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The diagnosis of “Chronic Pelvic Pain” written on a physical therapy prescription has always caused the patient confusion and sometimes outright indignance. A typical reaction is, “This has to be a mistake! The doctor obviously over-reacted, why am I here? Is my condition that serious? “

One of the challenges of treating a patient with chronic pelvic pain (CPP) is patient education. What is CPP exactly? The Mayo Clinic defines CPP as “Pain in the area below your bellybutton and between your hips that lasts six months or longer.” That not a definition, it’s a huge umbrella term that encompasses many different symptoms and presentations. No two patients will have the same kind of CPP and each patient requires a unique treatment plan.

That kind of definition leads to utter confusion. I try to reign in the enormity of a potentially terrifying diagnosis and explain that

  1. Yes, it is a pain below your bellybutton and between your hips, front and back, that has been occurring for six months or longer. I explain that it can be anywhere in that region, and yes, it is a huge region. The painful area(s) can be plural instead of singular. Can it be a sharp rectal pain or a deep vaginal pain you can’t describe with words, tip of the penis pain, or horrible bladder pain? Yes and yes and yes. Can symptoms occur in different locations all at once? Yes!
  2. There is almost never one cause as to why there is pain. As time goes on, it may become difficult to pinpoint a specific event that started the pain. In an article in the Journal of Obstetrics & Gynecology (2014), it was stated that “Chronic pelvic pain can be a vexing problem for the patient and physician. Seldom is a single source or cause found.” Does the pain occur because the pelvic floor muscles are weak? Is it because of that skiing accident that pulled your hamstring? Is it the soap that you use?
  3. The opposite may also happen and pain starts from a specific benign event, like a PAP smear, a UTI, or fall that pulled the groin muscles a little too much. Perhaps even a prolonged sitting event like a 22 hour plane ride that was super uncomfortable and left you sore for days…and days…and so on.
  4. CPP doesn’t have to be excruciating. When symptoms are reproducible and frequent for greater than six months defines CPP. There are those that go years without seeking medical attention because it feels like “such a little thing”, therefore hesitate and put off going to the doctor. The consistency of the pain specifically related to a movement(s), postures, or positions for 6 months or more. This when the pain would be considered chronic.  These patients often say things like, “I have this pain when I walk…”, or “I have tailbone pain with I sit too long….), or, “I get this horrible testicular and penile pain when I climb stairs…” or, “I have this burning at the vaginal entrance with intercourse”. Etc, for the last 6 months or more.
  5. CPP may be the outcome of a disease such as Endometriosis, Interstitial cystitis, Vulvodynia, Pudendal Neuralgia, etc. These conditions may last months to years resulting in persistent pain sx.

But what makes this pain chronic? Why won’t it just go away like a papercut or a banged elbow? One explanation is an abnormal triggering of the sympathetic nervous system; the “flight or fight” response. As the pain continues in frequency, the body starts to anticipate the pain with a stressor, which can be almost anything, a movement, posture, sensation, or a touch. In time, the body learns to stay in this heightened state of “fight or flight, and continues to put the body into a painful state, which repeats the pain cycle.

As I listen to your history, I start putting the puzzle together, and try to identify the triggers as a team.  I prescribe different exercises and administer an assortment of manual soft tissue techniques to decrease the amount, frequency, and intensity of your pain.  In addition, I try to encourage your parasympathetic nervous system, the one that elicits calm and relaxation responses, to respond to a much greater degree.  This process may take time and patience, but improving your quality of life is worth it.

Written by Elain Borja-Jaffe, PT, DPT, CERT. MDT, WCS

Reference:

Steege, John, F., MD; Siedhoff, Matthew, T., MD, MSCR. Chronic Pelvic Pain.  Obstetrics & Gynecology: September 2014 – Volume 124 – Issue 3 – p 616-629

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