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If you have ever experienced discomfort between your ribcage and knees, you might suffer from pelvic pain due to pelvic floor dysfunction. This could mean pain during or after sex, pain with arousal, severe pain during your period, or just pain in your genitals or rectum. Pelvic pain is rarely caused by just one issue. More often than not, it’s caused by a combination of factors, including impairments of the pelvic floor muscles, the central and peripheral nervous systems, and even behavioral issues, like poor posture or urinating “just in case.” If you have experienced pelvic pain, you are certainly not alone. It is estimated that 20% of women* and 8% to 10% of men* experience pelvic pain at some point in their lives. Your pelvic health is important because the pelvis helps support all of your pelvic organs which includes the bladder, colon and prostate for men or uterus for women. The muscles in the pelvis help provide stability and postural support, so it’s not all about the abs when it comes to your core!  

What is “pelvic pain?”

Common Symptoms of pelvic pain often include one or a combination of the following:

  • provoked or unprovoked vulvar, vaginal, clitoral, perineal or anal pain
  • pain during or after sex
  • interlabial, vulvar or genital itching
  • painful urination, urinary hesitancy, urgency, and/or frequency
  • abdominal and groin pain
  • sacroiliac joint/low back pain/instability
  • constipation
  • painful periods
  • difficulty wearing jeans, pants, or underwear
  • pain with sitting
  • difficulty exercising
  • penoscrotal/perineal or anal pain
  • post-ejaculatory pain
  • erectile dysfunction
  • tailbone pain/coccydynia
  • decreased force of urinary stream
  • constipation
  • groin pain

Is it all in my head?

No. Your pain is very real. However, it is important to recognize that pain does come from the pain center which is located in your brain. Typically, your brain sends out a pain signal to warn you that something “bad” is happening in your body. For instance, if you step on a nail, the nerves in your foot send a signal to the brain that damage has occurred, so your brain sends out a pain signal to let you know. Once you pull the nail out, the pain should decrease as your body realizes the threat is gone, and your brain realizes it no longer needs to tell you there is a problem. Sometimes, your brain sends out a pain signal when there isn’t a threat or damage occurring. Does this sound familiar: You think you have a UTI, so you go to the doctor, get a urine test, and the results return positive for bacteria. You are prescribed antibiotics and you take them, but you still feel like you have a UTI! You go back to the doctor, they repeat the urine test, and it’s negative. So there is no longer an infection, but you still have symptoms?! The phenomenon occurring is that although there is no longer an actual threat, your pelvic floor muscles may still be tightening to protect your bladder, but your brain only knows what the muscles tell it, so the brain sends out a pain signal. 

That was a very long winded way of saying, yes, your pain is real, but it does not necessarily mean there is active damage occurring. While you are not making up what you are feeling, it is important to recognize that the brain is in charge of the pain that your feel. 

Common diagnoses:

Dyspareunia

pain during or after sex or penetrative intercourse. There are many things that can cause or contribute to pain with sex. Some examples include: lack of lubrication, an infection or congenital abnormalities, such as an intact hymen or pelvic floor muscle dysfunction. Patients with other medical conditions such as endometriosis, fibroids, irritable bowel syndrome, or people with cancer or undergoing cancer treatment such as radiation or chemotherapy may also experience painful sex. Medications such as birth control, environmental factors, and even stress can lead to dyspareunia. 

Vulvodynia

pain in the vulva. In 2014, the Executive Council of the International Society for the Study of Vulvovaginal Disease (ISSVD), the Boards of Directors of the International Society for the Study of Women's Sexual Health (ISSWSH), and the International Pelvic Pain Society (IPPS) met to develop new terminology for vulvar pain and vulvodynia [1]. They determine vulvar pain could be divided into two categories: pain with a specific disorder and/or vulvodynia which is pain in the vulva with unknown origin that has persisted for at least three months. Some of the same comorbidities that lead to dyspareunia, can also cause vulvodynia. Vulvodynia is further broken down by multiple descriptors that you can find in this article here. 

Vaginismus

characterized by involuntary contractions of the pelvic floor muscles, particularly the muscles surrounding the vaginal opening. These muscle spasms can cause unexplained sexual pain and difficulty with penetration. Vaginismus is often revealed during penetration attempts, such as those made by inserting a finger, a tampon, a penis, or a speculum during a gynecological exam. The individual may report a feeling of having a “wall” at their vaginal opening, and that they/their partner/physician is unable to get past the “wall.”

Endometriosis

painful, chronic disorder that affects over 6 million women and girls in the U.S., and millions more worldwide. It occurs when tissue that normally lines the inside of your uterus (the endometrium) grows outside your uterus. This tissue breaks down and bleeds during your period, causing painful scar tissue. If you have signs or symptoms that may indicate endometriosis, see your doctor for treatment. Symptoms may include: 

  • heavy bleeding during and between periods
  • pain during sex
  • infertility
  • painful urination/bowel movements during menstruation

Uterine fibroids

another condition associated with painful periods. Fibroids are noncancerous growths of muscle tissue of the uterus that range in number and size. As many as 70-80% of all women have fibroids by age 50. In addition to cramping and pain during your period, the symptoms for fibroids may also include: 

  • heavier bleeding, sometimes with blood clots
  • longer or more frequent menstruation
  • spotting between periods
  • pressure on the bladder or rectum
  • frequent urination
  • constipation and/or rectal pain
  • lower back and/or abdominal pain

What about male pelvic pain? 

Male pelvic pain is pretty similar to female pelvic pain. All of the internal anatomy is the same after all, the only differences being that men have a prostate and different external anatomy. So, men can experience pain with erections, ejaculation/orgasm and sex. Just like women, male pelvic pain can be due to an infection or another medical condition: cancer, IBS or a hernia to name a few. Men can also develop pelvic floor muscle dysfunction that can contribute or cause pelvic pain. This dysfunction can also cause erectile dysfunction! 

How? 

In order for someone to have an erection several things need to happen. First, blood flow rushes into the penis and then the pelvic floor muscles contract to keep the penis engorged or hard. The pelvic floor muscles must stay in this contracted position to maintain the erection. Then these muscles contract and relax to allow an orgasm or ejaculation to occur. Therefore, if these muscles are dysfunctional and unable to do their job correctly you can see how a man may develop pain with sexual function or have difficulty obtaining or maintaining an erection. This is why pelvic floor physical therapy can help men who have erectile dysfunction and/or pelvic pain. 

* reference to cisgendered women and men

tabú tip:

Your pain is valid. If you experience chronic discomfort, seek the treatment you deserve!

This basic is brought to you by Rachel Gelman, DPT, PT at the Pelvic Health and Rehabilitation Center. PHRC specializes in the physical therapy management of numerous pelvic pain disorders. They believe in a multi-disciplinary, collaborative approach to diagnose and treat all components of pelvic pain. PHRC has five locations in San Francisco, Berkeley, Los Gatos, Los Angeles and Lexington, MA.


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