Historically, pelvic pain and dysfunction treatment has been compartmentalized into three outlets: the urethra and bladder are treated by urologists; the vagina and female organs are handled by gynecologists; and the colon and rectum are managed by gastroenterologists. Until the gradual integration of physical therapy treatment, the role of pelvic muscle dysfunction in pelvic pain took a back seat to the organs.

Incorporating rehabilitation clinicians into a pelvic dysfunction treatment team can be challenging. We're not used to working with the aforementioned medical specialties and they're not used to working with us. But this doesn't mean these clinical disciplines can't work together to provide optimal outcomes.

A body of knowledge supports the role of physical therapy to treat pelvic pain. We need to use this evidence to improve utilization and be accepted as integral members of the treatment team.

CAUSE AND EFFECT

Although some people present with specific pelvic issues, the pain can be diffuse and hard to localize. Understanding the musculoskeletal and nervous systems helps rehab clinicians assess and treat these patients.

Howard et al. postulates that pelvic floor pain arises from spasm or tension in the pelvic muscles (levator ani, coccygeus and piriformis) and referred pain in their attachments to the sacrum, coccyx, ischial tuberosities or pubic rami.¹Pelvic pain also presents as diffuse and may be reported in the anterior abdominal wall, below the umbilicus or in the spine from T10 or T12 to S5. These spinal levels represent nerve supply to the ovaries and testes, pelvic musculoskeletal structures and perineum.

Dysfunction may result primarily from the pelvic floor muscles (PFMs), occur secondary to visceral changes or be referred from other pelvic somatic structures.²As a result, you must create a treatment plan that encompasses broad descriptions of symptoms and overlapping systems.

Assessing PFMs is new territory for physical therapists just entering this field. Shelly's article on mapping the pelvic muscles and using depth and clock measurements provides a system that demonstrates consensus among examiners.³The levator ani muscle group plays a critical role in supporting pelvic organs.⁴

Weiss et al. demonstrates the relationship between the pelvic muscles and referred pain. When pressure is applied to pelvic floor muscles-especially the levator muscles-pain is elicited. Continued compression refers pain to the suprapubic regions, rectum, and glans penis and labia. ⁵

Kotarinos and Fitzgerald demonstrate that holding the PFMs in a shortened position results in pain perceived as aching or cramping in the coccygeal region or as a heavy feeling in the vagina or rectum. They describe the common finding of obturator internus, psoas, gluteal, abdominal and piriformis muscle abnormality and pain in patients with PFM pain.⁶These areas of referred, localized pain have been effectively treated with standard manual therapy techniques and techniques adapted for pelvic muscle dysfunction.

Biofeedback and manual assessments allow you to determine the need to relax or strengthen pelvic muscles. Relaxing the pelvic muscles should precede strengthening.⁷Routine techniques include contract-relax, strain-counter-strain, trigger point release and reciprocal inhibition.^8,9Once you restore normalization, PFM stabilization or strengthening exercises facilitate maintenance of normal function and prevent recurrence of pain and overactivity.⁷Specific nerve entrapment of the pudendal, iliohypogastric and ilioinguinal may result in a pain pattern distinct to their distribution. The common sites of scars produced by laparoscopic and open surgical procedures are consistent with the location of these contributing nerves. Pelvic therapists routinely perform neurotension testing of these nerves as well as scar mobility and paradoxical movement assessments to determine contributing factors.⁷

Unique to chronic pain is the concept of central sensitization. For example, chronic pain in the pelvic floor or bladder can affect the spinal and supraspinal neurons and create sensory changes such as decreased pain threshold. This can make a non-painful stimulus, such as touch or bladder filling cause pain, increased pain intensity with painful stimuli such as dietary irritants, expansion of the pain field or sympathetically maintained pain.⁵The symptoms of upregulation are often what prompt pelvic pain patients to seek specialists.

Wasselman provides further evidence of visceral inflammation that causes myofascial pain. Her studies observe that pretreating inflammation in the uterus of rats with dye resulted in dye extravasations in the skin over the abdomen, groin, lower back, thighs, perineum and proximal tail.¹⁰These are the specific areas that require treatment such as myofascial release and skin rolling, according Kotarinos and Fitzgerald. Staying current with research helps support manual therapy in areas that might cause skepticism.

ADJUNCT TREATMENTS

Pelvic pain also responds to other adjunct treatments that rehab clinicians can deliver. Patients suffering from chronic pain are often deconditioned. Aerobic conditioning, strengthening exercises directed to the trunk and limbs, postural correction and emphasis on function rather than impairment may aid recovery from chronic pelvic pain.^3,11

Biofeedback can also be useful. PFMs are a deep muscle group with neural control similar to axial muscles. They have prominent reflex control and relatively weak voluntary control, with poor sensory data that contribute to muscle awareness.¹Improved awareness gives patients more control over previously unconscious holding patterns that perpetuate pain and dysfunction.

Transcutaneous electrical nerve stimulation and interferential current therapy may be used for analgesic effects, based on the gate control theory of pain modulation. Consider vaginal dilators to stretch and mobilize contracted or inflexible soft tissues. These products also act as a desensitizing tool to progressively reduce a patient's fear and apprehension about coital function and an exam.

SPREADING THE WORD

While collaborating with medical specialties that treat the pelvic area, I've had to explain my role and the involvement of the musculoskeletal, nervous and visceral systems to treat pelvic pain. Having a foundation in published research facilitates the educational process and enhances treatment outcomes.

Three years ago, I attended a conference held by doctors interested in promoting the use of rehab clinicians for pelvic pain treatment. They quoted a study that indicated only 19 percent of patients with pelvic pain were seen by physical therapists, while 33 percent were referred to psychologists.

Since then, I've actively promoted my role in treating this patient population to gynecologists, urologists and colorectal specialists in my area. By presenting the aforementioned evidence, I've developed relationships of mutual respect with these practitioners and integrated myself into the treatment team.

References

1. Howard, F.M. (2000). Pelvic floor pain syndrome. In F.M. Howard, C.P. Perry, & J.E. Carter, et al. (Eds.), Pelvic pain: Diagnosis and management (pp. 429-432). Philadelphia: Lippincott.

2. Bo, K., Berghmans, B., Morkved, S., & Van Kampen, M. (2007). Evidence-based physical therapy for the pelvic floor. London: Elsevier.

3. Shelly, B., & Dunbar, A. (April 2004). Palpation and assessment of the pelvic floor muscles using depth and positional measurements. Journal of the Section on Women's Health, 28(1).

4. Porges, R.F., Porges, J.C., & Blinick, G. (1960). Mechanisms of uterine support and the pathogenesis of uterine prolapse. Obstetrics and Gynecology, 15, 711-726.

5. Weiss, J.M. (Dec 2001). Pelvic floor myofascial trigger points: Manual therapy for interstitial cystitis and the urgency frequency syndrome. The Journal of Urology, 166, 2226-2231.

6. Fitzgerald, M.P., & Kotarinos, R. (2003). Rehabilitation of the short pelvic floor I: Background and patient evaluation. International Urogynecology Journal and Pelvic Floor Dysfunction.

7. Fitzgerald, M.P., & Kotarinos, R. (2003). Rehabilitation of the short pelvic floor II: Treatment of the patient with the SPF. International Urogynecology Journal and Pelvic Floor Dysfunction, 14, 269-275.

8. Kusunose, R.S. (1993). Strain and counterstrain. In J.V. Basmajian, & R. Nyberg (Eds.), Rational manual therapies (pp. 323-333). Baltimore: Lippincott.

9. Simons, D.G., Travell, J.G., & Simons, L.S. (1999). Travell and Simons myofascial pain and dysfunction: The trigger point manual (2nd ed.). Baltimore: Lippincott.

10. Wesselmann, U., & Lai, J. (1997). Mechanisms of referred visceral pain: Uterine inflammation in the adult virgin rat results in neurogenic plasma extravasation in the skin. Pain, 73, 309-317.

11. Baker, P.K. (1993). Musculoskeletal origins of chronic pelvic pain. Diagnosis and treatment. Obstetrics and Gynecology Clinics of North America, 20(4), 719-742.

Julie D. Tanaka, PT, CAPP, owns Therapy for Life, a physical therapy practice in Monterey, Calif., that specializes in treating male and female pelvic pain and dysfunction. She can be reached at jdtanaka@comcast.net or www.julietanaka.com