• Emily Reul, PT, DPT

Chronic Pelvic Pain

May is pelvic pain awareness month. Almost 1 in 4 women experiences chronic pelvic pain. (Zondervan, 2001) Yet women with pelvic pain are often left feeling helpless and hopeless. While chronic pelvic pain is more common in women due to many factors like pregnancy and childbirth, it can also happen to men, too!


WHAT DOES CHRONIC PELVIC PAIN MEAN?

Chronic pelvic pain is a broad term that describes any pain in the pelvic region. Typically, pain must be present for at least 6 months to be described as chronic.


Pelvic pain can be very difficult to describe and pinpoint as it is often diffuse or in more than one area. Your providers may use fancy words like dyspareunia (pain with intercourse) or vulvodynia (pain around the opening of the vagina) but don’t be intimidated.


People who suffer from chronic pelvic pain often have to seek help from multiple healthcare providers, and often are still do not get the care they need. Women with chronic pelvic pain are often told to “have a glass of wine and relax,” or are told that there is nothing wrong with them. It is estimated that $881.5 billion is spent annually on outpatient medical visits to address chronic pelvic pain! That's a lot of money, especially considering many women don't find symptoms relief.


While anyone can have chronic pelvic pain, the following can make someone more likely to develop it: delivery of a large baby or difficult delivery, vacuum or forceps delivery, an episiotomy, muscle weakness and poor physical conditioning, lumbar lordosis (increase natural curvature in the lower spine), a history of abdominopelvic surgery, a fall (especially on the tailbone), and pelvic organ prolapse.


There are several different conditions that can contribute to chronic pelvic pain including: interstitial cystitis, vulvar pain syndromes, endometriosis, IBS, infective cystitis (bladder infections), hemorrhoids, anal fissures, and more.


SO WHY DO WE CARE ABOUT PELVIC PAIN?


It has been shown to have profound effects on both the physical and emotional health of women. With chronic pelvic pain, women are more likely to have depression, sleep disorders, and a history of abuse. It’s hard to live a normal life when you are constantly in pain!


Surprisingly, studies have shown that chronic pelvic pain is just as common as migraines, back pain, and asthma. We all know someone who has these conditions, or maybe suffer from them ourselves. Imagine each of those people suffering daily from chronic pelvic pain!


Because chronic pelvic pain can present itself in so many different ways and it can be caused by a wide array of problems, it is best to seek help from a medical profession to address your symptoms. With that said, if a medical professional tells you just to “deal with it,” do yourself a favor and find a new provider.


Pelvic floor physical therapy is a great place to start to address chronic pelvic pain. Most states in the US have direct access, which means you can see a PT without needing a referral from a physician. And the great news—pelvic PT is covered by most insurances!


A pelvic PT can help in so many ways! One of the biggest ways a PT can help is through education. The PT can explain to you the anatomy of your body and the way it functions. Understanding this, can be a big step towards managing your pain. They also help you to recognize habits you may have and help you to create new, healthy ones.


They can provide relaxation training and biofeedback (down training) to help relax tight pelvic floor muscles. They can also use manual therapy techniques, such as massage and trigger point release, to help relax the pelvic floor and surrounding muscles.

A pelvic PT may give you exercises to perform as part of a home exercise program to help maintain progress made in physical therapy. These exercises may be to stretch and/or strength your pelvic floor while also addressing any movement dysfunctions you may have. Below are examples of some of the stretches they may ask you to do.



PTs are often equipped with modalities that can help to address pain such as moist heat packs, ice, and electrical stimulation (sometimes called TENS).


A PT may suggest the use of bracing and orthotics depending on your symptoms. These may include a SIJ/pelvic belt, or even foot orthotics. Faulty foot position can influence your entire body and put a greater strain on the pelvis and pelvic floor.


A PT can provide pain neuroscience education, which means they will explain to you how pain works. In understanding your pain, you are better equipped to manage it.


If you are having pain with penetration of any kind, including inserting a tampon or having a vaginal exam, your PT may suggest the use of vaginal dilators. Vaginal dilators come in many different sizes and are used to gradually increase tolerance to objects entering the vagina. Often times with chronic pelvic pain, the pelvic floor muscles tighten in response to an object being inserted—which makes it painful. The dilators start smaller than the size of an index finger and get progressively bigger to help the pelvic floor muscles relax and allow penetration.


Along with pelvic floor PT, you doctor may prescribe medications to help with your symptoms. Some of the commonly prescribed medications are:

  • Elmiron: This medication is often used to repair the bladder lining in patients with interstitial cystisis. This medication can take 3 to 6 months to be effective and research has shown conflicting evidence on efficacy. (Giusto, 2018)

  • NSAIDs (Non-steroidal anti-inflammatory drugs): These drugs are better known for their over-the-counter names such as Motrin, Aleeve, and aspirin. These drugs are often prescribed in higher doses and used to calm down any inflammation and to help with pain relief.

  • Antidepressants: Medications like amitriptyline (Elavil) and nortriptyline (Pamelor) have been used to treat chronic pelvic pain.

  • Anticonvulsants: Drugs like Gabapentin (Neurontin) have been used to manage chronic pelvic pain due to limited side effects and minimal interactions with other medications.

  • Opioids: These drugs are reserved as a last resort when all other medications have failed. Long-term opioid usage must be closely monitored by your primary care physician. These drugs are often prescribed as a pill or in the form of a vaginal suppository.

Your provider may also recommend other treatment options such as, regional anesthesia, sacral neuromodulation, trigger point injections, and psychological therapies.


Your physician may recommend surgery to address your pelvic pain. Make sure to discuss your options in detail. It is recommended, that for most conditions, you try conservative management (like pelvic floor physical therapy) before having surgery.


Whew, that was a lot of information and we know it can be overwhelming! It’s possible you’ve already seen several healthcare providers with little to no improvements in your symptoms, or even worse, your symptoms may be harder to deal with now.


It is easy to lose hope and feel that this is your new reality, and you must live this way forever. This is simply not the case!


Find healthcare providers who listen to you and actively seek for solutions to your problems. Pelvic floor physical therapy with a therapist who is skilled at treating chronic pelvic pain can greatly improve your symptoms.


Ready to take back control of your life and your pain? Here are some steps you can take now:

What experiences or tips do you have that can help others? We’d love to hear them. Please join the conversation in the comments section below.  

By Emily Reul, PT, DPT

References

1. Abraham K, Scheufele L. Chronic pelvic pain. APTA section on women’s health.

2. How to use diazepam suppositories for pelvic muscle spasm. Pelvic Pain Foundation of Australia. https://www.pelvicpain.org.au/how-to-use-diazepam-suppositories-for-pelvic-muscle-spasm/. Published 2020. Accessed May 22, 2020.

3. Zondervan KT et al. The community prevalence of chronic pelvic pain in women and associated illness behaviour. Br J Gen Pract. 2001;(51):541-547.

4. Giusto LL, Zahner PM, Shoskes DA (2018) An evaluation of the pharmacotherapy for interstitial cystitis. Expert Opin Pharmacother. 2018;(19)10:1097-1108, DOI: 10.1080/14656566.2018.1491968

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This information is for awareness purposes and not individual medical advice. You should seek your own professional counsel for any medical condition or before starting or altering any exercise or fitness program.

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