Chronic Pelvic Pain
The anatomic pelvis consists of all 3 dimensional aspects of the male and female body between the umbilicus (belly button) and the mid thigh. It can be looked at as the "busiest" part of the human body because: 1. so much "function" goes on there: urinary bladder - lower bowel - reproductive and sexual functioning; and 2: so much of our structural activities center on the pelvic "core" regarding a great deal of muscles, nerves and ligaments. Chronic Pelvic Pain is a complex of painful pelvic symptoms including, but not limited to: 1) urinary frequency and urgency associated with pain, 2) irritable bowel issues, 3) lower abdominal bloating and pressure, 4) vaginal itching, burning, and sensitivity, 5) vulvar pain, burning, or itching, 6) sexual pain (entrance, during, and/or after in females, and erectile and ejaculatory in males), and 7) lower back and/or lower abdominal pains. Due to "cross-talk" of the nerves, (one stucture communicating with any or all of the others) various diagnoses are often connected to one another. For example, if there is a history of painful periods, the nerve activity could possibly lead to irritability around the lower bowel or bladder and vice versa. The following diagnoses and treatments help describe the most common problems we find in our typical patient and the multiple ways in which we treat them.
When someone is suffering from persistent or intermittent pain in the pelvic region for more than 3-6 months, the primary diagnosis is pain itself.
What is pain?
Pain is a warning system in the body. There are two types of pain: acute pain and chronic pain. We need acute pain to survive. If we step on a nail or burn our skin, we need to know that something is wrong so we can seek proper medical attention. When this happens, a signal is sent up the spine through the nervous system and into the brain where it is then evaluated by different parts of the brain. These different parts of the brain include the motor cortex (what you are doing in that moment) and the sensory cortex (what part of the body the signal is coming from). The signal also travels to the parts of the brain where thoughts, memories, and knowledge of our bodies are stored. Therefore, the brain is looking at our “neuro-matrix”, which is the accumulation of our past experiences (those we remember and those we do not - from birth to death), beliefs and thoughts we focus on throughout the day at any given moment, our emotional state, and our overall understanding and perception of the situation. The brain decides what is painful or not, depending on our brain’s perception and understanding of the situation. This process happens in micro-seconds, without our conscious control. This process can decrease or increase our experience of pain, depending on the perceived “danger” level of those signals. The more we understand what is going on in the body, how chronic pain or “danger signals” are processed in the body and mind, and the more “tools” we have to temper these signals and how they are reacted to in the brain, the less pain we are likely to experience.
“Chronic pain” is the result of our brain interpreting signals through our nervous system often long after the actual tissue damage has healed. Triggers of these signals can include one or all of the following: functional systems (bladder, bowel, or uterus/prostate), structural systems (muscles and ligaments in spasm, nerves firing, tingling, burning, itching of surface tissues), all of which add up in our memories, emotions, and thoughts. When the trigger is a memory, emotion, or thought (conscious or unconscious), it lights up the neuro-matrix connected to our sensory cortex. This phenomenon is similar to “phantom limb syndrome” where the individual experiences pain in a part of the body that is no longer there.
Our Body’s “Fight or Flight” Response & Post-Traumatic Stress Disorder (PTSD)
Fear triggers our brain to produce chemicals that make it more difficult for us to relax. In fact, mere emotions and thoughts (both conscious and unconscious) can trigger this chemical reaction placing us in the “fight or flight” response. When the body goes into this mode, it is an evolutionary protective response, as if there was a dangerous lion in the room. This “fight or flight” response causes muscle spasm (to give you strength to fight or run away), increased heart rate, dilated pupils, shallow breathing, and other autonomic nervous system responses, such as dry mouth, slower immune response, and inhibited digestion. The brain then seeks more feedback from the body to know more about what’s happening, increasing the sensitivity in the nervous system. Our brain “turns the volume up” on our nervous system. Regretfully, this means that our physical sensations increase and consequently we feel more pain. In other words, when it comes to pain, the more we fear it, the more we feel it.
Post-Traumatic Stress Disorder (PTSD) is when our body stays in this "fight or flight" mode due to traumas in our life. These traumas can consist of physical, emotional, psychological, or social traumas. Sometimes, we experience a physical trauma we don't mind too much, such as injuries resulting from athletic activity or play. We can also experience trauma that we do not want, such as car accidents, abuse, and falls. Our bodies can also experience trauma from persistent stress in our life stemming from work, family, finances, and other life events. PTSD adds to chronic pain because it keeps our body in the "fight or flight" mode, which maintains the nervous system to operate on a "high volume" level of functioning. Consequently, smaller stimulus can equal greater amounts of pain.
Chronic pain can be treated in many ways. The most effective treatment is three-fold: 1) treat the pain with effective medications that help "turn the volume down" on our nervous system; 2) treat the visceral triggers of the pain (organ systems such as the bladder, bowel, or reproductive organs when they are suffering from dysfunctional disorders); 3) treat the muscle spasms that inevitably occur when our bodies react to painful stimuli.
Furthermore, focused training redirecting the mind can help our brains avoid the particular triggers in the neuro-matrix as much as possible. Mindfulness-based stress reduction (MBSR) and diaphragmatic breathing techniques are proven tools to help guide us through this process.
Trigger Point Injections
Trigger point injections are a procedure for treating pain. They are used to treat painful areas that contain trigger points, or knots of muscle that form when muscles do not relax. A needle containing a local anesthetic is inserted into the trigger point to make it inactive and therefore alleviate the pain. The procedure takes just a few minutes, is very safe, and has minimal side effects. Trigger point injections not only relieve pain, but also loosen the muscles which are causing the pain, therefore enhancing the help that can be achieved with specialized pelvic floor physical therapy.
Pelvic Floor Dysfunction
When part of our body is injured or traumatized, the muscles around that area spasm as a protective mechanism. If there is injury or trauma in the pelvic region due to accidents, injury, surgeries, trauma during the birthing process, functional disorders among organ systems, etc., the muscles within the pelvic floor region spasm. Furthermore, if our body remains in the "fight or flight" mode for a long period of time, either due to continuing visceral triggers or outside stress, the muscles can stay in spasm for longer than necessary. When the muscles stay in spasm for a long period of time, they become exhausted, weak, and tender to the touch.
The pelvic floor muscles look like a basket of muscles, through which the urethra, vagina, and rectum pass. If these muscles are in spasm, it is more difficult for anything to pass out of the body, such as urine or bowels, and it is more difficult for anything to enter the body, such as a tampon, GYN speculum, or penetrative intercourse. It is also important to remember that our muscles are connected by a web of nerves. So if one muscle begins to spasm, this can cause a domino effect on other surrounding muscles and ligaments.
One of the largest muscles in our "core" is the psoas muscle, which extends from the hip joints all the way up past the diaphragm on each side of the spine, in front of the back muscles and behind the abdominal wall. The psoas muscle is thickest deep in the pelvic floor region. If this muscle goes into spasm, it can feel like a "charlie horse" deep inside the abdomen and can reach through to the lower back. We hear many women tell us stories of when they go to the ER bent over in pain and either leave without a diagnosis or are diagnosed with a "possible" ovarian cyst, adhesions, ovulatory pain, or even labelled with an STD. Often, however, there is a significant chance that their pain was secondary to these main core muscles being in major spasm.
Treatment for pelvic floor dysfunction is treated best by specialized physical therapy of the pelvic floor. Not all physical therapists are trained in the pelvic floor so it is important that you find someone who has received extra training in this area. We have a long list of pelvic floor physical therapists in many different localities. Please visit our Independent Providers tab of this website for local information or contact us for further assistance in finding someone in your area. Trigger point injections in the pelvic region as well as localized peripheral nerve blocks and Botox are used in our practice and also certain compounded formulations that can be used topically or as vaginal or rectal suppositories as further aids in reducing pelvic floor clenching. Couples are also appropriately taught how to properly use vaginal dilators to help in this process.
PGAD is a pain disorder. PGAD is NOT a sexual disorder.
PGAD is a neuropathy, a condition that arises from traumas as well as dysfunctions of the body that cause nerves to “fire off” when they should not. When nerves are hyper-sensitive and fire off around the clitoris WITHOUT any sexual arousal or sexual thoughts, a woman feels a variety of sensations that may be linked to pleasurable clitoral (genital) stimulation but very quickly result in painful spasmodic contractions of the pelvic floor muscles and ligaments that mimic spasmodic orgasmic activity – except there is no pleasure and only a variety of different types of pain, including burning, stabbing, cramping, and worse.
Millions of women have various aspects of CPP/CAPPS, but only a small percentage of these have PGAD. In my opinion, as I answered above, all women with PGAD have pudendal neuralgia, and/or pelvic floor dysfunction (chronically tight or “hypertonic” pelvic floor muscles), and most of the women I have seen with PGAD also have combinations of bladder, bowel, and/or reproductive organ dysfunctions. An orgasmic response in these women with PGAD can occur independently of sexual activity. When these patients try to be sexually active, this too “triggers” off painful orgasmic responses.
Obviously when this spontaneously occurs in the daily life of a woman at work or in school or just when walking around, there is a tremendous embarrassment, shame, and anxiety, which ultimately increases depression, anger, frustration, and many other upsetting emotions.
There are five main root issues that can result in a woman developing PGAD. They include:
- Organ and structural “triggers” of the urinary bladder, such as Painful Bladder Syndrome/Interstitial Cystitis (PBS/IC);
- Lower bowel issues such as Irritable Bowel Syndrome (IBS) and Inflammatory Bowel (IBD);
- Gynecologic disorders such as endometriosis, vulvodynia, and vestibulitis;
- Previous accidental injuries, surgeries and childbirth; and
- Sports injuries to the lower genital structures.
PGAD is treated like other peripheral neuropathies and chronic pelvic pain disorders. Find and treat all “triggers” which may be pudendal neuralgia, IC/PBS and others, treat the pain adequately and always find a qualified pelvic floor physical therapist for the inevitable pelvic floor dysfunction or clenching.
There are medications such as anti-depressants, anti-seizure medications, beta-blockers, and even peripheral nerve blocks on the pudendal nerve that I have seen to be quite effective. Also, because of the secondary anxiety and depression, it is very helpful to utilize many different types of mind/body relaxation techniques. The more we learn about chronic pain in general, the better the research will be towards treating all of the genital pain syndromes.
Vulvodynia & Vulvar Vestibulitis
Vulvodynia is classified as chronic vulvar pain or discomfort, including burning, stinging, irritation or rawness of the female genitalia. The word vulvodynia actually means painful vulva. This condition can severely impact the quality of life for affected women and may prohibit participation in sexual activity, physical exercise, social activities, and even just sitting without pain. However, this condition is believed to be underreported because of its lack of visible signs, and often a woman's embarrassment and lack of hope in finding care for her intimate condition delays treatment Also, the majority of ob/gyns, urologists, and general doctors do not have specific training, knowledge, or even interest in providing care for women with intimate pain. And as many as one in six women may be affected by vulvodynia at some point in their lives!
Vulvodynia does not have one set cause, but several factors can contribute to the development of chronic vulvar pain. A history of recurring vaginitis, as well as allergies or injury can cause this condition. Various sporting and even dance injuries or repetitive physical stress in youthful girls and young women such as straddle and coccygeal traumas to the pudendal nerves and other nerve endings in the lower genital region may have contributed to the development of vulvar pain. Some women can point to a particular event associated with the beginning of their pain, others cannot. Some women may in fact have a form of vulvodynia from birth. Often other organs in the pelvic region are involved in the pain process, especially the bladder and bowels. There are 2 major subtypes of vulvodynia: vulvar vestibular pain and generalized vulvodynia. Several less common but highly devastating subsets include clitoral pain/sensitivity and Persistent Genital Arousal Disorder(PGAD). Our program assesses, educates about, and treats all of these conditions.
Vulvar vestibulitis syndrome, or vestibulodynia, is by far the most common reason for entrance discomfort or pain in reproductive aged women. The vestibule (or entrance way) of the vaginal opening is the narrow strip of skin that lied between the outside skin of the genital area and the vaginal lining. Vestibular pain usually only occurs with touch or pressure to the area. Burning sensations are the most common symptom, but it is not uncommon for many women to describe "severe dryness", stabbing pain, "sandpaper like sensations" and worse.
Dermatoses, caused by dermatologic conditions such as exczema around the labial folds, perineum, and per-rectal areas are also common in many of the young women we see with vulvar symptoms. These conditions are often not diagnosed early, especially in younger women, and commonly are treated unsuccessfully as recurrent "yeast" and other types of vaginal and vulvar infections. The names of these skin problems are Lichen Simplex, Lichen Sclerosis, and quite uncommonly Lichen Planus. They are all felt to be auto-immune type skin disorders and are NOT STDs nor are they bacterial or fungal infections. They all can add itching, burning, and other uncomfortable symptoms to the lower genital tract and need to be diagnosed accurately and treated correctly.
Treatment for vulvar pain disorders are managed very successfully in our program. Through education, appropriate diagnosis, and multiple modalities of treatments, we usually see progress at different paces, depending on the type of problem, how long it has been untreated or treated for the wrong issues. Usually combinations of topical agents, central acting medications to decrease neural sensitivity, specific peripheral nerve blocks when indicated, and treating the "triggering" entity which commonly is either dysfunctions of either bladder or bowel or both. Pelvic floor physical therapy treats abnormal muscle and nerve function and allows patients to counteract the inevitable pelvic floor dysfunction which accompanies vulvar pain syndromes. Targeted nerve blocks may be inserted to calm the nerves in the pelvic area. Many oral medications also help soothe the injured nerves. BOTOX® injections can help reduce muscle spasms. Other treatments include the discontinuation of irritants, including over-the-counter feminine products such as perfumed bubble baths, soaps, sprays, douches, and laundry detergents that can irritate the vulvar tissue.
The pudendal nerves arise from fibers of the sacral nerve roots in the lower back beneath the sacrum or "tailbone". These nerves course through the muscles and ligaments of the pelvic floor and buttocks. They are responsible for sensation and muscle function in the pelvic floor, vulva and clitoris, rectum, base of the bladder, and the lower outer third of the vagina. In males the pudendal nerves also innervate the perineum and portions of the scrotum and penis. They relay pain messages to the spinal cord and to the brain. Pudendal nerve pain (neuralgia) may occur when the nerve is injured, inflamed, compressed, restricted, or "trapped". This can be caused by inappropriate pelvic floor muscle spasms, recurrent microtrauma from certain repetitive flexion exercises, or tendinous or bony abnormalities around the course of the pudendal nerve. (Biker's Syndrome in long distance bikers is a common example of pudendal neuralgia. Over time, the nerve malfunctions, developing abnormal fibers and producing local chemicals, which send pain signals described as burning, stinging, itching, crushing, aching, or numbness, to the level of the brain. Neuropathy, a more complicated nerve disorder, may also develop with chronic cases. In cases of pudendal neuralgia the vulvar, penile or perineal and peri-rectal tissue may either appear only mildly abnormal or completely normal.
A pudendal nerve block injection is a procedure by which medications that inhibit pain and inflammation are injected into a space around a nerve, thereby preventing pain messages that travel along the nerve pathway from reaching the brain. Pudendal nerve blocks are most frequently used to provide anesthesia for pain releif in patients with chronic vulvar pain and/or itching that does not respond to topical or oral medications. It may be diagnostic, in that if the pain is temporarily relieved, then the pudendal nerve is held responsible for that pain. Usually a series of pudendal nerve block injections, combined with pelvic floor muscle physical therapy, is used to treat the persistent pudendal nerve pain. We have been successfully lowering the levels of pain in both women and now men with this approach for a number of years in our pelvic pain program.
The easiest approach to the pudendal nerve is outside the vaginal opening, or just beneath the scrotum near the "sit bones" that are landmarks easily felt by an experienced pelvic specialist. These blocks are not only effective in lowering the sensitivity of the nerves but are extremely safe and in the past were used routinely in childbirth to numb the "saddle area" just before delivering the newborn.
If the pudendal nerve is the causative structure producing vulvar pain then the block will be quite effective and provide immediate relief. At a minimum there will be partial relief, depending on what percentage of pain is produced by the tissues innervated by the pudendal nerve or damage to the nerve itself. Pain relief can vary dramatically from person to person. In some advanced cases, in which the pain has become neuropathic, pain may increase briefly following the procedure before more lasting improvement is seen. More "permanent" attempts to correct a small but difficult subset of these patients may include referral for "pudendal release surgery". Only a small number of surgeons are trained in the US to do such surgery and Dr. Echenberg with his networking in pelvic pain organizations and resources has a working relationship with selected physicians if needed (both for pudendal neuralgia and other peripheral neuralgias).
Interstitial Cystitis (IC) or Painful Bladder Syndrome (PBS)
IC consists of pelvic pain, pressure, or discomfort related to the bladder and associated with a persistent urge to void. It occurs in the absence of urinary tract infection or other pathology. As many as 85% of women who seek care for chronic pelvic pain have IC/PBS instead of, or in addition to, a gynecologic diagnosis. IC/PBS occurs when the protective lining of the bladder thins, which then exposes the soft tissue of the bladder to the acidic nature of the urine. This causes an inflammatory response, releasing hystamine and sending signals through the nerves to the brain that are similar to the symptoms of a full bladder. Over time, the bladder becomes increasingly sensitive and can cause pain during deeper penetration. Anatomically, you can not have intercourse without bumping against the bladder. Therefore, if the bladder is inflamed and sensitive (as well as causing reactive muscular spasms - pelvic floor dysfunction), deeper penetration will be painful for a woman with this condition.
Oral medications, including Elmiron and anti-histamines, can help decrease the symptoms of IC. Elmiron helps reline the protective layer in the bladder, a process which can take 3-5 months to take effect. Anti-histamines help decrease inflammation. Other medications that help "turn the dial down" on the nervous system will also help IC.
Bladder instillations are a treatment method used to relieve painful bladder symptoms. During this procedure, the bladder is filled with a soothing therapeutic solution and held for a certain amount of time. The procedures known as bladder instillations are usually given in 9 weekly installments and symptoms tend to mitigate as the process continues. Bladder instillation is a simple procedure and side effects are minimal. Many of our patients see results within 3-4 weeks of starting these treatments, which can help jump-start the recovery process while waiting for Elmiron to reline the bladder.
Increasing water intake to 40-50 oz per day helps to dilute the urine, making it less acidic. Following a low-acid diet and taking Prelief prior to each meal will also help decrease the acidic nature of the urine.
Irritable Bowel Syndrome (IBS)
Irritable Bowel Syndrome (IBS) is a functional disorder of the bowel, which can cause the bowel to be overactive (diarrhea dominant) or underactive (constipation dominant). IBS can cause cramping and bloating as well as pain around the anal opening. IBS can be caused by the nervous system being "turned up" due to stress, trauma, anxiety, and other autonomic nervous system dysfunctions.
If the IBS is underactive, stool softeners such as Collace, Miralax and Benefiber are recommended on a daily basis or in some combination that works for that individual. If the IBS is overactive, we recommend Bental or Hyomax to calm the bowels. Pelvic floor physical therapy can also help with the muscle cramping around the lower bowels and rectum (pelvic floor dysfunction).
In our experience vulvar vestibulodynia is commonly associated with either or both IC/PBS or IBS.