Chronic Pelvic Pain

What is "Chronic Pelvic Pain Syndrome"?

When constant, strong pain continues for a long period of time, it can become phys­ically and mentally exhausting. To cope with the pain, an individual may alter her or his emotional and behavioral responses. When pain has continued for so long and to such an extent that the person in pain is changing emotionally and behaving differently to cope with it, this is known as “Chronic Pelvic Pain Syndrome”.

It is not “all in your head,” but your pelvis and nervous system are connected, and with­out a brain and spinal cord (central nervous system) you could not experience pain! 

Pelvic pain is described as pain in the lower abdomen, pelvis, perineum or low back and is considered to be chronic when symptoms have been present for more than six months.  The pain may be described as aching or burning in the area of the perineum, abdomen and/or back.

What cause pelvic pain?

Pelvic pain can be caused by problems such as pelvic joint dysfunction, muscle imbalance within the muscles of the pelvic floor, trunk, and/or pelvis, incoordination in the muscles related to bowel and bladder function, tender points in the muscles of the pelvic floor, pressure on one or more nerves in the pelvis, and weakness in the muscles of the pelvis and pelvic floor. Pelvic pain can also be related to the presence of scar tissue after abdominal or pelvic surgery. There can be organic disease processes related to pelvic pain as well therefore it is important to consult your physician to fully determine the cause of your pain.

What are the symptoms of pelvic pain?

Symptoms of pelvic pain, in addition to pain in the lower abdomen and pelvis, may include: pain in the hip or buttock, pain in the tailbone, limited sitting tolerance, pain in the joints of the pelvis, pain with sexual intercourse, tender points in the muscles of the abdomen, reduced range of motion in the hips and lumbar spine, urinary frequency, urgency, or incontinence, painful bowel movements, constipation and/or straining with bowel movements,

What are the Characteristics of Chronic Pain?

Pathology at the Site of Origin

There is, or was an injury (pathology) at the place (site of origin) where the pain first started. This injury might be endometriosis, ovarian cysts, pain from the bowel, bladder infection, or adhesions (scar tissue from surgery). The pathology may also be an injury to a nerve in the abdominal wall, pelvis or pelvic floor, or genital area.

What about Male Pelvic Pain?

Guys suffer similar pain issues but have the pains in different anatomy. The male does not worry about endometriosis and/or female organ issues. However, his pain can be extremely severe. Pain in the perineum (between the anus and scro­tal sac) is often confused with a prostate infection. Pain in the urethra or bladder may be erroneously treated as a bladder infection or sexually transmitted disease. Testicular pain may be treated as epididymitis. Some men have had varicose vein surgeries or even removal of the testicle without pain relief. Often these men are found to have abnormalities of the pelvic nerves, called the pudendal nerves. This type of nerve pain can affect women as well. Typically those with pudendal neu­ropathy were active in high school sports and later were very active exercisers. At sometime, a fall onto the tailbone/buttocks caused their pains. Another “at risk” group are accountants, computer programmers, etc., who sit at their jobs for years. For women, pregnancy and childbirth or pelvic surgeries can be the cause.

Action of the Brain

Your brain influences your emotions and behavior. It also interacts with your spinal cord and affects how you perceive the visceral and referred pain. For instance, if you are depressed, your brain will allow more pain signals to cross the gates of the spinal cord to the brain. Certain regions of the brain are also “off-line” when you have chronic pain and may not be functioning effec­tively to inhibit pain signals. Sometimes the nervous system is overwhelmed by pain signals and there may be excessive sweating, nausea or loss of appetite, fatigue, and other problems.

It is important to remember that all of these levels of pain must be treated togeth­er (“multidisciplinary therapy”) for CPP therapy to be successful. Treatment of CPP can include psychological counseling, physical therapy, medications, nerve blocks, and surgery.

Nerve Irritation

Several peripheral nerves surround the abdomen and the pelvis. These can be irritatedor compressed individually in any one person, or there can be combina­tions of painful nerves that confuse both the patient and his/her doctors. The most commonly affected are the abdominal cutaneous nerves and the pudendal nerve although other nerves can be affected as well.

Abdominal cutaneous neuropathy is usually due to nerve injury. Ilioinguinal and iliohypogastric nerves can be injured during abdominal surgery or with exercise, heavy lifting, or an accident.

Pudendal Neuropathy:

There is a pudendal nerve on each side of the pelvis. It travels a twisting pathway after it forms from nerve fiber from sacral cord lev­els. Pressure may occur between two ligaments that French physi­cians’ call the clamp or lobster claw.

Pressure can be caused by coverings over the obturator internus muscle. The muscle is important in all hip rotations such as jogging, skating, yoga, etc. Only after a fall is the pain’s onset immediate. Usually, the onset is slow and not recognized early (often referred to as repetitive microtrauma). Because the nerve can affect blad­der, bowel, and/or sexual function it is called the “social nerve.” Bladder irritation and vulvar pain are common. Painful intercourse/orgasm/ejacu­lation can occur in many bizarre combinations. This is why patient and doctor may be confused in the diagnosis.

Referred Pain and Up-Regulation of Nerve FIring

Your body has two types of nerves: (1.) Visceral nerves carry impulses from the organs and structures within your abdomen and chest (stomach, intestines, lungs, heart, etc.); and (2.) Somatic nerves bring messages from the skin and muscles.

Myofascial Dysfunction

Myofascial pain can be the primary source of pain, unrelated to organ pathology or a secondary source of pain due to a re­flex response (visceral-muscular reflex). Often trigger points develop in the affected muscles. Trigger points are specific areas of tenderness occurring in the muscle wall of the ab­domen. Trigger points may start out as just one symptom of your pelvic pain or they may be the major source of pain for you. For this reason, treating the trigger points may signifi­cantly reduce the pain. For others, the original source of injury as well as the trigger points must be treated. Nerves in the pelvis, such as the pudendal nerves, can also stimulate the pelvic muscles and cause myofascial pain.

How Can Physical Therapy Help?

What about my muscle aches and pains?

Even if you’re not aware of specific muscle aches per se, the muscular system is often involved in producing the CPP. Treating problems with your musculoskeletal system is an important part of your care. You may be referred to a physical therapist for an in depth evaluation A physical therapist may examine and evaluate your posture, gait (how you walk), your abdomen, pelvis, and legs. The therapist will do various examinations to look for abnormalities and to find muscle strength, tenderness, length, and flexibility. The therapist will also determine your “trig­ger points,” or areas where your muscles are especially tender. The Physical Therapist may utilize hands on techniques to address muscle tightness and trigger points, scar tissue that may be contributing to your pain as well as joint mobilizations to correct your pelvic alignment.  You will then receive a home exercise program using many different techniques to continue your care at home and help you to develop healthier, stronger muscles. You may learn special exercises for specific muscles or work with special equipment, such as ultrasound or muscle stimulators. You will also learn relaxation and breathing techniques. The physical therapist will work closely with your doctor to coordinate a program of exercises and pain medications by mouth and/or injection as needed.