Persistent Pelvic Pain
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Persistent Pelvic Pain

It is important to consult your doctor or women's health physiotherapist about your pelvic pain in order to ensure that all possible causes are investigated and treated.

Persistent pain

It is also very important that you understand that your pain is real. Sometimes pain science can be explained in such a way that people think they are saying it is all in my head. Whilst it is your brain that creates the sensation of pain and your brain is inside your head that's as close as it gets to being "all in your head".
Your brain interprets all the information sent to it, assesses the current danger and responds accordingly. This is explained using analogies in the section below 'how do I explain this to my patients?' 

What is Persistent Pelvic Pain?

Persistent pelvic pain is the term for any pain in the pelvic area that lasts for six months or longer.
The term "pelvic pain" is used for pain anywhere in the lower abdomen, below your bellybutton and between your hips.
Short term (acute) pain will come and then go whilst long term, persistent pain (previously described as chronic pain) doesn't go away - even when the original cause of the pain has resolved. It is a bit like the memory of the pain, the tissues become sensitized and nerve endings easily fire off warning messages to the brain which are interpreted as pain, because the brain remembers reacting strongly last time a similar sensation was felt. The nerves become hypervigilant and some of the normal filtering of information to the brain doesn't happen.

Think about a time you walked through a cobweb and the resident spider landed on you. Your reaction to that is the spider dance and associated fear of the spider being on you.
Next time even a small cobweb touches you - you get the same over- the -top response, even if there is no spider. Or you can even get the same response from a cotton thread hanging down that feels like a spider web . This is a simplistic way of explaining what happens when nerves become hypersensitive in persistent pain conditions and the smallest of sensations can result in the largest responses thus perpetuating the pain response. It may have been appropriate in the first place with the initial injury (or when the spider was on you) but the same response is not required once the injury has healed, or when there is no spider, yet your nervous system produces the same response.

It can be worse if you experience ongoing intermittent episodes of severe pain- for example this often happens with endometriosis on a monthly cycle. Just as your nervous system has a chance to settle down it gets bombarded again with significant input from the endometrial tissue bleeding.

Persistent pelvic pain can involve either steady or intermittent pain, dull aches or sharp cramps, or feelings of heaviness and pressure. It can vary from mild to severe and disabling.
In addition to generalised persistent pelvic pain, a number of specific pain conditions have been identified in women, the most common being Vulvodynia, Vestibulitis and Vaginismus.
Men also experience persistent pelvic pain. Some of the conditions related to this can be prostatitis and urinary tract infections.
In both men and women  pudendal nerve entrapment or irritation (pudendal neuralgia) can also be a cause as can the coccyx.

You can read more about these conditions here.

What causes persistent pelvic pain?

Common physical causes of pelvic pain include

  • endometriosis
  • pelvic inflammatory disease
  • pelvic congestion
  • fibroids
  • ovarian cysts
  • irritable bowel syndrome
  • urinary tract infections
  • prostatitis
  • interstitial cystitis , now termed bladder pain syndrome
  • pelvic floor muscle tension
  • direct trauma such as a fall on the coccyx (tailbone)

Psychological factors can also play a part and can set up a cycle of anxiety and pain. It can be very hard to work out what is causing persistent pelvic pain and many people who experience it never really know the cause. However, even if the cause isn't determined, it can be possible to manage and even cure the symptoms.

Pelvic floor muscle spasm and hypertonicity can be helped significantly by an experienced pelvic floor physiotherapist who will teach you how to downtrain your tight painful pelvic floor muscles; stretch relevant muscles and do some massage or releasing of these muscles to help lengthen and relax them.

What are the treatments for persistent pelvic pain?

Because the causes of persistent pelvic pain are diverse, your doctor may arrange for a variety of tests to determine which treatment is best.
You should always consult your health professional before embarking on any form of treatment.
Depending on the symptoms and the cause (if known), you may be prescribed drugs to manage pain, infection, or the menstrual cycle or help lift your mood. In some cases, surgery might be indicated and counselling may be helpful to assist with pain mangement strategies.

Pelvic floor physiotherapy can also be the treatment of choice especially when the pelvic floor muscles are hypertonic (too tight or tense) causing pain.
The main goal of physiotherapy for persistent pelvic pain (PPP)  is to downtrain the pelvic floor as many of the symptoms are related to, or made worse by, too much tension in the pelvic floor muscles. So we aim to do the opposite of what you would normally be taught when strengthening the pelvic floor muscles, we teach you how to lengthen, relax and stretch these muscles.

Physiotherapy treatment for persistent pelvic pain may include :

- Pelvic floor muscle releasing or massage
- Use of a Therawand to continue pelvic floor massage at home
- Relaxation exercises. Using a guided relaxation CD such as Pelvic Floor Muscle Relaxation for Women or for Men
- Stretching and breathing . Physiotherapist Dustienne Miller's yoga DVD is great for this
- Relearning to co-ordinate the pelvic muscles
- Use of vaginal trainers or Dilators
- Sometimes  TENS can be helpful in pain reduction and neuromodulation.
- Teaching the correct way to sit on the toilet and how to void/defaecate to reduce pelvic floor muscle strain and tension
- Biofeedback may also be used

How do I normally explain this to my patients?

Above we spoke of the spider's web. This is one of the analogies I find my patients often relate to.
Such responses are regulated or controlled by our Autonomic Nervous System (ANS) which we have no great control over. It regulates our heartbeat, blood flow and gut so these, and more, vital activities happen in the background, keeping us alive. This happens with various hormones like adrenaline and cortisol.
Another is when we talk about the flight and fight response. This is a natural response we all have and is a defence mechanism to keep us safe. When something happens (in caveman days it was when a bear or lion attacked) our ANS sends out adrenaline and possibly cortisol to help us to fight the lion or run away from it. Nowadays your 'lion' could be someone who cuts in front of you at the traffic lights. You need adrenaline to help your reflexes to slam on the  brakes and avoid a collision. This surge of adrenaline increases your heart rate , makes you alert as well and is useful as it helps you respond. Once the danger is over, the levels of adrenalin should drop and you should be back to a calm state until the next time you need a surge of adrenaline.

When you have ongoing severe pain, it can be like the threat of the lion is always there, you constantly expect it to jump out at you so your adrenaline levels can be elevated all the time "just in case". Because your experience has been when you do certain things the pain occurs, so your levels can be high when you do that activity - where's the lion? For example if you get severe pain when passing a bowel motion due to high tone pelvic floor muscles
(caused perhaps by endometriosis)  a slight sensation of discomfort can feel like more because the dimmer switch is on full so the response required for the actual lion is activated when in fact it wasn't the lion but some wind passing through your gut. The concept of the dimmer switch is your brains ability to filter out much of the information it constantly receives from around the body so it can pay attention to the things that are actually necessary at the time. When the dimer switch isn't on, filtering the information, then everything that shouldn't be a warning sign to the brain gets through and the brain becomes hypervigilant - there's a lion!  and sends the high response when in fact it wasn't the lion at all so that surge of adrenaline has turned up the dimmer switch for no real reason yet that has set off a heightened response and you feel significant pain.

Pain itself causes increased release of adrenaline, initially for good ( think of the stories you hear of people walking miles on a broken leg to get help, they don't feel the pain until out of danger, the adrenaline helped them) but over time it can become a hinderance to getting better. If you are stressed about your injury or condtion, levels of adrenaline and cortisol will be higher, driving that greater response in the tissues and nerves.

Some people take this as meaning they are causing it all themselves and just need to "lighten up". This is not true at all. It can often be due to a perfect storm - an injury, a stressful time in your life, worried about how the injury will impact you, people's expectations of you, the length of recovery time, even your genetic predisposition to stress responses can all play a role in pain persisting. This is why treatment with a multidisciplinary team ( MDT) is beneficial so we can address not only the medical aspects but also the physical and emotional aspects. The connection between mind and body is very strong.

I sometimes liken pelvic pain to a stress headache. A stress headache is caused by tension in the neck muscles. You don't purposely tighten your neck muscles to give yourself a headache but over the day they can tighten due to increasing stress, positions you are in and your state of mind (I must meet this deadline!) The stress drives the physical response of muscle tightness which in turn causes pain and ends up as a painful headache. 
The same can happen in the pelvis with the pelvic floor muscles responding to stress, a UTI, painful episode of sex etc. You don't purposely tighten these muscles - it is a physical response to the pain. Quite often with either the headache or pelvic pain, after a while even the thought of that deadline or having sex can cause protective tightening in the muscles resulting in pain ( there's the lion or spider again)

The muscle tension is real, the pain is real but it can be driven by past experience, not current input.

There are many resources available to assist you in management of chronic pelvic pain. Australia now has a Pelvic Pain Foundation which has many resources to assist you as does the International Pelvic Pain Society


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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