I have been asked about the effectiveness of pre-sacral neurectomy (PSN) in providing pain relief and if it should be routinely performed as a part of endometriosis and pelvic pain surgery.  For those of you not familiar with this term (PSN), it is a nerve cutting procedure done during laparoscopy in an attempt to decrease pelvic pain. This should not be confused with another similar procedure, Laparoscopic Uterosacral Nerve Ablation (LUNA) that has been shown in multiple studies to be ineffective and is not recommended.

PSN has been shown to be effective in relieving midline pelvic pain (pain only in the middle of the pelvis behind the pubic bone) but not pain on the sides (in the area wear the ovaries are located). In my experience a patient’s pelvic pain resulting from endometriosis resolves after appropriate surgical removal and additional treatment is needed.   PSN may be most useful in treating pain that is both in the midline and has been present since the first period, the medical term for this primary dysmenorrhea.

Pelvic pain is transmitted through not one or two nerves but many different nerves throughout the pelvis, which is one of the reasons it can be so difficult to treat.  This is different than your picky finger, which is innervated by only one nerve, the ulnar nerve.  If a person had chronic pain in their pinky that did not respond to other treatments a nerve block of this nerve would relieve the pain.  There is an area inside the body on the front side of the lower back called the superior hypogastric plexus that contains the major sensory nerves from the uterus and cervix but not the ovaries.  This is the reason a PSN helps with pain coming from the uterus or cervix (midline) but not from the ovaries (lateral or on the sides).

There are surprisingly few studies on PSN.  Information on the efficacy, or how well the PSN works, varies depending upon which scientific study is quoted.  Most but not all studies show that when PSN is used in conjunction with other procedures to treat endometriosis or adhesion, about 75% to 80% experience a decrease in pain, especially painful periods (dysmenorrhea) while about 60% patients not receiving PSN as part of the pelvic pain surgery experience a decrease in their pain. Some studies have shown a decrease painful sex (dyspareunia) following PSN while others have not shown a difference. This may be due to the multiple different causes of pain with intercourse, some of which may be helped with a PSN while others are not.

But like any surgical procedure PSN has potential risks and complications.  The complications associated with this procedure include constipation, urinary urgency and decrease vaginal lubrication with sex, altered sensation bladder fullness.  There is also a risk of damage to the ureters, bowel or blood vessels during surgery.  The actual risk of developing these complications including constipation is not well documented in the scientific literature.  The few studies that we have report a postoperative rate of constipation to be between 14% and 74% and about 5% of patients experiencing urinary urgency.

The possibility of chronic constipation as a result of PSN is most concerning.  So many of my patients have a significant problem with constipation to begin with that adding a procedure which can make this worse is of questionable benefit.  A PSN is not reversible if it causes an unacceptable level of constipation.  The approach and techniques I use to treat endometriosis and pelvic pain have a level approaching a 90% response rate (at least somewhat better) and thus I usually do not use PSN as an initial treatment.  Patients who have always had killer periods from the very start, or patients with pain as a result of significant adenomyosis (endometriosis in the muscle wall of the uterus) should consider PSN.  Otherwise, I feel, PSN should be reserved for patients with midline pain that is unresponsive to conservative surgery.  In conclusion, PSN seems to be effective in relieving midline pain, but with the potential for permanent side effects conservative use for specific conditions is probably the best approach.

Pain, suffering, poor treatments, loss of important life fulfilling activities, invalidation and eventually loss of hope.  This is the unfortunate plight for many women with endometriosis and pelvic pain.

It is outrageous this type of cruelty of women is allowed in our society.   To quote our past vice-president, “it is an inconvenient truth”.  The medical system trying to treat these conditions is quite frankly ill equipped to deal with the medical problems these women are facing.  As I realized what was happening to literally millions of women, I knew this needed to change.  There had to be a better way, a more effective way Read more…»

Let’s face it – pain is unpleasant and no one wants to experience pain. Some pain, however, is good in that it protects us from damage to our body. Without a pain mechanism, we would be vulnerable to damaging our body, which could even be life-threatening.

The “good type of pain” that protects us from injury is known medically as nociceptive pain. Nociceptors are Read more…»

There is an amazing team of people that helps Dr. Cook provide the comprehensive care for which Vital Health Institute is known. They take care of all of the day-to-day details so that Dr. Cook can focus on what he does best – diagnosing and treating complex health conditions including endometriosis and pelvic pain. Read more…»

As a healthcare practitioner who has devoted my life to helping diagnose and treat women with endometriosis and pelvic pain, I see the real-life pain and suffering caused by this disease. The magnitude of the pain and suffering and the ensuing impact on quality of life can be almost incomprehensible.

The first worldwide study on the societal impact of endometriosis was presented recently at the 26th annual meeting of the European Society of Human Reproduction and Embryology. This study found a significant loss of productivity of over 11 hours per woman per week. Read more…»

My vision in creating Vital Health Institute was to provide the best possible medical care for patients in a respectful healing environment. Simply put, my goal was to correct the medical problems that patients presented to me. But no one seemed to have the answers. In spite of having the good fortune to train at some of the best institutions in the world with some of the best doctors, I wasn’t able to find anyone who understood what this disease was really all about and what was needed to fix the problem. Thus, I embarked on my 20-year medical journey to seek the answers to these questions. Read more…»

I learned some important lessons in New Orleans. The most important lesson was to completely trust what my patients were telling me about their bodies and the pain they were experiencing.

I had one patient in particular who came to see me six weeks after she had surgery with another physician. Read more…»

This award-winning research definitely opened up the door to a fellowship in Reproductive Endocrinology and Infertility at Johns Hopkins School of Medicine. Wow! Another step and another door opened to an amazing opportunity. I mean, Johns Hopkins! This was arguably the best fellowship at the best medical school in the country. Read more…»

How far I had come and how lucky I was to have the support of so many great people! They say that opportunity is the result of hard work in preparation for taking advantage of the right circumstances. My mom and dad had taught me discipline and a great work ethic. They also taught me humility, maybe even a little too much, but they are great parents who raised three amazing sons. I am so proud of my brothers. Any parent knows how challenging it is to raise successful, well-adjusted children.

Anyway, although it had been 12 years since high school, where I was an ok student, here I was standing on the stage being given the presentation for the best research in the world for an OB/GYN resident physician in 1987. How did that happen? Read more…»

I headed out of Houston in 1985 having completed 4 hot muggy years of medical school to become a medical doctor. It was official; degree in hand I was actually a real medical doctor, but I needed to undergo additional postgraduate training. In my case this would be four more years in an OB/GYN residency-training program. The OB/GYN program at Wichita (University School of Medicine at Wichita) was a unique and very special program headed up by a guy named Daniel Roberts, MD, PhD. He was a benevolent dictator, very tough but also provided an unsurpassed training experience. Read more…»