Pelvic Pain 101: Reasons for Pelvic Pain and What You Can Do
What is Pelvic Pain and What are the Reasons for Pelvic Pain?
Let’s dive right in! Pelvic pain is a term used to describe pain at and around the area of the pelvis. All the areas that are included in the general term of pelvic pain include the: low abdomen, vulva, vagina, pubic symphysis (where the pubic bones connect in the front), perineum (area between the vagina and anus), anus, pelvic floor muscles and nerves, tailbone, low back, SI joints (two joints on the back of the pelvis) and hips.The reasons for pelvic pain can be multifaceted and complicated, but read on to help you better understand the pesky pain or discomfort you’ve been experiencing.
The Good and Bad of Pelvic Pain
Did you know that 1 in 7 American Women (ages 18-50) experience pelvic pain?1 Of these women, up to 61% have no diagnosis for the issue they experience.1 Any type of pelvic pain can lead to depression, anxiety, decreased libido, and decreased ability to tolerate daily life activities. Unfortunately many types of pelvic pain are uncomfortable to talk about, or easily brushed off by healthcare providers with the instruction to relax more, drink wine, and use lube. These simple instructions may sound like a good idea, but they aren’t getting to the bottom line of the issue. The good news is ALL types of pelvic pain CAN be addressed with physical therapy.
The Types of Pelvic Pain
Read each section below to learn more about each of the categories that fall under pelvic pain! We’ll cover everything from pubic symphysis dysfunction to interstitial cystitis!
Coccygeal (aka Tailbone) Pain
The coccyx, also known as the tailbone, is the tiny bone at the very end of the spine. Pain in this area can range from dull to sharp, and the pain is most commonly experienced with direct pressure to that area such as sitting slouched or on a very firm surface. Sitting more upright on the sit bones will help take pressure off the coccygeal area. Pain can occur from a fall directly to this area, childbirth, or pelvic floor muscle issues as some of the pelvic floor muscles directly attach to this bone.
2. Dysmenorrhea
Dysmenorrhea is defined as painful and intense cramping that occurs with menstruation.2 Stretching, heat, and manual therapy from a physical therapist can help to improve these symptoms. Endometriosis is a common issue that can also cause dysmenorrhea where uterine tissue begins to grow outside of the uterus. With endometriosis, there may be intense cramping throughout the abdomen, not only at the area of the uterus. A firm diagnosis of endometriosis is done via testing of a tissue sample. Physical therapy can help with pain associated with endometriosis!
3. Dysparenuia
Dyspareunia is pain or discomfort experienced with attempted or complete vaginal penetration. Pain will be experienced at the vagina (near the vaginal opening or deep) or at the low abdomen. Pain with intercourse can occur from a large variety of issues from tight pelvic floor muscles to scar tissue from a procedure or childbirth (this even includes scar tissue from a cesarean delivery!)
To learn more about pain with sex check out our blog post HERE!
4. Vaginismus
This is similar to dyspareunia, however, there can be no tolerance to any penetration at the vagina. There will be an involuntary spasm of the pelvic floor muscles around the vaginal opening preventing even superficial penetration.
5. Vulvodynia
Also similar to dyspareunia is vulvodynia. This is pain at the vulva (external genital tissue) without a clear cause. The pain can be throughout the entire vulvar tissue or just at one specific area such as the labia or the bottom of the opening of the vagina. Other symptoms from pain can be: burning, stinging, and irritation/rawness.
6. Interstitial cystitis
Another common name for interstitial cystitis (IC) can be painful bladder syndrome. The pain associated with interstitial cystitis occurs while the bladder is filling. This leads to more frequent urination to relieve or avoid the pain. Pain with IC can be experienced at the urethra, bladder, vulva, rectum, low back, and abdomen.
7. Levator ani syndrome
Levator ani syndrome is described as pain, pressure, or achy discomfort around the anus. The levator ani is a deep pelvic floor muscle and with levator ani syndrome this muscle spasms or tightens up leading to pain. Usually, episodes of levator ani syndrome will occur in periods of 20 minutes or more. Pain can occur while sitting or lying down. Levator ani syndrome can occur in up to 50% of people from age 30-60!3
8. Low Back and SI Joint Pain
Low back pain is described as pain in the area between the bottom of the ribs and to the top of the pelvis. The whole low back area contains the lumbar spine and the sacrum (the triangle bone at the bottom of the spine). SI (or sacroiliac) joint pain is commonly linked with low back pain because of the close proximity of the pain. The SI joints are the two joints that close up the back of the pelvis, this joint connects the spine (sacrum) and the pelvis together on the back side of the pelvis.
Low back pain can be a large area or confined to just one small area of muscle or tissue. It can also span across both sides of the back or be one-sided. Low back pain can occur with any activity or movement depending on the cause, it can be experienced while sitting at rest or with walking, lifting, or activity. Most commonly SI joint pain will occur on one side. SI joint pain can be worse with sit-to-stand movements, standing, stairs, moving in bed, and standing on one leg.
Interestingly enough, even though these two types of pain can occur at a specific area of the spine (such as at a disc) or joint, both of these areas are places the pelvic floor muscles refer to. This means, if there is an issue with the pelvic floor muscles sometimes pain can present in the low back or SI joint areas to signify an issue to you. If you have tried standard PT without full resolution of symptoms, the pelvic floor muscles should be considered as a pesky cause!
9. Pelvic Congestion
Pelvic congestion is a condition that affects the veins in the pelvis, where the veins are enlarged leading to backup of blood into the pelvis. Most commonly this will feel like a constant, dull aching in the pelvis or low back. Symptoms worsen with prolonged standing/sitting, around period, during or after intercourse, and late in pregnancy. Symptoms usually improve with lying down.
10. Pubic Symphysis Pain
The pubic symphysis is the joint at the front of the pelvis where the pubic bones join together. Pubic symphysis pain will hurt at the pubic bones and worsen with getting dressed, stairs, standing on one leg, and when the legs are wide apart or going in opposite directions (like getting in and out of the car). Commonly this is a very sharp, intense pain and is related to pelvic alignment. This issue is common during or after pregnancy.
11. Pudendal Neuralgia
Pudendal neuralgia can be an intense or sharp pain, burning, itching, or raw feeling. Usually, this pain is worse in sitting. Pain can occur at the vulva, labia, clitoris, perineum, low buttocks/sit bones areas, and around the rectum or anus. Most commonly occurs due to the pudendal nerve getting pinched or stuck up in the surrounding tissues.
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Causes of Pelvic Pain
Although there are many types of pelvic pain, the causes for all of them can be similar. Some of the most common causes of pelvic pain can include:
Pelvic floor muscle tightness or weakness - This is one of the top causes of pelvic pain. It’s important to understand that the pelvic floor muscles attach from the front of the pelvis (at the pubic symphysis) and swoop all the way back to the coccyx (or tailbone), and even at the sit bones! These muscles also have connective tissue connections to the abdomen and abdominal/low back muscles!
Prior abdomen, pelvic, hip, or low back surgery
Pregnancy
Childbirth
Sexual injury or trauma
Pelvic infection
Inflammation or swelling in the pelvis
Poor posture
Fall onto buttocks, hips, or tailbone
Increased stress
Holding bowel movements or needing to urinate too long
Straining with bowel movements or urination
Scar tissue
Abdominal muscle tightness or weakness
Diastasis rectus abdominis
Poor strength in muscles supporting the pelvis
Impaired bladder, uterine, and rectal alignment, and positioning
Lack of belly breathing at rest
Poor pelvic alignment
Pelvic organ prolapse
Basic Treatment Information
Pelvic floor physical therapy should always be considered in conditions of pelvic pain because it can be a conservative approach to some seriously painful issues. Many times, pelvic floor therapy can be more helpful than most medications for the above issues. Finding a physical therapist who specializes in the pelvic floor area is important when considering pelvic pain because many times the pelvic floor muscles are impaired and need to be addressed beyond “just doing kegels”.
Other simple changes you can make at home on your own can include:
Diaphragmatic breathing. The diaphragm muscle is located at the level of the lower ribs, and it closely related to normal functioning of the pelvic floor. Doing diaphragmatic breathing (aka belly breathing) can help this muscle to function more normally and help with pelvic floor tightness.
Steps to diaphragmatic breathing:
1. Sit in a supported chair or lie down.
2. Place one hand over your chest, the other over the abdomen.
3. Take slow, deep breaths (in through your nose, out through your mouth). Go at a pace that feels comfortable for you.
4. As you inhale, the belly should expand (hand over abdomen will move forward). The hand over the chest should stay more stationary throughout the whole breathing cycle.
5. As you exhale, the belly will fall.
6. Perform for 2-5 minutes (before bed this is super relaxing!)
Good vulvar (labia) hygiene. It’s normal to experience vaginal discharge to protect the vaginal skin and vulva. It’s best to be gentle while washing the vulvar tissue and to not wash too frequently. It’s best to just use water and to be gentle with the tissues, without rubbing too hard, your hands can be the best tool to use with water. No need to buy special washes and for sure stay away from anything scented.
Wear cotton underwear and avoid tight/restricting clothing.
Prevent constipation. Be sure to drink plenty of water and eat enough fiber (35-40 grams per day). You should have bowel movements every 1-2 days with minimal effort to expel.
References:
1= Chronic Pelvic Pain. (2014).From http://www.pelvicpain.org/docs/patients/Patient-Education-Brochure.aspx.
2= Proctor, M., & Farquhar, C. (2006). Diagnosis and management of dysmenorrhea. BMJ (Clinical Research Ed.), 332 (7550), 1134-1138.
3= Bharucha, A. E., & Trabuco, E. (2008). Functional and chronic anorectal and pelvic pain disorders. Gastroenterology clinics of North America, 37(3), 685–ix. https://doi.org/10.1016/j.gtc.2008.06.002