In our last blog post, Sarah Shaw, PT, DPT, touched on the prevalence of pelvic floor dysfunction in relation to bowel and bladder function, but can pelvic floor dysfunction be painful as well? In a word, YES. But how and why will depend on a multitude of variables.
Pelvic pain is defined as pain between the pelvis and lower abdomen and affects approximately 15% of women[1],[2], and men.[3] Pelvic pain is generally a broad term used to include pain from many possible sources, including the genitourinary system, gastrointestinal system, and neuromusculoskeletal systems, and can cause functional deficits in bowel and bladder control and negatively impact sexual function, including pain with intercourse, inability to orgasm, or pain after orgasm.
Pelvic pain can be divided into acute and chronic varieties as well, with acute pain having a recent onset and chronic pain being present for more than 3-6 months. Examples of acute pelvic pain include appendicitis, hernia, ectopic pregnancy, endometriosis, urinary tract infections, ovarian cysts, prostate dysfunction, and cancers related to the pelvic organs, such as uterine, ovarian, bladder, prostate, or rectal cancer. These are medical conditions that warrant screening by a physician to address the cause of pain and may require treatment, such as medications or surgery that are out of the scope of physical therapy. However, the pain and neuromusculoskeletal dysfunction associated with them may persist longer than the original pathology and become chronic pain. Chronic pain develops once the acute cause has been managed, but the pain signals continue to be sent from the body to the brain, despite the absence of a clear medical cause.
Pelvic pain that begins acutely but becomes chronic over time is a form of “centralized pain,” or pain signals that are not processed correctly by the brain. In an optimal setting, the body is stimulated by something, such as a kiss on the cheek from a lover or dropping a book on your toe, and the signal is transferred through the peripheral nervous system (like nerve endings in skin and muscles) to the brain, where it is then interpreted for meaning. The kiss from the lover feels wet and squishy and we interpret that in the brain as GOOD and lean in to return the favor. The book being dropped on our foot is very hard and a lot of pressure in a short amount of time and the brain interprets it as BAD, so we jerk back and rub our foot to provide an alternative sensation to override the PAIN signals. This system tends to work well for us…until it doesn’t. After continually sending pain signals from the body to the brain, the nervous system becomes more reactive to input causing the body to change its threshold for pain, meaning that it interprets previously mild-moderate painful stimuli as severely painful (hyperalgesia) or it interprets previously non-painful stimuli as painful (allodynia).
It is important to understand that pain is a sensation, not an indicator of tissue damage. Pain is an unpleasant sensation that gets our attention and causes us to change our behavior to fend off further intensifying that sensation, but the intensity of the pain sensation is not proportional to the amount of tissue damage that may be occurring. The pain signals are sent from the body to the brain for interpretation, and this tends to be where things can go off-track.
When we don’t receive reliable information from the body or the information is reliable but interpreted incorrectly, things go awry for us. We may start to interpret the kind tickle from a friend as being painful or the loving embrace from our partner as crushing and suffocating. This is especially detrimental with respect to nerves and muscles in the pelvis, where that change in sensation can cause urination, bowel movements, vaginal/rectal penetration, intercourse, ejaculation, and/or orgasm to become painful. Physical therapy can help with desensitization and repetitive exposure to non-painful stimulation that helps to improve the reliability of the signals from the body to the brain and how the brain process and interprets the signals that it is receiving to reduce pain levels and improve bodily functions.
Chronic pelvic pain can also develop gradually over time, related to poor function of the pelvic floor muscle group, causing a myofascial pain syndrome known as levator myalgia or levator ani syndrome. Typically, levator myalgia develops as the pelvic floor muscles are subconsciously activated and tension develops within the muscle group. This gradual muscle activation cycle can also develop in response to biomechanical changes, such as “sucking in” the stomach, a fall that jars the coccyx or pelvis, pregnancy, and delivery (both vaginal and c-section delivery) or musculoskeletal changes in the spine, pelvis and lower extremities that alter the available range of motion or strength, or psychological factors, such as generalized anxiety disorder, post-traumatic stress disorder, or sexual assault.[4] Physical therapists are neuromusculoskeletal experts and are equipped to help identify and address range of motion deficits, weakness, and poor movement patterns that may be contributing to poor pelvic floor muscle function. By addressing biomechanical dysfunctions and helping with desensitization of the nervous system, physical therapy can improve the symptoms related to pelvic pain.
As physical therapists, we are equipped to help patients navigate the neuromusculoskeletal dysfunction and improve habits related to bowel and bladder function. In the absence of an acute medical cause for pelvic pain, physical therapists can help with understanding the dysfunctions present, rather than just the main symptom we recognize (PAIN).
Whitney Landis, PT, DPT, FAFS, is a Physical Therapist, Director of Pelvic Health, and Fellow of Applied Functional Science. Whitney graduated with her Doctorate in Physical Therapy from Chapman University in 2010 and has taken numerous continuing education courses pertaining to Women’s/Pelvic Health through Herman and Wallace Pelvic Rehabilitation Institute and Pelvic Guru. She has also completed the Gray Institute of Functional Transformation (GIFT) Fellowship in 2015.
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