What is pelvic pain?
Pelvic pain affects 1 in 5 women and 1 in 12 men in Australia (* Pain Australia)
It comes in many forms and is defined as pain in the area below your bellybutton and between your hips
- acute ( < 3months duration)
- persistent (previously known as chronic) pelvic pain has been present for 3- 6 months or longer.
Common types of persistent pelvic pain
Dyspareunia is defined as painful sexual intercourse. Although men can experience this problem, it affects far more women. Dyspareunia usually begins with a physical cause and is generally thought to be a physical rather than an emotional problem, although an emotional component will often develop due to the distress this condition can cause.
It can be difficult to separate dyspareunia from vaginismus, as vaginismus may occur following a history of dyspareunia, and mild vaginismus is often accompanied by dyspareunia. Dyspareunia can develop at any stage of life. It can occur from the first attempt at penetrative sex, after childbirth due to temporary hormonal changes and scar tissue from stitches, and after menopause due to the loss of eostrogen and hence elasticity and lubrication of the vaginal tissues. It can occur during every sexual contact, or only in certain situations. It can be felt around the opening of the vagina or (anus) or deep within it.
Treatment can include the use of lubrication; eostrogen replacement creams for the vagina; and pelvic physiotherapy to help downtrain tight pelvic floor muscles with stretching, massage and breathing / relaxation techniques; progressive vaginal dilation with vaginal dilators or trainers and sometimes working with a psychologist to resolve any issues that may be contributing.
Vaginismus occurs when the pelvic floor muscles contract involuntarily to prevent vaginal penetration, making sexual, or any, penetration painful or impossible. This can include trying to insert a tampon, a finger, a sex toy or a penis.
Vaginismus usually involves the outer or superfical layer of the pelvic floor muscles, specifically the bulbospongiosus (sometimes called bulbocavernosus) In females this is a circular muscle that surrounds the vestibular area at the entrance to the vagina and basically acts as the guardian for entrance into the vagina. If this muscle spasms, insertion of a tampon or penetration of any kind is painful and often impossible. This is a protective response, it is not something you do on purpose. Your body wants to prevent pain if that action has hurt in the past so it goes into protection mode which is, unfortunately for some, an overreaction by the tissues and a cycle of pain and spasm can be set up.
Vaginismus can be described as
- Primary : never been able to engage in any activity that involved vaginal penetration) or
- Secondary : the problem has developed, perhaps in response to painful or difficult earlier experiences or hormonal changes following childbirth or menopause
Treatment should be multimodal and focus on desensitisation and encouraging relaxation of the tissues and reducing the pain response. Involving a psychologist for a few sessions can be very helpful to assist you with strategies to reduce stress that may be present ( due to the condition, or causing it)
Stretching, breathing, mindfulness, dilators and manual therapy are all techniques used to help with vaginismus.
These are all terms used for pain in the region of the vulva or vestibule ( vaginal entrance)
'dynia' means pain and 'itis' means inflammation so vulvodynia and vestibulodynia are pain in the vulva (the external female genitalia) or vestsibule (vaginal entrance) so technically vestibulodynia is a subset of vulvodynia. Vestibulitis is inflammation of the vestibule area.
They can occur at any age and can be very distressing. Somen women experience tenderness in the area and difficulty with any form of penetration. Others find even wearing under wear impossible, some can't sit or wear tight clothes. Any contact with the vulval region can be exquisitely painful.
Localized vulvodynia is described as pain in one area of the vulva, and generalised vulvodynia is pain the general area of the vulva. It is often a burning sensation, and is usually provoked by touch or pressure, such as intercourse or prolonged sitting. This is called provoked vulvodynia.
Treatment may include any of the techniques described for vaginismus but may also need medications, topical and oral, to help reduce pain and inflammation.
This is a condition where endometrium (the tissue that lines the uterus and is shed each month during a period) grows outside the uterus. Unfortunately it also responds to the hormonal changes that cause a period so can grow and spread as it can't exit the body as it would from the uterus during a period.
Young girls with very painful periods need to be investigated early to help avoid the long path of painful periods that can end with persistent pelvic pain. The average time to diagnosis is 7 years which is not acceptable. Periods can be uncomfortable but if they are debilitating requiring time off school or work and high levels of pain relief please push for investigation. Periods are not meant to be this painful.
Is inflammation of the prostate which is usually bacterial and can be treated with antibiotics. Unfortunately most male pelvic pain is attributed to this condition so other causes are often overlooked. Pain from prostatitis and UTIs can lead to pelvic floor muscle spasm which in turn causes pelvic pain.
Treatment will involve similar techniques to those used for women: pelvic floor downtraining, relaxation and massage, stretching etc.
This condition can affect both males and females.
'Neuralgia' means pain in the distribution of a nerve.
Pudendal neuralgia is shooting, stabbing pain along the distribution of the pudendal nerve.
The pudendal nerve gives sensation to the external genitalia of both sexes and the skin around the anus, anal canal and perineum.
So if you have pudendal neuralgia, you may experience pain in the skin of the genitals, the perineum and the anus. Often it will be very specifically on one side as you have a pudendal nerve on the right and the left.
However, there are many nerves in the pelvic region, some of which supply a similar area to the pudendal nerve so diagnosis can take some clever detective work by your doctor and physiotherapist as other nerves and biomechanical factors need to be ruled out.
The pudendal nerve itself follows a torturous path into the pelvis from the spinal cord, around a few corners and down towards the pubic bone. Anywhere along this pathway it can be compressed by tight muscles, ligaments or fascial/elastic tissue.
One common cause of pudendal neuralgia is bike riding- due to the constant pressure on the perineum.
Treatments will be similar to above but often have a foucs on manually loosening the muscles with massage and gentle pressure on the sore sections of the pelvoic floor muscles. Your physiotherapist can do this in the clinic and you can be shown how to do it at home with a Therawand or dilator.
stretching and movement are also importnat parts fo treatment.
Very rarely surgery may be necessary to release the elastic tissue that may be compressing the nerve .
The pain/fear cycle
Our brains remember pain, and things that cause it, so may try to protect you from the same situation in the future depedning on the circumstances. This can be very helpful in avoiding burning your hand when taking a hot pan out of the oven. You only do that once! This is an appropriate response by your brain to protect you and prevent you from touching the hot pan without a glove on.
If we look at this fro a pelvic pain point of view, you may experience pain with penetrative intercourse due, for example, to lack of lubrication (not aroused enough, or due to low hormone levels followng childbirth) and next time you attempt it your brain may decide it needs to protect you from the potential pain and causes spasm of the pelvoic floor muscles. This hurts and the cycle can be perpetuated. Pain causes fear and fear leads to higher levels of stress and anxiety which, in turn, leads to a more sensitive nervous system so pain is experienced with less provocation.
In fact, your whole nervous system becomes more sensitised and more likely to react to less of a stimulus.
Some people interpret this as "it's all in your head" . THIS IS NOT TRUE! whilst the pain response is a brain reaction, the pain is very real and treatment is aimed at reducing the sensitivty of the nervous system and tissues to calm the system down. This needs to address all the aspects of pain - the physical, the emptional and the social.
Some conditions like endometriosis can be ongoing physically for some women, whilst others are successfully treated with excision surgery and have no further episodes. Mangement needs to be very individual.
Treatments for persistent pelvic pain can include:
Physical therapies such as the use of
- vaginal dilators and wands
- pelvic floor muscle relaxation and massage techniques
- general stress management
- breathing to help reduce the levles of stress hormones which are known to drive the pain response within the nervous system.
- understanding pain science is crucial as is not blaming yourself.
- pain relieving drugs
- changes in hygiene
Psychological therapies such as:
- pain science education
- stress management
- your current relationship/s and work and whether you have good emotional support etc are all important factors in recovering from any injury or condition.
Together these treatment paths are known as a biopsychosocial approach which looks at you as a whole person and not just a body part.
Bio (physical causes) Psycho ( the emotional and stress causes) Social (environment and social support)
Remember that you should always consult your health professional before embarking on a course of self-help, in order to ensure that the cause of your pain has been fully investigated and appropriately diagnosed.
The material presented here is intended as an information source only. The information is provided solely on the basis that readers will be responsible for making their own assessment of the matters presented herein and are advised to verify all relevant representations, statements and information. The information should not be considered complete and should not be used in place of the advice of a health care provider. Pelvic Floor Exercise does not accept liability to any person for the information or advice provided , or for loss or damages incurred as a result of reliance upon the material contained herein.
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