Introduction to Pelvic Pain
Hi again, Bestie. Have you ever had a pain “down there” while you were exercising? Like your favorite yoga pants were rubbing you just the wrong way? Or have you ever had an intimate experience that was cut short due to pelvic discomfort or pain? Maybe you felt a burning sensation or just way too much stretching. Or do you dread going to the gynecologist, not because it is just generally kind of a strange experience, but because you know you’re going to leave feeling worse than when you went in? Well, today, we’re chatting about pelvic pain and we will merely graze the surface of this incredibly complex and broad topic. There are tons and tons of reasons you could be experiencing pelvic pain. These could range from endometriosis to hormonal abnormalities, from pelvic floor muscle tension to anal fissures. We will take on each topic in its own time, but for today, let’s just get a basis for what counts as pelvic pain and when to see your pelvic floor specialist.
The term “pelvic pain” encapsulates anything involving pain or discomfort in the pelvic region. This could include coccyx pain, pain during penetrative vaginal intercourse, pain with defecation, pain relating to constipation, pain in the external genitalia region of the pelvis, and so much more. Pelvic pain is common during or after pregnancy. Though pelvic pain is common, it is not normal, and this distinction is absolutely essential.
Pelvic pain may be acute or chronic. The term “acute” refers to experiences that are intense and sudden. Acute pain often decreases as quickly as it comes on. For example, someone who has recently undergone a vaginal delivery may have acute pelvic pain, and this pain should go away on its own. Even in cases where the pain is expected to decrease by itself, pelvic physical therapy may be appropriate and help to ease or manage symptoms. The term “chronic” refers to experiences that are longer lived and occur over a greater period of time. For example, if someone underwent a vaginal delivery a year ago and has continued to have pain with vaginal penetrative intercourse ever since, this would be a chronic condition. Pelvic physical therapy is helpful for these conditions, as well.
Let’s talk a little bit more about chronic pelvic pain conditions. Per the American College of Gynecology (ACOG), the four most common chronic pelvic pain diagnoses are irritable bowel syndrome (IBS), endometriosis, interstitial cystitis/painful bladder syndrome (IC/PBS), and adhesions (1). We will deep-dive into each of these another time.
Astoundingly, approximately 60% of females struggling with chronic pelvic pain never receive a definitive diagnosis (2, 3). Pelvic pain can be difficult to diagnose, and people with chronic pelvic pain have often told me they had to see many health care professionals before figuring out the problem at hand. I bring this up to say: don’t give up. You know your own body better than anyone else knows your body. You know if something just isn’t right. There are thousands of stories out there about people talking with their doctors about their symptoms and being written off or told their pain is in their head. Your pain is valid; your pain is real; you deserve to work with a provider that believes you and understands your pain; you deserve to live without pain. If you have experienced something similar, please continue to advocate for yourself. Find a provider who will be on your team and who will advocate for you. No one should feel like their complaints are discarded or brushed aside after visiting the doctor and sharing personal information, but if this is your experience, keep looking and know you’re not alone.
Pelvic floor physical therapy has been shown to be effective in improving symptoms of chronic pelvic pain in patients (4). However, this improvement is dependent on the skill and training of the therapist. In the case of pelvic pain, the therapist will more likely have success with internal muscle and fascia release compared with therapists that focus on muscle strengthening. It is common for the pelvic floor muscles to present with tension and tightness in folks with pelvic pain (5). Why is this? Think about a time when you “slept wrong.” You woke up with a crook in your neck and protectively held your head bent toward the painful side with the same shoulder raised up. This is a protective posture. All of the muscles surrounding the site of pain are engaging in an effort to avoid an incidence of further pain. The pelvic floor is just like any other group of muscles. When pain is present, those muscles tend to tense up, in protection. However, over time, this constant protective tension leads the muscles to remain in a shortened position and often worsen pain and/or other bowel or urinary symptoms. Your therapist will assess you to see if you do have pelvic floor muscle tightness or tenderness, and to localize exactly where the root of the problem is.
Your therapist should, first and foremost, develop a treatment plan that you are 100% comfortable with and on-board with, and secondly should be incorporating manual therapy techniques into the treatment (5). Manual therapy can be performed internally, directly to the PFMs, or externally to surrounding structures of the pelvis. Your therapist may also present you with the possibility of using dilators. Dilators help you to massage the PFMs on your own, at home. Think of a dilator as a foam roller for your PFMs. We’ll get into detail about dilators another time, but I promise they’re not as scary as they seem at first glance.
Other treatments for pelvic pain can include use of a TENS unit, surface EMG biofeedback, stretches, breathing exercises, pelvic floor muscle lengthening exercises, heat, use of topical compounds, botox, and surgery. You could also benefit from referral to a dietician or mental health provider, depending on the root cause of your symptoms. Often times, an interdisciplinary approach, that is a treatment plan that utilizes the expertise of multiple providers in different fields, will yield the best results. Remember that treatment for your symptoms of pelvic pain will be specific to you and your case. You should not receive a general “pelvic pain program,” but rather a program designed specifically for you that encompasses techniques tested for your condition, as well as your own preferences and abilities.
We have got so much more to discuss with regard to pelvic pain, but I hope this brief introduction serves as a reminder that you are not alone in your symptoms, and there are providers out there that want to help you reach your goals, whatever they may be. Pain can be absolutely debilitating and it can greatly affect quality of life. There is help out there, and as we continue to share our stories, we can work toward a world where access to care for pelvic pain is much more common and streamlined.
XOXO,
Your Pelvic Bestie
References:
1. ACOG Committee on Practice Bulletins–Gynecology. ACOG Practice Bulletin No. 51. Chronic pelvic pain. Obstet Gynecol. 2004;103(3):589-605.
2. Ortiz DD. Chronic pelvic pain in women. Am Fam Physician. 2008 Jun 1;77(11):1535-42. PMID: 18581833.
3. Montenegro ML, Vasconcelos EC, Candido Dos Reis FJ, Nogueira AA, Poli-Neto OB. Physical therapy in the management of women with chronic pelvic pain. Int J Clin Pract. 2008 Feb;62(2):263-9. doi: 10.1111/j.1742-1241.2007.01530.x. Epub 2007 Dec 7. PMID: 18067562.
4. Polackwich AS, Li J, Shoskes DA. Patients with Pelvic Floor Muscle Spasm Have a Superior Response to Pelvic Floor Physical Therapy at Specialized Centers. J Urol. 2015 Oct;194(4):1002-6. doi: 10.1016/j.juro.2015.03.130. Epub 2015 Apr 23. PMID: 25912491.
5. FitzGerald MP, Payne CK, Lukacz ES, Yang CC, Peters KM, Chai TC, Nickel JC, Hanno PM, Kreder KJ, Burks DA, Mayer R, Kotarinos R, Fortman C, Allen TM, Fraser L, Mason-Cover M, Furey C, Odabachian L, Sanfield A, Chu J, Huestis K, Tata GE, Dugan N, Sheth H, Bewyer K, Anaeme A, Newton K, Featherstone W, Halle-Podell R, Cen L, Landis JR, Propert KJ, Foster HE Jr, Kusek JW, Nyberg LM; Interstitial Cystitis Collaborative Research Network. Randomized multicenter clinical trial of myofascial physical therapy in women with interstitial cystitis/painful bladder syndrome and pelvic floor tenderness. J Urol. 2012 Jun;187(6):2113-8. doi: 10.1016/j.juro.2012.01.123. Epub 2012 Apr 12. PMID: 22503015; PMCID: PMC3351550.
*The information contained in this article is for educational and informational purposes only and is not intended as health or medical advice. Always consult a qualified health provider regarding any questions you may have about a medical condition or health objectives.
