The world’s leading experts have recommended treatments provided by pelvic floor physiotherapists for pelvic pain and treatment options. Read on to find out which treatments are available for your pelvic sexual pain problem.
People with pelvic or sexual pain may have been diagnosed with vaginismus, vulvodynia, dyspareunia, endometriosis, pudendal neuralgia, painful bladder syndrome, irritable bowel syndrome, and often have a combination of these problems contributing to their individual pain experience. Nerve and muscle overactivity, particularly in the pelvic nerves and pelvic floor muscles, lead to a number of problems, including ongoing pain in the region from increased tension and an inability to relax the pelvic floor muscles in anticipation of penetration, causing problems with sex, and pain with tampon use and internal examinations with care providers. Because your pain experience will be unique to you, treatment will also be very individualised based on the symptoms you are experiencing, your goals, and your medical history. Your physiotherapist will work with you to determine the most appropriate management plan, this may include stretches, pelvic floor relaxation exercises, vaginal trainers as well as techniques for vulvar desensitisation and vulval care.
Keep reading for more information about the ways which a pelvic physiotherapist may be able to help you.
PFMT traditional exercises (Kegels)
Traditional pelvic floor muscle training exercises (Kegels) are generally not recommended for women with pelvic or sexual pain. However, modified versions of these exercises may be a useful part of your program so it is important to get evaluated before you embark on a strength based pelvic floor training program.
PFMT down-training/relaxation exercises
Pelvic floor down-training is a technique used to improve your awareness of the pelvic floor muscles, with the aim of relaxing them. It is the opposite to pelvic floor ‘up-training’ regimes where the goal is to strengthen and stiffen the muscles further. There are many ways to practice pelvic floor relaxation, however the first step is to learn what relaxation feels like and how to do this in practice. Often learning a technique called diaphragmatic breathing is an excellent first step and can help you connect with your pelvic floor. This is because the diaphragm works with your pelvic floor during normal relaxed breathing. If you are in pain or have been in pain, these muscles may have taken on other roles and learning diaphragmatic breathing with a focus on pelvic floor relaxation can help to ‘reset’ the muscular system of the pelvis and abdominal wall.
Vulval care, desensitisation and vaginal trainers
If you are experiencing sensitivity in the vulval area, it is important to take extra care to avoid any potential irritants, even if they have not caused discomfort in the past. Your physiotherapist will discuss common irritants with you and can make recommendations on suitable lubricants, body washes, liners and/or tampons. Physiotherapists also teach you how to re-train or ‘desensitise’ the nerves in the vulval area by gradually exposing the area to light touch under a framework involving neuroscience education and pelvic relaxation techniques. Vaginal trainers are instruments (often made of silicone or plastic) that come in a range of sizes and can be gradually and comfortably inserted into the vagina to assist in re-training the protective responses of the body, in particular the tendency for pelvic floor muscles to contract / clench. Over time, women use vaginal trainers to slowly teach the pelvic floor muscles to remain in a relaxed state when pressure is applied to the pelvic area and can be an excellent tool in helping women achieve their goals of painfree sex, tampon use or pelvic examinations.
Stretches and movement to restore normal flexibility of the hips and pelvis
The following exercises are designed to reduce tension in the muscles of the pelvis including the pelvic floor, inner thighs and hips.
The regular practice of gently lengthening these muscles when combined with relaxed belly breathing can be an effective part of your pain management program. Ensure you take the movements to a comfortable stretch only and discuss with your physiotherapist if you have any concerns. Exercises are most effective if performed daily.
In women with bladder pain syndrome (or any bladder symptoms such as urgency, pain when voiding or when your bladder is full, having to get up in the night to urinate or using your bladder a lot) bladder training is recommended by experts as an integral part of treatment. This may involve education around normal bladder function, a voiding schedule, and strategies to control urgency or leakage such as bladder calming, distraction, relaxation and pelvic floor muscle contraction. Understanding how the bladder and brain work together to process all the incoming information is the first step to regaining control of your bladder problem.
When you experience pain with urinating, or when your bladder is full it is tempting to reduce the amount you drink. Unfortunately this often makes things worse for a number of reasons, such as making the urine more concentrated and more likely to lead to irritation or pain. Alternatively you may be so worried about getting another urinary tract infection because of the pain you feel so you constantly sip at water all day long to reduce the risk of this happening. Analysing your fluid intake with the help of a pelvic physiotherapist will help you find the optimal balance.
There are many foods that are thought to make bladder pain worse, so it is useful to consider whether this may be the case for you. Some examples are:
- Acidic foods: Tomatoes, citrus
- Foods that affect the nervous system: Caffeinated coffee, cola drinks, chocolate
- Foods high in sodium or potassium: eg bananas
- Artificial sweeteners: eg diet soft drinks or “sugar free” cordial
- Carbonated drinks: mineral water, soft drinks
For all persistent pain conditions, including pelvic pain, diet and nutrition can have a major influence on your experience of pain. This is because:
- Diet can directly affect the function of nerves and the immune system and therefore the way danger signals are interpreted.
- Diet can reduce other chronic diseases which can impact on your pain such as your cardiovascular disease and mental wellbeing
- Diet can lead to improved energy levels and therefore impact what you can and can’t do and your overall quality of life.
Remember to seek help from your GP or a practicing dietitian if you are unsure of what to do next.
Medications can be a really useful part of your overall treatment plan when you are managing persistent pelvic pain. It is very common for it to take some time to find the right medication and dose that helps you. Medication is very rarely a stand alone treatment. Often it can be most useful in combination with other therapies such as those provided by a pelvic physiotherapist. In fact, for treatment to be effective, it needs to be delivered by a team of practitioners. Read on to learn about some of the most common medications used for women with chronic pelvic pain.
Neuromodulators are a type of drug that influences the nervous system and can help dampen down sensitivity of the pelvic muscles and nerves. These may include medications that have been traditionally used to treat mood disorders but can be prescribed to you by your doctor for the effect they have on pain. It is important for you to discuss whether these medications are suitable for you with your doctor, they need to consider any interactions with other drugs you may be taking, allergies and pre-existing conditions to decide if this is appropriate for you.
Low dose amitriptyline might be a good first choice as it can help general pelvic pain, as well as bladder related symptoms such as frequency, urgency, pain and the number of times you pass urine at night. It can also aid your sleep. It is important to take this medication a few hours before bed and then slowly increase the dose as prescribed by your doctor. Often the morning drowsiness can wear off in a week or two so you may have to stick with it. Remember that this medication needs to be taken every day, not just the times you have your pain.
Pregabalin (Lyrica®) is medication for nerve pain (neuropathic pain) which may help some people with pelvic pain.
Opioids are a group of pain medicines used to treat pain such as Tramadol, Endone, Codeine, Panadeine forte etc. They work really well for short-term pain, like pain associated with recovery from surgery, but pain researchers and doctors have discovered that they are associated with lots of problems when used to treat long-term or chronic pain.
If you have been reading other sections of this blog you will know by now that persistent pain, including persistent pelvic pain, is more of a reflection of how sensitive the tissues are (such as the organs, muscles and nerves of the pelvis) and less about the physical condition of the tissues themselves. That’s why, it may sound strange to hear that taking opiods, especially in the long term will increase your sensitivity to danger signals. Yes, you read this correctly, your pain will become worse by taking them. Watch this youtube video where brainman explores this topic further:
The Pelvic Pain Foundation of Australia website has some excellent resources on medications commonly prescribed for women suffering from pelvic pain. It is important that you consult with your doctor to ensure that if you are taking medications for pain that they are the best ones for you, that there are no negative interactions with other drugs you may be taking and that the combination you are taking is safe overall.
The research well and truly shows that seeing a pelvic health physiotherapist can help women improve, better manage and in many cases, completely cure their problem!
There is strong evidence to support the role of physiotherapists with additional training in women’s and pelvic health to treat a number of conditions across all life stages – from more commonly known pelvic health issues affecting women such as incontinence and prolapse, to pelvic and sexual pain concerns and also for helping children and adolescents with bed wetting or other bladder/bowel control concerns.
We hope the information in this blog has been useful and should always be considered in conjunction with an individual assessment with your physiotherapist and/or other health care provider skilled in the area such as a GP or gynaecologist.
We would love to help you manage your concerns and get you back achieving your goals worry –free!