Persistent pelvic and/or abdominal pain post c-section often poses a diagnostic and treatment dilemma, because most OB/GYNs know very little about pain and most pain doctors know very little about the pelvis.
But that’s where I come in, being both board certified in OB/GYN and Pain Medicine.
It is hard to know how many women have persistent pain post c-section, because it hasn’t really been studied. All I can tell you is that I see several women a month with this problem. We do know is that 1-3% of women will have persistent nerve pain post c-section (although this is only one cause of pelvic pain). Today’s post will focus on that one type of pain, which typically means pain from one or all of these three nerves in the belly wall: ilioinguinal nerve, iliohypogastric nerve, or genitofemoral nerve.
This kind of nerve pain does not imply that anything was done incorrectly at the time of surgery. Surgery is injury and unfortunately as surgeons cut tissues we also cut the small nerves in the skin (that is what produces the weird numbness or strange feelings that you have over a scar that came sometimes persist for years, because nerves don’t heal quite as well as other tissues). I had a nephrectomy when I was 11-years-old and my scar is still numb in places and gets odd sensations, especially itching, from time to time (that’s part of my massive scar in the picture, BTW).
With surgery we avoid the important nerves; however, the ilioinguinal, iliohypogastric, and genitofemoral nerves (which allow you to feel sensations on your abdomen) run quite close to the edge of a c-section incision and they can be bruised, crushed, or trapped by scar tissue. The nerve can also be cut, but this is less likely to cause pain and more likely to produce complete numbness. Sometimes when these nerves are cut both numbness and pain can result, a condition called anesthesia dolorosa, which can be very challenging to treat.
How do you know if the pain that is persisting after your c-section is this kind of nerve pain?
Pain from the ilioinguinal, iliohypogastric, and/or genitofemoral nerves is a superficial pain that is typically felt at the edges of the scar. It will almost always be described as a burning pain and sometimes there may be electric shock-like sensations. The area will hurt to light touch, meaning clothes, the waist band of pants/jeans, wearing a seat belt, or just touching the area lightly with your fingers will hurt. If you can push on the area and not reproduce the pain, the ilioinguinal/iliohypogastric/genitofemoral nerves are less likely to be the culprit.
The diagnosis is confirmed with a nerve block, basically injecting an anesthetic (numbing medication, typically lidocaine) around the nerve to cause temporary numbness. If there is both numbness and pain relief, the diagnosis of a peripheral nerve injury is confirmed. If there is numbness but no change in the pain the cause is probably something else. If there is no numbness then the nerve block was done incorrectly and should be repeated or you should see someone who can do it correctly. The doctor should keep you in the office after the nerve block and repeat their exam once the area is numb to A) confirm that they have done the nerve block correctly and B) to see if the nerve block worked.
Once neuropathic (nerve) pain from the ilioinguinal/iliohypogastric/genitofemoral nerves has been confirmed, initial treatment may include all or some of the following:
- A Lidoderm® patch (topical numbing medication applied to the affected area).
- A series of nerve blocks using steroid medication. At a cellular level, pain is related to inflammation and steroids are potent anti-inflammatories. Sometimes there is scaring around the nerve, and since steroids cause fatty tissue to shrink a little for some people this extra millimeter or two of space that is freed up after the injection takes the pressure off the nerve and reduces the pain. Most people feel improvement from steroids 5-7 days after the injection.
- Adjunctive mediations, which work on how the pain is processed at a cellular level. The best and most studied option is a class of drugs called tricyclic antidepressants (TCAs, although they are no prescribed because your doctor thinks you are depressed, they are pretty poor antidepressants). Drugs traditionally used for epilepsy (like gabapentin or topiramate) can also be used. I favor nortriptyline because it has fewer side effects than some of the other TCAs and unlike the epilepsy drugs is only once a day. Nortriptyline is also generic and can be taken if you are breastfeeding. Often these types of medications are not needed long-term. The goal is to get the pain controlled for 4-6 months and then assess whether or not a trial of stopping the medication is indicated and desired.
- Getting screened for depression. Depression makes pain worse. It’s not the cause of your pain, but it is like pouring fuel on a fire and you can’t put out a fire out with a steady infusion of gasoline.
- Controlling the pain with ibuprofen or opioids, although in reality opioids are not that great for this kind of nerve pain. The BEST pain relief you can expect from opioids with any kind of chronic pain is about a 30-60% improvement, and in my experience it seems to be less than that for nerve injury related pain.
- Weight loss if you are overweight. When you are overweight and your belly hangs down a little (I hate to use this term, but if I say muffin-top everyone knows what I mean) it puts traction on the ilioinguinal and iliohypogastric nerves. Some people can even develop nerve pain from the ilioinguinal and iliohypogastric nerves simply due to obesity without any prior surgery in the area.
- Mind-body work. Stress and anxiety make pain worse. This doesn’t mean the pain is in your head, but rather the chemical changes of stress and anxiety will worsen your pain. Deep belly breathing (like Lamaze) or yoga are just a couple of ways to harness the mind-body connection to improve your pain.
If all else fails (and in my experience this is rare) surgery on the nerve ending to clean up scar tissue or even removing the damaged end of the nerve can be an option. However, this should only be considered when A) the diagnosis is 100% certain (meaning confirmed by nerve blocks), B) the other treatments have been tried and failed and C) there has been an in-depth discussion about the bad things that can happen after this kind of surgery.
There are certainly many other causes of persistent pain after a c-section and I will address those in another post in the next day or two. Remember, this blog does not represent individual medical advice.