1 Introduction to Pelvic Pain

As clinicians treating patients suffering from pelvic pain, and chronic maladies alike, we are in a unique position to offer relief and restoration of comfort and function. Our patients come to us often with the most private concerns and histories. It is imperative that we always maintain a professionally strict level of respect and privacy, knowing that these patients have often been labeled and mischaracterized by other medical practitioners and loved ones alike.

It is the intention of this text to provide an accurate, repeatable, and reliable means of deducing the cause of patients’ pain, and the activities that perpetuate their dysfunction. ¹ , ² Multiple structures must be considered, and their interplay can’t be minimized. This patient population is complex, and their symptoms often do not follow a traditional pattern of linear healing; their clinical presentation is frequently confounding. This patient population will often experience a sinusoidal healing pattern, where the ebb and flow of symptoms to the uninformed are random and unpredictable. With a greater understanding of the body’s natural reaction to pain, stress, emotions, and hormonal fluctuations, our patients’ healing process will be better understood.

The content of this textbook focuses on pain, and in particular pelvic pain. The concepts, however, are applicable to all chronic, musculoskeletal, and urogynecologic ailments alike. This textbook discusses the evaluation and treatment of the pelvis and local genital anatomy. As such, it is imperative that the clinician maintain strict professional conduct to ensure patient comfort and modesty. When possible, drape the patient. Visualize only that which requires visualization, and only for so long as it requires visualization. Once the clinician has concluded the visual inspection of the genitals, there is often no reason to maintain an in-line view of the pelvis. Very often, the clinician will have the opportunity to sit aside the plinth, with the patient draped from the abdomen to foot, from where the clinician can conduct internal evaluation and subsequent treatments.

In maintaining and maximizing patient comfort and modesty, it is suggested that the clinician request permission each and every time visualization or contact to the genitals is to be introduced. This allows the patient to maintain control over their body, and helps ease any anxiety.

Chronic pelvic pain is defined as nonmenstrual pain localized to the pelvis that is severe enough to cause functional disability, requires medical attention, and lasts for 3 or more months. It is a confounding ³ condition or set of conditions to the patient and physicians alike where a “negative laparoscopic examination is not synonymous with the absence of disease and does not rule out physical basis for the pain the woman is experiencing.” ⁴ Pelvic pain may be due to visceral, somatic, or neurological disorders. Visceral disorders can initiate in the genitourinary or gastrointestinal organs. Pelvic pain can also originate in the peripheral or central nervous system. All visceral structures found within the pelvis can give rise to pelvic pain, affecting the bladder, terminal ureters, urethra, ovaries, fallopian tubes, uterus, vagina, sigmoid colon, rectum, and associated vasculature and lymphatic structures. Examples of visceral pathology are endometriosis, pelvic adhesions, ovarian masses, pelvic inflammatory disease, and irritable bowel disease. The somatic structures (fascia, musculature, ligaments, and bone) can also initiate pelvic pain, and they can refer pain to their respective dermatome. Due to the complicated nature of pelvic neuroanatomy, convergence of symptoms and cross-system expression of pain, in addition to the phenomena of central centralization and peripheralization of symptoms, have further confounded both patients and clinicians. ⁵ , ⁶ , ⁷

Further complicating the patients’ presentation is the frequent accompaniment of an overbearing psychosocial component, which through perseveration and activation of the periaqueductal gray and the rostroventricular mater has the capacity to expand the region of pain and increase the degree of pain experienced. Those suffering with pelvic pain undergo a barrage of psychological, sexual, and interpersonal disturbances that have been found to diminish their quality of life and will often interfere with their ability to seek a healthy, intimate relationship and may be an initiator of depression. ⁸ , ⁹ , ¹⁰ , ¹¹

Chronic pelvic pain is a frustrating condition for patients and clinicians alike ⁵ , ⁶ , ⁷ , ¹² , ¹³ and accounts for 10 to 15% of all gynecologic referrals, 25 to 35% of all laparoscopies, and 10 to 15% of all hysterectomies. ⁴ Zondervan and colleagues state that 33% of all women will experience pelvic pain in their lifetime ¹⁴ , ¹⁵ and 15 to 20% of the female population age 18 to 29 years will suffer from dyspareunia, ⁸ whereas Sobhgol et al found the incident rate to be 54.5%. ¹⁶ , ¹⁷ Chronic pelvic pain, as a debilitating condition, is approaching the level of significance equivalent to that of lower back pain with regard to the interruption of work days, with 3-month prevalence in 24% of those suffering. ⁶ , ⁸ , ⁹ The prevalence of chronic pelvic pain among 18- to 50-year-old women is similar to that for asthma and migraine headaches. ⁴

Complicating the evaluation of a patient with pelvic pain is the nature of the involved anatomy. Often too embarrassed to discuss their pain with a medical provider, those who suffer will often attempt to self-medicate and neglect their painful condition(s) for many years. ¹⁸ , ¹⁹

Further confounding the medical community and complicating the formation of an accurate diagnosis and subsequent management strategy of the patient with pelvic pain is the terminology that is commonly used by the medical profession. Terms such as vulvodynia, vaginissimus, levator ani syndrome, and others are simply references to symptoms. These terms are as generalized as “sciatica.” They do not provide the clinician or patient an indication of the origin of the symptoms or offer a direction as to possible treatment strategies. ¹ , ²

Physical therapy is noted as an “integral” component of a multidisciplinary approach to the treatment of pelvic pain and associated sexual dysfunctions, as musculoskeletal factors are recognized as significant contributors to the initiation and propagation of pelvic pain conditions. ²⁰ , ²¹ A review of the current treatment literature reveals a reliance on palliative treatments that focus on the alleviation of muscle spasms through stretching (dilation therapy), massage (trigger point, Thiele’s, and other), meditative/conscious relaxation (biofeedback), or surgical management (labiaectomy or pudendal nerve decompression) without consideration of the cause of the muscle spasms, nerve entrapment, or fascial restrictions.

Of interest to the clinician, and the purpose of this discussion, is the provision of a means of understanding the interrelationships of the neurological, visceral, and somatic structures and their interactions when considering the initiation and propagation of pain.

The following discussion takes into consideration the multiple possible origins of pelvic muscle spasms, hyperalgesia, and allodynia through a differential diagnostic approach that integrates the concepts of symptom reproduction, symptom elimination, embryological derivation, and neurological interactions into a model that will allow the clinician to have the opportunity to accurately determine the origin of a patient’s pain and, more importantly, how to accurately and effectively eliminate the pain. Direct treatment options that consider the role of cognitive behavioral management, postural corrective exercises and postural awareness management, spinal segmental mobility and facilitation (central and peripheral sensitization), in conjunction with fascial, ligamentous, dural mobility, and referred pain patterns, are presented in a fashion that is efficient, effective, and self-manageable. This can be accomplished only through the thorough understanding of the local boney, neural, fascial, and muscular systems and the interrelationships each has with the other, the various referral patterns of each, and how to determine the origin of pain propagation to most effectively eliminate the patient’s suffering.

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