Fibromyalgia and episiotomy

Mrs. X, 35, has been coming to a chronic pain consultation for a diffuse pain syndrome labeled as fibromyalgia for several years.

Background:

• Surgical:
  • Tonsillectomy in childhood
  • wisdom teeth in adolescence
  • curettage 13 years ago
  • 2 children (10 and 8 years old), episiotomy for the first delivery
• Medical:
  • Ulcerative colitis since 2013
  • There is no notion of physical or psychological trauma particular to the interrogation

Current treatment:

• Pentasa, 1 per day (for his digestive pathology)
• Izalgi, between 6 and 8 per day (paracetamol and opium powder)
• duloxetine 60 mg once daily (antidepressant)
• seresta 10 mg, 3 per day (anxiolytic)

History of the disease :

Appearance 6 years ago of rapidly extensive pelvic pain on the lower limbs with burning sensation. Then gradually extension of the pain upwards with the final appearance of a diffuse pain syndrome associated with sleep disorders, extreme fatigability making daily life difficult.
The patient also describes moderate dyspareunia (pain on intercourse).
The patient has been off work for several years. Setting up a professional support activity of 6 hours a week is difficult. Any activity being exhausting and requiring prolonged rest in the suites.
The pain is felt as intense (EVA 7/10)

Physical examination :

We find :

• Diffuse cutaneous hyperesthesia
• Intense muscle pain predominating in particular in the small glutes, large dorsals, infraspinatus, sternocleidomastoids. Muscle pain is asymmetrical with a more tender left side.
• The rest of the exam is normal

Normal paraclinical examinations

Supported :

Given the normality of the examinations, the absence of trauma, in particular psychological, and the presence of dyspareunia, it was decided to check with a gynecologist for his episiotomy scar.
On examination we find an episiotomy scar of several centimeters. Its palpation causes neuropathic pain (electric shock, stabbing). The treatment of his scar causes, in the following minute, a disappearance of pain in the pelvis and lower limbs, persisting pain in the upper part (back, shoulders and head).
The patient was seen again the next day by the pain consultation nurse and described a complete disappearance of these painful symptoms.

Discussion :

In some cases, there is a link between obstetrical trauma and fibromyalgia with, often, a lag of several years between the trauma and the onset of diffuse pain.
The probable mechanism is first of all the existence of a cicatricial neuropathy. Over time, this neuropathy sends nociceptive information to the central nervous system, extensively causing its hypersensitivity and the appearance of diffuse pain.
This clinical case is not isolated. We note in our structure a frequency of 20% of caesareans and 20% of episiotomy in fibromyalgia patients.