Pain doesn’t differentiate between genders. Obviously, there are differences between boys and girls, men and women. These result in different conditions effecting different people; but often due to the same underlying causes or drivers of pain.

Many pain patients over-inhibit – they try to ignore the bowel or bladder. Others have hyper-focus or attention to a specific habit, like over cleaning the vagina. Yet others are purposefully ‘tucking the tailbone under’ which is contributing to tightness in the pelvic floor muscles and a bio-mechanical load through the sacroiliac joints. Please note there is variability and complexity in each case.

All chronic pain management is rooted in pain neuroscience. Manual techniques are used to  create a shift in the body’s patterns. These need to be ‘owned’ between sessions and may incorporate breathing, muscle activation, or postural awareness. The approach is not therapy-intensive, but seeks to shift and balance movement patterns and behaviours.

The approach to pain remains the same, albeit by varying access and approach, depending upon age and gender:

  • assess the same systems (e.g. behaviour, breathing, posture, movement patterns, muscles, nerves, connective tissue,)
  • treat (e.g. pain neuroscience education, myofascial release, connective tissue mobilization, visceral manipulations)

Musculoskeletal Pain

Activity or Sports related pelvic pain

Abdominal, groin, hip, low back, buttock, posterior thigh and inner thigh pain may have a component of pelvic floor muscle imbalance or dysfunction. Scoliosis results in imbalances, and although many are pain free, rotation through the pelvis may need to be considered.

Often aggravated by weight-bearing on (standing) or moving (swinging) the leg. May also be aggravated by sustained sitting or standing.

Pregnancy related pelvic girdle pain (PGP)

Pain felt in and around the pelvis, abdomen, groin, symphasis, hips, low back, buttocks and inner thighs. Aggravated by weight-bearing (standing on one leg, pushing on it to roll in bed at night, walking, stairs) and separating the legs (standing on one leg to get dressed; or in / out the bath or car). Ante-natal, post-natal or persistent pelvic girdle pain need differing approaches in management.

Chronic Pelvic Pain (CPP)
incl. Visceral Pain and Pelvic Pain Syndrome (PPS)

This list is long, and by no means extensive. Many of these are definable pain presentations to which the medical profession has been able to ascribe diagnostic criteria. However, your pain might not fall into any specific category – an assessment is advised to form a clinical hypothesis and refer on as necessary.

If you have heard the words “There is nothing wrong with you” – they could be translated into the more compassionate “There is nothing sinister wrong with you that my tests can detect. However, you are clearly in distress – may I refer you to someone else who assesses different aspects of function and dysfunction?”

In theory, you should be re-assured that there is no sinister cause for your experience. You would be well advised to investigate imbalance and dysfunction as drivers of your pain.

Should you see your doctor first?

Please see your doctor if you want i. investigations to exclude pathology ii. medication iii. surgery.

Instances (red flags) in which you must see your doctor first include:

  • Infection (pus, discharge, bad smell/odour)
  • Blood
  • Sudden loss of both bladder and bowel function (urinary and faecal incontinence)
  • Sudden onset of not being able to feel your undercarriage (saddle parasthesia)
  • Sudden onset bilateral pins and needles (tingling in both feet and/or hands)
  • Sudden onset of acute weakness in the lower (or upper) limbs
  • Sudden onset chest pain and shortness of breath
  • Sudden onset of dizziness or confusion
  • Sudden onset of not being able to move one side of your body
  • Acute urinary retention (not able to empty the bladder at all)
  • Change in bowel behaviour (not related to dietary or exercises changes)
  • Changes in symptoms, related to changes in medication – you should be refereed on for physio, if the medication cannot be moderated to minimize unwanted side-effects
  • Persistent pain that is not as responsive as it should be to treatment, in cancer survivors
  • A palpable lump, bump or nodule

Could you see a pelvic physiotherapist first?

In South Africa, physiotherapists are autonomous first-line practitioners, meaning we do not need a referral from a doctor in order to assess and treat patients.

Consider physiotherapy if symptoms have developed gradually over time and are not accompanied by any of the red flags above. Consider physio is there was a change in function associated with a change in activity e.g. you didn’t leak, started running and started leaking, tried to squeeze pelvic floor muscles harder and developed buttock pain. Also consider physio if everything is going just a little bit wrong – pelvic pain and a few drops of stress incontinence, moderate urgency, mild constipation….

Definition of dynia

Dynia means pain.

  • coccydynia is pain in the coccyx
  • prostadynia is pain in the prostate
  • vulvodynia is pain in the vulva

It describes the symptoms, but doesn’t identify the cause.

Pelvic pain patients should consider a pelvic assessment with an appropriately trained physiotherapist with any of the following symptoms or complaints:

  • Bladder pain; bladder pain syndrome (BPS); interstitial cystitis (IC)
  • Urethral pain; urethral syndrome; frequency : urgency syndrome
  • Prostate pain; chronic non-bacterial prostatitis; prostadynia
  • Pain with sex (dyspareunia ) and pain with penetration
  • Endometrisis
  • Orgasmic pain; ejaculatory pain
  • Penile pain; testicular pain
  • Vulvar pain; vulvar vestibulitis; vulvadynia
  • Anal pain; rectal pain; anal fissures and haemorrhoids need to be considered; protalgia fugax
  • Sensation of a foreign object (interestingly, often a Lego block with specific orientation!?)
  • Sensation of constant pressure
  • Coccyx pain; coccydynia
  • Irritable bowel syndrome (IBS); constipation, loose stools, swinging consistency; abdominal cramping and pain; difficult bowel motions
  • Persistent genital hyper-arousal disorder (PGHD)
  • Hard : flaccid – which lacks the ‘pain’ component, presenting with a sense of diminished or disturbed sensation, and other erectile abnormalities of filling, shape and performance
  • Clothing intolerance – hate wearing jeans, or any trousers?
  • Post surgical pain – pain that is relieved in the short term, but returns with greater intensity after a surgical procedure

Pudendal neuralgia; pain and dysfunction of varying presentations; invariably aggravated by sitting; may have worsened after surgical intervention

Peritonitis survivors –  if you are one lucky enough to have survived peritonitis, there is likely to be extensive scarring in the abdomen resulting in pain and dysfunction that may be responsive to treatment

Cancer survivors – if you are one of the increasing number of cancer survivors, the impact on your quality of life can be profound; persistent pain and a ruined sex life can negatively impact your experience; your symptoms may be responsive to treatment

Athletes – if you have rehabilitated one injury e.g. hamstring, only to have it morph into another e.g. groin pain, it is likely you have not maintained balance through the pelvic ring and have shifted the pressures elsewhere