Pelvic Pain: What you — and your doctor — may be overlooking

by Janelle Moulder, MD, MSCR — Assistant professor of obstetrics and gynecology; University of North Carolina at Chapel Hill; Division of Minimally Invasive Gynecologic Surgery

In my clinic, I see patients with pelvic pain from a variety of sources — from ovarian cysts and fibroids tumors to endometriosis and pelvic adhesions. With medical therapy, and sometimes surgery, most pelvic pain can be treated.

Dr. Janelle Moulder

When pelvic pain returns again and again, despite a medical or surgical resolution, it can be incredibly frustrating. I see many patients who are looking for a definitive resolution to often debilitating pain, including further surgeries. But, sometimes the pain originates from a place many doctors may overlook: the pelvic floor.

This group of interconnected muscles is like a hammock or sling supporting the organs of the pelvis. Involuntary tightening of these can cause spasm and overuse fatigue. This can result in pain that radiates into the vagina, hips, buttocks and legs, and can be experienced during intercourse or bowel movements as well.

If you have recurrent, unresolved pelvic pain, here’s what you need to know:

Ask your doctor to evaluate your pelvic floor muscles.

Pelvic pain is one of the top complaints in gynecology clinics. Many patients come with prior diagnoses, but musculoskeletal contributions are often overlooked. For this reason, we include evaluation of the pelvic floor muscles as part of our assessment, and train our residents to consider these contributions in their evaluation of patients. This portion of the pelvic exam is one that not all OB-GYNs are familiar with.

It’s important to know that your pelvic floor muscles shouldn’t hurt when evaluated. Many patients with pelvic pain dismiss pelvic floor spasms because they are so used to experiencing pain in this part of the body. If you’re seeing an OB-GYN for pelvic pain, and he or she doesn’t bring up this exam, ask them about it.

It’s not in your head.

Pelvic floor spasms can be very painful, debilitating, and in some cases, can stop you in your tracks. Many women are shocked when they have a laparoscopy (a minimally invasive surgery performed with a small incision through the navel to explore the pelvic cavity) that doesn’t reveal a source of their pain, but their pain remains.

It can be frustrating to be in so much pain, especially when it mimics a problem you thought you’d solved. I recently saw a patient with deep infiltrative endometriosis previously treated by surgery. After having a baby, her pain returned, and she was convinced her endometriosis had returned worse than before. However, her pelvic ultrasounds, and even an MRI, were completely normal. An examination of her pelvic floor muscles revealed a tightness and tenderness that, when manipulated, replicated the severe pain she was experiencing.

The pain was real, but it was caused by something completely different than the original diagnosis, and something that didn’t show up in an imaging study. This is pretty common for painful pelvic floor dysfunction.

Pelvic floor physical therapy can work wonders.

The idea of an internal pelvic exam from anyone other than your gynecologist can be off-putting, and many patients never even make it to the referral. But I’m a big believer in pelvic floor physical therapy for this issue. Pelvic physical therapists are specially trained to treat patients with chronic pelvic pain, urinary and bowel incontinence, sexual dysfunction, vaginal and rectal pain, problems with urination and more.

Pain from endometriosis, fibroids, vulvar pain or other medial problems can often lead to musculoskeletal problems that must be addressed along with those primary issues if the patient is going to get relief. Short, tight muscles from a tense pelvic floor — think of a dog holding its tail between its legs — can lead to a great deal of pain and spasm. A trained pelvic physical therapist can perform a thorough evaluation of the musculature surrounding the pelvis to determine any restrictions that may be contributing to pain and find the best exercises and treatment for each patient.

Even if further surgery is medically necessary, surgery won’t address the musculoskeletal pain. Physical therapy will still be necessary to relieve the muscle spasms and will also aid in a faster recovery from surgery.

It’s important to remember that physical therapy is an investment in yourself and your well-being. It may take multiple visits, but the end result can be long-lasting, and you will receive life-long tools to help manage your pelvic pain.

Opioids won’t help here.

With any condition, I like to start with the least invasive measures that offer the greatest impact — and in this case, that’s physical therapy. Solving the problems in the musculature is really the goal.

For patients who also need medication, opioids won’t be much help. With this kind of pain, NSAIDs (non-steroidal anti-inflammatory drugs) like ibuprofen and naproxen or muscle relaxants are appropriate when used in combination with physical therapy. Muscle relaxants act on the central nervous system, so each patient will tolerate these medications differently. Some patients have even found relief from diazepam inserted vaginally. Muscle relaxants on an as needed basis can be a useful adjunct to more conservative measures like a heating pad, or a hot tub bath.

You might have to try a few different treatment methods to find the best fit. If you need a change, tell your doctor. Work together until you find a combination that brings relief.

Don’t give up.

Painful pelvic floor dysfunction can be a complex problem to have, and resolving it will take time. This can become very frustrating. Because the pelvic floor muscles can affect so many different pelvic organs and their functions, it may be a while before you are able to untangle each part of the problem. Sometimes the appropriate therapy is exercise, sometimes it’s medication, and most often, it’s a combination of many different approaches to fully resolve the problem.

But, remember, this problem has a solution. Hang in there, and you’ll be glad you did!