How Do You Treat Pelvic Pain From a Physiotherapy Perspective?
When you ask a patient with persistent pelvic pain “What do you believe is driving your pain?”, or “Why do you think it persists despite all you have done to try to change the pain and to heal?” you get a variety of answers. Many of these answers are not consistent with what we understand about tissue injury and function, and reveal underlying fear, as well as a lack of understanding regarding changes and sensitivity of the nervous system during chronic pain states. Chronic, or persistent pain, is complex. For more detail on the complexity of persistent pain, see the You Tube video, Understanding Pain: What To Do About It In Less Than Five Minutes. When patients with persistent pelvic pain seek medical attention, they see many doctors before someone can give them a diagnosis, and once given, the diagnosis is often not helpful from a treatment perspective. Added to this general misunderstanding of chronic pain are the mysteries and misconceptions that are common with pain through the pelvis and the genitals. Social challenges can further limit the medical system’s ability to make a clear assessment of a person with chronic pelvic pain, including sexual health issues, cultural expectations, privacy, and religious issues.
Dr. Andrew Goldstein, in the foreword for Healing Pelvic Pain Naturally by Amy Stein (2008), recounts that even gynaecologists have very little training in pelvic pain. He reports that “…despite completing nearly 20,000 hours on internship and residency in obstetrics and gynecology, I heard only one hour-long lecture on vulvar pain and sexual dysfunction. I was taught that pain during sex was the result of “vaginismus”, an involuntary contraction of the vaginal muscles during attempted penetration. I was further taught that vaginismus was a psychological issue resulting from trauma or abuse, and it was to be treated through psychotherapy and sex therapy. Physical therapy was never mentioned. Other types of vulvar pain were thought to be caused by nerve injury and were treated- as much as possible- with drugs. Again, physical therapy was never discussed as a treatment for women suffering this pain, nor was I ever taught anything about pelvic disorders in men!…” It is not too far-fetched that Amy and her colleagues had to beat down the doors of the medical establishment-figuratively, anyway- to be heard………. The pain, they explained, was a result of the muscles having tightened and shortened. The tightening had decreased the blood flow and therefore the supply of oxygen to the affected muscles; as a result, lactic acid built up, irritating the nerves that pass through the muscles. As the brain perceives pain as being located in the end organ reached by the affected nerve, the person felt vulvar pain. In addition, the irritation of the nerve typically gives rise to an inflammation that produces redness and swelling, and the redness and swelling, like the pain, show up in the “endpoint” organ reached by the irritated nerve- namely, the vulva……………Many of the pain syndromes doctors and patients have struggled with for years now turn out to derive from myofascial disorders. For example, women are frequently diagnosed with irritable bowel syndrome or interstitial cystitis when in fact all of their pain may be myofascial in origin.” (Stein 2008)
“We live in a somewhat puritanical society, where the issues of pelvic floor disorders are not discussed openly, if at all. What’s more, our culture’s attitudes toward health care often encourages the quick fix- make an appointment and get a prescription- and certainly, our current system of health-care insurance favours such efficiency. In France, however, it has long been the custom for every women who goes through a vaginal delivery to see a physical therapist as part of her postpartum treatment. The muscles are massaged, lengthened, stretched, and strengthened prophylactically so as to prevent the weakness that can lead to incontinence or the tightness that can result from a tear or episiotomy and can lead to so much pain, discomfort, and limitations of functioning. We also tend to believe that there’s so much health-care information available- in newspapers and magazines and all over the Internet- that we should be in charge of our medical treatment, even to the point of self-diagnosis and self-medication. Studies show, however, that when a woman diagnoses herself with a yeast infection based on the symptoms of itching, burning, and discharge- to take a common example- she is incorrect more than 50 percent of the time. The symptoms are just as likely to be a result of nerve irritation or tightened tissue. Yet far too many women head to the drugstore for creams to treat chronic itching and burning- often with dire consequences-when what they really should be doing is the exercise program in this book.” (Stein, 2008)
People with pelvic pain need to address Pelvic Tissue Dysfunction, Connective Tissue Dysfunction and the Sensitive Nervous System in order to successfully address their pelvic pain. A physiotherapist specializing in pelvic pain, specifically using internal treatment techniques for the pelvic floor muscles, connective tissues and nerves, needs to be consulted in order to address your particular tissue problems. There is a section in this website to help you locate a physiotherapist who has met the high standards of this organization to provide pelvic health in Ontario. However, this website is a good place to start in order to understand the importance of addressing the central nervous system through:
- Understanding the need for shifting your thoughts and beliefs about persistent pain
- Understanding the Neurophysiology of pain and the Neuromatrix
- Understanding and addressing your sleeping difficulties as they relate to persistent pain
- Train yourself to think positively, using healing imagery and guided relaxation
- Last but not least, chose at least one activity to decrease the sensitivity of your nervous system and practice it daily. Let your interests, previous experience or intuition help you chose which might be the most appropriate activity for you.