Pain from Pelvic Floor Dysfunction
by Gwenda C. Jonas, MD
Pelvic pain has many causes. One less commonly discussed cause is pain from Pelvic Floor Dysfunction (PFD). This is pain within the pelvic floor muscles caused by weakness, spasm or lack of coordination. It may be felt in the lower abdomen, pelvis, vagina, external vaginal area, rectum or bladder. This pain may be present constantly, intermittently, or with certain activities including exercise, prolonged sitting or sexual activity. The pain is often described as achy, heavy or burning in nature. It generally comes and goes over time. Pelvic muscles often have discreet knots known as trigger points. Touching or pressure on these trigger points can result in pain, and symptoms such as heart racing, sweating, tearfulness, coldness, and even a runny nose can occur. Symptoms may be “referred” to other areas and manifest in different ways, such as having to urinate frequently or suddenly, having burning with urination, or even experiencing vaginal or vulvar itching and burning.
WHY DOES IT HAPPEN?
It is not understood exactly how PFD is caused. There are twenty-eight pelvic floor muscles, many of which form a “bowl” at the base of the pelvis. These muscles are involved in supporting our posture, bowel, bladder and sexual function. Oftentimes, these muscles must contract asymmetrically, predisposing to muscle tension. And because all the muscles of this area work together, dysfunction in one muscle may eventually lead to dysfunction in other muscles over time.
Possible causes of PFD include acute strain, chronic overuse, poor posture, scar tissue or trauma. Trauma can be small repetitive events or a single significant event like childbirth, surgery, even a fall. Certainly, sexual trauma may result in long-standing pelvic pain and PFD. The pelvic floor can be affected by psychological as well as physical stresses. Often, we subconsciously hold stress in our muscles, including those of our pelvis. Prolonged muscle contraction may result in decreased blood flow and oxygen in the tissue. This in turn causes release of substances that cause pain and can even change how pain is perceived by the body. Ongoing pain in one area may cause the central nervous system to be overly sensitive, magnifying the perception of pain in another area.
Many women with pelvic floor pain also have endometriosis, painful bladder syndrome, pain with intercourse, painful periods or irritable bowel syndrome. It is unclear how these are related to each other or if, in some cases, one may cause the other.
HOW IS PFD PAIN DIAGNOSED?
A medical professional, most often a gynecologist, will discuss the history of symptoms and then perform a physical exam. This exam should include an external exam of the lower abdomen, lower back, buttocks, and legs, followed by a careful and detailed gynecologic exam. Special attention will be paid to the muscles of the pelvic floor, putting pressure on them one at a time to determine if they are tight, tender, and whether pressure results in a woman’s symptoms. In addition, a woman may be asked to try to tighten or relax pelvic floor muscles during the exam. A pelvic ultrasound will often be ordered to evaluate for other causes of pain.
HOW IS PFD PAIN TREATED?
Treatment most often requires a combination of approaches. The most important treatment for pain of pelvic muscular origin is pelvic floor physical therapy. This involves pelvic floor muscular strengthening, biofeedback, and sometimes electrical stimulation. It should be performed with a physical therapist specifically trained in pelvic floor therapy. It may take 3-4 months to begin to see improvement. In some instances, pelvic floor physical therapy may take as long as 12 months.
Medication therapy will often also be needed. Medications used may include non-narcotic medications that affect how our bodies process pain, anti-inflammatories, muscle relaxants, and vaginal estrogen or anesthetic gel (narcotic medications are avoided due to the risk of addiction). Some antidepressants are used to affect the way pain is processed by our nervous system. In addition, anxiety and depression can result in muscle tension, therefore, decreasing psychological stress will help to relieve pelvic muscle tension. Occasionally, actual injections of medication into the muscles themselves may help make the diagnosis or relax muscles for physical therapy work.
Counseling with cognitive behavioral therapy has been demonstrated to be extremely helpful for some patients. This involves seeing a counselor who specializes in training patients to identify stress or psychological triggers that result in tightening their pelvic muscles. A patient can then learn to break the cycle by consciously relaxing muscles in response to triggering events. In addition, if the pelvic pain is associated with physical or sexual abuse, counseling may help begin healing of psychological trauma.
Home exercise programs, yoga for pelvic pain relief, Pilates, or stress-reduction techniques are often incorporated.
Treatment of coexisting conditions such as endometriosis, pelvic or abdominal scar tissue or ovarian cysts may be necessary.
It is particularly important to realize that pelvic pain of muscular origin is often a chronic condition that will wax and wane over time. A woman may go through therapy, resolve the majority of her symptoms and still have flare-ups from time to time. Recognizing these flares and immediately beginning a regimen that has been found to work for her in the past will decrease the severity. Occasionally, a full course of physical therapy and other therapies may need to be repeated for severe flares.
WHAT SHOULD I DO IF I THINK I HAVE PAIN RELATED TO PFD?
See your medical provider and ask for a referral to a gynecologist with expertise in pelvic pain. If you do not have a primary care provider, you can make an appointment with a specialist directly.
MORE INFORMATION:
International Pelvic Pain Society: www.pelvicpain.org
Facebook is a great resource to find Pelvic Floor Dysfunction support groups.