• Birth control pills or hormone treatment for problems related to your periods.
• Surgery to remove a growth, cyst, or tumour.
• Medicine to treat the problem, such as an antibiotic for infection or medicine for irritable bowel syndrome.

Chronic pain can become a medical problem in itself. Whether or not a cause is found, your doctor can suggest treatments to help you manage the pain. You may get the best results from a combination of treatments such as:

• Pain relievers called NSAIDs, like ibuprofen (such as Advil or Motrin) or naproxen (such as Aleve). You can buy these over the counter, or your doctor may prescribe stronger ones. These medicines work best if you take them on a regular schedule, not just when you have pain. Your doctor can tell you how much to take and how often. Be safe with medicines. Read and follow all instructions on the label.
• Tricyclic antidepressant medicine or anticonvulsants, which can help with pain and with depression.
• Cognitive-behavioural therapy or biofeedback, to help you change the way you think about or react to pain.
• Counselling, to give you emotional support and reduce stress.
• Physiotherapy to help you relax your muscles, improve your posture, and be more active.
• Pain relievers that are injected (local anesthetic) into specific areas to help with pain.

You may need to try many treatments before you find the ones that help you the most. If the things you’re using aren’t working well, ask your doctor what else you can try. Taking an active role in your treatment may help you feel more hopeful.

Cause

Female pelvic pain is typically caused by a medical condition involving the reproductive organs, urinary tract, lower gastrointestinal tract, or nerves or muscles of the abdominal wall, hips, or pelvic floor. Some causes are always short-term (acute), and others can become long-lasting (chronic) unless successfully treated. Sometimes, no cause can be found.

Pain with no known cause

Experts don’t yet understand all possible causes of pelvic pain, especially when it has become chronic. So even after a lot of testing, many women never find out the reason for their pain.

One reason might be what’s called neuropathic pain. Long after a disease or injury has healed, nerves can continue firing pain signals. This is thought to be caused by an overloading of the nervous system by extreme or long-lasting pain.

Not finding a cause doesn’t mean that there isn’t one or that there’s no possible treatment.

Problems with the reproductive system that can cause chronic pain

• Endometriosis
  . This is when the tissue lining the inside of the uterus starts growing outside of the uterus.
• Adenomyosis
  . This is when the lining in the uterus starts growing into the uterine muscle.
• Non-cancerous (benign) tumours of the uterus, such as fibroids or polyps.

Other problems in the pelvic area that can cause chronic pain

• Scar tissue (adhesions) inside the pelvis and belly. This is usually caused by pelvic inflammatory disease, radiation treatment, or surgery.
• Bowel problems, such as irritable bowel syndrome.
• Urinary tract problems, such as bladder inflammation.
• Various cancers that occur in the pelvic area.
• Muscle spasm or pain in the lower abdominal wall muscles. This is sometimes linked to past surgery in that area.
• Pelvic congestion syndrome. This is a problem caused when veins in the pelvis don’t drain properly and get enlarged or twisted as a result.
• Pudendal neuralgia. This is a rare problem with the nerve that runs through the pelvic region, including your genitals, urethra, anus, and the area between the anus and genitals (perineum).
• Referred pain from the abdomen, lower back, or hip, which can cause pain that is felt in the pelvic area.

Physical or sexual abuse

Although the link isn’t well understood, past or current abuse is strongly linked to chronic pelvic pain.

Symptoms

Female pelvic pain symptoms can include:

• Pain that ranges from mild to severe.
• Pain that ranges from dull to sharp.
• Severe cramping during periods.
• Heavy or irregular vaginal bleeding.
• Pain during sex.
• Pain when you urinate or have a bowel movement.

Depression symptoms are commonly linked to chronic pain. Signs of depression include:

• Sleep problems.
• Appetite changes.
• Feelings of emptiness and sadness.
• Slowed body movements and reactions.

For the best chance of recovery from pain, depression must be treated along with any known physical causes of pain.

What Happens

It can sometimes be hard to know how long pelvic pain will last and how best to treat it. It’s a little different for every woman. But in general:

• When a cause is found and treated, such as an ovarian cyst, the pain will most likely go away.
• When it’s hard to find a cause, your doctor can do a number of tests and try certain treatments to see if they work.
• Symptoms that are caused by hormone fluctuations often go away without treatment when menopause occurs and the ups and downs of hormone levels settle down.

What Increases Your Risk

Risk factors are things that increase your chances of getting a certain condition or disease. Risk factors for pelvic pain that becomes chronic include:

• History of pelvic inflammatory disease.
• History of physical or sexual abuse. Women with chronic female pelvic pain are more likely to report abuse in their past.^{footnote 1}
• History of radiation treatment or surgery of the abdomen or pelvis. This includes some surgeries for urinary incontinence.
• History of depression. Pain and depression seem to be related.
• Substance use disorder.
• Something abnormal in the structure of the female organs.
• Pregnancy and childbirth that put stress on the back and pelvis, such as delivery of a large baby, a difficult delivery, or a forceps or vacuum delivery.

When should you call your doctor?

Call a doctor for immediate care if you have sudden, severe pelvic pain, with or without vaginal bleeding.

Call a doctor if:

• Your periods have changed from relatively pain-free to painful.
• Pain interferes with your daily activities.
• You start to have pain during intercourse.
• You have painful urination, blood in your urine, or an inability to control the flow of urine.
• You have blood in your stool or a significant, unexplained change in your bowel movements.
• You notice any new pelvic symptoms.
• You haven’t yet seen a doctor about your chronic pelvic pain.

Watchful waiting

Watchful waiting is a period of time during which you and your doctor watch your pelvic pain symptoms without using medical treatment.

During this period, you can keep a daily record of your symptoms and menstrual cycle and any other life events that you consider important. A watchful waiting period may last from a few days to weeks or possibly months.

Who to see

Your family doctor, general practitioner, or nurse practitioner can generally evaluate and help you manage the symptoms of female pelvic pain.

For advanced treatment methods, you may be referred to a gynecologist or a urologist who specializes in female pelvic disorders.

If you have ever been physically or sexually abused, that trauma may be playing a part in your pain. So you’ll need to let your doctor know about the abuse. This may be hard for you, but it may be easier if you find a doctor you feel comfortable talking to.

Examinations and Tests

Although your condition may be diagnosed during your first examination, don’t be surprised if you need to have a series of medical appointments and tests. For many women who have pelvic pain, diagnosing the cause is a process of elimination that takes a while.

Even if tests don’t find any problems, it doesn’t mean that there’s no physical cause for your chronic pain. Tests aren’t yet able to detect all causes.

Initial tests

It’s a good idea to make a calendar or diary of your symptoms , menstrual cycle, sexual activity, and physical exertion. And keep track of any other things that you think are important, such as stressful events or illnesses. Bring it with you when you see your doctor.

To begin narrowing down the list of possible causes of your pain, your doctor will review your symptom diary and:

• Ask about your health history. This includes the history of your menstrual cycle and any pelvic surgery, radiation treatment, sexually transmitted infection, pregnancy, or childbirth.
• Do a pelvic examination to look for signs of abnormalities. You may also have a digital rectal examination. Your doctor may conduct these examinations in a slow, thorough manner, carefully checking for tender areas.

You may also have tests, such as:

Further testing

Sometimes more tests are needed. Your doctor may recommend one or more of the following:

• Imaging tests (tests that take pictures of the pelvic area), such as:
  • Abdominal ultrasound and/or transvaginal ultrasound of the pelvic area using a small ultrasound device inserted into the vagina.
  • Intravenous pyelogram, which uses an injected dye combined with X-rays to create pictures of the kidneys, bladder, ureters, and urethra.
  • CT scan, which uses X-rays to create pictures of organs and bones.
  • MRI, which uses a magnetic field and pulses of radio wave energy to create pictures of organs and bones.
• Laparoscopy. This surgical procedure uses a thin, lighted viewing instrument inserted through a small cut in the belly. If needed, scar tissue or a growth can also be removed during the procedure.
• Cystoscopy, which uses a viewing instrument inserted through the urethra into the bladder.
• Urodynamic studies. In these tests, a catheter is inserted through the urethra into the bladder to check for bladder problems.
• Other evaluations:
  • For irritable bowel syndrome.
  • For abdominal wall “trigger points.” These are specific places on your abdomen that cause pain when pressed.

Your mental health

Chronic pain can have a wearing effect on the mind and emotions, which can in turn make harder to manage pain.

Your doctor may recommend a mental health assessment. You’ll be asked questions to find out whether such conditions as depression, insomnia, or stress are adding to or being caused by your chronic pain.

For the best chance of recovering from pain, you will need treatment for emotional problems like these, plus treatment for any known physical causes of pain.

Treatment Overview

Treatment for chronic female pelvic pain can be approached in two ways: treating a known, specific cause of the pain or treating the pain itself as a medical condition. When it’s possible, your doctor will do both.

Treating a known or suspected cause

Depending on the cause, treatment may include:

• Medicine to control or stop the ovulation cycle. This is done if cyclic hormonal changes seem to make your symptoms worse.
• Medicines to treat other diseases, such as an antibiotic for infection or medicine for irritable bowel syndrome.
• Cognitive-behavioural therapy, counselling, or biofeedback to treat depression or other mental health problems.
• Surgery to remove painful growths, cysts, or tumours.
• Healthy lifestyle choices, such as regular exercise to manage stress and improve strength, mood, and general health, along with dietary changes, such as those recommended to manage irritable bowel syndrome.

Treating the pain itself

Finding a treatment that works may take a while. It’s common for women to try many treatments before finding one or more that help.

Medicines that may help manage your pain include:

• Non-steroidal anti-inflammatory drugs (NSAIDs). These medicines are the first-choice treatment for relieving pain and inflammation. They work well for menstrual pain. Be safe with medicines. Read and follow all instructions on the label.
• Medicines that control hormone levels, such as birth control pills. They sometimes work well for pain that seems to be caused or made worse by menstruation.
• Certain antidepressant medicines. These are used to treat chronic pain in other areas of the body also.

Counselling and mental skills training, such as cognitive-behavioural therapy, help you manage your pain and the stress that makes it worse. For more information, see Other Treatment.

Alternative pain treatments that may help you manage pain include such things as acupuncture and transcutaneous nerve stimulation (TENS). For more information, see Other Treatment.

If your chronic pain hasn’t responded to treatment or seems to have no physical cause, you may have neuropathic pain. This means that your nerves still create pain signals long after an original injury or disease has healed. If your doctor suspects that you have neuropathic pain, he or she may refer you to a pain management clinic for evaluation and treatment.

What to think about

Decisions are complicated when you are considering treatment for chronic pelvic pain. Think about these questions, and talk to your doctor about them:

• Are the symptoms bothersome enough to require treatment?
• Do you want to have a child or more children?
• Has a specific cause of the pain been discovered? Or is the cause unclear?
• Is menopause, which may stop symptoms, going to occur soon?
• Would an opinion from another doctor be helpful?
• Would an opinion from a doctor who specializes in chronic pain be helpful?

If you are close to menopause (usually around age 50) and your symptoms are likely related to hormones, your best option may be home treatment and medicine while you wait for menopause.

The hormone changes of menopause may get rid of your chronic pain, but the pain may come back if you use hormone therapy. If you are nearing menopause, talk with your doctor about your options.

Prevention

Early diagnosis and treatment of pelvic pain may help keep the pain from becoming chronic.

One cause of chronic pelvic pain is pelvic inflammatory disease. You can greatly lower your risk of getting this disease by practicing safer sex. Safer sex includes using condoms and using them correctly.

Home Treatment

You can try these steps at home to ease pelvic pain:

• Try non-prescription medicine, such as ibuprofen (for example, Advil or Motrin) or acetaminophen (for example, Tylenol).
• Try heat. Put a heating pad, a hot water bottle, or a warm compress on your lower belly, or take a warm bath. Heat improves blood flow and may relieve pain.
• For back pain, lie down and elevate your legs by placing a pillow under your knees. When lying on your side, bring your knees up to your chest.
• Try relaxation techniques, such as:
• Exercise regularly. It improves blood flow, increases pain-relieving endorphins naturally made by the body, and reduces pain.
• Try sexual activity, which may relieve pelvic cramping and backache. If your pain is related to endometriosis, though, sex may make the pain worse.

Medications

Medicine won’t cure female pelvic pain. But it can help control the pain and keep it from getting worse or becoming chronic. There is no one medicine that works for all women.

Medicines to control hormones

• Birth control pills are commonly used for menstrual pain. They are also often prescribed for endometriosis-related pain.
• High-dose progestin is sometimes prescribed for pain related to endometriosis.
• Gonadotropin-releasing hormone agonists can relieve pain from endometriosis by stopping production of the hormones that make endometriosis worse. This treatment may also relieve pelvic pain that comes in cycles but isn’t related to endometriosis and pelvic pain related to irritable bowel syndrome. This short-term treatment brings on menopausal symptoms, though, with side effects such as hot flashes and loss of bone density, for as long as you take it.

Medicines to control pain

• Prescription non-steroidal anti-inflammatory drugs (NSAIDs), taken on a regular schedule, help relieve pain caused by inflammation or menstruation. If one type doesn’t work for you, then your doctor may recommend another.
• Tricyclic antidepressant medicines are sometimes used to treat chronic pain in other areas of the body. Limited research suggests that they help relieve chronic pelvic pain in some women.^{footnote 2}
• Anticonvulsant medicines such as gabapentin are sometimes used to treat chronic pelvic pain.
• Opioid pain medicine is only recommended as a last-resort treatment for severe pelvic pain.

Surgery

Surgery is most likely to help when it’s done for a specific condition, such as fibroids or endometriosis.

Hysterectomy, the removal of the uterus, is sometimes used as a last-resort treatment. Depending on the cause, hysterectomy may relieve pain for some women.

Most studies have shown that surgery to remove scar tissue (adhesions) from previous surgery or from pelvic inflammatory disease or endometriosis doesn’t relieve pain.^{footnote 3}

With any surgery for chronic pelvic pain, such as hysterectomy or cutting of specific pelvic-area nerves, there is a risk of persistent pain or pain that is worse after surgery. And it can have serious side effects.

Laparoscopy to diagnose chronic pelvic pain may be done before other treatment. Areas of endometriosis or scar tissue may be removed or destroyed during the laparoscopy.

Other Treatment

Chronic pelvic pain takes time to develop and can take a long time to treat. Take charge of how you cope with pain by using one or more of the treatment choices below. Combining your medical treatment with these practices can help you keep a positive state of mind.

Counselling and stress management

Counselling and mental skills training help you learn the mental and emotional tools for managing chronic pain and the stress that makes it worse. Combining medical and psychological treatment increases your chances of treatment success.

Commonly used treatments include:

• Cognitive-behavioural therapy focused on changing the way you think about and mentally manage pain. See a psychologist, licensed counsellor, or clinical social worker who specializes in pain management skills.
• Biofeedback. This is the conscious control of body function that is normally unconsciously controlled.
• Interpersonal counselling, focused on managing your life events, stressors, and relationships.

Physiotherapy

Physiotherapy can help you learn specific exercises to stretch and strengthen certain muscle groups. This helps you to improve posture, gait, and muscle tone.

Alternative pain treatments

Alternative pain treatments for chronic female pelvic pain aren’t well-studied. But they are considered helpful for managing stress and building mental mastery over pain.

Acupuncture and transcutaneous nerve stimulation (TENS) have shown some success in relieving painful menstrual periods. Acupuncture and TENS have also been used as a treatment for non-menstrual chronic pelvic pain, but it isn’t yet well-studied.^{footnote 3}

Other low-risk alternative pain treatments that many people use to help manage pain include:

References

Citations

1. Andrews J, et al. (2012). Noncyclic Chronic Pelvic Pain Therapies for Women. Comparative Effectiveness Review No. 41 (AHRQ Publication No. 11(12)-EHC088-1). Rockville, MD: Agency for Healthcare Research and Quality. Available online http://www.ncbi.nlm.nih.gov/books/NBK84586.
2. Rapkin AJ, Nathan L (2012). Pelvic pain and dysmenorrhea. In JS Berek, ed., Berek and Novak’s Gynecology, 15th ed., pp. 470–504. Philadelphia: Lippincott Williams and Wilkins.
3. Andrews J, et al. (2012). Noncyclic Chronic Pelvic Pain Therapies for Women. Comparative Effectiveness Review No. 41 (AHRQ Publication No. 11(12)-EHC088-1). Rockville, MD: Agency for Healthcare Research and Quality. Available online http://www.ncbi.nlm.nih.gov/books/NBK84586.

Credits

Current as of:
November 8, 2019

Author: Healthwise Staff
Medical Review:
Sarah Marshall MD – Family Medicine
Thomas M. Bailey MD – Family Medicine
Kathleen Romito MD – Family Medicine
Adam Husney MD – Family Medicine
Martin J. Gabica MD – Family Medicine
Kirtly Jones MD – Obstetrics and Gynecology
Kevin C. Kiley MD – Obstetrics and Gynecology

90,000 causes, symptoms, treatment, what to do in case of acute pain

If a person says: “I have abdominal pains,” it is important to understand: the problems of any organs of the abdominal cavity, retroperitoneal space, small pelvis can be hidden behind pain in the abdomen.

If a person says: “I have abdominal pains”, then it is important to understand: the pain in the abdomen can hide problems of any organs of the abdominal cavity, retroperitoneal space, small pelvis. The intestines (ileum, lean, large, sigmoid, colon, transverse intestine), appendix, stomach, liver, duodenum, spleen, ureters, kidneys, mesenteric (mesenteric) vessels of the intestine can give painful sensations to the abdomen.Therefore, pathologies can be gastroenterological, surgical, gynecological, urological in nature.

Types of pain

Abdominal pain is very different:

• Acute and chronic . Acute pains come on suddenly, chronic pains develop gradually, their intensity increases step by step – sometimes over several weeks. In this case, a special kind is formed by chronically recurrent abdominal pain. They can suddenly make themselves felt, and then also suddenly pass and resume after a certain period of time.
• Tonic and clonic . With tonic pains, the muscles are strongly tense, and compacted areas appear on the abdomen, an uncontrolled muscle contraction is observed. Tonic pains are accompanied by quite rhythmic spastic spasms.
• Burning (cutting) and aching – reminiscent of hunger.

Localization of pain can be the abdominal cavity, hypochondrium, zones above or below them.

Symptoms

Symptoms may vary in a person who complains of abdominal pain.Most often it manifests itself in the form of spasms, colic.

• Colic – attacks, primarily stitching (hence the name) pain. With colitis, a person has colitis in both sides, with appendicitis or inflammation of the ovaries – in the lower abdomen, with poisoning, the localization of colic can be in different parts of the abdomen and most often an additional symptom (vomiting, diarrhea) appears.
• Spasms – pains that are accompanied by involuntary muscle contraction. In this case, the skin turns pale.Pain can cause a person to faint. If spasms are in inflammatory bowel diseases, stomach, they are accompanied by fever. Gynecological problems are indicated by spasms accompanied by bleeding.,
• Anginal pain – an unpleasant sensation with a strong burning sensation.
• Sharp pain in the area above the navel is a common occurrence in appendicitis.
• A feeling of “fullness” in the lower back may indicate problems with the colon
• Cyclical pain (that intensifies, then subside) – characteristic symptoms in diseases of the bladder, intestines.
• Pain with severe flatulence indicates that the colon is not working properly.
• Pain sensations against the background of itching of the anus – symptoms of rectal lesions.
• Unpleasant sensations in the abdomen , which intensify at rest and disappear with movement, are the result of circulatory problems.

Causes

What are the causes of abdominal pain, abnormalities in the abdominal organs and retroperitoneal space?

The cause of colic can be appendicitis, inflammation of the ovaries (in these cases, colic in the lower abdomen), poisoning, colitis.With colitis, a person has colitis in both sides. If the colic is cramping and at the same time is localized in the abdomen and in the lower back, the pain is more intense, the cause is most often in urolithiasis, kidney injury or pyelonephritis. Colic in the navel can be a response to irritants of the sensitive mesenteric plexuses of the intestine.

Among the common causes of paroxysmal spasms – intestinal obstruction, gastroduodenitis. And for spasms during urination in women, endometriosis of the uterus is most often.

If abdominal pains are accompanied by increased gas production, frequent urge to defecate, then the cause will most often be associated with diseases of the colon.

Ate abdominal pain – anginal, and at the same time the patient is worried about an expressive burning sensation – the cause is most often gastritis (inflammation of the gastric mucosa) or pancreatitis (inflammation of the pancreas). If pain and burning are accompanied by strong tension of the muscles of the abdominal wall, and the person complains that he is pressing in the chest, the reason may be associated with heart pathologies: in particular, such pains are typical for 60% of patients with myocardial infarction.

The cause of abdominal pain accompanied by low-grade fever (for a long time the temperature is kept at the level of 37.1-37.5 ° C ) most often are inflammatory bowel diseases.

Diseases

Most often diseases of the intestines, stomach, pancreas, problems with the gallbladder, as well as the resulting hernia are behind pain in the abdomen.

Bowel diseases

• Ulcerative colitis – diffuse inflammation.The rectal mucosa is affected. In the initial forms of ulcerative colitis, inflammation affects only the proximal part (the entrance to the intestine), with neglected – the problems concern the entire colon. With the progression, exacerbation of the disease, the patient feels a sharp deterioration in well-being, the intoxication of the body begins, the pulse quickens, and in most cases blood appears in the feces. If the disease is not treated, then the body can poison itself, peritonitis can develop – damage to the abdominal cavity that poses a threat to life.
• Enterite . The small intestine becomes inflamed. At first, the disease is “disguised” as a departure, and is often an accompaniment to this problem. If the disease is started to heal out of time, then the functions of the small intestine are impaired. Food begins to be poorly absorbed by the intestinal walls. Digestion processes are disrupted.
• Crohn’s disease . One or several parts of the intestine can become inflamed. But at the same time, almost always the whole inflammation affects the junction of the colon and small intestine.One of the most unpleasant moments is that inflammation affects the entire thickness of the wall, and a complication of the disease is intestinal obstruction syndrome, the treatment of which requires a set of measures related to the simulation of motility and the restoration of bowel function.
• Dysbacteriosis – violation of intestinal microflora. In the intestine, the number of beneficial bacteria decreases, and pathogenic microflora develops. As a result, gas formation occurs, a person cannot digest food, and stool is disturbed.Very often, the development of dysbiosis is a consequence of incorrect antibiotic therapy or a reaction to stress.

Diseases of the pancreas

• Pancreatitis . The most common disease affecting the pancreas is pancreatitis. With inflammation of the pancreas, a person feels severe discomfort in the upper abdomen, it becomes difficult for the body to digest proteins and fats. Often in everyday life in this case they say: “There are not enough enzymes.” And it really reflects the real picture.In the affected pancreas, the production of lipase, chymotrypsin, trypsin is significantly reduced.
• Cystic fibrosis is a disease that disrupts the functioning of the pancreas and respiratory organs. It is a non-inflammatory pathology. The reason is hereditary factors. A complication of the disease can be the formation of a duodenal ulcer.

Diseases of the stomach

One of the most common diseases that affect people of all ages, are accompanied by abdominal pain – this is the pathology of the stomach, especially its mucous membrane.Leaders – gastritis, ulcer, gastroesophageal reflux disease.

• Gastritis . It is an inflammation of the stomach lining. The whole stomach or some parts of it can become inflamed. With gastritis, pain with burning, cramps prevail. The patient is worried about discomfort after eating, a feeling of a full stomach, or, on the contrary, “suction” and a constant feeling of hunger. Companions of the disease in the acute stage – vomiting and nausea.
• Stomach ulcer .Pain occurs against the background of characteristic ulcerative lesions of the gastric mucosa. Expressed dyspeptic symptoms: heaviness in the stomach, a feeling of oversaturation of the stomach, cramps in the epigastric region.
• Gastroesophageal reflux disease (popularly referred to as “reflux”). The disease is associated with a weakening of the valve between the stomach and esophagus. The result of this relaxation is pain, accompanied by heartburn. Very often gastroesophageal reflux disease occurs in patients who have already experienced gastritis or stomach ulcers.

Hernias

Often abdominal pains are caused by abdominal hernias. They can be umbilical, inguinal, diaphragmatic. Umbilical hernias are more often formed during pregnancy or in the postpartum period, inguinal hernias are caused by excessive stress, diaphragmatic hernias are defects of the abdominal wall that form as a reaction to improper bowel function, improperly selected corset, and lifting weights. The insidiousness of diaphragmatic hernias lies in the fact that at the initial stage of the disease, a person believes that he has typical gastritis – with heartburn and belching, but traditional therapy does not give treatment, and ultrasound shows that the reason is not in inflammation of the stomach, but in the presence of a hernia.In a toga, to combat pathology, it is not required to remove inflammation, eliminate spasms, but surgical treatment, which is aimed at strengthening the abdominal wall.

Diseases of the gallbladder and bile ducts

A special group is made up of diseases associated with the gallbladder and bile duct.

• Cholangitis . Inflammation of the bile ducts. The pain is unbearable. Mostly in the right side. It is complicated by the fact that it requires not only a quick relief of the attack of the pains themselves, but also the normalization of blood pressure.
• Cholecystitis . Sharp pains on the background of the intake of fatty foods. Often the pain itself is followed by vomiting with an admixture of bile. Flatulence (flatulence) and vomiting may be troubling.
• Cholelithiasis – formation of solid structures in bile – stones. The pain in the disease is paroxysmal. Especially if the stones move along the gallbladder and ducts.

Contraindications

An incorrect diagnosis is fraught with the fact that the treatment will not only be useless, but will provoke serious complications.Indeed, many medications, physiotherapeutic techniques that are effective for some diseases accompanied by abdominal pain – are strict contraindications for other diseases with similar symptoms.

For example, if a number of medications prescribed for pancreatitis are prescribed to patients with hepatic colic, the response may be unpredictable. And the treatment of a number of stomach diseases with an antibiotic can cause serious dysbiosis.

And the absolute contraindications in case of pain in the abdomen, stomach is self-medication – especially an independent decision to take an anesthetic or antispasmodic.If, for example, such drugs are used by a person who has an inflamed appendix, then relief will follow for a while. But this will not be help, but false help to oneself. It is not uncommon for patients who did not get to the surgeon to remove appendicitis in a timely manner, necrosis of the tissues of neighboring organs began.

In no case, without a diagnosis, one should not even grasp at seemingly “harmless” means to combat high acidity. What appears to be just the release of excess hydrochloric acid and inflammation of the stomach may be a symptom of a completely different disease, such as a heart attack.

Also, in case of abdominal pain with an unexplained diagnosis, a heating pad with hot water should not be applied. In a number of pathologies, heat only accelerates the inflammatory process, activates bleeding.

Examinations

An effective examination of a patient who is worried about abdominal pain consists of interviewing, palpating the abdomen, laboratory, and functional diagnostics.

The smallest details are important for the doctor to make a diagnosis. For example, even an elementary assessment of feces can clarify a lot with pain in the abdomen.

• Hard lumps (“sheep” feces) are a frequent companion of colitis, lengthening of the sigmoid colon, stomach ulcers.
• Watery stools often accompany poisoning, infectious diseases.
• In case of parasitic disease (the presence of worms in the intestines), dysbiosis, the particles of feces are usually very loose.

Oral interrogation of the patient is also important for the choice of the instrument and diagnostic technology. The doctor asks the patient how long the pain lasts, whether there are seizures, what exactly causes the pain – physical movements, going to the toilet, eating, taking a certain position.

Diagnostics

Especially for identifying the cause of the disease and finding methods of treatment for abdominal pathologies, the following types of research are valuable:

• Ultrasound of the abdominal cavity . One of the most prompt measures in diagnosing diseases of the abdominal cavity and small pelvis, identifying the cause of abdominal pain is ultrasound diagnostics. With the help of ultrasound, it is possible to identify pathologies of the liver, gallbladder, spleen, kidneys, uterus, ovaries.Many people ask the question: is the stomach and intestines visible on ultrasound. It is impossible to examine the stomach with the help of ultrasound, the intestines – partially. If the equipment is with good resolution, for example, volumetric formations are visible in this area.
• FGDS (gastroscopy, probing, swallowing “intestines)” is a diagnostic method with which you can get an objective picture of the state of the stomach, duodenum, esophagus. If necessary, you can immediately conduct an express test for Helicobacter pylori (Helicobacter pylori) (which is the cause of ulcers), make cytology and biopsy – to exclude the oncological nature of the disease, determine the “acidity”.
• X-ray. A long-standing, but still practiced method of diagnosis. It can be used as an emergency measure for examining the stomach if, for some reason, EGD cannot be done. In addition, X-ray is informative in identifying diseases accompanied by symptoms of intestinal obstruction. Depending on the nature of the patient’s pain and complaints, a traditional X-ray or X-ray with contrast enhancement (irrigoscopy) can be used.
• MRI – a progressive diagnostic method for abdominal injuries, enlarged liver, uninformative picture of the abdominal cavity during ultrasound (for example, due to severe flatulence).
• Colonoscopy. One of the most accurate methods for examining the intestines. It is carried out using a fibrocolonoscope. With the help of the device, you can explore everything – even the most difficult areas, including the inner surface of the colon.
• Cholescintigraphy . Isotope research. It is carried out with the use of a radio pharmacological preparation. Informative for problems with the gallbladder and bile ducts.
• Blood, urine and canal tests .In the analysis of blood, special emphasis is placed on ESR (inflammation can be determined by the rate of erythrocyte sedimentation), biochemical indicators, and feces are examined for occult blood in many types of examinations for abdominal pain.

What to do?

So, the main thing with pain in the abdomen is not to self-medicate, not to delay the visit to the doctor and diagnostics.

At the same time, in some cases, it is important not just to sign up for the clinic, but to immediately call an ambulance. In what cases is an ambulance required?

• The abdominal pain is very intense.
• Cold sweat comes in.
• Severe vomiting of blood begins.

If the pain is not acute, there is no blood in the vomit, the temperature is different from that of a healthy person, but there is no fever, consultation with a therapist, gastroenterologist and diagnostics are recommended.

Timely diagnosis is a guarantee that the most gentle methods will be used to fight the disease. Even when it comes to surgery.

• Laparoscopy is used to remove gallstones and appendicitis (if the situation is not running).
• For the treatment of g astroesophageal reflux disease laparoscopic funduplication is used.
• Surgical hernioplasty is used to effectively solve hernia problems and strengthen the abdominal wall.

If there are no indications for surgical treatment, the therapeutic effect for many diseases of the intestine, stomach provides an integrated approach based on diet therapy, physiotherapy and drug therapy – antibiotics, antiparasitic agents, corticosteroids, prokinetics to improve intestinal motility.

Where to go?

Extensive experience in carrying out laparoscopic operations, hernioplasty in Minsk – at the doctors of the 5th clinical hospital.

In addition to receiving patients who are citizens of Belarus, the 5th city hospital in Minsk also accepts foreign citizens (on a paid basis). Each of them can undergo complex diagnostics and treatment on the basis of the surgical, therapeutic department.

The hospital has its own clinical diagnostic laboratory, X-ray department, RCT and MRI rooms.The physiotherapy department has all the conditions for carrying out rehabilitation programs.

Prevention

Doctors of the 5th hospital will not only select the optimal diagnostic and treatment option for each patient, but will also advise on preventing relapse.

Diet occupies a special place among measures for the prevention of intestinal and stomach diseases. In nutrition, it is important to learn how to maintain balance. You can not overeat, you should chew food carefully and slowly.Sufficient amounts of water, tea or mate should be consumed; coffee is not recommended in this case. At the same time, when choosing a diet, experienced doctors take into account all factors:

• functional state of the intestines, liver, pancreas
• secretory function of the stomach,
• intestinal motility,
• the presence of other concomitant diseases.

Beyond your diet, it is important to rethink how you store and handle food. Do not leave food open in the sun.Avoid damp food storage areas. Otherwise, they may start to mold and rot. Eliminate contact between raw and cooked foods.

Exercise therapy is also of great importance in the complex of preventive measures. Instructors-methodologists select their own loads and exercises for each patient.

Uterine fibroids. Effects on pregnancy. Treatment at SRI OMM

UTERINE MYOMA

What is uterine fibroids?

Myoma (fibroids) of the uterus is the most common benign tumor of the female genital organs.Fibroids can be found in one in three women of reproductive age, and more than 70% of women are asymptomatic carriers.

Unfortunately, uterine fibroids can be asymptomatic until they reach a sufficiently large size. Or it happens that the symptoms are smoothed out and are often perceived by a woman as a variant of the norm. Many women do not even know that they have this disease and go to the doctor only when the myoma reaches a significant size.

When to see a doctor?

Possible manifestations of uterine fibroids, which should alert you:

• Menstrual disorders – menstruation becomes prolonged, irregular, profuse.Often there is bleeding that is not associated with menstruation. Blood loss leads to iron deficiency anemia – the hemoglobin level gradually decreases. Weakness, pallor of the skin appears, which is not always noticeable immediately, and is perceived as a common malaise.
• Pain, feeling of heaviness in the lower abdomen and lower back. If blood circulation in the myomatous node is disturbed, then the pains are acute. However, more often the tumor grows gradually, and the pains are more of a aching nature, even if the myoma is large.
• Abdominal enlargement, feeling of something extra inside.
• Dysfunction of adjacent organs – the urinary tract and organs of the gastrointestinal tract. In particular, this applies to the bladder and rectum – the tumor squeezes these organs. As a result, there may be difficulty with urination, chronic constipation.
• Discomfort during intercourse.
• Infertility. The location and size of uterine fibroids significantly affect the local blood circulation in the genital organ, robbing the implantation zone and leading to a violation of the invasion of the ovum into the uterine wall.
• Miscarriage. A change in the shape and size of the uterine cavity can lead to a violation of the development of the ovum, the formation of placental insufficiency, the threat of termination of pregnancy, and the failure of the cervix during gestation.

How does uterine fibroids affect pregnancy?

Women with uterine fibroids often suffer from infertility.

Fibroid nodes growing into the uterine cavity deform it and disrupt the process of attachment of a fertilized egg to the uterine wall.

If pregnancy occurs, then it often ends in spontaneous miscarriage or the birth of a premature baby, since fibroid nodes, occupying a significant place in the uterine cavity, interfere with the development of the fetus.

During pregnancy, fibroid nodes usually increase in size due to edema and changes in hormonal levels, causing pain and discomfort to the woman.

Childbirth in women with uterine fibroids, as a rule, is difficult, with the development of abnormalities of labor.In such situations, uterine fibroids are an indication for a caesarean section. In addition, the postpartum period is in some cases complicated by bleeding.

Therefore, when planning a pregnancy, the best is the surgical removal of the node, followed by reliable suturing of the uterine wall. Only then is a successful pregnancy possible.

What happens to uterine fibroids without treatment?

Once it appears, the tumor tends to grow in size, more and more new nodes appear.The growth of fibroids in each woman is at a different rate. A growing fibroid can destroy the uterus and fill the entire pelvic cavity and even the abdominal cavity. Uterine fibroids sooner or later lead to uterine bleeding with the development of anemia, pain, disruption of neighboring organs, infertility and termination of pregnancy when it occurs.

Sometimes serious complications can occur associated with torsion of the leg of the node and the development of inflammation in the abdominal cavity. In these situations, emergency surgery is required.In rare cases (1 in 100), a malignant tumor, a sarcoma, may appear in the myoma node.

With the onset of menopause, the tumor usually shrinks. The ovaries stop working. Due to the lack of female sex hormones, fibroids begin to “shrink”. But, in the presence of sufficiently large tumors, and here the woman is in danger – as a result of a malnutrition of the fibroid, her death and severe inflammation can occur. And this leads to the need for emergency surgery.

Is it possible to save the uterus during the surgical treatment of fibroids?

The question of the possibility of preserving the uterus is decided by the operating gynecologist. With fibroids, it can almost always be saved. Our gynecologists-surgeons have a number of techniques that allow to reduce the fibroids before the operation, to bleed the uterus during the operation, and, accordingly, to minimize the risk of organ loss.

What types of surgical treatment for uterine fibroids are used in the gynecological clinic of the Ural Research Institute for the Protection of Motherhood and Infancy?

The vast majority of operations in the gynecological clinic of the Ural Research Institute of Maternity and Infancy Protection are performed using sparing organ-preserving technologies: laparoscopy (endoscopic surgery through abdominal wall punctures 5-10 mm in size), hysteroscopy (through the cervical canal of the cervix).Removal of myomas growing into the uterine cavity is possible with hysteroresectoscopy through the vagina without incisions and punctures.

Our clinic has developed unique technologies for the surgical treatment of uterine fibroids, which allow not only to leave the uterus, but also to preserve its ability to bear a baby and a successful birth.

We are currently working with a unique suture material – the so-called harpoon thread. This technology allows to adequately restore the integrity of the uterine wall without imposing many sutures and knots on the uterus.Thus, the traumatic effect on the uterine wall is minimized, the operation time is reduced and, what is most valuable, conditions are created for the formation of a high-quality full-fledged postoperative scar on the uterus. Namely, this determines the course of subsequent pregnancy.

What are the advantages of laparoscopic (endoscopic) surgery?

• Organ-preserving technologies of operations.
• Instead of a wide incision in the abdominal wall (from 7 to 30 cm in length), several punctures from 3 to 10 mm are made.Therefore, there are practically no postoperative pains, cosmetic defects, there is no need to follow a strict bed rest, a strict diet.
• The duration of hospitalization is 1-3 days. Normal health and ability to normal household and work activities are quickly restored.
• Due to the absence of a large incision, incisional hernias are very rare.
• The optics used in laparoscopic interventions give a multiple magnification, therefore, the surgical intervention is performed, more delicately, almost microsurgically.
• The surgeon has a much better view of the abdomen with a laparoscope than with a large incision. As a result, the level of intraoperative blood loss is several times lower, tissue trauma is less, it is possible to clarify the existing diagnosis, to instantly change treatment tactics if necessary, to diagnose concomitant pathology.
• In our clinic, it is possible to conduct an intraoperative ultrasound examination with dopplerometry, which allows you to clarify the mode of blood circulation in the node and in the uterus in real time, which allows you to operate with practically no blood loss.
• During endosurgical intervention, there is no contact of tissues with the surgeon’s gloves, talc does not get on organs and peritoneum, less manipulation of the intestines, no gauze wipes are used – all this eliminates the development of infectious complications and reduces the possibility of postoperative adhesions, leading to infertility, intestinal obstruction, and other severe pathologies.
• The use of modern suture material and a knotless technique of internal suture on the uterus minimizes the traumatic effect on the uterine wall, shortens the operation and rehabilitation time, and improves the quality of the postoperative scar on the uterus and the course of subsequent pregnancy.

We are ready to help every woman suffering from uterine fibroids, and at the same time find the very individual path, following which every woman can become a mother and give birth to a healthy baby.

Reception of women for diagnostics and solving the issue of the need for surgical treatment is carried out in our scientific polyclinic of the Federal State Budgetary Institution “Ural Research Institute of Maternity and Infancy Protection” of the Ministry of Health of the Russian Federation, at the address: Yekaterinburg, st. Repin, 1, 2 entrance.

Reception is carried out by highly qualified specialists:

Make an appointment for a consultation at the Consultative and Diagnostic Department on weekdays from 9:00 to 16:00 by phone 8 (343) 371 08 78, contact the Hospitalization Department by phone 8 (343) 371-17-24 or send your medical documents by email This email address is being protected from spambots.You need JavaScript enabled to view it.

90,000 Can Contractions Give Into the Rectum

How to distinguish false contractions from true (birth) contractions during pregnancy

A woman is living a new life while waiting for a child. Everything changes: taste, lifestyle. At different times, changes occur with her body: first, a brutal craving for one product wakes up, then toxicosis, a weighty belly begins to interfere with movement, and later false contractions appear.It is the latter that should be given special attention so as not to miss the onset of labor (women often confuse false and true contractions).

Signs of contractions

Training, false contractions (you can find the name “Braxton-Hicks contractions”, after the name of the scientist who first described them) are felt as rhythmic contractions of the abdomen. Most often they do not cause significant discomfort, but this is individual and depends on the pain threshold. They begin randomly and end as abruptly as they appear, and no sequence can be traced.

This condition can be traced from about the 20th week and can accompany a woman until the very birth, slightly increasing in the last months of waiting for the baby. More often, contractions are felt in the evening or at night, when all other muscles are relaxed and sensations are focused on changing the tone of the uterus. Often, contractions occur during exercise. In some women, they are asymptomatic.

Symptoms of false contractions :

• Irregular contractions of the uterus (may appear several times a day, then do not bother for a while, and reappear).
• Most often, the sensations during false contractions are painless, or cause minor discomfort.
• Seizures resolve with a change of position, cessation of activity, or increased activity.
• There is no cervical dilatation (only a doctor can determine).

How to ease the condition

When false contractions begin, accompanied by discomfort, you can alleviate the condition in several simple ways. First of all, you should calm down and try to relax.Be sure to change the type of activity and body position. Some women benefit from a warm bath, a pleasant massage, or a snack. You can practice breathing and birth gymnastics, then during real contractions and childbirth, the pregnant woman will feel more confident.

True contractions take place individually for each pregnant woman. Some women in childbirth feel severe pain already at the beginning, others – only mild discomfort, which increases with the frequency of contractions. The pain can radiate to the back, lower back, lower abdomen, lateral region, thighs, legs, bladder, or rectum.The sensation can be compared to pain in the first days of menstruation with painful periods (dysmenorrhea) or bouts of pain with diarrhea.

A distinctive feature of true contractions is their frequency. A decrease in the interval between pain attacks is clearly observed, the attacks themselves become longer, with a change in position, a change in the type of activity, they do not weaken. Often there is diarrhea, a feeling of nausea and even vomiting. In parallel, the amniotic bladder can open with the discharge of amniotic fluid.The obstetrician-gynecologist notes the gradual opening of the cervix.

Questions, the answers to which will help determine the nature of contractions

The difference between false contractions and real contractions for doctors is quite understandable and clear, but a panicky pregnant woman, constantly worried about the health of her child, often cannot correctly navigate in a variety of signs and symptoms. Questions will help you get an accurate answer. If the first option is your case, then the contractions are false, if the second option, then the contractions are true and you need to seek help.

How often do they occur?

1. Appear from time to time, do not have a specific interval.
2. There is a regularity of contraction attacks, the interval between them is from half a minute to a minute, their frequency gradually increases and their duration increases.

Do uterine contractions weaken with a change in body position and type of activity?

1. There is a weakening of the state when changing activities, after resting or walking.
2. Contractions continue at the same intensity even after changes in position and activity.

What is the intensity?

1. There is a weakening of contractions, the intensity of pain does not increase.
2. Each fight feels stronger than the last.

Where is the pain localized?

1. Pain is noted only in the anterior abdominal region, or in the pelvic region.
2. Pain and contraction are first felt in the lower back and then spread to the front of the abdomen.

If most of the answers are the second option, and it is too early to give birth in terms of timing, then you need to contact the doctor in charge of the pregnancy and clarify the situation with him, or go straight to the hospital.

When to see a doctor for false contractions

It happens that not everything goes smoothly and there are situations when training also requires medical attention. Moreover, it does not matter how long the false contractions last, and what is their intensity, help is required immediately.These signals include:

• The appearance of vaginal discharge (they may be bloody or watery).
• Drainage of amniotic fluid, or their leakage (in the first case, a large volume of fluid splashes out of the vagina, in the second, moisture is constantly felt in the vaginal area, the panties get wet quickly).
• Pain during contraction of the uterus is severe, but its regularity cannot be traced.
• Severe pain is felt in the lumbar region.
• The child began to move less (less than 10 movements over two hours) or froze altogether.
• Strong contractions at any time up to 37 weeks of gestation.
• Contractions are not strong, but they are repeated often (more than 4 attacks per minute).
• Contractions are not regular, but their intensity is increasing.
• Pressure on the perineum increases and causes significant discomfort and pain.

Why training contractions

False contractions are an integral part of preparing the muscles of the uterus and cervix for childbirth.The contractions help train the muscles (as well as exercise for the muscles of the back, legs, arms, and other parts of the body). Without them, the uterus will not be able to contract at the right time and push the baby through the birth canal (and this requires a lot of effort). There is an increase in muscle endurance, because in childbirth they will have to work hard more than once. Otherwise, the uterus will “hang like a bag” and will not be toned at the right time.

Training contractions also stimulate blood circulation in the genital organs, and thereby increase the supply of oxygen and nutrients (including to the baby).

Don’t worry if you don’t feel contractions at all. They are, you just have a high pain threshold or you do not attach importance to them (you are constantly busy with work, are in motion, confuse them with increased gas production, bouts of abdominal pain or another phenomenon). The body of a pregnant woman works as an autonomous system and will take the necessary actions by itself.

How contractions begin

Most of all pregnant women are afraid of contractions, and especially those who have not given birth before and only know about contractions from the stories of “experienced”.And what do women in labor usually tell about this phenomenon (or, most likely, what all women in position willingly and indisputably believe in)? Firstly, contractions are the beginning of labor – and this is a correct statement (although not completely, since there are so-called “false contractions”). Secondly, almost all women in labor remember the incredible pain during labor (although in fact few people remember this pain, since it is forgotten and it is impossible to compare it with anything) and most importantly, all pregnant women in the last trimester of pregnancy ( or even much earlier!) expect painful contractions.And try to tell them that your contractions were almost painless and that in fact not everything is so scary – they will never believe it. Moreover, already at the beginning of pregnancy, they will agree with the doctor about labor pain relief.

Fortunately, there are few such pessimists, and the majority of expectant mothers still tune in to “tolerable” pains, although they fear contractions before childbirth. Ignorance is always frightening, and, as a rule, contractions come certainly not by our will (unless, of course, we resort to stimulation of childbirth).So how do these contractions start? How not to let them out of sight? And what actually lies in this “terrible word”?

What does it feel like when contractions start

Contractions are called contractions because they cause a feeling of grasping, sharp contraction. When it comes to the upcoming birth, cramping sensations naturally occur in the area of ​​the hip joints.

In fact, contractions are a very complex “biochemical process”, as they involve the baby’s pituitary gland and the placenta itself, which begin to produce special substances, which in turn contribute to the opening of the cervix, which is accompanied by contractions.

During contractions, the uterus contracts, its muscle fibers thicken and shorten, which contributes to the opening of the cervical pharynx to the extent that the baby’s head can squeeze through it. Full disclosure is recorded when the cervix is ​​open by 12 cm, while the intrauterine pressure also increases, as a result of the rupture of the fetal bladder – and the amniotic fluid leaves.

How to find out that contractions have begun

When can a pregnant woman expect contractions? We have all heard about the threats of premature birth, which also begins with contractions, however, along with these signs of an impending birth, a woman also discovers other symptoms.In any case, cramping pains require special attention from the expectant mother. Practice shows that the contractions themselves and the sensations with them are different for all women. Even false contractions, which doctors love to talk about, are not noticed by all pregnant women. Moreover, even the expectant mother can learn about real labor pains only when she has a desire to push. We’ve also heard about rapid childbirth, when the contractions cannot be confused with anything.

Ideally, everything happens like this: starting from the 20th week of pregnancy, the body begins to “rehearse” the upcoming birth, contracting the muscles of the uterus.The woman feels that something is wrong with the uterus: she stiffens and relaxes at random intervals. So, a woman can “grab” for a whole minute, then the pain subsides and disappears without a trace, and soon resumes, but the regularity of such contractions cannot be noted. We are talking about false contractions – the harbingers of the upcoming birth. But not all women are faced with this condition, and their childbirth begins on time with real contractions.

How to recognize them? Again, ideally, the first contractions pass imperceptibly for a woman, except that there is very little discomfort in the abdomen or lower back, well, and a strong premonition that childbirth is about to take place (it is difficult for a woman’s intuition to find an explanation, but almost every woman subconsciously knows : it’s time!).

Gradually, the second, active, phase of contractions begins, when they proceed with an exact interval, which is shortening all the time: cramping attacks are repeated more and more often, continue for longer, not only the frequency and duration, but also the degree of painful sensations increase. So it comes to the point when one contraction lasts more than two minutes, and the second comes after 60 seconds. At this time, you should already be in the hospital, because in 30-40 minutes the birth itself will begin. The last stage of contractions is the most painful, since the woman has an irresistible feeling of going down in a big way.But if the uterus is not open, she will have to restrain her attempts so as not to harm herself and the baby.

31.08.2019 admin Comments No comments

At 40 weeks of gestation, the fetus fully develops and forms. However, the likelihood that he will be born during this week is negligible. According to statistics, only 5% of women have childbirth at this time, while the rest either give birth earlier or later by 2 – 3 weeks.

And this is completely normal, there is no reason to worry.Most likely, this is due to the incorrect set date, and not to deviations. A lot of women give birth at 41 – 42 weeks, and this is also considered normal.

How does the expectant mother feel

This period is difficult for a woman. The abdomen becomes petrified, becomes very large and interferes with free movement. Some women at this time cannot even get out of bed or get dressed on their own. Constantly worried about aching pain in the lower back and joints. At the same time, pain can be given both to the arm and to the leg.
Most women complain that at this time their belly seems to be stiff. This is completely normal. And this is due to the lowering of the abdomen and an increase in the tone of the uterus.

By the end of 39 weeks, a pulling sensation in the lower abdomen may appear – this is a sign that the cervix is ​​softening, preparing for the onset of labor. In addition, pain in the perineum and lower body may occur. During this period, the fetal head exerts great pressure on the pelvic floor.As a result, severe pain in the sacrum area is formed, as due to pressure, the hip joint is pinched.

Every day, the increase in pressure on the veins of the pelvis increases, which leads to filling of hemorrhoids. As a result, painful nodules appear in the anus, which leads to easy bleeding during bowel movements.

Compression of the femoral veins prevents normal blood flow in the lower extremities. This usually leads to temporary numbness of the legs.

At 39 – 40 weeks of pregnancy, the mammary glands of a woman are completely ready for breastfeeding. During this period, colostrum appears, which can provide the baby with all the necessary substances from the first days of his life. Then, about 3 to 5 days after giving birth, colostrum replaces milk.
Future mothers need to remember that during this period, all the inconveniences and unpleasant sensations need to be urgently reported to the doctor. After all, these can be both characteristic events of the final stage of pregnancy, and a “signal” foreshadowing the imminent opening of labor.

How does the fetus feel?

By the end of 39 weeks, the fetus is fully formed. His height is approximately 50 – 55 cm, and his weight is 3200 – 3500 kg. He already has little space in the uterus, so his movements are limited. But this does not mean at all that the activity of the baby decreases. On the contrary, he begins to move more often, mainly with his arms and legs. In case of decreased physical activity, you should immediately visit a doctor.

However, excessive fetal activity may indicate a lack of oxygen, which is typical for 39-40 weeks of pregnancy.During this period, the placenta is no longer able to fully cope with its duties, as a result of which the child experiences colossal oxygen starvation, which can lead to serious disturbances in the fetal brain activity, the work of its heart and other organs. And in severe cases, prolonged oxygen starvation even leads to the death of the child.

At this time, the uteroplacental barrier is violated due to a decrease in the thickness of the walls of the placenta, which protects the baby from infections and the penetration of toxic substances.The consequences of this are the unhindered penetration of pathogenic microorganisms into the fetus, which leads to the development of intrauterine infection.

Harbingers

As a rule, literally a week before the onset of childbirth, the stomach turns to stone, and the woman begins to actively lose weight. There is nothing wrong with that, unless, of course, the weight of the pregnant woman has decreased by more than 5-10 kg. Otherwise, urgent hospitalization is required.

Weight loss occurs due to the excretion of excess fluid from the body.It is manifested by frequent urination and excessive sweating, especially if, when 39 – 40 weeks of pregnancy occurs in the summer period.
Approximately 3 to 4 weeks before childbirth, aching pains in the lower back and lower abdomen appear, resembling cramps during menstruation. Periodically there is pain in the pubic region and a feeling of fullness. This is due to the pressure of the presenting fetus on the pelvic floor.

At 39 – 40 weeks of pregnancy, false contractions or Braxton Hicks contractions may periodically occur →

Strange as it may seem, but as a rule, those women for whom childbirth is not the first to react to false contractions, since they already know what to expect and follow all the processes in the body more closely.They are accompanied by pain or simply discomfort in the lower abdomen. It is very easy to determine whether it is false contractions or birth. When labor opens, uterine contraction occurs after a certain time, for example, every 15 to 20 minutes, while false contractions are not systematic.

The closer the delivery, the more often uterine contraction can be observed. This happens 1 – 2 times a day and lasts from 1 to 20 seconds. At this time, the uterus contracts and becomes hard.

About a day later, brown mucus, reminiscent of the onset of menstruation, begins to stand out from the vagina. The color and amount of discharge are individual, but their presence indicates the imminent onset of childbirth.
Immediately before childbirth in a woman’s body, the digestive system begins to empty the stomach. This is a kind of reaction to hormones that regulate labor.

Also, literally in a day or two, a woman may experience an increase in temperature.

Discharge from the genital tract for 39 – 40 weeks, carrying a purulent or mucopurulent character, informs about the presence of infectious diseases requiring urgent treatment. Especially if they have a characteristic smell. You should not wait for childbirth, since in the presence of pathogenic microbes in the vagina, infection of the child is inevitable. It is necessary to go to the maternity ward and undergo treatment on the spot, because childbirth can occur at any time.

In case of abundant liquid discharge, it is necessary to immediately call an ambulance and go to the hospital, even if no contractions have yet been observed.Since they indicate a premature rupture of amniotic fluid. Normally, the discharge of amniotic fluid occurs immediately at the time of the onset of labor. A long anhydrous period is fraught with infection of the fetus.

A very unpleasant symptom when bloody discharge appears from the genital tract. It is impossible to leave them unattended, even if the stomach does not hurt and the amount of blood is small. Bleeding can open at any time, which can become a big threat, both for the life of the expectant mother and for the unborn child.Urgent hospitalization of the pregnant woman is required.

The appearance of a large lump of mucus, slightly colored with blood, from the genital tract indicates the imminent beginning of labor. This lump of mucus is called a plug, which throughout pregnancy blocked the entrance to the uterus and protected the baby from infection in its cavity. When the cork leaves, you need to wait for the appearance of regular contractions, and then go to the hospital. The cork can come off as a couple of hours before the opening of labor, and in a day.Therefore, you should not go to the hospital without the appearance of regular contractions.

Ultrasound and analyzes

Ultrasound at 40 – 41 weeks of pregnancy determines the level of development (full-term) of the child. In addition, you can see the Beklar nuclei – the ossification nuclei near the long bones. Also, ultrasound at this time allows you to compare the echogenicity of lung tissue with liver tissue, suspension in waters, which is exfoliated skin particles and cheese-like lubricant of the fetus.

When conducting ultrasound, the following indicators are considered normal:

• biparietal size (BPR) – 89-103 cm;
• frontal-occipital size (LZ) – 110-130 cm;
• head circumference (OG) – 312-362 cm;
• fetal abdominal circumference (OB) – 313-381 cm;

90,015 forearm bones – 5.4-6.2 cm;

• humerus – 6.2-7.2 cm;
• femur – 7-8 cm;

90,015 shin bones – 6.1-7.1 cm.

On the Internet, you can find and watch a video guide detailing ultrasound in the 40th week.

In the period from 39 to 41 weeks, a pregnant woman needs to undergo tests of the OAC and OAM every 5-7. According to the test results, if abnormalities are detected, the pregnant woman is taken under strict control. She is prescribed medications, additional ultrasound and Doppler measurements are performed.

Intimate life at 39 – 41 weeks of gestation

In the late stages of pregnancy, namely at 39 – 41, you can have sex only with the approval of your doctor.In some cases, sex is beneficial to pregnancy, and in others it is not. It all depends on the state of health of the mother and child, as well as on the location and thickness of the walls of the uterus.

Sex at this time can contribute to the onset of labor, since the hormones prostaglandins contained in male sperm soften the cervix, and orgasm stimulates the onset of contractions. This method of stimulating labor should not be used without the consent of the doctor, since the labor provoked by this method is long-lasting – the contractions are long and strong, which can cause significant harm to the health of both the child and the woman in labor.

Hazards of the 40th week

The main danger that can accompany a woman in late pregnancy is rapid childbirth. A child can be born very quickly, there have been cases when only 2 – 3 hours passed from the moment of the onset of contractions until the birth of the child. Therefore, you should go to the maternity ward in advance, about one week before the PDD (estimated date of birth), or, if your home is not far from the hospital, avoid long trips and shopping trips.Basically, rapid childbirth is observed in second-bearing women.

It is also extremely important to monitor your vaginal discharge. The likelihood of infection of the fetus at this time increases several times.

Lack of oxygen is associated with a decrease in hemoglobin in the blood, so you should carefully monitor your diet. Be sure to include in the diet buckwheat, beans, peas, apples and other foods containing a large amount of iron.

Recommendations

It is very important to remain calm during this period.The emotional state of the expectant mother directly affects the child. During this period, one should tune in to the upcoming birth, think only about their good outcome, rest more and listen to calm music. In general, you need to enjoy the last days of pregnancy, because after the birth of the baby you will not have time to rest.

As soon as you feel the onset of labor, do not go to the hospital on an empty stomach. Energy reserves should be replenished. But do not gorge yourself on cutlets and fried potatoes.Snack on light yogurt, low-fat cottage cheese, bread with cheese, or have a mug of sweet tea, compote or jelly. During labor, even a small piece of chocolate can cause nausea and vomiting, making labor difficult.

Another reason why you should not eat a lot before going to the maternity ward is the possibility of urgent surgery.

During contractions and attempts, food and liquid intake is completely excluded. But after giving birth, you need to recuperate.Do not “lean” on food immediately after the end of labor. You should wait about two hours, and then you can eat something light, such as fruit puree or vegetable broth.

As soon as the contractions began to last about one minute, and the break between them is 5-7 minutes, it’s time to go to the hospital. Very soon you will see your long-awaited baby!

Video guide 40 weeks of pregnancy

How to understand that contractions have begun.What contractions are like

How to recognize contractions before childbirth?

Basically, during the first birth, pregnant women ask themselves how to recognize contractions before childbirth. Quite often, women, even before the onset of labor, intuitively feel that labor will begin soon. With contractions, pain does not immediately appear, usually it all starts with a feeling of discomfort in the abdomen or lower back, some women experience pain similar to menstrual pain. Gradually, these sensations become stronger, spreading to the entire abdomen and lower back, pain appears, which can range from fairly strong pressure to twitching sensations.

Pain during contractions is paroxysmal, its occurrence, intensification, reaching a peak and gradual decrease is clearly felt, then a period of no pain begins. At first, contractions before childbirth occur with an interval of 15-30 minutes and last 5-10 seconds. For the first few hours, they bring a little more discomfort than pain. Gradually, the duration and strength of the contractions increase, and the intervals decrease.

Before childbirth, bloody discharge appears – this is how the mucous plug leaves.It shouldn’t be bright red with a lot of blood. The cork can come loose before the start of the contractions. Sometimes the water also drains before the start of the contractions.

Just before the birth of the child, the contractions become so frequent that they pass one into the other almost without intervals. Further, they are joined by attempts – contractions of the muscles of the uterus, abdominal wall and perineum. At this time, the child presses his head on the small pelvis, and the woman in labor has a desire to push, and the pain moves to the perineum.When the cervix is ​​fully dilated, the birth process begins.

How do contractions take place?

Contractions before childbirth develop gradually, so three stages can be distinguished:

• The first stage – initial, lasts 7-8 hours. At this time, contractions occur at intervals of about 5 minutes, and their duration is 30-45 seconds.
• The second phase is active. Its duration is about 5 hours, uterine contractions become more frequent and last longer – with an interval of 2-4 minutes, the duration of contractions reaches 60 seconds.
• The last, transitional phase – from half an hour to 1.5 hours. The contractions are getting more frequent and longer. They can occur at intervals of a minute and have a duration of 70 to 90 seconds.

If the birth is not the first, the process is faster.

How to distinguish real contractions from false ones?

False or training contractions, also called Braxton-Hicks contractions, are contractions of the uterus, as a result of which its cervix does not open. They appear long before childbirth and, unlike real ones, are irregular.

Not every woman feels false contractions, everything is individual here – both their presence and absence is a variant of the norm. They are painless but uncomfortable.

Training contractions are called training contractions because they prepare the uterus for contractions during labor. Also, with false contractions, blood rushes to the placenta, which is good for the fetus. False contractions are the norm for pregnancy and do not pose any danger. False contractions start around week 20.

Women who are expecting a baby for the first time are often afraid to confuse false contractions with the real onset of labor. What is the difference between training and real fights?

1. False contractions can be repeated from several times a day to six times an hour. At the same time, they are irregular, and the intensity gradually decreases. Real contractions before childbirth are regular and repeated at shorter intervals and with greater intensity, and their duration also increases gradually.
2. The length of actual contractions may vary, but the intervals between them are almost always equal.
3. False contractions are painless, with a feeling of constriction in some part of the abdomen or groin. With real pain, the sensation spreads to the entire abdomen and hip joints.
4. With real contractions before childbirth, other symptoms are also observed: discharge of water, mucous plugs, pain in the lower back, diarrhea.

What to do when contractions start?

The time of onset of contractions, their duration and the size of the intervals between them should be recorded.This information is useful for obstetricians, in addition, keeping records will help calm and distract from pain.

You can safely go to the hospital. If the contractions are repeated after 15-20 minutes, the baby will not be born soon. If there are no pathologies, the pregnancy is not multiple, it is better to spend this period at home: a familiar environment will help you to relax better. You can do pleasant things: listen to music, watch a movie. If you are not going to have a caesarean section, you can have a light snack.

When the contractions of the uterus become more frequent and stronger, first of all the woman needs to take a comfortable position and relax. Then the pain will be less. Real contractions before childbirth are getting longer, and the intervals between them are short. The pain spreads from the abdomen to the lower back, does not diminish with a change in body position.

Signs of pathology during contractions

Sometimes, for various reasons, labor can be slowed down. Labor does not necessarily follow the first contractions – uterine contractions can only become regular after a few days.This is more common in primiparous women. In such cases, the maternity hospital resorts to the stimulation of labor.

When is it time to get ready for the hospital?

If real contractions have begun before childbirth, it means that childbirth is approaching. Don’t worry, you have time to calmly gather while the contractions are at intervals of 20-30 minutes. Of course, it is advisable that the bag with things has already been collected in advance.

How to reduce pain during labor?

The onset of labor is a rather painful process, but a woman can help herself without resorting to medication.The body itself helps her in this by producing endorphins and other hormones that naturally ease painful sensations. There are several proven ways to reduce pain during labor:

• Massage and self-massage. Relaxes muscles and relieves pain. Ask a loved one to massage your lower back, shoulders, and protruding pelvic bones. If no one is around, massage your lower back and protruding pelvic bones with your own hand clenched into a fist.
• Correct breathing.It may seem that holding the breath makes the pain easier to bear. This is not the case, and the lack of oxygen can harm the baby. You need to breathe during contractions deeper and slower than usual, inhaling through the nose and exhaling through the mouth. At the peak of pain, intermittent breathing may help. Try to relax between contractions. Also, focusing on your breathing will help you distract yourself from the pain.
• Water procedures. You can take a warm bath, if the water and mucous plug have not yet departed (after that, the bath is contraindicated, since the water can introduce an infection).You can also take a shower (at home or in the hospital), directing the jet to the abdomen, lower back, and shoulders.
• Movement and Position. During contractions, it is better to be in an upright position – this way the baby’s head puts less pressure on the small pelvis, the vessels are not pinched, and childbirth occurs faster. You can take any comfortable position that feels less painful, such as getting on all fours or knees with your hands on a bed or chair, or leaning against a wall or headboard while standing. You can hang on your husband or even on a rope.
• Psychological attitude. Try to see childbirth as more than just painful. Think that you will soon see your long-awaited baby and take him in your arms. If you are giving birth for the first time, learn more about the birth process in advance, which will help you to be less afraid. Fear causes the muscles to contract, which increases the pain. Chat with women who have fond memories of childbirth. Sign up for childbirth preparation courses. It’s good if these are courses at the maternity hospital in which you are going to give birth.Then you can get to know the doctors and obstetricians in advance.
• Smile. It is believed that the position of a woman’s lips affects the state of the cervix: if the mouth is relaxed, the cervix also ceases to strain.

In the article you learned: how contractions begin before childbirth, what contractions are like before childbirth, and how to distinguish false contractions from real ones. We’ve also prepared a series of useful videos for your attention:

Video: Signs of incipient labor

Video: How to understand that labor has begun

90,000 Why do menopause pain occur and how to overcome them?

Why do menopause pains occur and how to overcome them?

Statistics

As statistics show, 45–55 years for a woman is the time of her greatest prosperity.This is a time of experience, self-sufficiency and conscious beauty. Unfortunately, the beautiful age is often overshadowed by the unpleasant manifestations of menopause. Along with hot flashes, the faithful companions of menopause are pains of various localization. In this article, we will deal with the causes of their occurrence and find out if it is possible to get rid of the painful sensations. We will discuss all the known ways to deal with pain in menopause – from taking hormones to changing your lifestyle.

Types and causes of pain in menopause

Climax is a grandiose restructuring of the female body.The gradual shutdown of the childbearing function is accompanied by changes in all organs and systems. This is manifested by unusual and sometimes not the most pleasant sensations, including pains of different localization, strength and duration. The root cause of all types of pain in menopause is a sharp change in hormonal status. The decrease and then the cessation of the secretion of estrogen and progesterone is reflected not only in the state and functions of the reproductive system. Cells that are sensitive to sex hormones are present in various tissues and organs.Therefore, estrogen deficiency during and after menopause leads to changes in the cardiovascular, musculoskeletal, nervous, endocrine systems, affects metabolism, emotional and mental sphere, etc. With menopause, women are most often worried about pain in the abdomen, lower back , perineum, headache, joint, muscle and bone pain. They are quite intense and often reduce the quality of life, especially when combined with other symptoms of menopause. We will look at the mechanisms of occurrence of different types of pain during menopause and learn how to deal with them.

Low back pain

With menopause, lower back pain is most often a pulling, aching character. They are rarely strong, but they cause a lot of discomfort to a woman. During menopause, your lower back can hurt for a variety of reasons. Most often this is due to changes in the reproductive system due to the weakening of the activity of the ovaries. Unpleasant sensations in the lower back in this case are often accompanied by pain in the lower abdomen. Lower back pain, aggravated by bending, physical exertion, signals problems with the spine.With menopause, the risk of developing or exacerbating osteochondrosis increases. The lumbar spine is subjected to the most severe stress, so it suffers first. Another cause of back pain can be bone degeneration – osteoporosis. A sharp decrease in estrogen production leads to disruption of mineral (primarily calcium) metabolism and other processes, as a result of which bone tissue resorption is enhanced, and its synthesis, on the contrary, is inhibited. Bones become fragile and the risk of fractures increases.To identify osteoporosis at an early stage and stop its progression will help the timely initiation of calcium and vitamin D3 preparations, phytoestrogens.

Joint pain

Complaints of joint pain are very typical for women who have entered the time of menopause. In childbearing age, metabolic processes in the connective tissue are regulated by sex hormones. Without estrogen protection, metabolism is disrupted. In addition, collagen synthesis is inhibited. All this leads to degenerative processes – arthrosis and osteoarthritis.Sometimes joint pain during menopause is of an inflammatory nature. This is also due to a decrease in estrogen production. For such cases, the term “climacteric arthritis” is used. The manifestations of osteoarthritis and climacteric arthritis are similar: joint pain, stiffness in the morning, limitation of mobility. The defeat is often symmetrical. If the pain increases with exercise, this is a sign of osteoarthritis. In climacteric arthritis, movement, on the other hand, reduces the discomfort. Articular pain is also felt by osteoporosis.With the onset of menopause, it occurs several times more often than in other age periods.

Abdominal pain

Minor pains in the lower abdomen with menopause occur due to the extinction of the function of the genitals. Structural changes occur in the reproductive system: the ovaries decrease in size, the muscular layer of the uterus is replaced by connective tissue, and the endometrium atrophies. All this can be accompanied by discomfort in the pelvic area. But if the pulling pains in the lower abdomen become persistent, prolonged or intense, this may indicate the development of a disease – endometriosis, uterine fibroids, salpingitis, etc.e. The occurrence of such symptoms is a reason to immediately visit a gynecologist.

Perineal pain

The mucous membrane of the vagina and external genital organs is exposed to atrophic changes during menopause. A woman may complain of dryness, itching, and pain in the perineum. In severe cases, an inflammatory process develops – atrophic vulvovaginitis.

Headaches

Many women of reproductive age suffer from headaches and migraine attacks during the premenstrual period.As menopause approaches, these symptoms worsen. To one degree or another, almost every woman after 45 years old complains of a headache. Headaches with menopause are different – weak and strong, short-term and long-term, debilitating. By their nature, they are also diverse: squeezing, bursting, dull aching, stitching, burning, pulsating, etc. More often, the pain is localized in the back of the head and temples. Some women have classic migraine attacks. An exhausting headache is troublesome, disrupts the comfort of daily life, and negatively affects the ability to work.

Muscle pain

Reduction and gradual cessation of the secretion of female sex hormones directly affects the state of the muscular system. Dystrophic processes in the muscles lead to their weakness, increased fatigue. Reduced exercise tolerance. Muscle pain with menopause more often occurs in women who have not previously played sports. Muscle pain in menopause is varied. They are dull and sharp, long-term and short-term, they are felt as tingling, aches, etc.n. Most often, pain occurs in the legs, back, pelvic region. Calcium deficiency leads to spasms and cramps in the calf muscles. It is important to know that muscle pain during menopause is not always explained by age-related degenerative processes. Sometimes they are caused by a medical condition such as osteoporosis.

Chest pain

Often, when approaching and the onset of menopause, women are concerned about discomfort in the chest. Severity, enlargement of the mammary glands, increased sensitivity and pain occur cyclically, as before menstruation, and are caused by a change in the level of sex hormones.Sometimes there are sharp acute one-sided pains that disappear as suddenly as they appear. Chest pain with menopause, as a rule, does not indicate a dangerous disease. Discharge from the nipples, changes in the skin of the mammary glands, a clear localization of pain, its intensification over time should be alerted. After 40 years, women should be examined by a mammologist annually so as not to miss serious problems.

Bone pain

Most often caused by osteoporosis.In this disease, there is a decrease in bone density due to a violation of mineral metabolism (calcium loss), the predominance of destruction processes over synthesis. Bones become porous, brittle, brittle. In the later stages, pathological fractures occur that are difficult to heal. Women of reproductive age rarely suffer from osteoporosis. Calcium is accumulated in sufficient quantities in bone tissue due to the action of estrogens. But with the onset of menopause, the situation changes dramatically.The decrease in estrogen levels leads to the “leaching” of calcium from the bones. Together with the age-related slowdown of regenerative processes, this leads to the development of osteoporosis. Osteoporosis is characterized by pain in the spine (lower back, interscapular region) and lower extremities. At an early stage of the disease, they appear periodically, then become permanent.

How to get rid of pain in menopause?

Is it possible to completely get rid of pain during menopause? It depends on the immediate cause and mechanism of the pain syndrome development.For example, if joint and muscle pain during menopause is caused by a violation of mineral metabolism, taking vitamin-mineral complexes will help to replenish the calcium deficiency in bone tissue and thereby eliminate the main factor in the onset of painful sensations. In general, we can say that all methods of dealing with pain in menopause should be aimed at solving two main tasks – the correction of hormonal imbalance and the prevention of osteoporosis.

Diet

For pain and other pathological symptoms of menopause, a varied diet rich in vitamins and calcium is indicated.A woman’s diet should include dairy products, fruits and vegetables, herbs, nuts, eggs. Soybeans contain not only calcium but also phytoestrogens. Foods rich in vitamin E are useful: potatoes, beans, brown rice. During menopause, the risk of being overweight increases, so the calorie content of the diet should not be high. It is recommended to limit the consumption of sugar and animal fats. It is useful to replace red meat with sea fish and seafood.

Sport

Sports activities help to maintain good health, prevent excess weight, prevent the development of diseases of the joints and spine.