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Chronic pelvic pain is defined as pain in the abdominal and/or pelvic area that has been present for at least 6 months. Some symptoms of chronic pelvic pain include low back pain, radiating leg pain, pain with urination or/and defecation, heavy feeling in the pelvis, coccyx (tailbone) pain, abdominal pain, dyspareunia (pain with intercourse), or perineal pain. The pain that is experienced sometimes is as a result of a diagnosis such as interstitial cystitis (an inflammatory disease of the bladder), prostatitis (an inflammatory disease of the prostate), vulvodynia (pain in the vulvar area), or levator ani syndrome (pain in the perineum). Other times, an individual experiences many symptoms but does not fit into a diagnosis category. It can be very frustrating for someone who is experiencing these symptoms, but is unable to achieve a diagnosis or put a name to what is causing their pain. That frustration can lead to anxiety and increased tension, which exacerbates the pain that they already have.
Pelvic floor dysfunction has been identified in almost all individuals who have chronic pelvic pain. The pelvic floor is made up of a muscle called the levator ani as well as other small muscles that give support to the contents of the pelvis and are involved in urination, defecation, sexual activity and physical movement. Hip musculature, including the piriformis and obturator internus, also contribute to the support given by the pelvic floor. Normally, the pelvic floor muscles work and rest throughout the day; contracting and relaxing without an individual knowing.
Research has shown that people with chronic pelvic pain tend to have increased tension in the pelvic floor musculature, even at rest. Their pelvic floor no longer can contract and relax appropriately and the muscle remains in a state of contraction (increased tension). Increased tension in the pelvic floor can lead to feelings of burning, aching, tightness, tearing or an area that feels raw. Individuals will note that their pain becomes worse with increased stress or anxiety. Also, the pain itself can lead to muscle contraction of the pelvic floor which may result in even more pain and dysfunction for people with pelvic pain. The more muscle tension that is present in the pelvic floor, the more pain is experienced.
Clinically, patients seen for treatment of chronic pelvic pain tend to have chronic stress. Several research articles have indicated that the pain from trigger points worsen with a stressful event. Anxiety, anger, fear and sorrow can cause increased pain in areas that have trigger points.
Dr. David Wise, author of the book “A Headache in the Pelvis: A new understanding and treatment for prostatitis and chronic pelvic pain syndromes” has created an illustration of the tension-anxiety-pain cycle:
Although the pain of chronic prostatitis (CP)/chronic pelvic pain (CPP) is poorly understood, nearly all clinicians agree that almost all CP/CPP patients have some chronic tension and tenderness of the pelvic floor musculature. It is probable that the chronic tension contributes significantly to the pain of CP/CPP. This pain could be primarily due to muscle abnormalities from poor posture, chronic stress injuries or neurologic abnormalities.
A muscle that is chronically contracted develops areas of tenderness or trigger points. Trigger points are taut bands in a muscle that, when touched, are painful. Those trigger points can refer pain throughout the pelvis and even down the legs and up to the abdominal region. In turn, abdominal muscle trigger points can refer pain to the pelvic and back area, thus further complicating diagnosis of symptoms. Pain felt in the perineum may actually be coming from an area of tightness in the abdominal or hip musculature. In turn, pain felt in the lower abdomen may be actually coming from painful areas in the pelvic floor musculature.
With individuals who have chronic pain, it is important to evaluate all musculature in the abdominal, hip and pelvic floor region for tension and trigger points to fully understand what is contributing to their pain and symptoms. Treating a painful muscular trigger point in one location many times will decrease pain in another location.
The recognition of the role of muscle abnormalities of the pelvic in CP/CPP has led to several reports of CP/CPP symptom relief from treatment efforts focused on correcting those muscular abnormalities.
It may be difficult to talk about pelvic pain, incontinence or lower abdominal pain to your physician. It is good to know that physicians are familiar with talking about these problems and it is worth mentioning your symptoms because they can be treated. Physicians can perform a thorough evaluation as well as prescribe medications if indicated.
Physical therapy is another treatment option for people with chronic pelvic pain. In individuals who have not responded as expected to treatment under the supervision of their physician, muscular pain and dysfunction may be the cause of their symptoms. Some physical therapists have been specially trained to evaluate posture and muscle function in people with chronic pelvic pain. Published studies have shown the benefit of physical therapy interventions in treatment of chronic prostatitis and chronic pelvic pain.
Physical therapy for pelvic pain addresses the following:
1) Education of the patient about pelvic muscle function and pain
2) Education about lifestyle issues that may exacerbate the pain
3) Education about how posture affects the pelvis and surrounding musculature
4) Education about exercises that may be of benefit and those that may be harmful
5) Specific stress-reduction techniques incorporating diaphragmatic breathing into exercises focused on relaxing tight muscles
6) Manual therapy such as myofascial trigger point release
7) Specific exercises to improve strength, relax muscles, and restore balance
8) Exercise aimed at improving core posture and general health and well-being
Michelle Spicka, DPT
Husker Rehabilitation and Wellness, PC