Urogenital System Causes of Low Back Pain


Endometriosis


    The endometrium is the lining of the internal cavity of the uterus that provides a barrier against infection, regulates menstruation, and assists implantation of the embryo.  Endometriosis is defined as the presence of endometrium external to the uterus.  The ectopic endometrial tissue is active and responds similarly to the eutopic endometium during the menstrual cycle, resulting in internal pelvic bleeding, inflammation, and scarring.    

            Endometriosis is a common gynecological disorder affecting an estimated 5.5 million women in North America, and the cause is generally unknown.  This condition is more common than previously thought, and it is estimated that up to 50% of the female population who are infertile are affected by endometriosis.  Endometriosis is important for physical therapists to consider during differential diagnosis because of the high morbidity and its tendency to manifest as nonspecific low back pain.  Pain can occur anywhere, but women mostly experience back, pelvic, hip, and/or sacral pain that can be mistaken for a musculoskeletal impairment.  Delays of appropriate intervention can place patients with endometriosis at risk for chronic pain and infertility.   

Risk Factors

  • Hereditary - two thirds of women with a diagnosis of endometriosis report having a family member with endometriosis)
  • Endometriosis has been linked with other comorbidities including:
  •     Fibromyalgia
  •     Chronic fatigue syndrome
  •     Hypothyroidism
  •     Allergies
  •     Asthma
  •     Autoimmune disorders.

Signs and Symptoms

  • Hallmark symptoms are generalized pelvic pain, dysmenorrhea, and dyspareunia
  • Intermittent, cyclical, or constant pelvic and/or back pain (unilateral or bilateral)
  • Pain during or after sexual intercourse
  • Painful bowel movements or painful urination during menstrual period
  • Small blood loss (spotting) before or between periods
  • Heavy or irregular menstrual bleeding
  • Bleeding anywhere else (nose bleeds, coughing up blood, blood in urine or stools)
  • Fatigue
  • History of ectopic pregnancy, miscarriage, infertility
  • GI problems (abdominal bloating and cramping, nausea, diarrhea, constipation)

Urinary Tract Infection


            UTI’s frequently occur in the general population.  However, women and older adults comprise the majority of cases.  Urine in the bladder and kidney is normally sterile, but urine is a good medium for bacterial growth.  Interferences in the defense mechanisms of the bladder can promote bacterial growth.  Infection of the urinary system can result in low back pain that can be misdiagnosed as a musculoskeletal condition.  Onset of nonspecific low back pain that is not related to any specific motion should be further evaluated.            


Risk Factors

  • Age
  • Immobility/inactivity
  • Instrumentation and urinary catheterization
  • Frequently catheterized neurogenic bladder
  • Atonic bladder (spinal cord injury; diabetic             neuropathy)
  • Increased sexual activity:
  •     Spermicide use with diaphragm or condom
  •     Uncircumcised penis (first year of life)
  • Obstruction:
  •     Renal calculi
  •     Prostatic hyperplasia
  •     Malformations or urinary tract abnormalities
  • Constipation
  • Female gender
  •     Anatomic variations
  •     Surgical or natural menopause without                  hormone replacement therapy
  • Pregnancy
  • Kidney transplantation
  • Diabetes mellitus
  • Sexually transmitted disease (STD)

Signs and Symptoms

  • Urinary frequency
  • Urinary urgency
  • Low back pain
  • Pelvic/lower abdominal pain
  • Dysuria (discomfort, such as pain or burning during urination)
  • Fever and chills
  • Hyperesthesia of dermatomes
  • Hematuria
  • Pyuria
  • Bacteriuria
  • Dyspareunia (painful intercourse)
  • Mental status changes in the older population (ex/ confusion)


Urolithiasis - Ureteral Stones

    Urolithiasis is a condition caused by formation of stones within the ureters obstructing the urinary tract and causing excruciating diffused pain within the abdominal wall and low back.  Males between the ages of 20 to 30 are affected three time more than females.  The most likely mechanisms include: the presence or abundance of substances that promote crystal and stone formation, a possible relative lack of substances that inhibit crystal formation, and a possible excessive excretion or concentration of salts in the urine.  Calcium stones account for 75-85% of urinary calculi in which half of these stones are composed of a mixture of calcium oxalate and calcium phosphate.  Patients will state having a "colicky" type of pain which noted by an abrupt start and stop of pain.  A through subjective examination regarding the presence of any constitutional symptoms or changes in bowel and bladder is imperative.  Therefore, patients with any pattern of signs and symptoms or risk factors should be referred to their primary care physician for further testing.


Risk Factors

  • High intake of animal proteins, sodium, refined sugar, oxalate, grapefruit juice, apple juice, and soda
  • Low fluid intake
  • Family history - 55% of recurrent stones reported cases within their family
  • Males between the age of 20 - 30


Signs and Symptoms

  • Hematuria
  • Nausea
  • Vomiting
  • Colicky pain
  • Diffused pain within abdominal, low back, and pelvic region
  • Reduced urine volume
  • Dysuria

Uterine Fibroid


    Uterine fibroids (UF) are the most common benign tumor in women.  They affect women of all ages, races, and ethnicity.  However, they are most common in African-American women and in women over 45 years of age.  The prevalence of uterine fibroids is unclear as it has been estimated that 50% of all UF are asymptomatic.  When uterine fibroids become symptomatic they can cause excessive menstrual bleeding, intermenstrual bleeding, dysmenorrheal, pelvic pain, pelvic pressure, bloating, dyspareunia, urinary and bowel disturbance, sub-fertility, and pregnancy-related complications.  Also, they have been reported as a cause of low back pain and sciatica, supposedly as a result of enlargement significant enough to impinge on neural structures within the pelvic cavity.   


Risk Factors

  • Heredity
  • Over the age of 45 years
  • African-American race
  • Nulliparity
  • Obesity
  • Polycystic ovary syndrome
  • Diabetes
  • Hypertension


Signs and Symptoms

  • Excessive menstrual bleeding
  • Intermenstrual bleeding
  • Dysmenorrhea
  • Pelvic pressure
  • Bloating
  • Dyspareunia
  • Urinary and bowel disturbance
  • Subfertility
  • Pregnancy-related complications
  • Dull aching low back, buttock, pelvic, or groin pain
  • Sciatica pain  
  • Not maintaining gains with physical therapy