Chronic Pelvic Pain and the Effects on Digestive Health

Podcast Transcript

Dr. Scott Steele: Butts & Guts, a Cleveland Clinic podcast exploring your digestive and surgical health from end to end.

Hi again, everyone, and welcome to another episode of Butts & Guts. I'm your host, Scott Steele, the president of main campus and colorectal surgeon here at the Cleveland Clinic in beautiful Cleveland, Ohio. And today we're always pleased to have a first time guest and I'm very pleased to welcome Dr. Ashley Gubbels, who is the director for the Center of Chronic Pelvic Pain and a minimally invasive gynecological surgeon in the Center for Endometriosis and Chronic Pelvic Pain here at the Cleveland Clinic.

Ashley, welcome to Butts & Guts.

Dr. Ashley Gubbels: Thanks so much for having me.

Dr. Scott Steele: So we always like to start out just knowing a little bit more about you. So where are you from? Where did you train and how did it come to the point that you're here at the Cleveland Clinic?

Dr. Ashley Gubbels: I'm originally from the Midwest, grew up in the military. Went to medical school at the University of Minnesota, residency at the University of Nebraska. And then I was actually in the Air Force for four years before going back to fellowship in Phoenix, Arizona at St. Joseph's Hospital where I received kind of specialty training within my minimally invasive GYN surgery realm in chronic pelvic pain conditions. Circumventially, ended up back in the Midwest, recruited here to build up the chronic pelvic pain program.

Dr. Scott Steele: Well, thank you for your service. And we're super glad to have you here. So today we're going to talk a little bit about pelvic pain. So that's a pretty broad term, pelvic pain.

Dr. Ashley Gubbels: It sure is.

Dr. Scott Steele: Can you tell us, I mean, we all have pain, so what is chronic pelvic pain. And maybe a little bit further, is it only men? Is it only women? Is it in everybody? Is it age groups? What is it?

Dr. Ashley Gubbels: Yeah. Chronic pelvic pain in general can really affect anyone. It essentially is defined as pain lasting greater than three months, three to six months in women, essentially below the navel, and can be caused by a multitude of things. So commonly, we think gynecologic issues such as endometriosis, adenomyosis, painful periods, things such as that. Gastrointestinal overlay, urologic symptoms such as the bladder, pelvic floor musculature, which is very, very common. And there's increasing understanding about the potential of neuropathic or nerve-related pelvic pain.

Dr. Scott Steele: Do you see differences in the underlying causes for men and women or are some of them the same? Is there overlap there? And then a little bit more onto that is you mentioned the timeframe there. Does it have to be continuous or is it intermittent? Is it spaces in between? How does that all work?

Dr. Ashley Gubbels: Generally, we think it's more of a continuous. Certainly in women because of menstrual cycles, it can be more intermittent where they're noticing a distinct change in certain parts of the cycle, which transition. I can't speak as much about men as a gynecologist. I'm not treating men, but certainly urologic conditions and pelvic floor and nerve, common, as well as obviously the gastrointestinal portion of that.

Dr. Scott Steele: So how are digestive system and pelvic region anatomically connected? It'll help our listeners a little bit to understand how or why these two systems may influence one another.

Dr. Ashley Gubbels: Obviously anatomically, they lay close to each other in the body, but it's way more complex than that. Within the nervous system, there's a huge overlap in the spinal cord where the neurons from the bowel and the neurons to the bladder, the gynecologic system, and the pelvic floor are all overlapping. And our system is not as well-defined as the sensation in our skin where you can close your eyes, touch an area, and be able to tell me exactly where I'm touching. In the visceral organs, that is a much more muted signal. And so it's very easy for that brain to sort of get confused. And these organs actually crosstalk between one another so they can sensitize each other. The bowel is definitely known to sensitize the bladder much more frequently than the bladder sensitizes the bowel because of the size of that organ.

We also know they're interconnected via the gut microbiome, which more and more data is coming out as well in terms of how do the bacteria in the gut cause leaky gut syndrome, which may increase inflammation, driving up inflammation of the nerves within that system and kind of being that thing that is driving the whole process.

Dr. Scott Steele: Leaky gut syndrome sounds awful. We'll skip that today. I'm a colorectal surgeon. So can digestive issues... We see constipation, we see this. You mentioned also that it could be a menstrual cycle that causes this. I'm sure that there's multiple women who have a scale of pain with it, but may not extend to this chronic pelvic pain. So can these all digestive issues actually cause pelvic flame or influence maybe menstrual cycles or anything, or is it the other way around? A little bit of back and forth there.

Dr. Ashley Gubbels: It's a little bit of back and forth. Certainly if you have chronic constipation, you have inflammatory bowel disease, you have irritable bowel syndrome. Any of those things that are affecting how your gut is functioning can, again, irritate the rest of the nervous system. Those can also irritate pelvic floor if you're having to really frequently bear down to try to empty stool. The further backed up you are, the increased pain you can get purely from those types of conditions.

The influence on the menstrual cycle certainly has influence even in normal patients with how their bowel is functioning around menstrual cycles. But when we take into account the specific endometriosis population, you can have endometriosis growing actually into the bowel leading to occlusion and things such as that that will very much contribute to pain throughout the month, but much more markedly during their menstrual cycle.

Dr. Scott Steele: You hinted at this at the last answer. What specific digestive conditions are most commonly linked with chronic pelvic pain?

Dr. Ashley Gubbels: We would most commonly see kind of the blanket irritable bowel syndrome, which I think eventually as we have more research will be broken down into much more distinct disease processes. Really, these are now called functional disorders of the brain gut connection. So it's an issue of how the enteric or the gut nervous system is functioning. So you have patients that can develop paralysis anywhere from the esophagus stomach all the way down into the colon. So paralysis where things are not moving through is quickly, again, leading to backup that can further contribute to pain. And again, a lot of these syndromes are probably very much linked via other conditions.

Dr. Scott Steele: Yeah. You mentioned some of these shared underlying mechanisms between pelvic pain and digestive problems. Can you explain a little bit why they might occur together?

Dr. Ashley Gubbels: That is a great question that I don't think we really fully know the answer to. There are different types of pain out there. One of the more recently classified ones is nociplastic pain, which is really an issue where the brain is amplifying pain response and kind of misunderstanding pain signals. So the brain is becoming hypersensitive to any of the input that's coming in. And certainly most of the time we have a low grade sensation of our bowels, but that can become hypersensitized as the bladder, et cetera. And so it probably is a component of underlying nervous system function that is playing in there. Of course, there's a big overlap in terms of how much immunology may be playing in as well. Are there other common genetic links that we're just not fully aware of yet?

Dr. Scott Steele: Okay. Ashley, we'll focus on women now since you're a gynecologist.

Dr. Ashley Gubbels: Yep.

Dr. Scott Steele: So I'm a woman that feels maybe I got chronic pelvic pain and listened to this podcast and wants to come and see you. I'm going to just guess that they're maybe a little bit nervous and maybe a little bit sensitive to examinations if it is. So walk me through what their journey in your office is. How do you go about diagnosing this? What's a patient interaction be like? What's a typical exam going to be like that they can expect here at the Cleveland Clinic?

Dr. Ashley Gubbels: So our process really starts well before they're making their appointment and in the exam room. Because patients have so many overlapping conditions, often their pain has been going on for a long time. They may have been dismissed by providers for an extended amount of time. We start off by collecting a very detailed pain questionnaire to really better understand what organ systems are involved, how is it affecting their mental health, their physical health, wellbeing, so that we can walk into that room and really be able to hone in on their specific symptoms.

Then I really start with a timeline once we're in the exam room together. I start with, "Take me back into childhood. Tell me kind of when you first started noticing which symptom, what happened next, what did you try, what was your response." Really getting a very detailed look at that overall picture and the order that these symptoms kind of started to develop in gives me a better idea of what I think maybe the underlying cause is.

And then once we've sort of gone from head to toe on that, we'll do a physical exam. I call it the pain mapping exam, kind of trying to understand how much their abdominal wall and pelvic floor musculature may be involved in their pain, understanding the gynecologic contributions, what hurts, what reproduces which pains. And then we have the patient get dressed again and come back and kind of put together a broad overlay of, "Okay, here's our initial plan based on what is your most severe symptom and/or what I think your most likely underlying cause is," which the vast majority endometriosis is one of the higher causes in there. And then again, we set forth kind of a plan of action. And after each intervention, we step back, we evaluate what was the response, what do we think the next right move is? Until we kind of put all of these, I tell my patients, "I want to put all of these conditions into the smallest little jail cell that I can so that you can live your life without having to think about them on a day-to-day basis."

Dr. Scott Steele: We'll get into treatment in a second here, but are there any diagnostic tests that you routinely? Do they have to have scopes or scans or fluoroscopy or see urology? I'm sure it depends a little bit on the patient's symptoms, but can you talk about that?

Dr. Ashley Gubbels: Very much. Yeah. It depends on what we think the underlying condition is. For a lot of our endometriosis patients, we're certainly getting ultrasounds, dedicated endometriosis ultrasounds, as well as MRI to be able to give us a better idea of what might be lurking under the surface, especially related to the bowel. We see a lot of bowel and colorectal endometriosis here at the clinic. Laparoscopy is certainly really our main way to diagnose endometriosis and treat that. And then if we start looking at bladder symptoms, many of those are symptomatic, but we do sometimes cooperate with urology in terms of doing cystoscopy and other diagnostic exams.

Dr. Scott Steele: So I'm going to take a tangent here, but it is relative to this. Can you talk a little bit about what is Ehlers-Danlos syndrome and how does it impact chronic pelvic pain and gut function?

Dr. Ashley Gubbels: Yeah, that's a great question and evolving information coming out about that. In short, Ehlers-Danlos syndrome is a group of connective tissue disorders. There are, I think, 13 at current, and the one that we would most commonly see in kind of the chronic pelvic pain population is the hypermobile type, which unfortunately doesn't have a singular genetic test. So it's very hard to kind of diagnose based on symptoms, based on how flexible is the patient.

And we think that there's a big overlay in that population. We see they have increased risk of POTS or cardiac dysautonomia, irritable bowel syndrome, gastroparesis, gynecologic either pain and/or abnormal bleeding. So it's really wide-reaching. And we have a team of us here that are looking into each of those conditions and trying to understand that overlap better.

Dr. Scott Steele: So let's now go to treatment. What treatment approaches work best when you're dealing with somebody with maybe both chronic pelvic pain and digestive issues? You mentioned laparoscopy in the past, but walk us through the treatment options.

Dr. Ashley Gubbels: So again, really depends on what the underlying mechanism is. I think that the key is getting the right diagnosis first and then connecting those patients to the right specialist. I am not a gastroenterologist. I'm not doing colonoscopies or EGDs, but we have a wonderful gastroparesis clinic here. We have our functional GI team who is good at dealing with that functional brain gut connection. Gut directed hypnosis can be very helpful in some of the hypersensitivity. And then again, I guess I didn't mention, doing things like anal manometry testing and understanding how is the patient emptying, how is their pelvic floor potentially related to how their gut is working, and utilizing physical therapy and different resources such as that.

So it really becomes multidisciplinary. And that's the big key in treating patients with chronic pelvic pain. It's very rarely ever a single issue by the time they've reached our clinic. And so we really need to have interdisciplinary care through the multiple groups that we have and we're blessed to have here at the clinic.

Dr. Scott Steele: So what advice would you give to someone who's been struggling with these symptoms, but really hasn't found answers yet?

Dr. Ashley Gubbels: I would say you are your own best advocate. There are increasing number of people out there that are interested in these conditions, though certainly they're not in your rural hospitals and things such as that. So investigate online, joining patient support groups often helps you connect to others who have found physicians who are willing to listen, who are involved in multidisciplinary care.

Don't give up hope. I tell patients at the first visit, "I'm not going to cure your pain. I'm not going to make it zero or have it never come back, but our goal is really how do we get this to be as well controlled as possible so that you can go about your day-to-day life and not have to think about it."

Dr. Scott Steele: Fantastic. And so now it's time for our quick hitters, a chance to get to know our guests a little bit better. So first of all, what was your first car?

Dr. Ashley Gubbels: It was a 1990 Pontiac Grand Am.

Dr. Scott Steele: Nice. Fantastic. And so salt or sweet?

Dr. Ashley Gubbels: Sweet.

Dr. Scott Steele: And is there a place out there that you would like to visit that's on a bucket list for you?

Dr. Ashley Gubbels: I have actually always wanted to go to Moscow. In terms of seeing the palaces, I'm kind of a history nerd. So I've been able to visit many of the places on my bucket list. That's one that someday I would like to be able to see.

Dr. Scott Steele: Hopefully the times will get better, you can do that.

Dr. Ashley Gubbels: Exactly.

Dr. Scott Steele: And then finally, if you could go back and give yourself advice when you were maybe starting college or something, what advice would you give it to yourself?

Dr. Ashley Gubbels: I would say never cross anything off the list. I never knew the career that I have now existed. And so be open to where the world takes you and how the roads connect.

Dr. Scott Steele: Fantastic.

Dr. Ashley Gubbels: Your passion will reach you some way.

Dr. Scott Steele: Really super advice. So give us the final take home message regarding chronic pelvic pain.

Dr. Ashley Gubbels: Chronic pelvic pain is a tough condition to live with, but again, my job is to make sure that I can help patients find hope and find ways that we can minimize the impact of their symptoms as much as possible, and it is possible.

Dr. Scott Steele: Fantastic. And so to connect with the Center for Endometriosis and Chronic Pelvic Pain at the Cleveland Clinic, please call 216.444.6601. That's 216.444.6601. You can also visit clevelandclinic.org/endometriosiscare. For more information, that's clevelandclinic.org/endometriosiscare.

Ashley, thanks so much for joining us on Butts & Guts.

Dr. Ashley Gubbels: Thanks for having me.

Dr. Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts & Guts.