Pelvic pain is considered “chronic” or “persistent” when it is non-cyclical in nature and lasts longer than 6 months. It affects up to 1 in 5 women and around 1 in 15 men, and can significantly impact well-being in many areas of life – physical, social, relational, and psychological.

Female pain can occur in the vulva, vagina, tailbone, bladder, joints of the pelvis (the pubic bone and the sacro-iliac joints), and lower abdomen. It can affect bladder, bowel, and sexual function, as well as physical functions like sitting, standing, exercising, sleeping, etc. Conditions related to chronic or persistent pelvic pain include Endometriosis, Bladder Pain Syndrome, Interstitial Cystitis, Pudendal Neuralgia, Vulvodynia, among others. 

Male pelvic pain can occur in the groin, perineum, testicles, penis, tailbone, lower abdomen, joints of the pelvis (the pubic bone and the sacro-iliac joints), bladder, and prostate. Similar to females, it can affect bladder, bowel, and sexual function, as well as physical functions like sitting, standing, exercising, sleeping, etc. Conditions related to chronic or persistent pelvic pain include Prostatitis, Bladder Pain Syndrome, Interstitial Cystitis, Pudendal Neuralgia, among others.

Importantly, chronic or persistent pelvic pain can also be considered a condition itself, rather than a symptom of a condition. While sometimes referred to as Chronic Pelvic Pain Syndrome (CPPS), it doesn’t need a name or label to be valid or deserving of treatment. Research and clinical treatment approaches are shifting from a biomedical model of pain to a biopsychosocial model of pain. This shift sees pain as more multi-faceted, acknowledging that biological, medical, as well as psychological and social factors are impacted by pain and reciprocally impact pain. It’s a move beyond black and white labels to the consideration of systems and context.

To begin managing and healing chronic or persistent pelvic pain, it is helpful to understand the concept of pain itself. While pain is traditionally attributed to a biomedical injury of something in your body, research from a biopsychosocial perspective has deeply challenged this understanding.

Pain is currently defined as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage” (Moseley and Butler). This definition highlights pain as physical and emotional, as a warning signal, and as an experience not always related to the status of tissues (muscles, ligaments, tendons, bones, etc). Accordingly, navigating pain is more than addressing injured tissue, it is addressing a whole-body system and process of perception and protection. 

Pain is processed in the context of your central nervous system (CNS), which is made up of your brain and spinal cord. Pain is ultimately an output from the brain rather than an input to the brain. Thus, the context in which your brain sends out signals impacts the types of signals being sent out.

As a metaphorical example, your level of anxiety hearing a noise in your home at night will differ after a recent robbery in your neighbourhood versus none at all. The perceptions of danger and safety make a significant impact on our psychology as much as they do on our physiology. Our CNS is constantly adapting based off the signals it receives, including during the experience of pain.

Chronic or persistent pain can occur as a result of danger signals “hijacking” the CNS, demanding more signalling capacity and more brain pathways, dominating other pathways that can mitigate the pain experience . The good news is that if the CNS is adaptable and has the capacity to turn up unhelpful signalling (upregulation), it has the capacity to relearn to turn down unhelpful signalling as well as turn up helpful signalling (downregulation).

From a mechanical standpoint, research shows that people with pelvic pain have dysfunction in their pelvic floor muscles, which are a group of muscles at the base of the pelvis. They control bowel and bladder function, contribute to sexual function, and play a role in supporting and controlling all types of movements as part of your deep core. Thus, pelvic health physiotherapy can help chronic or persistent pelvic pain by: 

• Reducing high pelvic floor muscle tone (or tightness) 
• Guiding you in improving the ability to relax or lengthen the muscle through its full range of motion
• Assessing for and address any muscle or connective tissue imbalances through your torso, pelvis, and hips that may contribute to unhelpful movement strategies

From a holistic standpoint, research shows factors that contribute to CNS upregulation include stress, trauma, shame, hopelessness, anxiety, depression, fear, low positive affect, insomnia, and loneliness. Contextual factors that contribute to downregulation are self-compassion, breathing techniques, sleep hygiene, social support and empathy, non-threatening exercise, nutrition, high positive affect (including hopefulness), and meditation or mindfulness. Thus, pelvic floor physiotherapy can further help chronic or persistent pelvic pain by:

• Assessing the state of your nervous system and providing tools and guidance that work towards downregulation as appropriate
• Provide guidance for other factors related to optimal CNS function including stress management, sleep hygiene, mood, fear of movement, as well as diet and fluid intake
• Provide accurate and dependable resources for further information, education, and support 

All in all, any experience of pain is disruptive and difficult, especially the experience of chronic or persistent pelvic pain. Fortunately, there is help at all levels – physical, neurological, psychological, emotional, and mental.

We at The Mama’s Physio would feel privileged to journey with you and help you in your experience of pelvic pain.

By Sophia McLean – PT, DPT

Sources:

Ahangari, Alebtekin. “Prevalence of chronic pelvic pain among women: an updated review” Pain Physician 17 no. 2 (2014).

Doiron, Christopher R and J. Curtis Nickel. “Management of chronic prostatitis/chronic pelvic pain syndrome” Canadian Urological Association Journal 12 no 6 (2018), S161-163.

Goldberg, DS and SJ McGee. “Pain as a global public health priority” BMC Public Health 11 (2011).

Loving, Sys, T. Thomsen, P. Jaszczak, and J Nordling. “Pelvic floor muscle dysfunctions are prevalent in female chronic pelvic pain: a cross-sectional population-based study” European Journal of Pain 18 no. 9  (2014).

Moseley, G. Lorimer and David Butler, “Fifteen Years of Explaining Pain: The Past, Present, and Future” The Journal of Pain 16 no. 9 (2015): 807-13.

Patterson, Debbie. “Key Concepts in Pain Science” (2017). 

Vandyken, Carolyn, and Nelly Faghani. “Level 2/3 Female and Male Pelvic Pain: Clinical Skills for Treating Pain.” Vaughan, Ontario, January 10-13, 2019.