Pelvic Pain 101

What is Pelvic Pain and What are the Reasons?

Let’s dive right in! It's time for some Pelvic Pain 101. Pelvic pain is a very broad term used to describe pain at and around the area of the pelvis. This includes all of the surrounding anatomy also! More importantly, the reasons for pelvic pain can be multifaceted and complicated. Read on to better understand the pain or discomfort you’ve been experiencing.

The Good and Bad

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 won't help you get to the root of the problem. The good news is ALL types of pelvic pain CAN be addressed with physical therapy.

Different 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!

  1. 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. It is most commonly experienced with direct pressure to that area such as sitting slouched or on a very firm surface. You may have pain if you had a fall directly to this area, childbirth, or pelvic floor muscle issues as some of the pelvic floor muscles directly attach to this bone.
  1. 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.
  2. Endometriosis is a common issue that can also cause dysmenorrhea. This is where uterine tissue begins to grow outside of the uterus. If you have endometriosis, you may get 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.
  3. Dysparenuia: Dyspareunia is pain or discomfort experienced with vaginal penetration. You will experience pain at the vaginal opening, deep inside, or in your low abdomen. The causes of this can be tight pelvic floor muscles, scar tissue, surgery, or childbirth. 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 location of your pain can be more general throughout the entire vulvar tissue or at a specific area. Other symptoms from pain can be: burning, stinging, and irritation/rawness.
  6. Interstitial cystitis Another common name for interstitial cystitis (IC) is painful bladder syndrome. The pain you feel with interstitial cystitis occurs while the bladder is filling. This leads to more frequent urination to relieve or avoid the pain.
  7. Levator ani syndrome  Levator ani syndrome is described as pain, pressure, or achy discomfort around the anus. The levator ani is your deep pelvic floor muscles and the muscle can spasm. When this occurs, you can experience pain that will last 20 minutes or more. Your 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. Sacroiliac (SI) joint pain is commonly linked with low back pain because of the close proximity of the pain. The SI joints are what connects the spine and the pelvis together posteriorly with the sacrum.

Low back pain can be a large area or confined to just one small area of muscle or tissue. It can 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 while walking, lifting, or activity.

Most commonly sacroiliac (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, both of these areas are also 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. If you haven't had a full resolution of symptoms, you should consider the pelvic floor muscles 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, you will likely feel a constant, dull aching in the pelvis or low back. Your symptoms will worsen with prolonged standing/sitting, around your period, during or after intercourse, and late in pregnancy. Lying down will typically provide some relief for you.

10. Pubic Symphysis Pain  The pubic symphysis is the joint at the front of the pelvis where the pubic bones join together and can be painful. This can occur when getting dressed, walking up 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). You may feel a very sharp, intense pain, or dull, achy pain.

11. Pudendal Neuralgia   Pudendal neuralgia can be intense or sharp pain, burning, itching, or raw feeling. Usually this pain is worse in sitting. Pain can occur at the vulva, labia, or clitoris, perineum, and around the anus. This most commonly occurs due to the pudendal nerve getting pinched or stuck up into the surrounding tissues.

Common Causes

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:

  • Inflammation
  • Poor posture
  • Increased stress
  • Constipation or holding bowel movements or urination
  • Scar tissue
  • Abdominal muscle tightness or weakness
  • Impaired organ and/or pelvic alignment

Other Causes

You may be experiencing pelvic pain partially because of other issues including:

  • Pelvic organ prolapse
  • Diastasis rectus abdominis
  • Prior abdomen, pelvic, hip, or low back surgery
  • Fall onto buttocks, hips, or tailbone
  • Pregnancy & childbirth
  • Sexual injury or trauma
  • Pelvic infection

The Most Common Cause

The top cause for pelvic pain is pelvic floor muscle tightness or weakness due to all of their attachments! Your 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). These muscles also have connective tissue connections to the abdomen!

Basic Treatment Information

Pelvic floor physical therapy should always be considered in conditions of pelvic pain. Your pelvic floor muscles likely need to be addressed beyond “just doing kegels”. This conservative approach can even be more helpful than most medications for the issues mentioned above.

Other simple changes you can make at home on your own can include:

  • Diaphragmatic breathing. Doing diaphragmatic breathing (aka belly breathing) can help this muscle to function more normally and help with pelvic floor tightness. Follow these steps to perform:
    1. Place one hand over your chest, the other over the abdomen.
    2. Take a deep inhale and your belly should expend. Your hand on the chest should stay stationary throughout the whole breathing cycle.
    3. As you exhale, the belly will fall.
    4. Perform this breathing for 2-5 minutes before bed this is super relaxing!
  • Good vulvar (labia) hygiene. It is normal to experience vaginal discharge to protect the vaginal skin and vulva. You need to be gentle while washing the vulvar tissue and don't wash it too frequently. Using only water is preferred; no need to buy special washes. And avoid 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