Chronic pelvic pain is a condition that lasts more than six months without the presence of disease. In females the pain may be located in the lower abdomen, mons pubis, vulva, vagina, perineum, anus, or tailbone. In males the pain may be in the lower abdomen, perineum, penis or penis shaft, testicles, anus, or tailbone. It may limit your activities or interfere with intercourse, and, in women, may worsen during the menstrual or ovulation cycle. Often, the cause of the pain is unknown, making it more difficult to treat.
Chronic pain is different from acute pain, which occurs following an injury, infection, or surgery. The acute pain from these events may have healed, but a new chronic pain may persist. This progressive pain occurs due to hypersensitivity in the surrounding tissue, such as muscles, connective tissue, fascia, nerves, ligaments and fat cells. When chronic pain is experienced for a long time, it may become difficult to contend with, causing emotional and behavioral symptoms.
The pelvis is connected to the central nervous system, so can cause additional pain responses and constrictions in an overactive nervous system. This chronic condition creates an unhealthy environment of inflammation, reduced blood and lymphatic flow, trigger points in muscles, ligaments, and fascia, and painful fat cells in the abdomen, pelvis and legs.
Your physician will evaluate your condition and may choose medication, surgery, or a multidisciplinary treatment approach with a physical therapist, pharmacist, and/or psychotherapist. Keep in mind that the symptoms did not begin suddenly and are unlikely to go away immediately with treatment. You will need to be patient with the treatment process and allow your body to thoroughly heal.
Physical therapists have an in-depth knowledge of the musculoskeletal, fascial, and nervous systems. A physical therapist will evaluate your posture, gait, fascial system, musculoskeletal system, and nervous system to determine the connection between your pelvic pain and the rest of the body. Your therapist will perform many tests related to muscle strength, flexibility, trigger points, decreased circulation, lymphatic congestion, the nervous system, and restricted connective tissue. Your therapist will develop a treatment program designed specifically for you, and may involve hands-on therapy, exercises practiced both in the clinic and at home, gentle electrical stimulation to encourage the nerves and muscle to heal, behavioral pattern changes, and education on dietary concerns related to your condition. Many patients are able to achieve full recovery, while others may achieve 50-80% recovery.
Female chronic pelvic pain can have a complicated pathology and may co-exist with other conditions. Some of the female pelvic pain conditions are painful bladder syndrome (interstitial cystitis), endometriosis, infertility, vulvodynia, vaginismus, irritable bowel syndrome, constipation, abdominal bloating and inflammation, pelvic congestion, coccydynia, sacroiliac dysfunction, painful fat cells (adiposis dolorosa, Dercum’s Disease), dysparunia (painful sex), and dysmenorrhea (painful periods). All of these diagnoses are complex and must be treated by a physical therapist who can integrate information from the adjoining bodily systems.
Coccydynia is defined as chronic pain due to damage to the coccyx and surrounding soft tissue that gets worse when you sit or move. Possible causes are pressure during labor and delivery, falls, biking injuries, malalignment of the pelvis, and stress and strain to the coccyx. Physical therapy treatment consists of levator ani massage and stretching, joint mobilization, and manual lymph drainage to decrease the inflammation at the coccyx and pelvic floor. If the pain is related to painful adipose tissue, the adipose tissue will require soft tissue mobilization to decrease the strain on the coccyx. A patient had incurred a fall on her buttocks 5 years earlier and had pain sitting more than 5 minutes. One visit involving a coccyx mobilization corrected her pain and was able to return to full function.
Dyspareunia is a pain syndrome that involves recurrent or persistent genital pain associated with sexual intercourse and can occur in both men and women. In women, the pain can occur in the introitis, vagina, vulva or pelvis and can occur before, during, or following intercourse. It often accompanies other pelvic pain diagnoses and is usually related to hypertonic pelvic floor muscles. For example, a patient may have a diagnosis of vulvodynia or vaginismus, and one of the symptoms is dysparunia. There are three stages of dysparunia according to the Marinoff Scale:
- Discomfort that does not disrupt completion
- Pain interrupts or prevents completion
- Pain prevents any attempt at intercourse
Other possible causes of pain during penetration can be due to lack of lubrication, injury, surgery, inflammation from a skin or fat cell disorder, or infection. If the pain occurs during deep penetration it may be caused by endometriosis, pelvic inflammatory disease, uterine prolapse, tilted uterus, uterine fibroids, bladder infection, irritable bowel syndrome, hemorrhoids, or ovarian cysts. There is also a psychological component, such as anxiety, depression, stress, or a history of sexual abuse. Your medical experts will coordinate hypotheses and treat accordingly.
Endometriosis is a painful condition in which the endometrium from inside the uterus grows outside the uterus in the form of cysts, and can also be present on the ovaries, bowels, or other tissues in the pelvic region. During the menstrual cycle in a patient with endometriosis, the endometrium thickens, breaks down, and bleeds in the uterus as well as outside the uterus. This cascade of events amplifies menstrual pain and causes scar tissue and adhesions. Other symptoms may include pain with intercourse, bowel movements or urination, excessive bleeding, fatigue, constipation, bloating, or nausea, and may worsen during menstruation. Infertility may develop due to this unhealthy connective tissue environment. Frequency specific microcurrent (FSM), visceral manipulation, and manual lymph drainage are very successful in decreasing the pain and healing the surrounding tissues.
Following physical therapy treatment, patients commonly report less bleeding, pain-free intercourse, and decreased menstrual pain following 5-10 sessions of manual therapy and frequency specific microcurrent. Patients become hopeful about pregnancy.
Anorgasmia is a medical explanation for people who regularly have difficulty achieving an orgasm following sexual stimulation. This condition is more common in women than men, and can cause significant anxiety and frustration. Research shows that thirty percent of women have consistent orgasms with sexual activity. Many women have benefitted from working with a trained psychotherapist regarding their concerns. Physical therapy can also provide help by aligning the musculoskeletal and fascial system and restoring circulation and space to the pelvic visceral organs.
Interstitial Cystitis/Painful Bladder Syndrome
Painful bladder syndrome (IC) is painful bladder that is relieved by urination. Possibilities causes of bladder hypersensitivity and dysfunction are:
- Fascial and connective tissue restrictions in the surrounding area
- Restrictions in the ligaments that attach the bladder to pubic bone
- Lack of flexibility or circulation in the nearby organs
- Inflammation in the small intestines or large intestines
- Chronic pressure on pelvic peritoneum, causing neurological pain
Physical therapy treatments can remediate these problems with manual therapy, neuromuscular re-education, therapeutic exercises, electrical microcurrent, dietary and behavioral changes and relaxation techniques.
Vaginismus/Pelvic Floor Tension Myalgia
Vaginismus, a subcategory of vestibulodynia, is a pelvic floor dysfunction involving hypertonic muscles. The patients have an uncontrollable spasm of the pubococcygeus muscle, causing the levator ani and transverse perineal muscles to be excessively tight and painful. Due to the lack of blood flow and oxygen, the muscles have a build-up of lactic acid and an increase in nerve endings in their vestibule. They can have other pelvic pain diagnoses accompanying their condition, including pain with, and inability to, complete intercourse. The treatment consists of reducing the pain sensitivity, anxiety, and catastrophizing thought, and increasing sexual function. Topical anesthetics or injections may be given by the physician to allow for gynecological treatments. Manual lymph drainage will decrease the inflammation and slow the mast cell activity. A patient with vaginismus reported she has been married and intimate with her husband for 17 years but was never able to attempt intercourse due to severe and uncontrollable vaginal spasming. Visceral manipulation, manual lymph drainage, and vaginal dilators beginning with a Q-tip® and ending with a size equivalent to her husband’s penis, allowed her to overcome her vaginal spasms. After 13 treatment sessions she was able to successfully accomplish intercourse without pain.
Vulvodynia is a vulvar pain syndrome that is characterized by burning, stinging, and irritation on the vulva, introitus, hymen, or female genitalia. Other associated symptoms that may aggravate or cause the pain are pudendal nerve damage, an infection, skin disease, or painful fat cells. Often the pelvic floor muscles are hypertonic and can be accompanied by the thinning of the vulva from long-term use of hormonal contraceptives, repeated yeast infections, frequent antibiotics, or trauma to the pelvic area. The vulvodynia classifications are generalized, localized, provoked, spontaneous, or mixed. Vulvodynia is aggravated by an increase in inflammatory cells in the vulva, causing excessive oversensitivity. The nerve fibers overreact to normal stimuli and do not turn off when the stimuli has stopped. Simply stated, the neurons wind up to deliver the pain signal, but won’t wind down to down-regulate. A physical therapy multi-treatment approach will allow the nerve signals to down-regulate, decrease the inflammatory cell process, and restore biomechanical symmetry to joints, muscles fascia, and nerves.
Your physical therapist will assess all of your connective tissue restrictions to determine if there is a strain pattern irritating the vulvar. A patient who could only tolerate sitting for 2 minutes and standing for 10 minutes was treated for vulvodynia, Dercum’s Disease, and endometriosis. Her lymphatic system was sluggish and she had increased bloating in her abdomen. She greatly benefited from decreasing inflammatory foods in her diet and performing manual lymph drainage specifically for patients with vulvodynia. She was able to achieve a 50+% increase in sitting and standing tolerance and decreased vulvar pain when she was consistent with her home program.