00:00 – Dr. Fogelson: Sometimes people have sciatic pain and it’s a cyclic sciatica,
00:03 – where every single time when they’re on their menstrual cycle, they have sciatic
00:04 – pain. But they don’t have endometriosis, or they have endo but it’s not anywhere near
00:11 – the sciatic nerve.
00:25 – Melissa: The first one is, if changes in temperature trigger UTI symptoms, could
00:26 – this be due to nerve involvement or is there an infectious explanation for why that
00:26 – would happen?
00:40 – Dr. Fogelson: I don’t know, good question.
00:43 – Melissa: It’s not the only person that has asked this in the past but I’ve never found
00:46 – an answer for it.
00:46 – Dr. Fogelson: But temperature making it worse, there are some bacteria
00:51 – that grow better in higher temperatures but our bodies pretty warm all the time so it’s
00:51 – hard to imagine that.
00:59 – The thing is that if it’s hot out, your body temperature doesn’t change very much.
01:00 – If it does then you’re in heat stroke. That’s a pathological condition if your body
01:10 – temperature is actually changing. And if it’s cold body temperature, it’s the same. Your
01:10 – skin gets colder, but again, if your internal body temperature changes
01:20 – when you get cold, we call it hypothermia. Again, that’s a pathologic condition. So
01:21 – now
01:29 – there’s almost like a rheumatologic question that I don’t
01:35 – know that much about. But people that have arthritis, so they have more joint pain
01:35 – when it’s cold. I’m not really sure why. So inflammatory conditions perhaps get
01:42 – worse when it’s cold and get somewhat better when it’s warm. And people that
01:46 – have a bad back usually feel better when it’s warm. And they feel worse when it’s
01:51 – cold and they say, oh my back’s cold. But I don’t really understand what that
01:55 – mechanism is. Perhaps it’s just that things are a little bit more contracted or… I don’t
02:00 – know. I’m just thinking, speculating.
02:03 – Melissa: Someone else asked what pelvic congestion syndrome is and how common
02:04 – it is.
02:04 – Dr. Fogelson: Okay so pelvic congestion syndrome is kind of a wastebasket
02:10 – term of things but it implies that there’s vascular compression of stuff. And so the
02:20 – classic pelvic congestion syndrome is
02:21 – coming from varicosities in the ovarian veins or gonadal veins. And so when the
02:27 – patient stands up, you basically get a column of blood over their ovaries. And
02:32 – usually if you’re getting congestion of the ovaries, you can get a dull, aching pain in
02:39 – the pelvis radiating into the back. And you can also get congestion of the venous
02:39 – drainage.
02:46 – I guess the easiest way to explain it is that if you’ve ever known what varicose
02:50 – veins is where your legs feel really heavy and your legs feel painful, and it’s because
02:54 – you don’t have good valves in your legs. So the blood should go up like
02:58 – an elevator. And each time it gets past a certain valve, it doesn’t go down anymore.
03:02 – So that’s why the blood keeps circulating, because the heart pushes it, which in turn
03:02 – pushes the blood
03:07 – down your foot. Just pushing the blood up your foot, as long as these valves are
03:08 – there, then as the blood gets up, it can’t go back down. Well, if these valves are
03:14 – incompetent, which is what we call varicose veins, then in certain situations
03:15 – where you’re upright, the blood just wants to stay in your legs. And so that same
03:23 – situation can happen in your pelvis. So if there’s something that’s keeping blood
03:27 – from getting out of your pelvis very well,
03:30 – then that can cause pelvic congestion syndrome. There’s a couple different
03:36 – reasons why this could happen, and probably some reasons that we don’t
03:40 – understand also. But one reason is varicosities of the gonadal veins, which is
03:44 – the ovarian veins. And so one classical treatment is
03:48 – embolizing the gonadal veins. And so interventional radiologists do that. It
03:54 – works in some people, not in others. So there’s this other thing called May-Thurner
03:55 – syndrome, which is
04:00 – where the left common iliac vein is compressed by the left artery. We have an
04:06 – anatomical situation in our body where the aorta is like this and the vena cava is like
04:06 – this and they split kind of like that. And so what happens is, this vein is getting
04:15 – compressed by this artery.
04:19 – There’s no other way to do it. Somehow you got to arrange it. No matter how you
04:19 – arrange it, some vein is going to be under. I guess if the veins all went on top, but they
04:20 – don’t. So the veins go under the arteries. So what happens is, sometimes this artery, for
04:29 – one reason or another, is particularly compressive of this vein. And that vein is
04:35 – the common drainage of the whole left side of the pelvis. The big vein, it’s the
04:40 – biggest vein in the body other than the whole vena cava, which is the huge vein
04:46 – that goes up up your abdomen. And so there are some some people that have pain
04:50 – in the left side, mostly on the left side, because they have this quote “May-
04:55 – Thunder” syndrome. And interventional radiologists have diagnostic criteria for
05:00 – this. It can be seen on a CAT scan. And there’s also some endo vessel ultrasounds
05:04 – that they do where they put a catheter in the vein and actually some sort of
05:08 – ultrasonography that’s on the end of the catheter. I don’t know exactly how it works,
05:13 – but there are some criteria. And in people who truly have May-Thurner syndrome, the
05:17 – interventional radiologist can put a stent in that vein. It’s basically like a
05:22 – scaffolding that holds the vein open. So now that artery that’s going over the vein is
05:26 – kind of pushed up because the vein is holding itself up by an internal scaffolding.
05:34 – Again, these are things that work sometimes, not other times. The question
05:35 – is, is scaffolding going to clot off eventually? That’s a big problem with
05:42 – endovenous prosthesis. Effectively, if you’re putting a piece of material inside a
05:46 – vein for the rest of your life,
05:50 – if you do it when you’re 30 years old, what’s it look like when you’re 70? And you
05:53 – don’t know. So then there are some conditions where you literally just have
06:00 – venous malformations where a vein is very tightly wrapped around a nerve. And in
06:00 – neuropelveology, I deal with that sometimes. So sometimes people have
06:07 – sciatic pain, and it’s a cyclic sciatica where every single time when they’re on their
06:12 – menstrual cycle, they have sciatic pain. But they don’t have endometriosis. Or they
06:16 – have endo, but it’s not anywhere near the
06:18 – sciatic nerve.
06:19 – Some of those patients, the common iliac vein that comes off into the internal iliac
06:20 – vein, it gives off a couple veins that go over the top of the sciatic nerve called the
06:27 – gluteal veins. They go in, they drain the buttocks. And in some people, those veins
06:34 – are really tightly around the nerve. They should be loosely around the nerve, so
06:38 – there’s plenty of fat in there and it doesn’t really. But occasionally you see it and you
06:42 – can see that the nerve is really tightly bound up by that vein. And so when blood
06:46 – flow is increased in the pelvis, that vein is getting plump and it’s constricting the
06:51 – nerve and causing sciatic pain. So in that kind of circuit circumstance, we can
06:56 – address that surgically. You can actually dissect out down to the sciatic nerve and
06:56 – you can coagulate those veins and free up all the space around the nerve. And again,
10:00 – these are things that you have to intellectually reason out. Think, this
10:01 – probably is the case. And then you have to go look. There’s
10:07 – almost no way to confirm or deny this by any pre-operative imaging. That’s kind of
10:08 – what neuropelveology is. You intellectually figure out what must be going on and then
10:14 – you look there surgically. It’s very hard to confirm this with any kind of imaging
10:21 – study. Maybe, and in some circumstances, but if the clinical situation tells you this
10:27 – thing may be there, and the imaging study says it’s not there, it still may be there.
10:35 – So you still have to potentially go look. So pelvic congestion syndrome…
10:46 – one of the most effective ways of dealing with pelvic congestion syndrome
10:54 – is just to do a hysterectomy and possibly even an oophorectomy.
10:59 – Unfortunately, of course, that’s going to make someone unable to bear children.
10:59 – But
11:04 – the pain is often because of the high amount of blood flow to the pelvis. If there
11:05 – is no uterus there anymore, the arterial blood flow to the pelvis is much reduced.
11:11 – And so that actually has a fair amount of effectiveness. Taking progesterone, which
11:18 – just causes the uterus to
11:22 – not cycle, get a very thin lining, and over time it’s going to decrease
11:26 – blood flow to the uterus. That actually is also associated with improving pain
11:27 – from pelvic congestion syndrome. So I think that just
11:36 – anything that’s going to decrease blood flow in the uterus, in the pelvis, is going to
11:36 – make pelvic congestion syndrome less symptomatic. And so that’s why
11:41 – hysterectomy can be helpful.
11:44 – Melissa: Right. We have a question also about peripheral neuropathy in the legs,
11:50 – hands, and feet, and whether this could also then be the cause of urinary
11:50 – incontinence.
11:59 – Dr. Fogelson: Well, there’s potentially a common pathway. So if you have
12:04 – peripheral neuropathy, that would imply that you have something that is causing a
12:09 – global injury to your small nerves in your body.
12:12 – So the most common one would be diabetes with poor
12:16 – blood sugar control. So people that have chronically high blood sugars will
12:16 – eventually injure their peripheral nerves. And they can in turn get bladder
12:23 – dysfunction from that also. There are other neurologic conditions like multiple
12:30 – sclerosis. I’m not a neurosurgeon or neurologist so I don’t know what all these
12:36 – conditions are. But there are
12:39 – neurologic conditions that could cause both peripheral neuropathy and then in
12:42 – turn cause neuropathy in the pelvis also. So I don’t think that peripheral neuropathy
12:42 – is…
12:48 – well, I think peripheral operating can cause those things. But
12:52 – the fact that your hand has neuropathy is not causing your pelvis to
12:57 – have neuropathy. But there’s a common pathway to both.
12:58 – Melissa: Okay, and what about stenosis of the spinal canal? Is that related to
13:04 – intermittent UTI symptoms at all?
13:11 – I don’t know that I absolutely know the answer to that. In order for it to be
13:17 – true, it would have to be in the sacral roots. So if you had stenosis in S2, S3, S4,
13:18 – then yes, potentially. But you don’t have any discs there, and you don’t get herniated
13:24 – discs in your sacrum,
13:30 – so I think that that’s uncommon. There is a condition called Tarlov cysts which is a
13:37 – it’s almost like a herniation of the nerve sheath, and that exists in sacral nerve
13:37 – roots. And it happens within the bone of the sacrum where you get this bubble of
13:44 – fluid within the nerve. It’s highly controversial whether these cysts are
13:49 – pathological or not. There was one study that looked at the laterality of pudendal
13:54 – neuralgia and then looked at
13:59 – the frequency of Tarlov cysts and the frequency of pudendal neuralgia. And it
14:05 – showed that Tarlov cysts are more common in people that have pudendal
14:10 – neuralgia than they are in people that don’t have pudendal neuralgia. But the location
14:15 – of the Tarlov cyst did not seem to correlate to where the pudendal neuralgia was. So if
14:21 – they have pudendal neuralgia on the left side,
14:24 – they’re no more likely to have… they’re more likely to have trouble of cysts, but
14:25 – they’re no more likely to have it on the left side than they are on the right side. And so
14:30 – what that would suggest is, there may be a common pathway to pudendal neuralgia
14:35 – and Tarlov cysts. But the cyst itself does not seem to be causing the pain we think.
14:41 – Because you would have assumed that that Tarlov cyst would be on the same
14:50 – side as the pain.
14:50 – Melissa: I would think so, yeah.
14:55 – Dr. Fogelson: There are surgeons that do surgery for Tarlov cysts. Again, we get into
14:58 – these weird circumstances where you have these really weird conditions that are
15:01 – uncommon, that most people don’t know anything about, and always you have
15:05 – surgeons pop up that say they can fix it. They’re not taking insurance, they’re
15:08 – charging a lot of money.
15:10 – I don’t take insurance either but I try not to charge too much. I actually
15:14 – don’t charge nearly as much as some of my colleagues do. And
15:21 – there’s not any strong evidence that that particular surgery works.
15:24 – I’m kind of getting off on something.
15:25 – Melissa: On non-surgical techniques, people often talk about rewiring these
15:30 – neural pathways to prevent this chronic pain. Can you talk a little bit
15:36 – about how that works and whether it’s effective?
15:39 – Dr. Fogelson: I don’t know, it’s a made-up idea. You’re obviously not rewiring it, you
15:46 – only got one set of wires physically. But there’s different ideas there. So there’s
15:53 – psychological rewiring. There’s a difference between pain and suffering. Pain is a
15:59 – physiologic, neurologic phenomenon. Suffering is a psychological phenomenon.
16:09 – So it is possible to feel pain but not feel suffering.
16:10 – There’s Shaolin monks that have figured that out.There are clearly people
16:18 – that have learned how to not suffer in the face of pain. I’m not saying it’s easy. I
16:24 – don’t know how to do it. But I’m telling you, given enough psychological
16:28 – indoctrination or learning or whatever, there seem to be people that are able to do
16:29 – that.
16:36 – So that is a certain kind of rewiring. I’m not sure it’s achievable, but it may be
16:37 – achievable to some extent by a lot of people. I don’t know that it’s achievable to
16:43 – the point where the Shaolin monk is hitting themselves over the head with a board and
16:47 – they say it doesn’t hurt, that’s pretty intense, but if you can decrease the level of
16:50 – suffering by some sort of perceptive change, than that that is something. And
16:58 – ultimately that’s something that you work with with a psychologist. But to the extent,
17:03 – can you rewire the actual neurologic impulses in your nerves? I don’t know.
17:05 – There are people that claim to know, but I think that they’re full of crap to some
17:15 – extent. They’re not maybe totally full crap but
17:18 – I don’t think that that’s a reliably reproducible thing you can do.
17:20 – But I do think there’s medications that can decrease the intensity of nerve signals
17:26 – getting into your brain that aren’t just pain medications. They’re literally affecting the
17:33 – nerves.
17:37 – Marc Possover does stuff with neurostimulation that I haven’t gotten into
17:38 – yet where you do seem to be able to create something called neuro regeneration or
17:44 – neuro remodulation, which could be another term for what you’re talking about
17:50 – where by doing very high frequency nerve stimulation of nerves that are in pain, you
18:00 – seem to be able to cause a long-term impact on the nerve to where even when
18:00 – you turn that stimulation off, the nerve seems continues to function better. So that
18:09 – does seem to be a concept of what you’re talking about. But it’s experimental and not
18:15 – really proven.
18:15 – Melissa: Okay. Do you work with a lot of patients that have chronic UTI and nerve
18:25 – problems? And if so, what are the outcomes like for those patients usually?
18:27 – Dr. Fogelson: They’re mixed.I don’t know that I work with a lot of those patients.
18:30 – I work with some.
18:31 – I think we can usually resolve the chronic UTI. If their nerve problems are secondary
18:36 – to their bladder constantly being inflamed, if we can resolve the chronic UTI, then
18:37 – probably over time, the nerves can stop being irritated. Now if it’s the other way
18:43 – around where they don’t have anything wrong with their bladder and their nerve
18:47 – problems are causing their bladder to hurt, then you can pour antibiotics in that
18:51 – bladder ’til the end of time and it’s not going to fix the problems in the nerves.
18:57 – So I don’t really like to quote outcomes because I think that
19:00 – it’s a mishmash of a million different things. If I can say I’m 50 percent
19:02 – successful at x patients, I’m 100 percent successful with half of them. There
19:13 – are individual patients that I see that I’m like, yeah I probably can make you better
19:14 – because I can really figure out what I think this is going on. There are other patients I
19:14 – see where I don’t have any idea what’s going on. And if I do this, I just do
19:24 – something, it’s probably not going to work. And so all I can do, I can talk to an
19:30 – individual person and try to think about what is going on with them. And I may or
19:38 – may not come up with a good idea of what to do. And it’s a lot better than just telling
19:45 – them to go away and I don’t know what’s wrong with you. We will figure out some things and some things we won’t figure out.