Pelvic, sexual and vulval pain are hidden problems and women often suffer in silence, or due to misdiagnosis, for years before they find help. They can be very distressing problems and cause both physical and emotional suffering. 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.
What causes pain?
Your brain is constantly receiving messages from all over the body called inputs – from the eyes, ears, nose, tongue and the body’s tissues. Your brain relies on all of these messages, as well as the things you say, do, think and believe, as well as your past experiences, to create context.
Your brain constantly scrutinises these inputs as you go about daily life, but if the brain ever concludes there is more credible evidence of danger than safety, it will go into protection mode – this means the brain will produce an output of pain. Pain is not the only output that the brain uses to protect you, it can also mobilise other protective systems in the body such as those from the immune, endocrine, respiratory, emotional, autonomic and motor systems. This is extremely useful in the short term, but if this goes on too long it can become maladaptive and create more suffering than is useful.
Is pelvic or sexual pain different?
In pelvic or sexual pain the mechanism is the same but some contributing factors are different. The initial danger sensors could have been triggered in the bladder, bowel, uterus, pelvic floor muscles, skin or elsewhere in the body. The danger sensors and pathways could have been activated by an infection, irritation or injury but also psychological and/or emotional trauma or experience. Examples of experiences that may initially activate this protective mode could be those related to endometriosis, a painful or stressful experience with constipation (even if it only happened once), or a painful sexual experience. Although the original problem may have been resolved (e.g. the constipation treated), the danger system may remain sensitive, and easily activated.
Once your system has been in protective mode for a longer period of time, changes occur in the nerve endings, nerve pathways, spinal cord, the brain and the immune system. These structures become sensitised and the body’s danger alarm system becomes easily and unnecessarily activated. This means that stimuli such as touch, stretch, warmth or cold which will not cause any tissue damage are now being interpreted by the brain as danger signals – and the brain will produce a real pain response to protect you, even though there is no actual threat to the body. Normal physiological processes such as urination or defecation, or your monthly period may now be triggered and contribute to the pain experience.
The other thing about pelvic or sexual pain, is that it is a highly private experience for most people and so they are more likely to keep it to themselves for longer, thus delaying getting the help they need.
Causes of Pelvic Pain
Read on to find out how overactive pelvic floor, history of painful periods, irritable bowel syndrome or painful bladder syndrome may contribute to your pain experience.
Overactive pelvic floor
The muscular system is another protective system utilized by your brain to protect you from perceived threat. The pelvic floor muscles support and protect the pelvic organs from below, and the abdominals support the organs from the front. If your muscles have been tense for long periods of time, it becomes difficult for them to relax at all and can now be a source of pain due to fatigue, incoordination or lack of movement. In addition, anticipating discomfort during intercourse, using tampons or during routine internal exams will trigger these muscles to tighten further as a protective response. In this instance the output (protective response) can now become an input too.
Painful periods with or without endometriosis
The hormone changes related to your monthly period may also act as ‘inputs’ to your pain experience. If you have been diagnosed with endometriosis, cells that are normally found in the uterine lining are found elsewhere in the pelvis and are a potential trigger for a protective pain response. Even if you do not have endometriosis, it is quite normal for the tissue and hormonal changes to elicit a pain response over 1 or 2 days. This may be enough to trigger a full blown pain flare even though there is no tissue injury or damage.
Irritable Bowel syndrome (IBS)
It is very common for women with pelvic pain to have an irritable or sensitive bowel, or be formally diagnosed with IBS. Typical features of IBS are pain in the mid to low abdomen, diarrhoea, constipation or bloating. It can feel similar to pain associated with endometriosis, painful bladder syndrome or other types of pelvic pain. Typically, the pain associated with IBS will improve after passing wind or using your bowel.
If the bowel is sensitive, it is easy for danger sensors to be triggered with minimal input. This original sensitivity could have been triggered by an event such as constipation, an illness, and infection, or emotional triggers. It could have had nothing to do with the bowel originally, but now your system is being particularly protective and caused your bowel to become on high-alert to any potential change. Normal stimuli such as pressure from the movement of stool within the bowel, the build up of gas or the different compounds in food could trigger the protective response even though there is no structural problem. This is also why your ultrasound, laparoscopy and colonoscopies look normal even though you feel far from normal. Another protective response is bloating. It could be a way for your system to get your attention- just like pain does. Once your system has been in protective mode for a longer period of time, changes occur in the nerve endings, nerve pathways, spinal cord, the brain and the immune system. This is why even if you look normal, you may feel bloated, or be really sensitive to touch around the abdomen.
Keeping a healthy bowel routine is one of the most important things you can do to minimise your symptoms. This may involve taking steps to address any constipation or straining and working out any food triggers that may be aggravating your symptoms. This is best done with the help of your GP (firstly to rule out any other medical causes) , your physiotherapist with a special interest in pelvic health and with the help of a dietician. For example a low FODMAP diet may help to improve bloating.
For more help on managing IBS please visit pelvicpain.org.au.
Painful Bladder syndrome (PBS)
Painful bladder syndrome, or interstitial cystitis (IC) is also very common in women with pelvic pain and may be part of your overall pain picture. In essence PBS/IC is an irritation of the bladder wall without any infection present. It may have developed in the context of another type of pelvic pain- such as endometriosis or IBS, or it may have been triggered by previous bladder infections that have now resolved, yet left the bladder sensitive. Symptoms of PBS/IC can include:
- Frequency (needing to go to the toilet often)
- Nocturia (getting up to use the toilet at night)
- Urgency (rushing to the toilet and finding it difficult to ‘hold on’)
- Pain which gets worse as the bladder fills, and improves once the bladder empties
- Pain with intercourse in women, especially in positions that put pressure on the front wall of the vagina (near the bladder)
As with IBS, there is a lot that can be done to minimize the impact of your symptoms on your life. Because PBS/IC is poorly understood, there is no one-size-fits-all treatment and it needs to be individual to you.
There is strong evidence to support the role of women health 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!