Explaining Pelvic Pain
Excerpt By Christine Haran, Healthology

Some women, even younger women, feel like their lives revolve around their bladder.

They find themselves searching for a public restroom even though they went to the bathroom 20 minutes ago. Some of these women may also have nebulous pelvic pain, low back pain, bowel problems, or pain during intercourse.

Most will cope with their symptoms, despite the impact on their quality of life. And others will seek help from a variety of doctors, often trying pain medications and antibiotics that don't provide any relief.

Some doctors and physical therapists have begun to diagnosis women with these symptoms with pelvic floor dysfunction, concluding that their symptoms are due to problems with the muscles of the pelvic floor.

Because not all health professionals recognize pelvic floor dysfunction as a condition, it is a somewhat controversial diagnosis.

As a result, awareness of pelvic floor dysfunction among health professionals and patients is low.

But Dr. Elizabeth Kavaler, a urologist in private practice in New York City, and Amy Stein, a physical therapist with Sports Physical Therapy of New York, are hoping to raise its profile.

Although relative little research has been done in this area, physical therapy may be helpful in treating many pelvic floor dysfunction symptoms. Kavaler and Stein are planning a study that will examine how well physical therapy eases the symptoms of pelvic floor dysfunction.

Below, they discuss pelvic floor dysfunction diagnosis and treatment.

What is pelvic floor dysfunction?
Stein: Pelvic floor dysfunction is any kind of impairment in the pelvic floor area, which is part of the core of the body. The pelvic floor includes the muscles that surround the rectal area and genital area. The pelvic floor helps to support the internal organs and helps with the function of urination and defecation.

Kavaler: Pelvic floor dysfunction is not a very widely understood or necessarily accepted concept, but to those of us do accept it as a diagnosis, it is a muscular problem that involves spasming of the pelvic floor muscles.

What are the symptoms of pelvic floor dysfunction?
Stein: Common symptoms are urinary symptoms, such as urinary frequency and urgency, pelvic pain, low back pain and irritable bowel syndrome. I've found that some people have just one symptom, and other people have combinations of symptoms. Additionally, there are many different sub-classifications of pelvic floor dysfunction. Vulvodynia, for example, is defined as pain in the vulvar area and may also include chronic stinging, irritation, painful intercourse and burning.

Kavaler: Often pelvic floor dysfunction patients will present, at least to me, with urinary problems. So they may have a lot of frequency and urgency, but they have a normal exam and no evidence of infection in their urine. If I do studies on them, I find that their bladders work very well. But when they empty their bladders, the bladder doesn't empty very efficiently. It's slow and there is a lot of stopping and starting. That's because the muscles that are around the urethra are in spasm and are not relaxing enough to allow the bladder to empty.

What causes pelvic floor dysfunction?
Stein: Unfortunately, half the time we don't know. Sometimes it is evident, such as a traumatic childbirth where a nerve got damaged or stretched, or a fall onto the sacrum, back or coccyx, which is at the bottom of the spinal column. People may also have weakness and/or tension in the hip, back or pelvic floor. A lot of patients have had recurrent urinary tract infections (UTIs). These patients complain that they still feel like they have a UTI because the muscles are still in spasm, remembering what it's like to be in that pain.

Kavaler: Pelvic floor dysfunction is just like having a back spasm. It can come from the way you hold your body. If you have an injury, for example, you may compensate by putting stress on other muscles.

How is pelvic floor dysfunction treated?
Kavaler: One option is for the patient to just wait it out. A lot of times, urinary problems occur after recurrent urinary infections, or if there is something stressful going on in people's lives. The more tense people are, the more they tend to clench and hold abnormally. They can try lifestyle changes, such as exercising regularly, eating well, and getting a good night's sleep.

If people are urinating frequently at night, then I may give them a muscle relaxant because that will help both the spasm and the sleeping. That often will be the first step in breaking the cycle. But you can't give muscle relaxants during the day because patients will fall asleep at work. I also sometimes give medications that act like bladder anesthetics by coating the bladder wall to make it feel better.

If lifestyle changes don't help, the real mainstay of treatment is physical therapy, which is the same treatment that you would have for a back spasm.

What does physical therapy involve?
Stein: I do an extensive evaluation, with a lot of questioning, because everyone has different symptoms. Once I figure out what the problems are, I treat the symptoms. One of the things that I do is deep tissue massage and myofascial release. Fascia is connective tissue. If the fascia is very tight, which I see in most of my patients, it can pull and cause tightness in certain muscles. Physical therapy techniques can adjust the tight muscles and the trigger points, which are the tender spots.

I also teach deep breathing exercise with relaxation techniques, Kegel exercise to strengthen the pelvic floor muscles, and strengthening of the core area. The core area is the abdominal area, the back, the internal/external obliques and the transverse abdominus. I also teach stretching. I do biofeedback if people are having a hard time strengthening or relaxing the muscles. Additionally, patients have to take an active role in their healing and do exercises and stretching at home.

Behavioral changes are also part of the reeducation. For example, the average person should go to the bathroom once every three or four hours. If patients go to the bathroom every half hour, I tell them to stretch it out to 45 minutes, and then once they hit 45 minutes, they stretch it out to an hour, until they get to the norm.

What is the average length of time a patient needs physical therapy?
Stein: The average length of time usually varies from two months to a year. It depends on how severe the symptoms are and how long the patients have had them. It's estimated that most patients have had their symptoms for at least five years before they actually get some help.

Why do you think it's so hard for people to get diagnosed?
Stein: Many doctors, unfortunately, don't know a lot about pelvic floor dysfunction, or they just don't believe that the problems are muscular. A lot of pain patients, for example, have been to between five and ten doctors before being diagnosed.

More and more physical therapists are getting more involved in pelvic floor rehabilitation, but there are still few physical therapists who specialize in this condition.

Kavaler: I think a lot of these patients are just given pain medicines and other drugs. But I think that the most effective thing for the patient is to try to keep them off of medications. Number one, most of the medicines don't work and they are somewhat addictive. Secondly, this is a chronic condition that's going to come and go throughout people's lives. If there is something that can be done to manage this that's non-medicinal, it's better for the patient so they're not dependant on a doctor.

We're going to start a research project to see if patients have a response to physical therapy and how durable the response is. Certainly during therapy, patients seem to do well. But it would be interesting to see how long the results last, and if patients need to continue with therapy, or if they can maintain an exercise regimen at home.

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