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Continence Coach: Pelvic Floor Pain Syndrome in Chronic Pelvic Pain Revisited: A Case Study
In the February 2013 “Continence Coach,” Nancy Muller discussed pelvic floor pain syndrome in chronic pelvic pain (CPP).1 Pelvic muscle pain has several aliases and implies a pain source from the myofascial structures of the pelvis that sometimes goes undiagnosed. It can exist alone with no concomitant medical pathology or as either a precursor or sequela to urological, gynecological, and colorectal medical conditions or other musculo-skeletal-neural issues.2
Due to the phenomenon of somatovisceral convergence, primary pain generators can be elusive. Pathology in the viscera can refer pain and symptoms to somatic structures and vice versa.3 It is also well documented that chronic neuropathic and musculoskeletal pain are related to abnormal restructuring of the body’s somatosensory and motor cortices, as well as other areas of the brain.4 This makes treating the CPP patient more challenging, because clinicians must acknowledge the brain’s role in chronic pain.
The following is a case in point. The patient’s complex symptom presentation included both visceral and somatic dysfunction, a highly sensitive nervous system, and biopsychosocial factors that needed to be addressed over the course of her treatment. As the research5 suggests, a team approach was necessary for a successful outcome.
Case Report
Ms. R was a 53-year-old woman with an impressive hyperlordosis (“sway back”) of her lumbar spine that made her posture unique. She had two vaginal births, no prior surgeries, and denied trauma. She described herself as “very healthy” but had a diagnosed anxiety disorder for which she sometimes took medication. She’d been married 32 years but had abstained from intercourse for many years due to pain with vaginal penetration; her marriage was suffering. Her emotional state appeared to be deteriorating as her pain increased, and her coping skills sounded poor: she was labile, overate, and did not exercise.
Ms. R presented with a 2-year history of suprapubic pain, more recently spreading to her perineum, left sitting bone, vestibule, and deep into the vagina. As the intake progressed, she acknowledged she had been having pain longer than the stated 2 years; she recollected that as far back as college, she occasionally had problems with urinary urge “when anxious.” She used the descriptors burning and stabbing to describe her current left buttock pain, dull and achey for her suprapubic pain, and as if someone was crushing glass for her vulvar pain. She often used a small ice pack, wedged into her perineum, while at work. Her pain increased with sitting and would come and go for no apparent reason (stress was a likely source). She reported an abnormally high urinary urge and frequency, incontinence, and chronic, worsening constipation.
When her pelvic pain became unbearable, she visited her primary doctor, who referred her to her gynecologist, who sent her to an urologist, who diagnosed overactive bladder (OAB) and prescribed medication. When the medication failed to help, she was sent to another urologist, who recognized a muscular component to her pain and suggested pelvic physical therapy (PT).
The location of pain and Ms. R’s descriptors suggested pelvic floor muscle (PFM) involvement, possible vulvodynia, and pudendal neuralgia. She presented with allodynia, hyperalgesia, and symptoms that came and went without attributable cause — signs of a sensitized nervous system. Her psychological and social factors also needed to be addressed. Ms. R’s physical exam verified pelvic floor myofascial syndrome. Tender and trigger points — ie, hyperirritable points within muscle fibers6 — were located throughout her abdomen, gluteals, thighs, and PFM. Differentiation tests revealed both sciatic and pudendal nerve involvement. A Q-tip test suggested vulvar vestibulitis.7 Ms. R also presented with numerous skeletal alignment issues — eg, her lumbar hyperlordosis — that likely were contributing to her pelvic pain. In short, her symptoms were easily reproduced in the PT clinic, suggesting PT as an appropriate course of treatment
. PT sessions consisted of instruction in self-care techniques, manual therapy, and biofeedback. A cognitive-behavioral strategy was instituted immediately because this approach is proven to reduce fear, provide a sense of control over pain, and ultimately improve functional capacity.4 Strategies to respond to physiological stress included diaphragmatic breathing, guided imagery, and other specific techniques to change behaviors in response to pain.
Joint mobilization and neuromuscular reeducation improved mobility and retrained overactive muscle groups. Special exercises improved her posture, which reduced strain on her lumbar spine and unloaded her pelvic floor. She learned to stretch her hamstrings without irritating sensitive neural tissue. The most helpful manual technique was PFM release work. Accessing the PFM both externally and internally with targeted myofascial release techniques has been shown to be advantageous in urogenital pain conditions.8 Surface electromyography (EMG) or biofeedback, was used to reinforce her awareness of her muscle tension and to train her to relax. Her incontinence improved. Additionally, her diet, exercise, bowel, and sexual concerns were addressed.
Over the course of PT, which lasted almost a full year with weekly, then more intermittent sessions, she saw a different gynecologist who was familiar with pelvic pain and prescribed appropriate medication. She re-visited her primary doctor for management of her anxiety, and by her penultimate session, she was in counseling.
Ms. R is typical: although symptoms and pathology may vary, patients with CPP often present with several concerns and visit numerous physicians. The literature suggests a myofascial component exists in a significant percentage of people with CPP9 and interstitial cystitis.10 Yet, a recent review11 of 69 studies to determine how physicians examine women with CPP found only 19% mentioned digital examination, which is an important assessment tool.
Ms. R had the time and resources to attend therapy and was highly motivated, but not all patients respond in this manner. Many patients are underinsured and unable to keep regular medical appointments. Some don’t have the fortitude to stick with a difficult program. Ms. R’s case illustrates what is possible with a dedicated team approach in the treatment of a person with CPP, a patient population in dire need of the medical community’s attention.
Ms. Pastore is a physical therapist in private practice in association with POST-Wellness by Design in Petaluma, CA; she is on the advisory board for the National Association for Continence.This article was not subject to the Ostomy Wound Managment peer-review process.
1. Muller N. Pelvic floor pain syndrome in chronic pelvic pain. Ostomy Wound Manage. 2013;59(2):24.
2. Pastore EA, Katzman WB. Recognizing myofascial pelvic pain in the female patient with chronic pelvic pain. J Obstet Gynecol Neonatal Nurs. 2012;41(5):680–691.
3. Apte G, Nelson P, Brismee JM, Dedrick G, Justiz R 3rd, Sizer PS Jr. Chronic female pelvic pain—part 1: clinical pathoanatomy and examination of the pelvic region. Pain Pract. 2011;12(2):88–110.
4. Moseley GL, Flor H. Targeting cortical representations in the treatment of chronic pain: a review. Neurorehabil Neural Repair. 2012;26(6):646–652.
5. Abercrombie PD, Learman LA. Providing holistic care for women with chronic pelvic pain. J Obstet Gynecol Neonatal Nurs. 2012;41(5):668–679.
6. Dommerholt J, Bron C, Frenssen J. Myofascial trigger points: an evidence informed review. J Manual Manipulative Therapy. 2006;14(4):203–221.
7. Hartmann D. Chronic vulvar pain from a physical therapy perspective. Dermatol Ther. 2010;23(5):505–513.
8. FitzGerald MP, Payne CK, Lukacz ES, Yang CC, Peters KM, Chai TC, et al. Randomized multicenter clinical trial of myofascial physical therapy in women with interstitial cystitis/painful bladder syndrome and pelvic floor tenderness. J Urol. 2012;187(6):2113–2118.
9. Tu FF, As-Sanie S, Steege JF. Prevalence of pelvic musculoskeletal disorders in a female chronic pelvic pain clinic. J Reprod Med. 2006:51(3):185–189.
10. Bassaly R, Tidwell N, Bertolino S, Hoyte L, Downes K, Hart S. Myofascial pain and pelvic floor dysfunction in patients with interstitial cystitis. Int Urogynecol J. 2011;22(4):413–418.
11. Kavvadias T, Baessler K, Schuessler B. Pelvic pain in urogyaecology. Part 1: evaluation, definitions and diagnoses. Int Urogynecol J. 2011;22(4):385–393.
