Question: Hi sir I was advised to contact you by one of your student. I am currently undergoing treatment for Prudential neuralgia in a pain management clinic. On Tuesday night I had an overdose on an ayurvedic medicine and since then I am having severe pain and burning sensation in my stomach in the upper and lower left abdomen.I consulted a gastroenterologist and he prescribed me the following medicines - Drotin, Buscogert and Nizonide 500 mg and asked me to take a CT scan also. No issues were found in the scan and the doctor said that the pain may be due to some infections and advised me to continue taking the tablets for 5 days. But I am currently getting no relief from the pain. The pain increases after I eats something. Can you please advise me what should I do now. Stool passing is once in a day but loose. Can you please advise any painkiller for stomach pain

I was taking rabreprazole and domstal along with morphine up to 40 mg and fentanyl patch 50 much. I also take amitriptyline 25 mg for sleeping. Now since the pain began only taking amitriptyline 25 mg

Thank you sir for your quick and very detailed response. I have to spend lacs of rupees on treatment but no doctor has been so kind and able to explain things to me.
I have started on probiotics right away.
Answers to your queries are responded below with detailed case history of pudendal neuralgia.
I had an anal fissure in January 2020 which healed on its own but the rectal pain increased and I became bedridden. I was given various nerve blocks including pudendal nerve block , ganglion impar nerve block, inferior hypogastric nerve block but none of them help. I was also put on trial for pain pump implant where Morphine was injected as a trial intrathecally . It helped but also cause urine retention so I could not go ahead with the implant.as a diagnosis of exclusion I was diagnosed with pudendal Neuralgia or chronic pelvic pain. The doctor Who diagnosed me is pain management doctor Luv XXXXXXX Pandey in XXXXXXX .i am a resident of XXXXXXX and ultimately had to travel to XXXXXXX for pain management. At present I had to go through Botox injection in the pelvic floor and am doing dry needling at Aashirwad pain management Centre run by Dr XXXXXXX in Dadar XXXXXXX As a side effect of the conscious sedation anaesthesia that they give every week for dry needling in the pelvic floor muscles I get nausea. To manage it I was taking Ayurvedic medication called rajbindu. this is the medication which my care taker accidentally mixed more of it. I immediately started having a lot of burning sensation with diarrhoea within a few hours. I thought that the effect of the medication will go away with 24 hours but surprisingly it did not go away so I had to go to gastrointestinal doctor and also take CT scan.

Answer on medications Since I was bedridden with pain I was also taking Morphine up to 40 mg and fentanyl 50 mcg since September 2020. But that was stopped in January 2020 as I became tolerant to it and was then put on methadone 20 mg. I am also taking amitriptyline 25 milligram for sleep and antidepressant effect.
I was not prescribed antacid with any of these drugs but I was taking rabeprazole 20 mg and domstal to deal with the effects of frequent anaesthesia.

Rectal pain is there from January 2020 due to which I am bedridden.
I have taken pelvic MRI which were all clear.
I was advised to do mrn but since it is available in only New XXXXXXX and XXXXXXX there for I have not been able to do it so far.

Thank you sir for your quick and very detailed response. I have to spend lacs of rupees on treatment but no doctor has been so kind and able to explain things to me.
I have started on probiotics right away.
Answers to your queries are responded below with detailed case history of pudendal neuralgia.
I had an anal fissure in January 2020 which healed on its own but the rectal pain increased and I became bedridden. I was given various nerve blocks including pudendal nerve block , ganglion impar nerve block, inferior hypogastric nerve block but none of them help. I was also put on trial for pain pump implant where Morphine was injected as a trial intrathecally . It helped but also cause urine retention so I could not go ahead with the implant.as a diagnosis of exclusion I was diagnosed with pudendal Neuralgia or chronic pelvic pain. The doctor Who diagnosed me is pain management doctor Luv XXXXXXX Pandey in XXXXXXX .i am a resident of XXXXXXX and ultimately had to travel to XXXXXXX for pain management. At present I had to go through Botox injection in the pelvic floor and am doing dry needling at Aashirwad pain management Centre run by Dr XXXXXXX in Dadar XXXXXXX As a side effect of the conscious sedation anaesthesia that they give every week for dry needling in the pelvic floor muscles I get nausea. To manage it I was taking Ayurvedic medication called rajbindu. this is the medication which my care taker accidentally mixed more of it. I immediately started having a lot of burning sensation with diarrhoea within a few hours. I thought that the effect of the medication will go away with 24 hours but surprisingly it did not go away so I had to go to gastrointestinal doctor and also take CT scan.

Answer on medications Since I was bedridden with pain I was also taking Morphine up to 40 mg and fentanyl 50 mcg since September 2020. But that was stopped in January 2020 as I became tolerant to it and was then put on methadone 20 mg. I am also taking amitriptyline 25 milligram for sleep and antidepressant effect.
I was not prescribed antacid with any of these drugs but I was taking rabeprazole 20 mg and domstal to deal with the effects of frequent anaesthesia.

Rectal pain is there from January 2020 due to which I am bedridden.
I have taken pelvic MRI which were all clear.
I was advised to do mrn but since it is available in only New XXXXXXX and XXXXXXX there for I have not been able to do it so far.

Thank you sir for your prompt response and for your interest in my case. I am very grateful to you as No one so far has ever talk about this in detail.
To answer your question.
No Colonoscopy or sigmoidoscopy was done. There was no procedure where the abdominal cavity was opened for any structural problem. But MRI was done of the pelvis and spine and no abnormality seen. Actually in 2007 I had a similar problem where I had an anal fissure and then the fissure healed and the pain increased. I was bedridden for 2 years. In 2006 and again in 2021 I had done anal manometry which showed incomplete evacuation of the balloon that was inserted in the anus and that is why I was diagnosed with pelvic floor dysfunction and that was supposed to be the cause of repeated anal fissure. I somehow became better on my own in 2010 and started working again but the pain kept recurring and I lost 4 jobs as a result. But I was still able to keep it under control using pelvic floor physiotherapy where they put the finger inside the rectum and look for myofascial Trigger points and massage them. At the time Colonoscopy was done and nothing found. But no cystoscope was done as I was not having any urinary problem nor abdomen opened. I was told that I am just imagining the pain and ask to go to psychiatrist. Perhaps because of all of this history the pain management doctor put me on nerve blocks which included pudendal nerve block as well as ganglion impar nerve block and inferior hypogastric nerve block. None of these helped. I was given amitriptyline 25 milligram and gabapentin 500 milligram but Pregabalin I tried up till 300 milligrams but there was no relief.For duloxetine I had tremendous nausea so I could not take it but I did try it for 14 days until 60 milligram.Ketamine in fusion was given for just one day as the doctor said that it is only useful when the pain is spread throughout the body. The anal fissure happened in January 2020 get healed in February 2020. From March 2020 until August 2020 I tried all the the medications with no relief and then I was started on nerve blocks and November 2020 finally I reached the stage of pain pump implant. When it did not work then I had to come to XXXXXXX on a stretcher in the aeroplane and here I was told to do Botox injections. 300 units of Botox have been given until now. and every week I am put under conscious sedation and dry needling of as many as 50 needles is done on the abdomen and pelvic floor muscles. I have undergone 12 such procedures so far but perhaps due to regular anaesthesia I started getting constant nausea. I try to manage it with Ayurvedic medications and was doing ok until this past Tuesday when the severe stomach ache started. I thought it was because of accidentally taking more Ayurvedic medication whose name is rajbindu. That was because I had a lot of burning when I took it and immediate loose motion. I thought that the effect of that will go away in 24 hours but when it did not go away then I went to Gastroenterologist who did the CT scan and find nothing and then said it is probably an infection. I hope I am able to provide a complete picture now. I will also append case history recorded by XXXXXXX Hospital in March 2020. Actually I am having a problem appending more records but I hope I am able to do that so that I can provide you with complete picture.

Thank you sir for your prompt response and for your interest in my case. I am very grateful to you as No one so far has ever talk about this in detail.
To answer your question.
No Colonoscopy or sigmoidoscopy was done. There was no procedure where the abdominal cavity was opened for any structural problem. But MRI was done of the pelvis and spine and no abnormality seen. Actually in 2007 I had a similar problem where I had an anal fissure and then the fissure healed and the pain increased. I was bedridden for 2 years. In 2006 and again in 2021 I had done anal manometry which showed incomplete evacuation of the balloon that was inserted in the anus and that is why I was diagnosed with pelvic floor dysfunction and that was supposed to be the cause of repeated anal fissure. I somehow became better on my own in 2010 and started working again but the pain kept recurring and I lost 4 jobs as a result. But I was still able to keep it under control using pelvic floor physiotherapy where they put the finger inside the rectum and look for myofascial Trigger points and massage them. At the time Colonoscopy was done and nothing found. But no cystoscope was done as I was not having any urinary problem nor abdomen opened. I was told that I am just imagining the pain and ask to go to psychiatrist. Perhaps because of all of this history the pain management doctor put me on nerve blocks which included pudendal nerve block as well as ganglion impar nerve block and inferior hypogastric nerve block. None of these helped. I was given amitriptyline 25 milligram and gabapentin 500 milligram but Pregabalin I tried up till 300 milligrams but there was no relief.For duloxetine I had tremendous nausea so I could not take it but I did try it for 14 days until 60 milligram.Ketamine in fusion was given for just one day as the doctor said that it is only useful when the pain is spread throughout the body. The anal fissure happened in January 2020 get healed in February 2020. From March 2020 until August 2020 I tried all the the medications with no relief and then I was started on nerve blocks and November 2020 finally I reached the stage of pain pump implant. When it did not work then I had to come to XXXXXXX on a stretcher in the aeroplane and here I was told to do Botox injections. 300 units of Botox have been given until now. and every week I am put under conscious sedation and dry needling of as many as 50 needles is done on the abdomen and pelvic floor muscles. I have undergone 12 such procedures so far but perhaps due to regular anaesthesia I started getting constant nausea. I try to manage it with Ayurvedic medications and was doing ok until this past Tuesday when the severe stomach ache started. I thought it was because of accidentally taking more Ayurvedic medication whose name is rajbindu. That was because I had a lot of burning when I took it and immediate loose motion. I thought that the effect of that will go away in 24 hours but when it did not go away then I went to Gastroenterologist who did the CT scan and find nothing and then said it is probably an infection. I hope I am able to provide a complete picture now. I will also append case history recorded by XXXXXXX Hospital in March 2020. Actually I am having a problem appending more records but I hope I am able to do that so that I can provide you with complete picture.

Thank you again sir. You are faster and more accurate than any other physician that I have so far interacted with.

Internal massages are done by pelvic floor physiotherapist. There was one person in in XXXXXXX who was doing it and it was the only thing that was providing me relief. When I came to XXXXXXX I took it from doctor Bijal at sir hn Reliance Hospital. Physiotherapist find numerous Trigger points inside the rectum. I can send you links of more information if you require one such link is this https://pelvicpainrehab.com/female-pelvic-pain/492/pelvic-pain-trigger-points-explained/.

To answer your questions on the symptoms I have only left sided unilateral rectal pain and left sided lower abdominal pain. When the pain increase is then I also get left sided testicular pain. I occasionally get urinary burning but not much. The rectal pain is constant dull ache with sometimes a feeling of sitting on needles. I initially had problem with clothes also but now no longer. The pain increases post defecation almost always. Immediately after defecation I take a sitz bath. If I don't take it then the anal sphincter seems to go into a spasm which I can feel immediately. The physiotherapist has taught me breathing exercises through the abdomen to push the stool and not strain. But somehow I end up straining despite a lot of care. I take cremaffin as a laxative from allopathy and three other laxatives from Ayurveda one of which contains castor oil and I think it helps me. Yes I have tried baclofen 30 milligram and also suppositories made at home with baclofen and valium and also tramadol suppositories . out of it only tramadol suppositories help for sometime. I hope I have answered all your questions . if there is anything missing please do let me know but I have Double checked. Due to pain I cannot think properly so I may have missed something and I apologize in advance if it has happened

Thank you again sir. You are faster and more accurate than any other physician that I have so far interacted with.

Internal massages are done by pelvic floor physiotherapist. There was one person in in XXXXXXX who was doing it and it was the only thing that was providing me relief. When I came to XXXXXXX I took it from doctor Bijal at sir hn Reliance Hospital. Physiotherapist find numerous Trigger points inside the rectum. I can send you links of more information if you require one such link is this https://pelvicpainrehab.com/female-pelvic-pain/492/pelvic-pain-trigger-points-explained/.

To answer your questions on the symptoms I have only left sided unilateral rectal pain and left sided lower abdominal pain. When the pain increase is then I also get left sided testicular pain. I occasionally get urinary burning but not much. The rectal pain is constant dull ache with sometimes a feeling of sitting on needles. I initially had problem with clothes also but now no longer. The pain increases post defecation almost always. Immediately after defecation I take a sitz bath. If I don't take it then the anal sphincter seems to go into a spasm which I can feel immediately. The physiotherapist has taught me breathing exercises through the abdomen to push the stool and not strain. But somehow I end up straining despite a lot of care. I take cremaffin as a laxative from allopathy and three other laxatives from Ayurveda one of which contains castor oil and I think it helps me. Yes I have tried baclofen 30 milligram and also suppositories made at home with baclofen and valium and also tramadol suppositories . out of it only tramadol suppositories help for sometime. I hope I have answered all your questions . if there is anything missing please do let me know but I have Double checked. Due to pain I cannot think properly so I may have missed something and I apologize in advance if it has happened

thank you sir for your prompt response. I did go to the pelvic floor physiotherapist for 8 month in XXXXXXX and for 15 days in XXXXXXX They did say that the muscle was guarded. But they did not mention anything about fibrosus. After that I was told that since the internal work is not helping much therefore I should consider a pain management doctor. The pain management doctor injection Botox 300 units. She said that she will do dry needling in the pelvic floor in the abdomen and also in the back muscles so that the trigger points that have not removed due to Botox will also get removed. I was going for dry needling once a week for pelvic floor under general anaesthesia. It was causing increased pain for a day. But it was not causing severe inflammation at least I could not feel it. You have mentioned that in physiotherapy they would help in the guarding of the muscles. Where should I go now if you know anywhere in XXXXXXX also, the abdominal reduced little bit. But due to the bad posture and dehydration in the past 5 days I have now got severe pain on the right neck due to muscle spasm. That is why there may be spelling errors because I am sending the the message using voice recognition. Also in anal fissure actually started first and then I was given gabapentin which you correctly mentioned is very constipating. Even the other medication like Morphine that I have to take 1 is very constipating therefore I am taking cremaffin and three other Ayurvedic laxative one of which contains castor oil and somehow I am able to maintain proper motions despite the constipating nature of the medications. http://www.paincareindia.com/mobile/ is the pain management clinic that I am going to for dry needling. However due to Stomach problem I will not go there for another 14 days I think. Please advise what do you consider as the next step I should do and if you know any person in XXXXXXX who can help with the guarding of the muscle and fibrous. Again I apologize for that spelling error because now the neck is stuck and I will have to go for Physiotherapy for that. Thank you for your responses

thank you sir for your prompt response. I did go to the pelvic floor physiotherapist for 8 month in XXXXXXX and for 15 days in XXXXXXX They did say that the muscle was guarded. But they did not mention anything about fibrosus. After that I was told that since the internal work is not helping much therefore I should consider a pain management doctor. The pain management doctor injection Botox 300 units. She said that she will do dry needling in the pelvic floor in the abdomen and also in the back muscles so that the trigger points that have not removed due to Botox will also get removed. I was going for dry needling once a week for pelvic floor under general anaesthesia. It was causing increased pain for a day. But it was not causing severe inflammation at least I could not feel it. You have mentioned that in physiotherapy they would help in the guarding of the muscles. Where should I go now if you know anywhere in XXXXXXX also, the abdominal reduced little bit. But due to the bad posture and dehydration in the past 5 days I have now got severe pain on the right neck due to muscle spasm. That is why there may be spelling errors because I am sending the the message using voice recognition. Also in anal fissure actually started first and then I was given gabapentin which you correctly mentioned is very constipating. Even the other medication like Morphine that I have to take 1 is very constipating therefore I am taking cremaffin and three other Ayurvedic laxative one of which contains castor oil and somehow I am able to maintain proper motions despite the constipating nature of the medications. http://www.paincareindia.com/mobile/ is the pain management clinic that I am going to for dry needling. However due to Stomach problem I will not go there for another 14 days I think. Please advise what do you consider as the next step I should do and if you know any person in XXXXXXX who can help with the guarding of the muscle and fibrous. Again I apologize for that spelling error because now the neck is stuck and I will have to go for Physiotherapy for that. Thank you for your responses

Thank you sir for your prompt response. I was healthy before this all began full stop but I was told that since I was doing weightlifting improperly then the pelvic muscles got affected and probably went into more spasm. But I was not doing heavy weight lifting just doing 5 kg XXXXXXX as I was already 40 years old and was just trying to maintain some strength. But as I said the problem actually began in 2007 and in 2009 I did Magnetic resonance neurography in USA which I have appended now. I thought it was appended earlier. It indicates that the right side pudendal neurovascular bundle has low signal intensity but actually my pain was always on the left side so in XXXXXXX I was told to forget about this and go to psychiatrist. What do you think doctor I should do next . I know you are not an expert in this but until now you are the only person who has clarified the issue logical. If there is any other forum where I can send you more data please do let me know. My phone number is + 91 9900 576 519 and it is my WhatsApp number also. Also, from 2010 until 2020 the pain was less and I was able to work even though I lost 4 jobs whenever the pain flared up. But in the past year it is very bad and I am completely bedridden and can walk maximum of 5 minutes within the room

Thank you sir for your prompt response. I was healthy before this all began full stop but I was told that since I was doing weightlifting improperly then the pelvic muscles got affected and probably went into more spasm. But I was not doing heavy weight lifting just doing 5 kg XXXXXXX as I was already 40 years old and was just trying to maintain some strength. But as I said the problem actually began in 2007 and in 2009 I did Magnetic resonance neurography in USA which I have appended now. I thought it was appended earlier. It indicates that the right side pudendal neurovascular bundle has low signal intensity but actually my pain was always on the left side so in XXXXXXX I was told to forget about this and go to psychiatrist. What do you think doctor I should do next . I know you are not an expert in this but until now you are the only person who has clarified the issue logical. If there is any other forum where I can send you more data please do let me know. My phone number is + 91 9900 576 519 and it is my WhatsApp number also. Also, from 2010 until 2020 the pain was less and I was able to work even though I lost 4 jobs whenever the pain flared up. But in the past year it is very bad and I am completely bedridden and can walk maximum of 5 minutes within the room

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Thank you doctor. You seem to know everything. You are right the nantes criteria says that there should be at least 50% relief and I did not get any. To answer your question about whether any Gastroenterologist has exam and the rectum wall the answer is yes full stop they do not to Colonoscopy or sigmoidoscope but they did put what I think is a proctoscope inside and discovered only grade 1 internal hemorrhoid. I am attaching a report. Only after getting the verification from Gastroenterologist did the pain management doctor started putting needles inside the pelvic floor. Also I did go to 3 Neurologist this time in 2020 but at best they gave Pregabalin. I have taken it many times throughout 14 years but it has not helped.
The hormone tests were done by me on the suggestion a patient who had recovered and I verified after the need of it from a friend who who is running a pathology lab. That was done more out of desperation to find some way to heal. You can ignore that if you think there is no connection.

Can you please advise how is chronic rectal inflammation detected? If it is by proctoscope then it is already done. I don't have a Gastroenterologist as such. When I had an anal fissure then the Gastroenterologist surgeon in XXXXXXX looked at the anal fissure and after the MRI report was received he said that everything is fine. Then before getting the dry needling done I was referred to colorectal surgeon Dr Parvez XXXXXXX who seems to be the head of colorectal society of Asia Pacific and also and other colorectal surgeon in Reliance hospital in XXXXXXX and both of them did proctoscopy and only found grade 1 internal hemorrhoids. So this is the extent of Investigation that has been done now. I am appending the reports from doctor Parvez XXXXXXX colorectal surgeon and the Gastroenterologist from Reliance Hospital.

Also sir my mental condition is very poor. I think I am severely depressed despite taking antidepressants. My parents are old and not able to help me out now. I got divorced in 2007 when the pain first started because at that time I was completely bedridden and I was told that I am mentally unstable so my wife left me . So I am dealing with all of this all alone. I have procured poison to at least have a peaceful exit if the pain becomes unbearable and there is no help. I am just telling you this because you multifaceted awareness and maybe some solution to the mental aspect also. I am attaching the prescription of the psychiatrist also. He has given me venlafaxine for the day and amitriptyline at night. Amitriptyline helps to go to sleep but since the Stomach problem started a week ago when I initially contacted you sleep has been very bad. So I started taking clonazepamfor anxiety temporary.
Thank you again sir for your help and fore logically explaining the treatment to me.

Thank you doctor. You seem to know everything. You are right the nantes criteria says that there should be at least 50% relief and I did not get any. To answer your question about whether any Gastroenterologist has exam and the rectum wall the answer is yes full stop they do not to Colonoscopy or sigmoidoscope but they did put what I think is a proctoscope inside and discovered only grade 1 internal hemorrhoid. I am attaching a report. Only after getting the verification from Gastroenterologist did the pain management doctor started putting needles inside the pelvic floor. Also I did go to 3 Neurologist this time in 2020 but at best they gave Pregabalin. I have taken it many times throughout 14 years but it has not helped.
The hormone tests were done by me on the suggestion a patient who had recovered and I verified after the need of it from a friend who who is running a pathology lab. That was done more out of desperation to find some way to heal. You can ignore that if you think there is no connection.

Can you please advise how is chronic rectal inflammation detected? If it is by proctoscope then it is already done. I don't have a Gastroenterologist as such. When I had an anal fissure then the Gastroenterologist surgeon in XXXXXXX looked at the anal fissure and after the MRI report was received he said that everything is fine. Then before getting the dry needling done I was referred to colorectal surgeon Dr Parvez XXXXXXX who seems to be the head of colorectal society of Asia Pacific and also and other colorectal surgeon in Reliance hospital in XXXXXXX and both of them did proctoscopy and only found grade 1 internal hemorrhoids. So this is the extent of Investigation that has been done now. I am appending the reports from doctor Parvez XXXXXXX colorectal surgeon and the Gastroenterologist from Reliance Hospital.

Also sir my mental condition is very poor. I think I am severely depressed despite taking antidepressants. My parents are old and not able to help me out now. I got divorced in 2007 when the pain first started because at that time I was completely bedridden and I was told that I am mentally unstable so my wife left me . So I am dealing with all of this all alone. I have procured poison to at least have a peaceful exit if the pain becomes unbearable and there is no help. I am just telling you this because you multifaceted awareness and maybe some solution to the mental aspect also. I am attaching the prescription of the psychiatrist also. He has given me venlafaxine for the day and amitriptyline at night. Amitriptyline helps to go to sleep but since the Stomach problem started a week ago when I initially contacted you sleep has been very bad. So I started taking clonazepamfor anxiety temporary.
Thank you again sir for your help and fore logically explaining the treatment to me.