THE NIGHTMARE OF PELVIC PAIN
Pelvic pain is a debilitating condition that negatively impacts your quality of life. 2% of the female population suffers from chronic pelvic pain symptoms, the causes of which are so varied that finding the root of the issue is not easy. This site is focused on pelvic floor dysfunction, so for this page, we will focus specifically on non-relaxing pelvic floor dysfunction (NR-PFD) which is a condition that gets even less attention than pelvic floor dysfunction.
If the cause of your pelvic pain is one of the conditions listed below, click on the link to be brought to a support page that focuses specifically on that pelvic pain condition:
Endometriosis – Almost 20% of women who undergo an investigation for pelvic pain are diagnosed with Endometriosis, which is a debilitating condition in which tissue, that normally lines the womb, grows outside the uterus (commonly on fallopian tubes or ovaries). It can cause adhesions or scar tissue. Symptoms include painful periods (dysmenorrhea), painful intercourse and excessive bleeding (Menorrhagia).
Interstitial Cystitis (IC) – also known as painful bladder. This is a chronic condition where cystitis is present almost all the time. The symptoms of cystitis include a strong and persistent urge to pee, burning sensation when urinating and only passing a small amount at a time. Symptoms can also include blood in the urine, pelvic pain and sometimes a fever.
Irritable Bowel Syndrome (IBS) – this condition is a chronic condition of the digestive system. Typical symptoms are cramps, bloating, diarrhoea and/or constipation.
Menorrhagia (heavy periods) – this condition is not always accompanied by pelvic pain, however, it can be a cause. with Menorrhagia, periods are very heavy and tend to last longer than a week. It is normal to have to wake during the night to change sanitary protection.
Chronic pelvic pain can also have many other causes. You can read more on the Pelvic Pain Support Network.
WHAT IS NON-RELAXING PELVIC FLOOR DYSFUNCTION (NR-PFD)?
The pelvic floor consists of three layers of muscle that create a base for the pelvic bowl in which the pelvic organs rest. NR-PFD is a condition where some of the pelvic floor muscles remain in a hypertonic state for extended periods. Sometimes the condition can be given other names, such as hypertonic PFD, or levator ani syndrome. This condition can impact urination (peeing), sexual function and defecation (pooing). The pain can manifest in many different ways and can radiate to other areas. Pain can be constant or intermittent (for example, cramping in pelvic floor muscles following orgasm). The pelvic floor can have some muscles that are hypertonic (excessively tense) and others that are hypotrophic (lax/weak).
WHAT CAUSES THE NON-RELAXING PELVIC FLOOR DYSFUNCTION?
There is no definitive answer as this condition has not gained much attention from the research community. It can manifest at any time, even after you have given birth. Sometimes scarring from birth, especially following perineal repairs, can cause hypertonicity. The mechanism is not completely understood. With non-relaxing pelvic floor dysfunction, it can be painful to sit. Pelvic pain brings with it fear, which activates the “fight of flight” response, which can further exacerbate the situation.
I HAVE NR-PFD, DOES THAT MAKE MY PELVIC FLOOR MUSCLES STRONG?
No, a hypertonic muscle is not necessarily a strong one. Muscles that are overly tense have less blood-flow which, over time, will result in atrophy (muscle breakdown). A healthy pelvic floor is one that can both contract and relax and that maintains a balanced amount of tone under normal conditions. Depending on which muscles are hypertonic, urination can be affected. Non-relaxing pelvic floor dysfunction can sometimes exist with Overactive Bladder (OAB) which can be accompanied with urge incontinence in some cases.
CAN THE LOCATION OF MY PELVIC PAIN TELL ME ANYTHING?
According to a 2012 study, referral patterns for pelvic pain from pelvic floor muscles are as follows:
|Pelvic Floor Muscle||Referral Pattern||Potential Symptom|
|Bulbospongosus||Perineal pain or urogenital pain||Painful sex, pain with orgasm or clitoral pain|
|Ischiocavernosus||Perineal pain or urogenital pain||Painful sex, pain with orgasm or clitoral pain|
|Superficial transverse perineal||None documented||Painful sex|
|Anal sphincter||Pain on posterior pelvic floor, rectum/anus or pubic pain||Burning or tingling in anus/rectum. Pain before, during or after pooping|
|Pubococcygeus / Puborectalis||Low-belly pain, bladder pain or pain in perineum||Increased urgency and/or frequency. Painful sex or painful urination after sex|
|Iliococcygeus||Pain towards the sacrum or deep in the vagina, rectum or perineum||Pain before, during or after pooping. Painful sex, particularly with thrusting|
|Coccygeous||Pain towards the sacrum or buttock pain||Pain on sitting. Pain during pooping. Intestinal fullness and anal pressure/pain|
|Obturator internus||Pain in anus, coccyx, vulva or vagina. Pain on back of thighs||Generalisd pelvic pain, often with burning or aching|
|Piriformis||Pain in sacrum, pain on one side of buttock||Buttock or leg pain. Sometimes sciatic pain|
HOW IS NR-PFD TREATED?
The primary treatment for pelvic pain caused by non-relaxing pelvic floor is Physical therapy. Your pelvic health physiotherapist will make a complete assessment of your pelvic floor identifying the muscles that are hypertonic. Gentle to moderate pressure is applied to release the tension. Pelvic health physio’s are acutely aware of the pain and work with you on learning to relax while ensuring they stay within the boundaries of your pain tolerance. It is important to find a physio that you trust and relate to as this will make it easier for you to relax for the treatment.
As well as in-clinic treatments, your therapist may give you some massage techniques to practice at home. A massage wand is often given for this treatment as it can be easier to get to the tight spots with a wand than with your fingers.
SHOULD I STILL DO MY KEGELS WHEN I HAVE NR-PFD?
No, Pelvic floor exercises can aggravate non-relaxing pelvic floor dysfunction and heighten your pelvic pain symptoms. Your physiotherapist will help you to restore balance to your pelvic floor and will instruct you to do pelvic floor exercises if and when needed. It is more important that you learn to relax the pelvic floor muscles.
IS THERE ANYTHING ELSE I CAN DO TO HELP ALLEVIATE MY SYMPTOMS?
Yes, physiotherapy is typically localised to the muscles of your pelvic floor, however, your pelvic floor muscles do not work in isolation. Taking a whole body, whole life, whole mind approach will improve your chance of success.
If you are in pain daily, it is likely that you are holding tension in other muscle groups as well as your pelvic floor. Avoid doing things that can increase the level of tension in your muscles, opting for gentler exercises like walking versus pounding the pavements with running. If you are attending fitness classes, try to opt for those that have a more relaxing restorative focus.
Your posture and alignment can impact the stability of your pelvic floor and should be assessed as part of your rehabilitation. Your fascia (connective tissue) holds your posture. A 2008 study into chronic pelvic pain found that women who suffered from chronic pelvic pain were more likely to have asymmetrical iliac crests (61%). They also found that 78% were unable to maintain a relaxed pelvic floor for more than 10 seconds. Pain is not always related to your muscles. Your nerves and blood vessels which run thorough your network of connective tissue (fascia) can also play a role. 23% of those with chronic pelvic pain suffer from myofascial pain. Working with a specialist who focuses on myofascial release, structural integration or Rolfing can help to relieve myofascial tension while dramatically improving your posture and alignment. This, in turn, can have positive effects on the balance within your pelvis. You can find a local specialist in our specialist directory.
The connection between weight/BMI and NR-PFD is as of yet unknown, however, keeping your BMI within the healthy range is beneficial to your general health which gives you one less thing to worry about.
With NR-PFD, the mind connection is a critical. Any condition involving pain increases stress with the body can spending more time with the “fight or flight response active (parasympathetic dominance). Finding ways to reduce stress and calm the nervous system can help to relax the body, which in turn can help with relaxing the muscles of your pelvic floor. Meditation is a really good tool to help with de-stressing and relaxing.
The book details a number of different meditations and relaxation techniques to help lessen the symptoms of NR-PFD. There are also some meditations on conquering your fear. Fear plays a large part in NR-PFD as pain in the vaginal area can make you afraid to poo, afraid to have sex, afraid to touch yourself or to be touched. Conquering fear is a very important aspect of conquering NR-PFD. Once you have conquered fear, it is easier to let go. You can read about how letting go contributes to orgasm on the sexual dysfunction page. The meditations will be available for download once the book has been released.
Sharing is caring, and having the support of community, friends and relatives can help a lot in times of suffering. When you are dealing with NR-PFD, you should utilise your support networks. Join a weekly class, such as a yin yoga, restorative yoga or meditation class to help reduce your stress levels and encourage relaxation.
By far the best lifestyle change for NR-PFD is to destress. Whatever you need to do to reduce your stress levels, you should do it. It can be helpful to find something new to occupy your mind, like a new hobby or interest that involves your hands (art, crafts, cooking etc). Walking in nature can be very calming. Do what it is that takes to bring you to your peaceful place.
MEASURING YOUR PROGRESS
You should always start by establishing your baseline before beginning rehabilitation as this allows you to properly assess your progress. Your pelvic floor physiotherapist may perform biofeedback testing as well as ultrasound to directly see the function of your pelvic floor. The book has a simple system for establishing your baseline and assessing your progress.
There are numerous products available to manage the symptoms of incontinence from pads to pessaries. There are also devices to aide pelvic floor muscle training ranging from weights to electronic stimulation devices. Reviews of these products will be covered in our YouTube channel. If there is a specific product that you would like to see reviewed, just contact us and we will review. The images below link to the products on in your local amazon store.*
* I am an affiliate of amazon, iTunes and other affiliate services and may receive a small commission should you purchase through links on TheFlowerEmpowered.com
CONSERVATIVE TREATMENTS HAVE NOT WORKED FOR ME, WHAT NEXT?
You should give conservative treatments time to take effect. It takes time for physiotherapy to work, the amount of time is dependent on your own unique body. Consistency is key with any rehabilitation. Your pelvic floor physical therapist will refer you to a different type of specialist if needed.
WHAT OTHER TREATMENT OPTIONS DO I HAVE?
There aren’t many additional treatments for pelvic pain caused by non-relaxing pelvic floor dysfunction other than medication and botox injections, both of which come with side effects but can provide a lot of relief.
Medication is often the first thing we reach for when in pain. In the US, there is currently an opioid epidemic. Popping a pill is easy but it only masks the condition. Addressing the root cause of pain should be your goal. Your pelvic health physiotherapist can help with this. In the meantime, your doctor can advise on which medications to use for your type of pain, with the least chance of developing addiction.
There have been some very small studies into the efficacy of using Botox to treat pelvic pain. Botox works by blocking signals from the nerves to the muscles. These studies have shown to be effective with few adverse side effects. Long term studies are not available. Your pelvic health physiotherapist can advise if this procedure is right for you.