Pelvic Pain

Chronic pelvic pain is pain that occurs below the belly button and lasts for at least six months. It may or may not be associated with menstrual periods.

Chronic pelvic pain may be a symptom caused by one or more different conditions, but in many cases, is a chronic condition due to abnormal function of the nervous system (often called "neuropathic pain").

Causes:

- Gynaecologic causes e.g. endometriosis, uterine fibroids, pelvic inflammatory disease, and pelvic adhesive disease
- Irritable bowel syndrome
- Painful bladder
- Pelvic floor pain
- Abdominal myofascial pain
- Physical, sexual, or mental abuse

Pelvic floor physiotherapy focusses on the abdominal myofascial pain and the pelvic floor pain. The treatment consists of releasing the tightness, either by manual trigger point release, dry needling, fascia mobilisation, and/or pelvic girdle alignment, in the following muscles:

- Abdomen
- Vagina
- Hips
- Thighs
- Lower back

Vaginismus is the result of an involuntary vaginal muscle spasm, which makes any kind of vaginal penetration painful or impossible e.g. sexual intercourse, gynaecological examinations, and even tampon insertion.

The severity of vaginismus, as well as the pain during penetration (including sexual penetration), varies from woman to woman.

Factors contributing to vaginism:

- urinary tract infections
- vaginal yeast infections
- sexual abuse, rape, other sexual assault, or attempted sexual abuse or assault
- fear of pain associated with penetration, particularly the popular misconception of "breaking" the hymen upon the first attempt at penetration, or the idea that vaginal penetration will inevitably hurt the first time it occurs
- stress
- negative emotional reaction towards sexual stimulation, e.g. disgust both at a deliberate level and at a more implicit level
- strict conservative moral education, which also can elicit negative emotions

Persistent genital arousal disorder (PGAD) is a phenomenon, in which afflicted women experience spontaneous genital arousal, unresolved by orgasms and triggered by sexual or nonsexual stimuli, eliciting stress. Masturbation and orgasms offer little or no relief.

The primary symptom of PGAD is a series of ongoing and uncomfortable sensations in and around the genital tissues, including the clitoris, labia, vagina, perineum and anus.

These sensations can include wetness, itching, pressure, burning, pounding, pins and needles. It feels to the patient that they are about to experience an orgasm or they may experience waves of spontaneous orgasms. Episodes of intense arousal may occur several times a day for weeks, months, or even years.

However, these symptoms happen in the absence of sexual desire.

The condition can lead to psychological symptoms due to the persistent discomfort and impact on day-to-day living e.g. anxiety, depression, guilt and insomnia.

People with chronic, or incurable, persistent genital arousal disorder may eventually lose their notion of sexual pleasure, because the orgasm becomes associated with relief from pain rather than an enjoyable experience.

Causes can be:

- Central neurological changes e.g. brain lesion
- Peripheral neurological changes (e.g. pelvic nerve hypersensitivity or entrapment) vascular changes (e.g. pelvic congestion)
- Mechanical pressure against genital structures
- Medication-induced changes o Psychological changes (stress)
- Initiation or cessation of treatment with antidepressant medication and other mood stabilizers
- Onset of menopause
- Overactive bladder

Pudendal Neuralgia is a pelvic pain syndrome causing nerve-like pain in the areas where the pudendal nerve travels to. The pain can be described as sharp, shooting or burning pain in the territory of the nerve.

The pudendal nerve innervates the skin of the vulva, labia, and clitoris in women. It also innervates the perineum, anus, a portion of the urethra, part of the rectum and vagina, and the majority of the pelvic floor muscles. It has a vast distribution and when problems arise, people may experience pain in any of those areas and have issues with urinary, bowel, and/or sexual function.

Physiotherapy is an effective treatment option for this pelvic pain syndrome aiming for movement of the nerve without irritation.

Causes can be:

- Hypertonic muscles: Too tight pelvic floor muscles can cause compression along the course of the nerve and thus result in neural inflammation.

- Myofascial trigger points: Trigger points in the obturator internus muscles can cause the muscle to become hypertonic. In turn, this hypertonic muscle will compress the nerve.

- Connective tissue restrictions may irritate the dermatomal distribution of the pudendal nerve e.g. cannot tolerate wearing underwear. Tight connective tissue irritates the superficial nerve branches.

- Biomechanical/joint dysfunction: Sacroiliac joint dysfunction—The pudendal nerve runs out of the sacrum and through the sacroiliac joint ligaments. The space between those ligaments could be affected by a positional change of the joint, which in turn could compress the nerve. Changes in the mobility of the SI joint can also negatively impact the nerve at different locations along its course.

- Neural sensitivity and ischemia: Aggravating factors such as repetitive yeast or bacterial infections can sensitize the nerve. Visceral disease states can affect peripheral nerves and it is plausible that nerve irritation can irritate visceral structures.

- The pudendal nerve is rarely the sole driver of the symptoms but is rather one impairment of a myofascial syndrome comprised of many parts. This is one reason why interventions directed at the nerve alone, such as nerve blocks, often provide limited or no relief.