Name that Pain: Understanding Chronic Pelvic Conditions
Wednesday, April 3, 2017
Written by: Cora Tomowich
Hi there and welcome back to my pain saga. In my last piece, I spoke about eight new ways that we can think about pain in the hopes of redefining it and better understanding what it is really going on. Now, I will discuss some of the most common chronic pelvic pain conditions that I see in my practice and clarify some of the terminology that you might hear or see in the world of pelvic health.
Vulvodynia refers to discomfort, often described as a burning sensation, in the vaginal region. Many women liken the pain of vulvodynia to that of a yeast infection, however, with vulvodynia there is no infection present. Before a diagnosis of vulvodynia is made, symptoms should be present for 3-6 months and often include itching, burning, stinging, stabbing pain, and pain with intercourse. Vulvodynia is a diagnosis of exclusion, which means that we must first rule out other conditions, such as vulvovaginal candidiasis, herpes, HPV, lichens simplex/sclerosis, etc. before we can conclusively determine vulvodynia.
There are different classifications of vulvodynia which can sometimes get confusing for patients so let me break it down. Sometimes vulvodynia can be generalized (meaning it can affect the entire vulva) or localized (meaning isolated to either the clitoris or the vestibule of the vagina). It can also be primary (meaning always there) or secondary (meaning new or recent). Vulvodynia can also be provoked (usually by intercourse or tampon use), spontaneous (random moments of pain), or a mixture of both.
In my practice, I often see provoked and generalized vulvodynia where women feel worse during intercourse. Although the cause of vulvodynia is unknown, women who have experienced frequent urinary tract infections (UTIs), STDs, and/or yeast infections often are at greater risk for having long-term, insidious vulvar pain. Remember how the nervous system gets ramped up with repeat experiences of pain? Well, this is very likely the case in vulvodynia. Fortunately, conservative therapies such as pelvic floor physiotherapy have been shown by research to be highly beneficial in the maintenance and elimination of muscular and fascial tension that contribute to vulvar pain.
Vestibulodynia is a subset of vulvodynia whereby pain is localized to the vaginal vestibule. Symptoms of vestibulodynia are felt towards the inside of the labia minora, specifically Hart’s line, and often extend from the clitoris to the posterior fourchette or base of the vagina. With provoked vestibulodynia (PVD), there is usually no itching but a lot of touch sensitivity.
Once again, this is a diagnosis of exclusion and the cause is not well known. There is a lot of controversy as to whether some oral contraceptives are associated with vestibulodynia, but the jury is still out on that. As treatment, some women prefer to continue along the conservative therapy route while others may opt for a vestibulectomy, which involves the surgical removal of a portion or all of the vestibular tissue.
Persistent Genital Arousal Disorder (PGAD)
Although a rare condition, PGAD is another subset of vulvodynia whereby a woman may experience unwanted genital arousal that is painful and unrelated to sexual desire. The cause of PGAD is unknown and treatment may be difficult, however, conservative strategies such as pelvic floor physiotherapy can help with associated tissue tightness and nervous system regulation. PGAD is no laughing matter as those who experience it often feel a lot of social withdrawal for fear that arousal or pain can occur at any time.
Clitoral phimosis occurs when the clitoral prepuce (aka hood) adheres to the glans of the clitoris when it should instead be retractable and mobile. The result may be a combination of pain, impaired sensitivity, and the inability to orgasm. Causes of this condition may be inflammatory dermatoses, lichens sclerosis, inadequate hygiene, blunt trauma, or chronic infections. As part of treatment, I often spend a great deal of time educating patients about vulvar and clitoral hygiene care, as well as, manually mobilizing the external myofascial tissue of the vulva.
Dyspareunia is a blanket term that describes pain during intercourse. There are several times when this pain can be experienced by a woman: upon entry into the vagina, during certain positions, or with deep penetration. Dyspareunia can either be primary (a lifelong issue where penetration has always been painful) or secondary (pain-free intercourse was initially possible until it suddenly became painful).
I see dyspareunia a lot in my practice, particularly in young, nulliparous women and especially amongst new mums. For the first six weeks postpartum, mum shouldn’t engage in intercourse as it is normal to have residual pain in the perineum that needs time to heal. After the six-week mark, however, perineal pain should subside and intercourse may safely resume. Unfortunately, many new mums experience lingering pain and burning at the vaginal opening for quite a while postpartum, especially if delivery was difficult, long, or left mum with a painful scar, either from C-section, episiotomy, or natural tearing.
No matter the situation, there are many solutions to dyspareunia. Talking to a qualified counsellor, for example, can help women and couples overcome the anxieties around vaginal intercourse. A sex therapist can help women reconnect intimately with their partners without having to worry about pain, while a pelvic floor physiotherapist can work to stretch and desensitize painful tissue, restore normal pelvic floor tone and strength, and improve overall comfort with and enjoyment of vaginal penetration.
Vaginismus can be a subtype of dyspareunia as many women with this condition also experience significant pain during intercourse. Vaginismus indicates that the muscles of the vaginal wall have gone into spasm and are significantly reducing the size of the vaginal opening. Although vaginismus can cause significant pain during intercourse, specifically upon entry, it can also cause pain during the use of a tampon, a vaginal suppository, or a Diva Cup. Vaginismus can affect a woman of any age; and is often associated with significant stress and fear of intercourse, having children, or using feminine hygiene products. Again, the solution is to address any underlying anxieties or concerns while also stretching the vaginal opening gradually over time.
Interstitial Cystitis (IC) / Bladder Pain Syndrome (BPS)
Historically, the terms ‘IC’ and ‘BPS’ have been used interchangeably in clinical and research settings. Both refer to a condition of suprapubic pain that is related to bladder filling and increased urinary frequency in the absence of infection or other pathology. Essentially, it feels like a urinary tract infection without having a urinary tract infection. This type of pelvic pain can affect men or women of any age and the cause is not well-understood. IC and BPS are two different conditions that may initially present the same, however, they each tend to affect different age groups, require different treatments, and have unique prognoses. A diagnosis of IC, for example, is made when fibrotic lesions (known as Hunner’s Lesions) have been found along the bladder wall; an objective finding that is not present in BPS.
Those who experience either IC or BPS often report frequent urination (>8 times per day), symptoms that have persisted for more than three months, waking at night to pee, and painful intercourse. Objectively, both IC and BPS will demonstrate decreased bladder capacity and early sensory urgency with urodynamic testing and cystoscopy; while patients with IC will also show fibrotic changes to the bladder wall.
Although there is no uniformly effective treatment for those affected, there is a lot of research to support the use of pelvic floor physiotherapy as the first line of defense against the symptoms of IC and BPS. Relaxing tight muscles and fascia, for example, can improve overall global symptoms score and significantly reduce urinary urgency and frequency. In my practice, I find the best success with treating IC and BPS to be through the use of individually-tailored treatment programs that target individual needs. There is no ‘blanket cure’ for IC or BPS, it is a matter of treating the unique needs of each patient.
Coccydynia refers to tailbone pain as a result of a fracture, a fall injury, childbirth, blunt trauma, mobility or joint restrictions, muscular stiffness or strain, or chronic constipation. Symptoms often include pain with sitting or supine lying, as well as during bowel movements, especially ones that require a lot of strain. Treatment usually involves the restoration and maintenance of normal tailbone range of motion, as well as, the proper lengthening and strengthening of pelvic floor muscles.
Dysmenorrhea refers to abnormally painful cramping during a woman’s menstrual cycle. There are two classifications of dysmenorrhea: primary (menstrual pain without pelvic pathology that began shortly after menarche) and secondary (menstrual pain associated with a pathology that began years after menarche). Dysmenorrhea affects 40-90% of women and often leads to regular or intermittent absenteeism from work, school, or social engagements. Some risk factors that can promote dysmenorrhea include smoking, a low body-mass index (BMI), early menarche (onset <12 years of age), irregular or heavy menses, poor intake of calcium or magnesium, or a history of trauma.
Many women who experience severe cramping during their menses believe it so be normal, but this is not so. Pelvic floor physiotherapy can be quite helpful in managing the tissue tightness that occurs during menses. I often encourage patients with dysmenorrhea to come see me during their cycles so that we can better manage symptoms while they are happening. It is also important for women experiencing severe menstrual pain to continue seeking medical advice until the root cause of the pain is discovered.
Endometriosis is a complex condition that affects approximately 10% of women of all ages. It refers to the abnormal growth of tissue, similar to that of the uterine lining, in other areas of the pelvic cavity or over pelvic organs, which eventually leads to the formation of cysts, lesions, and nodules. While some women with endometriosis experience few to no symptoms, others may initially experience dysmenorrhea that gradually worsens over time, dyspareunia, infertility or difficulties getting pregnant, nausea, bloating, vomiting, fatigue, or pelvic pain during exercise.
Endometriosis is the third most common gynecological disorder that requires hospitalization and is the leading cause of hysterectomies. Diagnosis of endometriosis can be difficult as laparoscopic surgery (keyhole surgery) is still considered the only way to accurately confirm the presence of abnormal endometrial tissue growth.
To date, treatments have included hormonal therapies that stop ovulation or better regulate estrogen levels. Surgeries are also performed to remove abnormal tissue growth and/or the uterus. Conservative options include dietary changes, pelvic floor physiotherapy, stress management, acupuncture, and naturopathic medicine. If you would like more information about endometriosis, please visit www.endometriosisnetwork.com.
Irritable Bowel Syndrome (IBS)
IBS refers to abdominal pain or discomfort that is associated with a fecal urgency, bloating, straining during bowel movements, a sense of an incomplete bowel evacuation, and the passage of bowel mucous. IBS is often associated with stress, food intolerances, allergies, serotonin dysfunction, and more. It can exist in conjunction with other conditions such as BPS, chronic fatigue, fibromyalgia, temporomandibular joint (TMJ) disorder, vestibulodynia, and tension headaches.
In my practice, I see a lot of men and women with IBS who report chronic pelvic pain. As a physiotherapist, I will often teach patients proper toileting positions to better aide in the passage of stool, as well as, help to relieve any muscular or joint restrictions in the pelvic floor that are associated with IBS. A referral to a registered dietician or naturopath is also beneficial in helping the systemic causes of IBS.
Chronic Non-Bacterial Prostatitis (CPPS)
This may come as a surprise but males too suffer from chronic pelvic pain! Conditions such as coccydynia, IC, BPS, and IBS can all present in males of any age. CPPS is a subset of prostatitis that refers to chronic pelvic pain affecting 10-15% of males without the presence of an infection or inflammatory agent to suggest causation. Etiology is still unknown, however, some theories believe that CPPS is a result of an infectious or inflammatory initiator that created lingering pelvic floor muscle tightness.
Symptoms of CPPS include increased frequency, urgency, or difficulty with urination, decreased stream, painful or weak ejaculation, or a sense of incomplete urinary emptying. Men may also experience rectal, penile, tailbone, suprapubic, or groin pain in addition to painful orgasms and chronic low back pain. In my practice, many patients also report feeling significant pain with sitting or the sensation of feeling like they are sitting on a golf ball. Treatment of CPPS often includes the release of trigger points in the pelvic floor and exercises that can help to stretch pelvic floor muscles and improve tailbone mobility.
So there you have it folks – a brief list of some of the more common chronic pelvic pain conditions that I see on a regular basis. Please allow me to leave you with two final thoughts: first, pelvic pain can be managed and even eliminated; do not think that you simply have to live with it… know your options. Second, try to avoid self-diagnosing through Google where there can be a lot of inaccurate or misleading information. Instead, seek the advice of your trusted healthcare professionals and have your pelvic floor checked here at Darou Wellness!
- Pelvic Health Solutions [onsite course October 2016]
- ISSWSH, IPPS, ISSVD Consensus on vulvar pain terminology committee, 2015
- Markos AR and Dinsmore W. Persistent genital arousal and restless genitalia: sexual dysfunction or subset of vulvodynia (2013). Int J STD Aids:1-7
- Landry et al. Arch Sexual Behaviour (2010), epub
- Shoskes D, Nickel JC. Clinical phenotyping in chronic prostatitis/chronic pelvic pain syndrome and IC: a management strategy. Prostate Cancer and Prostatitis Diseases (2008)
- Fitzgerald MP et al. J Urol 2012; 187:2113-2118
- Chrysanthopoulou EL and Doumouchtsis SK. Neurourol Urodyn 2014; 18:183-188
- De Andres J et al. Pain Practice 2016; 16:204-236
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