Pelvic and Nerve Pain
Pelvic Pain has many names and causes, only a few of which are the pelvic floor: Treating pelvic pain is what we are known for and excel at. By using incredibly specific manual techniques such as visceral manipulation, neural manipulation, fascial work, internal (rectal and vaginal) and external pelvic muscle treatment, vascular enhancing techniques, bony alignment, we can change the structures that cause pain. Pelvic pain will rarely respond to exercise alone. It takes very specific manual treatment, which will be different each session, to change the pattern in the tissues.
Pelvic Floor Dysfunction
The pelvic floor is a wondrous structure: 4 superficial muscles, 4 mid-layer muscles, 4 pelvic floor muscles, and 2 pelvic wall muscles. Each can be reached and treated a bit differently. One can be tight and another weak, depending on the person. Each muscle has its own function, and after a baby comes through, they may be quite different side to side. When they are working well they control the appropriate flow and discharge of urine or feces, help us orgasm, support our pelvis, help with blood flow out of the pelvis after intercourse, and are generally pretty amazing. But when the nerve to them is overactive, they stay a bit tight, and sometimes after an incident, such as birth, they may need a bit of help learning to work again.
Pudendal (or other) Neuralgia
The pudendal nerve is amazing in function. It helps us feel sensations of pleasure, helps pelvic floor muscles to contract, and helps us to have control of our bladder and bowels. But this special structure has a somewhat tortured pathway: out the greater sciatic foramen, under the piriforms, wrapping around the sacrospinous ligament, back in through a hole called the lesser sciatic foramen, traveling in a tunnel between a pelvic floor and wall muscle (alcock’s canal), while under an incredibly dense ligament (the sacrotuberous ligament), then exiting the internal pelvis just inside the sitting bone (ischial tuberosity), where it is easily irritated by a bike seat, to travel in 3 branches (one to genitals, one to perineum, and one to anus). It can be entrapped anywhere along that pathway or pinched between the sacrospinous and sacrotuberous ligament. As if that is not enough, the plexus it comes from (sacral plexus) shares so many fibers with the sciatic nerve, that if
there is a history of sciatica, it can keep that pain alive. We treat every one of those structures, to give the nerve more room, less compression. Infact, I teach a class Iwrote with Herman Wallace that specifically teaches how to treat the pudendal and sacral plexus nerves. II have never seen a pudendal nerve calm down with pelvic floor stretching alone….it’s too non-specific for the problem. And the nerve will get irritated if you stretch and glide it without decompressing it. I’d love to help you get over this pain!
Coccyxdynia (tailbone pain)
The coccyx is wonderous structure. All of the pelvic floor muscles connect with it, it is the attachment site for the two most stabilizing ligaments in the pelvis, and it should have 30 degrees of motion and move with pelvic floor motion. The problem is when someone has a fall onto their behind (particularly on steps), or perhaps with birth, the tailbone can heal. Or, sometimes after surgical fixation to one of those ligaments after a hysterectomy, it can get pulled over to the side. If the pelvic floor muscles are firing unequally, it can get out of alignment. And then, the small coccygeal nerves, anococcygeal ligament, or the coccygeus muscle can get very tender. We can adjust this and treat all the attaching structures, so it does not have to hurt you.
Pudendal (or other) Neuralgia
The pudendal nerve is amazing in function. It helps us feel sensations of pleasure, helps pelvic floor muscles to contract, and helps us to have control of our bladder and bowels. But this special structure has a somewhat tortured pathway: out the greater sciatic foramen, under the piriforms, wrapping around the sacrospinous ligament, back in through a hole called the lesser sciatic foramen, traveling in a tunnel between a pelvic floor and wall muscle (alcock’s canal), while under an incredibly dense ligament (the sacrotuberous ligament), then exiting the internal pelvis just inside the sitting bone (ischial tuberosity), where it is easily irritated by a bike seat, to travel in 3 branches (one to genitals, one to perineum, and one to anus). It can be entrapped anywhere along that pathway or pinched between the sacrospinous and sacrotuberous ligament. As if that is not enough, the plexus it comes from (sacral plexus) shares so many fibers with the sciatic nerve, that if
there is a history of sciatica, it can keep that pain alive. We treat every one of those structures, to give the nerve more room, less compression. Infact, I teach a class Iwrote with Herman Wallace that specifically teaches how to treat the pudendal and sacral plexus nerves. II have never seen a pudendal nerve calm down with pelvic floor stretching alone….it’s too non-specific for the problem. And the nerve will get irritated if you stretch and glide it without decompressing it. I’d love to help you get over this pain!
Coccyxdynia (tailbone pain)
The coccyx is wonderous structure. All of the pelvic floor muscles connect with it, it is the attachment site for the two most stabilizing ligaments in the pelvis, and it should have 30 degrees of motion and move with pelvic floor motion. The problem is when someone has a fall onto their behind (particularly on steps), or perhaps with birth, the tailbone can heal. Or, sometimes after surgical fixation to one of those ligaments after a hysterectomy, it can get pulled over to the side. If the pelvic floor muscles are firing unequally, it can get out of alignment. And then, the small coccygeal nerves, anococcygeal ligament, or the coccygeus muscle can get very tender. We can adjust this and treat all the attaching structures, so it does not have to hurt you.
SI Joint Pain
The Sacroilliac joint connects the bottom of the spine with the base of the spine. It has very few degrees of motion. But, it can get inflamed. Often, this pain is kept alive with the uterosacral ligaments that are attaching to the front side, so doing visceral (organ) work, can often help resolve those cases that keep needing “realignment” that have not responded to other types of PT. Also, the coccyx should always be treated with the sacrum as well as dural tension throughout the nervous system. We can address all of that for
you.
Vulvadynia or Vulvar Vestibulitis
Vulvadynia is just the medical way of stating the vulva has pain. It’s a bit of a nonspecific diagnosis. Vulvar pain in the absence of other known pathology.
Common complaints are: a burning sensation in the vaginal region, simple touch feeling like burning or scraping, or poking. Patients may have an inability to wear tight or fittend slacks or tolerate the feel of underwear or sensation of tampons. Sometimes patients report an unrelenting itching that does not have a dermatologic or infection origin.
The reason? Well, that is not so well understood. There are literally dozens of possible reasons. In some cases, there is a link with autoimmunity or other inflammatory conditions in the body. Sometimes there are abnormal c-fibers in the tissue, sometimes it is a pudendal nerve issue.
Often tight pelvic floor muscles are involved (either a precursor or a result of the pain). The honest truth is that we often don't know the exact cause, but we have treatments which often help. Part of the reason for our 2 hour initial visit is to assess several possible factors: entrapped genitofemoral or dorsal or perineal branches of the pudendal nerve, carefully assessing the integrity of the skin, evaluating the pelvic floor muscle and wall tension, assessing the deep fascia in the abdominopelvic cavity, and getting a clear treatment plan. The truth is that the pain is often multifactorial, and it takes a bit of detective work to assess the system as a whole. We often find that treating the pathway of the genitofemoral, ilioinguinal and pudendal nerves and doing
very specific fascial work in the areas of the labia, mons, and peri clitoral tissues free up enough small and large nerve endings to help the pain reduce.
Vulvar vestibulitis is a specific form of vulvadynia, in which the tissues at the entry to the opening of the vaginal canal are hypersensitive. Vulvar vestibulitis patients often have increased c-fibers or pain sensitive fibers in the tissues in this small area. Sometimes the area just at the opening of the vagina is red and inflamed.
· Please know that whether you are vulvadynia or vestibulitis sufferer, you are not alone, and you are definitely NOT crazy. Many therapies are available to help reduce or eliminate this pain. Often many manual techniques internally and externally, including visceral mobilization, myofasical techniques and direct muscle release techniques (internal and external ) are helpful. We may contact your referring physician regarding topical agents we may suggest as prescriptions to assist the treatment. We may refer you to a vulvar pain specialist to help us. Additionally, extensive lifestyle modification tips, from self care to diet to meditation or yoga technique may be utilized.
Dyspareunia
Dyspareunia is the medical term for painful sex. I like to think of it as painful intimacy, because people can have many kinds of sex lives, and it can limit any of those, including self pleasure. It usually does not go away by ignoring it, and it can be very isolating and hard to talk about. There can be many components to dyspareunia. Sometimes it is a cutaneous/superficial irritation (see vulvadynia and vulvar vestibulitis above).
When it is due to spasm at the opening of the vagina causing a small opening (which is actually a SMALL percentage of dyspareunia), it is referred to as vaginismus. When the deeper muscles in the vagina or the pelvic floor are tight and painful, it may be referred to as levator ani syndrome. Men can also have dyspareunia, see male pain section.
Patients may report they have had pain since a vaginal birth injury or an episiotomy. Many patients also report pain after a pelvic floor repair or hysterectomy. Similarly, patients who are cancer survivors also have vaginal pain after radiation or hormone therapy.
· Common patient descriptors are as follows: “It feels like a too tight fit with my partner”, “ It feels like my partner is hitting something”, “I have cramping when I have sex”, I have a tearing sensation when I try to have sex”, “I have burning with sex”, "it feels like period cramps during and after sex," among many others.
· Regardless of the cause, it is not your fault or something you did wrong. There are many reasons for dyspareunia, and there are now many therapy options to heal it. Often very specific manual therapy that goes far more specific than stretching internal pelvic floor muscles can be helpful, as can working small fascial restrictions all around the vulvar (or penile) region.
Rectal Pain
The rectum is the end of the colon, before it exits the body at the anal canal.
· Patients may report pain with bowel movements that can last for hours. Sometimes it is before, sometimes after. It may or may not be related to when one has their menses, or perhaps when attempting to enjoy anal intercourse.
· When fleeting and intense, it can be called procticalgia fugax. At times it can cause a patient to awaken in the night or can come on with no rhyme or reason. Patients sometimes report a pain so severe that it stops them from leaving the house or working.
· At times it is more of a minor annoyance.
· Some people have a persistent ache or a pain that grows with sitting.
· The patient may state they have a pain deep in the buttock that is difficult to define.
· We can help stop the suffering! A muscle spasm by any other name is still a muscle spasm. It often responds well to direct stretching. Additionally, by releasing other structures in the region with visceral manipulation or neural manipulation or learning muscle retraining with biofeedback, patients can learn to break this cycle of pain. We do offer intrarectal as well as intravaginal manual therapies at our clinic, so we can get to the source of the problem.
Post birth pain (csection or vaginal)
Growing a baby is a lot of work. Getting it out is one of the most difficult things your body will have to do.
With vaginal birth, muscles can get stretched or torn. In almost 30 percent of births, women can have an avulsion (disconnection from bone) of the pubococcygeus muscle, and most may never know. Babies do not come through symmetrically, left and right sides may need to be retrained and rehabbed differently. It’s rare for every muscle to be tight or every muscle to be weak. Starting with a most excellent and thorough evaluation will allow us to make a plan and to understand how to care for your pelvis the rest of your life. The pelvis is meant to birth, but the US is one of the few developed countries that neglects the need for post vaginal birth care.
C-sections are necessary to preserve the health of the baby in many cases. It makes me sad when women feel like they somehow failed or were less than for this. The truth is, c-sections leave a more intact pelvic floor, and the safest birth for all parties is the best outcome. Usually the scar will benefit from care and manual therapy to help mobilize it and decrease adhesive or restricted motion issues around the bladder and the small intestine. Sometimes people come to me 3 or 9 years after a c-section with pain in the area or bladder leakage, and working the fascia, viscera, and scar almost always helps the issue
we can begin care as soon as 6 weeks after birth or as far out as a couple of decades. There is no expiration for care.
Male Pelvic Pain
Yes, men have pelvises, so yes, men can have pelvic pain. Whether it is testes pain from the spermatic cord and ilioinguinal nerve, or penile base pain from fascial restriction, or deep pelvic pain from levator tightness, we treat men’s pelvises with the same level of attention and specificity as women (not just rectal work or avoiding treating the pelvis). We treat post hernia repair pain, post vasectomy pain.
