Chronic Pelvic Pain and Dysfunction Practical Physical
Medicine
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Contents
Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii
Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi
1 An introduction to chronic pelvic pain and associated symptoms . . . . . . . . . . . . 1
Leon Chaitow, Ruth Lovegrove Jones
2.1 An introduction to the anatomy of pelvic pain . . . . . . . . . . . . . . . . . . . . . . 11
Ruth Lovegrove Jones
2.2 Anatomy and biomechanics of the pelvis . . . . . . . . . . . . . . . . . . . . . . . . . 13
Andry Vleeming
2.3 Anatomy of the pelvic floor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Ruth Lovegrove Jones
3 Chronic pain mechanisms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Andrew Paul Baranowski
4 Psychophysiology and pelvic pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Christopher Gilbert, Howard Glazer
5 Gender and chronic pelvic pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Maria Adele Giamberardino, Giannapia Affaitati, Raffaele Costantini
6 Musculoskeletal causes and the contribution of sport to the evolution of chronic
lumbopelvic pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
Bill Taylor, Ruth Lovegrove Jones, Leon Chaitow
7 The role of clinical reasoning in the differential diagnosis and management
of chronic pelvic pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
Diane Lee, Linda-Joy Lee
8.1 Multispeciality and multidisciplinary practice: A UK pain medicine perspective . . . 165
Andrew Paul Baranowski
8.2 Interdisciplinary management of chronic pelvic pain: A US physical
medicine perspective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
Stephanie A. Prendergast, Elizabeth H. Rummer
8.3 Chronic pelvic pain and nutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185
Leon Chaitow
9 Breathing and chronic pelvic pain: Connections and rehabilitation features . . . . . 193
Leon Chaitow, Chris Gilbert, Ruth Lovegrove Jones
10 Biofeedback in the diagnosis and treatment of chronic essential
pelvic pain disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227
Howard I. Glazer, Christopher Gilbert
11.1 Soft tissue manipulation approaches to chronic pelvic pain (external) . . . . . . . . 247
César Fernández de las Peñas, Andrzej Pilat
v
Contents
11.2 Connective tissue and the pudendal nerve in chronic pelvic pain . . . . . . . . . . . 275
Stephanie Prendergast, Elizabeth H. Rummer
12 Evaluation and pelvic floor management of urologic chronic pelvic
pain syndromes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 291
Rodney U. Anderson
13 Practical anatomy, examination, palpation and manual therapy release
techniques for the pelvic floor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311
Maeve Whelan
14 Patients with pelvic girdle pain: An osteopathic perspective . . . . . . . . . . . . . . 339
Michael A. Seffinger, Melicien Tettambel, Hallie Robbins
15 Intramuscular manual therapy: Dry needling . . . . . . . . . . . . . . . . . . . . . . . 363
Jan Dommerholt, Tracey Adler
16 Electrotherapy and hydrotherapy in chronic pelvic pain . . . . . . . . . . . . . . . . . 377
Eric Blake
Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 395
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 429
vi
Contributors
Tracey Adler DPT Linda-Joy Lee BSC, BSC(PT), FCAMT, MCPA
Physical Therapist, Orthopedic Physical Therapy Inc., Physiotherapist, SynergyPhysio, California, USA
Richmond, Virginia, USA
Andrzej Pilat PT
Giannapia Affaitati MD Professor, School of Physiotherapy, San Lorenzo de El
University of Chieti, Italy Escorial, Madrid, Spain
Rodney Anderson MD
Professor of Urology, Stanford University School of Stephanie Prendergast MPT
Medicine, Stanford, California, USA Physiotherapist, Pelvic Health and Rehab Center, San
Francisco California, USA
Andrew Baranowski MB BS BSc FRCA MD FFPMRCA
Consultant in Urogenital Pain Medicine, The National Hallie J. Robbins DO
Hospital for Neurology and Neurosurgery, London, UK Osteopathic Physician, Integral Rehabilitation, Salt Lake
City, Utah, USA
Eric Blake ND, MSOM
Adjunct Faculty, National College of Natural Medicine,
Elizabeth Rummer MSPT
Portland, Oregon USA
Physiotherapist, Pelvic Health and Rehabilitation Center,
San Francisco, California, USA
Raffaele Costantini MD, PhD
University of Chieti, Italy
Michael A. Seffinger DO
Jan Dommerholt PT, DPT, MPS, DAAPM Associate Professor and Chair, Department of
President & Physical Therapist, Bethesda Physiocare, Inc., Neuromusculoskeletal Medicine/Osteopathic Manipulative
Bethesda, Maryland, USA Medicine, College of Osteopathic Medicine of the Pacific,
Western University of Health Sciences, Pomona, California,
César Fernández de las Peñas PT, PhD USA
Doctor of Physiotherapy, Department of Physiotherapy,
University Rey Juan Carlos, Madrid, Spain William Taylor PT
Owner and Director, Taylor Physiotherapy, Edinburgh, UK
Maria Adele Giamberardino MD
University of Chieti, Italy
Melicien Tettambel DO, FAAO,FACOOG
Doctor of Osteopathy, Pacific Northwest University of
Christopher Gilbert PhD
Health Sciences, College of Osteopathic Medicine,
Staff Psychologist, Department of Physical Therapy,
Yakima, Washington, USA
University of California, California, USA
Howard I. Glazer Ph.D. Andry Vleeming PT, PhD
Clinical Associate Professor, Weill College of Medicine, Department of Rehabilitation and Kinesiotherapy,
Cornell University;Associate Attending, New York Medical University Ghent, Belgium Medical
Presbyterian Hospital of Columbia and Cornell Medical University of New England, Department of Anatomy,
Colleges, New York, USA Maine, USA
Diane Lee BSR, FCAMT, CGIMS Maeve Whelan PT
Owner, Director and Physiotherapist, Diane Lee & Chartered Physiotherapist, Milltown Physiotherapy Clinic,
Associates, Surrey, British Columbia, Canada Dublin, Ireland
vii
Intentionally left as blank
Foreword
The treatment of pelvic pain and dysfunction spans a all anatomical and pelvic structures, and including
very wide field of knowledge, expertise and practice. the essential role the nervous system plays.
Accurate diagnosis and successful treatment can be This book provides a wide-reaching and extremely
very tricky; to get to the root of the problem within comprehensive range of practical solutions to the
this area can be extremely difficult, and many spe- treatment and diagnosis of patients presenting with
cialists in related fields may well find this a very chal- chronic pelvic pain and dysfunction. Approaches in-
lenging an area into which to venture. cluding breath work and chronic pelvic pain, biofeed-
In this book, various aspects of chronic pelvic pain back techniques, and soft tissue manipulations are
are brought together. Although some may be well discussed. The result is a very practical, generously
known to experts in a particular field of knowledge, illustrated guide to the treatment and diagnosis of
they may be unknown to experts in other fields, so this chronic pelvic pain, and one that is innovative in its
book is a very welcome addition for any practitioner approach to dealing with pelvic pain and dysfunction.
whose work may routinely include treating patients In a difficult and challenging subject area, this is a co-
with pelvic pain of any kind. In making an informed herent volume that helpfully gathers together the va-
diagnosis, the anatomy of joints, ligaments, fasciae, riety of regimens and techniques that are often
muscles and viscera, biomechanics, and structural required in effectively diagnosing these all too com-
properties are just some of the factors that have to mon conditions with which so many patients present.
be taken into account, and these are all widely dis- This will be a welcome edition to the library of many
cussed and examined here. What this book further rec- a practitioner for years to come!
ognises is that the nature of pelvic pain is often
complicated, and although pain may be diagnosed Magnus Fall, MD, PhD
and treated as a strictly physiological symptom, it is of- Göteborg
ten the case that this underpins a constellation of symp- Sweden
toms, necessitating the consideration, in diagnosis, of May 2011
ix
Intentionally left as blank
Acknowledgements
As co-editors we wish to express our thanks to the three years of collaboration both harmonious and
editorial team at Elsevier, whose friendly support productive.
has helped to bring this text to the point of publica- My personal thanks go to my wife, Alkmini, for
tion. There are too many to mention, but a special creating and maintaining the peaceful and loving en-
vote of thanks goes to Alison Taylor, whose steadying vironment in which the arduous hours of writing and
advice helped us through difficult periods. editing passed peacefully.
Our sincere gratitude also goes to the wonderful RLJ: It’s true, I had no idea how much time and
team of chapter authors, without whose knowledge effort co-editing this, my first book, would take,
and skills the breadth and depth of the pelvic pain yet I am delighted that Leon Chaitow asked me, even
story could not have been adequately told. We are if times I have thought “what was I thinking?!” It has
hopeful that the contents of this book will shine some been a privilege and honour to work with this won-
light and ease the journey of those patients with derful teacher and his dedication to his path shone
chronic pelvic pain. through, even at our most difficult times. Finally,
LC: I wish to offer particular praise and thanks as is always the way; my personal thanks to Stevie
to my co-editor, Ruth Lovegrove Jones, who I be- Steve and our magnificent daughter Hannah Morgan,
lieve agreed to participate in this project without for all their love and support. Namaste.
realising just how much time and effort it would
demand. Her intellectual focus, innate skills and Leon Chaitow, Corfu, Greece
natural enthusiasm helped to make the almost Ruth Lovegrove Jones, Hampshire, UK
xi
Intentionally left as blank
1
An introduction to chronic
pelvic pain and associated
symptoms
Leon Chaitow Ruth Lovegrove Jones
CHAPTER CONTENTS Definitions of chronic pelvic
Introduction . . . . . . . . . . . . . . . . . . ...... 1 pain syndromes
Definitions of chronic pelvic pain
syndromes . . . . . . . . . . . . . . . . . . ...... 1
It is suggested that approximately 15–20% of
Chronic pain . . . . . . . . . . . . . . . . . ...... 4
women, aged 18–50 years, have experienced CPP
Pelvic girdle pain and CPP: lasting for more than one year (Howard 2000) and
To separate or combine? . . . . . . . . . . . . . . . 4
a prevalence of 8% CPPS is estimated in the US male
Connecting PGP with CPP . . . . . . . . . . . . . . 5 population (Anderson 2008). However, overall prev-
Aetiological features of CPP . . . . . . . . . . . . 5 alence rates of CPP are likely to be underdiagnosed,
Beyond single causes . . . . . . . . . . . . . . . . . 6 in part due to the lack of agreed-upon definitions and
Treatment aimed at pathology is only subsequent difficulty in categorizing CPP (Clemens
part of the answer . . . . . . . . . . . . . ...... 7 et al. 2005, Fall et al. 2010).
Pain is defined as ‘an unpleasant sensory and emo-
tional experience, associated with actual or potential
Introduction tissue damage, or is described in terms of such
damage’ (Merskey & Bogduk 2002) and central neu-
This book has a single primary aim – to offer a one- rological mechanisms will play a major role in the
stop source of relevant information for clinicians – aetiology and pathophysiology of CPP. To emphasize
specialists, practitioners and therapists – on the sub- that pathology would not always be found where the
ject of non-malignant chronic pelvic pain (CPP), with pain was perceived and that there would most likely
particular emphasis on current trends in physical be overlapping mechanisms and symptoms between
medicine approaches to assessment, treatment, man- different CPP conditions, the updated European
agement and care. Association of Urology (EAU) classification of CPP
The purpose of this chapter is to: (Fall et al. 2010) reflected a shift from definitions
1. Highlight the current classifications of chronic based on assumptions of pathophysiological causes,
pelvic pain syndromes (CPPS) and define the to one based on recommendations of the Inter-
terms used within this book; national Association for the Study of Pain (IASP)
2. Summarize the layout of the book and the topics (Merskey & Bogduk 2002) and the International
covered in individual chapters; Continence Society (ICS) (Abrams et al. 2003).
3. Inform the reader of how little is known about the Chronic pelvic pain is non-malignant pain perceived in
aetiology of CPP; structures related to the pelvis of either men or women.
4. Remind the reader that as most treatment options In the case of documented nociceptive pain that becomes
are currently empirical, there is a great requirement chronic, pain must have been continuous or recurrent for at
for careful clinical reasoning when approaching the least 6 months. If non-acute and central sensitization pain
mechanisms are well documented, then the pain may be
management of a patient with CPP.
ã 2012 Elsevier Ltd.
Chronic Pelvic Pain and Dysfunction
regarded as chronic, irrespective of the time period. In all cognitive, behavioural, sexual and emotional consequences
cases, there often are associated negative cognitive, as well as with symptoms suggestive of lower urinary tract,
behavioural, sexual and emotional consequences sexual, bowel or gynaecological dysfunction.
(Fall et al. 2010)
Therefore in most examples of CPP-related syn-
Chronic pelvic pain is then subdivided into those
dromes, and those listed in Box 1.1, marked with
conditions with well-defined classical pathology,
an asterisk, it is important to note that they are not
such as infection and cancer, and those where no
the result of infection or pathology, and are charac-
obvious pathology is found. Chronic pelvic pain syn-
terized by persistent, recurrent or episodic pain
drome (CPPS) is therefore defined as:
(Abrams et al. 2002, Fall et al. 2010).
The occurrence of chronic pelvic pain where there is no This shift in definition is important to avoid incor-
proven infection or other obvious local pathology that may rect diagnostic terms and descriptors as erroneous
account for the pain. It is often associated with negative diagnostic terms are frequently associated with
Box 1.1
Common chronic pelvic pain syndromes (Fall et al. 2010, Abrams et al. 2003)
Note: The selection of CPP-associated syndromes on this characterized by urgency, and (commonly) the finding of
list does not include acute variants, and the word chronic submucosal haemorrhage (glomerulations) on
implies the presence of the symptom for not less than endoscopy. IC is immediately ruled out in the presence of
6 months. a variety of pathological conditions, including bacterial
Note: Syndromes marked * have no proven infection or infection (Hanno et al. 1999, Peeker & Fall 2002).
other obvious pathology and are characterized by • Pelvic floor muscle pain: * Persistent or recurrent,
persistent, recurrent or episodic pain. episodic, pelvic floor pain with associated trigger
• Anorectal pain syndrome: * Persistent or recurrent, points, which is either related to the micturition cycle or
episodic rectal pain with associated rectal trigger associated with symptoms suggestive of urinary tract,
points/tenderness related to symptoms of bowel bowel or sexual dysfunction.
dysfunction. • Pelvic pain syndrome: Persistent or recurrent episodic
• Bladder pain syndrome: * Suprapubic pain related pelvic pain associated with symptoms suggesting lower
to bladder filling, accompanied by other symptoms urinary tract, sexual, bowel or gynaecological
such as increased daytime and night-time frequency, dysfunction. No proven infection or other obvious
with no proven urinary infection or other obvious pathology (Abrams et al. 2002).
pathology. The European Society for the Study of • Penile pain syndrome: * Pain within the penis that is not
IC/PBS (ESSIC) publication places greater emphasis primarily in the urethra. Absence of proven infection or
on the pain being perceived in the bladder (Van de other obvious pathology (Fall et al. 2010).
Merwe et al. 2008).
• Perineal pain syndrome: * Persistent or recurrent,
• Clitoral pain syndrome: * Pain localized by point- episodic, perineal pain either related to the micturition
pressure mapping to the clitoris. cycle or associated with symptoms suggestive of urinary
• Endometriosis-associated pain syndrome: Chronic tract or sexual dysfunction.
or recurrent pelvic pain where endometriosis is • Post-vasectomy pain syndrome: Scrotal pain
present but does not fully explain all the symptoms syndrome that follows vasectomy.
(Fall et al. 2010).
• Prostate pain syndrome: Persistent or recurrent
• Epididymal pain syndrome: * Persistent or recurrent episodic prostate pain, associated with symptoms
episodic pain localized to the epididymis on examination. suggestive of urinary tract and/or sexual dysfunction (Fall
Associated with symptoms suggestive of urinary tract or et al. 2010). This definition is adapted from the National
sexual dysfunction. No proven epididymo-orchitis or Institutes of Health (NIH) consensus definition and
other obvious pathology (a more specific definition than classification of prostatitis (Krieger et al. 1999) and
scrotal pain syndrome (Fall et al. 2010). includes conditions described as ‘chronic pelvic pain
• Interstitial cystitis (IC): Within the EUA guidelines, IC is syndrome’. Using the NIH classification system, prostate
included within painful bladder pain syndromes. It is pain syndrome may be subdivided into type A
frequently diagnosed by exclusion. Positive factors (inflammatory) and type B (non-inflammatory).
leading to a diagnosis of IC include: bladder pain • Pudendal pain syndrome: A neuropathic-type pain
(suprapubic, pelvic, urethral, vaginal or perineal) arising in the distribution of the pudendal nerve with
on bladder filling, relieved by emptying, and symptoms and signs of rectal, urinary tract or sexual
2
An introduction to chronic pelvic pain and associated symptoms CHAPTER 1
Box 1.1
Common chronic pelvic pain syndromes (Fall et al. 2010, Abrams et al. 2003)—cont’d
dysfunction. (This is not the same as the well-defined • Vestibular pain syndrome (formerly vulval
pudendal neuralgia.) vestibulitis): Refers to pain that can be localized by
• Scrotal pain syndrome: * Persistent or recurrent point-pressure mapping to one or more portions of the
episodic scrotal pain associated with symptoms vulval vestibule.
suggestive of urinary tract or sexual dysfunction. No • Vulvar pain syndrome: Subdivided into generalized
proven epididymo-orchitis or other obvious pathology and localized syndromes:
(Abrams et al. 2003). This may be unilateral or bilateral, • Generalized (formerly dysaesthetic vulvodynia):
and is a common complaint in urology clinics. Refers to vulval burning or pain that cannot be
• Testicular pain syndrome: * Persistent or recurrent consistently and tightly localized by point-pressure
episodic pain localized to the testis on examination, ‘mapping’ by probing with a cotton-tipped
which is associated with symptoms suggestive of applicator or similar instrument. The vulval vestibule
urinary tract or sexual dysfunction. No proven may be involved but the discomfort is not limited
epididymo-orchitis or other obvious pathology. This is a to the vestibule. Clinically, the pain may occur with
more specific definition than scrotal pain syndrome or without provocation (touch, pressure or friction)
(Abrams et al. 2002). (Abrams et al. 2002).
• Urethral pain syndrome: * Recurrent episodic urethral • Localized: Refers to pain that can be consistently
pain, usually on voiding, with daytime frequency and and tightly localized by point-pressure mapping
nocturia (Abrams et al. 2003). to one or more portions of the vulva. Clinically,
• Vaginal pain syndrome: * Persistent or recurrent the pain usually occurs as a result of
episodic vaginal pain associated with symptoms provocation (touch, pressure or friction) (Abrams
suggestive of urinary tract or sexual dysfunction. et al. 2002).
inappropriate investigations, treatments, patient Baranowski (2009) suggests that where pain is
expectations and potentially a worse prognostic out- a major feature of a condition it is appropriate to name
look (Fall et al. 2010). the region/area/organ where the individual perceives
Terms that imply infection or inflammation the pain – for example painful bladder syndrome. Such
should be avoided unless these are known to exist. a label does not imply any mechanism, merely a loca-
For example, treatment choices for chronic prostate tion, while inclusion of the word syndrome takes
pain are often based on anecdotal evidence, with account of any ‘emotional, cognitive, behavioural
most patients requiring multimodal treatment aimed and sexual [associations or] consequences of the
at their symptoms and comorbidities. Only between chronic pain’. The mechanisms involved may be asso-
5% and 7% of all chronic prostatitis complaints yield ciated with local, peripheral or central neural beha-
evidence of bacterial involvement (Anderson 2008), viour, and may involve psychological and/or
and the concept of chronic pain deriving from inflam- functional influences, reaction and effects. None of
matory conditions of the prostate is questionable these aspects are however implied by the name ‘blad-
(Nickel et al. 2003). Similarly, a diagnosis of intersti- der pain syndrome’, although all are subsumed into its
tial cystitis (IC) suggests that the bladder intersti- potential aetiology and presentation.
tium is inflamed, despite evidence to the contrary In general management of CPP Fall et al. (2010)
in most cases. suggest a sequence in which initial consideration
Additional confusion results from the presence of is given to the organ system in which the symp-
lesions necessary for diagnosis of type 1 IC in healthy toms appear to be primarily perceived. Where a
women following bladder distension (Waxman et al. recognized pathological process exists (infection,
1998). It appears that urologic chronic pelvic pain neuropathy, inflammation, etc.), this should be
syndromes (UCPPS) frequently evolve in otherwise diagnosed and treated according to national or
healthy men and women, with no obvious pathogenic international guidelines. However, when such
aetiological evidence, or objective biological markers treatment is ineffectual in relation to the pain,
of disease (Anderson 2008). EAU guidelines have additional tests, such as cystoscopy or ultrasound,
therefore moved away from using ‘prostatitis’ and should be performed. If such tests reveal pathology
‘interstitial cystitis’ in the absence of proven inflam- this should be treated appropriately; however,
mation or infection. if such treatment has no effect, or no pathology
3
Chronic Pelvic Pain and Dysfunction
is found by additional tests, investigation via Pelvic girdle pain and CPP:
a multidisciplinary approach is called for (see
Chapters 6, 7 and 8). To separate or combine?
The American College of Gynecologists (ACOG)
Chronic pain has proposed the following definition of CPP (lim-
ited to females):
As practitioners working with people in chronic pain,
Noncyclical pain of at least six months’ duration, involving
we therefore need to remind ourselves that the the pelvis, anterior abdominal wall, lower back, and/or
structural–pathology model for explaining chronic pain buttocks, serious enough to cause disability or to
is outdated, particularly as the relationship between necessitate medical care.
pain and the state of the tissues becomes weaker as pain (ACOG 2004)
persists (Moseley 2007). A summary of the sensitiza-
tion processes involved in CPP (Fall et al. 2010) sug- The definitions from ACOG and EUA, include
gests that persistent pain is associated with changes in phrases such as ‘structures related to the pelvis’ and
the central nervous system (CNS) that may maintain ‘involving the pelvis’ which suggests inclusion in such
the perception of pain in the absence of acute injury. definitions of the structural supporting features of
The CNS changes may also magnify non-painful stimuli the region – and not only the pelvic organs and soft
that are subsequently perceived as painful (allodynia), tissues.
with painful stimuli being perceived as more painful However, many researchers and clinicians make a
than expected (hyperalgesia). For example, pelvic floor distinction between pelvic pain and dysfunction that
muscles may become hyperalgesic, and may contain relates to the organs and soft tissues of the region,
multiple trigger points. This process may lead to organs and those chronic pain problems that involve the
becoming sensitive, for example the uterus with structural, osseous and ligamentous structures that
dyspareunia and dysmenorrhoea, or the bowel with irri- frame the pelvis – the pelvic girdle. Pelvic girdle pain
table bowel syndrome (IBS). Berger et al. (2007) have (PGP) therefore has its own definition, which specif-
indicated that men with chronic prostatitis have more ically excludes gynaecological and/or urological
generalized pain sensitivity, and current thinking sug- disorders:
gests that if there has been an inciting event, such as
PGP generally arises in relation to pregnancy, trauma,
infection or trauma, it results in neurogenic inflamma- osteo-arthrosis and arthritis. Pelvic girdle pain is
tion in peripheral tissues and the CNS (Pontari & experienced between the posterior iliac crest and
Ruggieri 2008). Later chapters – particularly the gluteal fold, particularly in the vicinity of the sacroiliac
Chapter 3 – will consider both the local and the joints. The pain may radiate in the posterior
general influences on, as well as the nature of, pain, thigh, and can also occur in conjunction with/or
occurring in pelvic structures. separately in the symphysis. The endurance capacity
for standing, walking, and sitting is diminished. The
The following chapters include pain-oriented
diagnosis of PGP can be reached after exclusion of
discussion: lumbar causes. The pain or functional disturbances in
• Chapter 3: Chronic pain mechanisms; relation to PGP must be reproducible by specific
• Chapter 8: Multispeciality and multidisciplinary clinical tests.
practice; Chronic pelvic pain and nutrition; (Vleeming et al. 2008)
• Chapter 10: Biofeedback in the diagnosis and
A reading of this definition of PGP can be seen to
treatment of chronic essential pelvic pain disorders;
specifically exclude the pelvic organs and soft tissues,
• Chapter 11.1: Soft tissue manipulation while the definition of CPP as provided in Table 1 in
approaches to chronic pelvic pain (external); Fall et al. (2004, 2010) appears to allow for the con-
• Chapter 11.2: Connective tissue and the pudendal sideration of all pelvic structures, including the pelvic
nerve in chronic pelvic pain framework.
• Chapter 13: Practical anatomy, examination, So whilst simultaneously reminding the reader
palpation and manual therapy release techniques of ‘no brain, no pain’ (Butler & Moseley 2003), one
for the pelvic floor; of the aims of this book is to avoid what can be con-
• Chapter 15: Intramuscular manual therapy: sidered to be an artificial separation of the functions
Dry needling. and structures of the entire pelvic region.
4
An introduction to chronic pelvic pain and associated symptoms CHAPTER 1
The urological and gynaecological, as well as the Additionally the pelvic floor itself may be involved
biomechanical (and other), features and functions in such adaptations – with the possibility of CPP
of the pelvis are therefore considered, throughout symptoms emerging (O’Sullivan 2005).
this text, as having the potential to mutually influ- Consideration of the biomechanical aspects of
ence each other. CPP and PGP will be found in:
Whenever the term chronic pelvic pain (or CPP) is • Chapter 2: The anatomy of pelvic pain;
used in this text, unless specifically stated to the con- • Chapter 9: Breathing and chronic pelvic pain:
trary, this will refer to pain anywhere in the pelvis, aris- Connections and rehabilitation features;
ing from, or being referred to part, or all, of the region
• Chapter 11.1: Soft tissue manipulation
that lies inferior to the lumbar spine (although this will
approaches to chronic pelvic pain (external);
be involved at times) and superior to the gluteal folds –
whether involving osseous, neurological, ligamentous, • Chapter 11.2: Connective tissue and the pudendal
or other soft tissues, including the viscera. nerve in chronic pelvic pain;
• Chapter 12: Evaluation and pelvic floor management
of urologic chronic pelvic pain syndromes;
Connecting PGP with CPP • Chapter 14: Patients with pelvic girdle pain – An
osteopathic perspective.
O’Sullivan & Beales (2007) suggest that the motor
control system can become dysfunctional in a variety
of ways, and that such changes may represent a Aetiological features of CPP
response to a pain disorder (i.e. it may be adaptive),
or might promote abnormal tissue strain, and there- Some identifiable aetiological features commonly
fore be seen to be ‘mal-adaptive’, or provocative of associated with CPP often involve one or more of
subsequent pain disorders (see Figure 1.1). the following factors summarized in Box 1.2.
Maladaptive changes might in turn lead to reduced However, in most cases the aetiology of CPP
force closure (involving a deficit in motor control of, remains unknown, with no identifiable organic cause
for example, the sacroiliac joint) or excessive force (Gomel 2007). Susceptibility to ill-health – in
closure (involving increased motor activation) result- general – and to particular conditions such as those
ing in a mechanism for ongoing peripheral pain involving CPP, usually has multiple causes, since all
sensitization, leading to chronic pain involving the manner of features, factors and events can compromise
sacroiliac and/or other pelvic structures. the individual’s ability to self-regulate.
Centrally mediated Pain aggravated Avoidance behaviour, altered
pelvic girdle pain with movement loading and movement patterns
‘Wind-up’ of central Belief that pelvis
nervous system is ‘unstable’
Amplification of pain, Interventions to ‘stabilise’
deconditioning, disability, no work the pelvis
Increased fear, anxiety, Failure
lack of awareness, of
loss of control, passive coping interventions
Figure 1.1 • The vicious cycle of pain for centrally mediated pelvic girdle pain. Adapted from
O’Sullivan P, Beales D (2007) Diagnosis and classification of pelvic girdle pain disorders, Part 2: Illustration of the
utility of a classification system via case studies. Manual Therapy 12 with permission
5
Chronic Pelvic Pain and Dysfunction
Box 1.2
Aetiological aspects of CPP
• Abuse (see also Trauma, below): Studies designed • Infection: Previous or concealed – for example
to evaluate factors predisposing to CPP and involving the periurethral glands or ducts (see note at
recurrent pelvic pain have demonstrated that start of Box 1.1) (Parsons et al. 2001).
several psychological factors, including sexual • Inflammation (though not always) (Bedaiwy et al. 2006,
abuse and alcohol and drug abuse, are strongly Twiss et al. 2009).
associated with CPP and with dysmenorrhoea • Neurological: A recent study suggested that
and dyspareunia (Raphael et al. 2001, Latthe ‘denervation that is caused by injuries to uterine
et al. 2006). neuromuscular bundles and myofascial supports is
• Adhesions: Found in 25% of women with CPP, but a succeeded by re-innervation that may provide an
direct causal link with associated pain has not been explanation for some forms of chronic pain that is
established (Stones & Mountfield 2000). associated with endometriosis’ (Atwal et al. 2005).
• Autoimmune conditions (Tomaskovic et al. 2009, Pontari & Ruggieri (2008) note that ‘Pelvic pain also
Twiss et al. 2009). correlates with the neurotrophin nerve growth factor
• Biomechanical: Levator ani spasm, piriformis implicated in neurogenic inflammation and central
syndrome, and other musculoskeletal conditions sensitization’.
have been associated with CPP in many instances • Psychiatric: The rate of major depression among
(Tu et al. 2006) as have trigger points (Carter 2000, patients with CPP has been found to be in the order of
Fitzgerald et al. 2009). 30–45% (Gomel 2006, Latthe et al. 2006). In a different
• Circulatory: In one study presence of pelvic varicose study depression was present in 86% of women with
veins was noted in 30 of 100 women with CPP of both endometriosis and CPP, and only in 38% of the
undetermined origin (Gargiulo et al. 2003). women with endometriosis and no CPP (Lorencatto
• Gender: Females predominate – with studies showing et al. 2006).
prevalence ranging from 10 per 100 000 to 60 per • Trauma (see also Abuse, above): 40–50% of women
100 000 (Bade & Rijcken 1995, Curhan & Speizer 1999), with chronic pelvic pain have a history of physical or
with significantly higher rates in young women (Parsons sexual abuse, which could explain psychological or
& Tatsis 2004). neurological components of pain. Research also
• Hormonal: Dysmenorrhoea and endometriosis may suggests that trauma may heighten physical sensitivity
benefit from hormonal therapy (Howard 2000). to pain (Howard 2000).
Beyond single causes aetiological features – possibly interacting with predis-
positions and altered stress-coping functions.
Beales (2004) has described a scenario that high-
A linking of genetic susceptibility with some instances
lights multiple contributory factors to functional
of CPP (discussed further below) suggests an inter-
somatic syndromes:
action between lifestyle and environmental factors,
and the unique genetic make-up of the individual Too much sustained, unhealthy, down slope arousal
(Dimitrakov & Guthrie 2009). (see Figure 1.2) leads to the loss of internal balance,
As to what such environmental factors might and results in reduced performance and a mind–body
system in overdrive. In this state, the metabolism is
be, Tak & Rosmalan (2010) discuss the role of the struggling and cholesterol, blood sugar and blood
body’s ‘stress responsive systems’ in what have been pressure are often raised, resulting in ill-health. The
termed functional somatic syndromes, for example more aroused we become, the more sleep, which would
IBS (Lane et al. 2009), as involving a ‘multifactorial be to some degree restorative, decreases. Signals of
interplay between psychological, biological, and social mind–body protest multiply. For instance, sufferers
factors’. They conclude that stress responsive system from irritable bowel syndrome may also commonly
experience back pain, fatigue and loss of libido.
dysfunction may be involved in the aetiology of such
Negative emotions, such as frustration and despair,
conditions. There is therefore a need to move beyond can trigger exhaustion, which in turn can trigger
a search for single causes of most conditions involving breathing pattern disorders, as a consequence of the
CPP, since, like many other complex and difficult-to- perceived threat to survival eliciting fight, flight or
treat conditions, CPP commonly has multifactorial freeze reactions.
6
An introduction to chronic pelvic pain and associated symptoms CHAPTER 1
Eustress (good) Distress (bad) A chronic bladder pain condition may be associated with
The ‘hump’ the presence of Hunner’s ulcers and glomerulations on
cystoscopy, whereas another condition may have a normal
appearance on cystoscopy. There will be two different
phenotypes. The same is true for the irritable bowel
syndrome (IBS) that may be subdivided into those with
Performance
primarily diarrhoea or those with primarily constipation
or both.
Making sense of the multiple clinical features in any
individual with CPP and arriving at a therapeutic plan
therefore calls for careful evaluation of the evidence.
In Chapter 7 the question of the role of clinical
Pressure reasoning, in the differential diagnosis and manage-
Safe
Health
ment of chronic pelvic pain, is explored in depth.
Boredom work Fatique Exhaustion How individuals and organizations set about com-
injury
zone
bining clinical assessment and therapeutic expertise,
Figure 1.2 • Human function curve. Healthy tension is experience and evidence is clearly of major impor-
represented by the up slope of the curve, where tance when handling complex problems such as
performance tends to improve in proportion to arousal. In this CPP and its multiple associated symptoms.
state of mind and body, activity can be balanced by
restoration, and so homeostasis is maintained. On the down
slope, effort continues despite fatigue; arousal increases but Treatment aimed at pathology
performance deteriorates, and eventually exhaustion is only part of the answer
worsens and health breaks down. Adapted from Beales (2004)
“I’ve got this pain . . .” Human Givens Journal 11(4):16–18 with permission
There would be little need for this book were current
treatment strategies that focus on CPP proving
successful. Anderson (2006) notes that traditional
Recent research has indicated that there may be a medical therapy to treat CPP conditions has failed,
genetic tendency operating in some people with ‘whether involving antibiotics, anti-androgens, anti-
CPP. Dimitrakov & Guthrie (2009) note that: inflammatories, a-blockers, thermal or surgical
therapies, and virtually all phytoceutical approaches’.
An increasing body of evidence showing familial clustering Shoskes & Katz (2005) concur – demonstrating that a
of urological chronic pelvic pain syndrome (UCPPS)
series of monotherapies, used to treat hundreds of
supports the notion of it being a genetic disease.
Indeed, familial clustering appears to apply to IC in men with prostatitis, resulted in only 19% reporting
families with other comorbidities such as panic disorder, any relief of symptoms. However a randomized
social anxiety disorder and thyroid problems. The well clinical trial designed to assess the feasibility of con-
established prevalence of comorbidities of interstitial ducting a full-scale trial of physical therapy methods
cystitis, such as fibromyalgia, allergies and Sjogren’s, in 48 patients with urological CPPS has shown
irritable bowel and chronic fatigue syndromes, present an
promise (Fitzgerald et al. 2009). It compared two
enticing picture of UCPPS as a set of conditions with
significant pathophysiological overlap with many other
methods of manual therapy: myofascial physical
diseases due to central, genetically defined risk factors. therapy and global therapeutic massage. The global
response rate of 57% in the myofascial physical ther-
Interesting as such considerations might be to apy group was significantly higher than the rate of
researchers, a finding of a genetic link to CPP is 21% in the global therapeutic massage treatment
unlikely to offer solutions to a patient’s current CPP group (P ¼ 0.03) suggesting a beneficial effect
problem. Yet phenotypes result from the expression of myofascial physical therapy.
of an organism’s genes, as well as the influence of However, Pontari & Ruggieri (2008) note that the
environmental factors and the interactions between symptoms of CP/CPPS appear to result from inter-
the two. Understanding the classifications, and possi- play between psychological factors and dysfunction
ble aetiological features of a particular manifestation of in the immune, neurological and endocrine systems.
CPP, should help determine a successful therapeutic It therefore seems unarguable that therapeutic
plan. For example, Baranowski (2009) explains: approaches should adopt strategies that take account
7
Chronic Pelvic Pain and Dysfunction
of these multiple interacting factors. And this is Attitudes
precisely the approach that this book takes. Recreational and beliefs Motor control and
For example psychological issues are considered in: and daily activities movement patterns
• Chapter 4: Psychophysiology and pelvic pain;
Pathology Nutrition
• Chapter 6: Musculoskeletal causes and the
contribution of sport to the evolution of chronic Accumulate
Cultural factors 10 points for Previous experience
lumbopelvic pain;
PAIN
• Chapter 8: Multispeciality and multidisciplinary
Hormones Emotional state
practice;
• Chapter 9: Breathing and chronic pelvic pain:
Social/work environment Genetics/tissue type
Connections and rehabilitation features;
Direct
• Chapter 10: Biofeedback in the diagnosis and trauma
treatment of chronic essential pelvic pain disorders; Figure 1.3 • Accumulate 10 points for pain; some
• Chapter 12: Evaluation and pelvic floor factors that appear to influence the accumulation of a pain
management of urologic chronic pelvic pain experience. Reproduced, with permission, from Jones (2003)
syndromes.
As expressed throughout this book, a background of
different influences will be found to accompany the
and works on the premise that pain is rarely the result
evolution of CPP, and its associated symptoms. Iden-
of one single incident, but normally stems from a
tifying the particular influences that have caused,
range of different issues or a whole lifestyle that con-
maintained and/or exacerbated a CPP patient’s con-
tribute to the 10 points and painful state.
dition is therefore an appropriate clinical ambition.
In this way, the patient and therapist can move
In the context of this book, a further ambition is
away from the solely structural pathological model,
the identification of those influences that may be
to one that considers, for example, the brain in pain,
amenable to therapeutic attention involving physical
their beliefs about their pain, nutritional issues, in
medicine. However, as pain involves many thoughts
addition to any pathology or motor control issues.
and emotional contributions, how we treat, talk, listen
For example, there is evidence that understanding
to and educate our patients about ‘their’ pain requires
pain reduces the threat of it, altering patients’ atti-
great skill. Reminiscent of the Indian parable regarding
tudes and beliefs, increasing pain thresholds and,
the elephant and a group of six blind men, many clin-
when combined with physiotherapy, reduces pain
icians would agree that if there were six therapists
and disability (Moseley 2007). It is therefore impor-
examining one chronic pain patient, the most likely
tant to understand what the patient believes the pain
outcome would be six different diagnoses and six
means and help explain modern pain biology, thereby
different treatment approaches. Further resembling
reducing the patient’s attitude and beliefs points. For
the wise man’s explanation, all could be correct but
example the patient may have a belief that:
no-one would know the whole truth. The patient
may have all the features the therapist individually • All pain is harmful;
described, but it would be influenced by the thera- • Pain only occurs when they have damaged or
pist’s perspective and different belief systems. Further injured themselves;
complicating matters, any dysfunction observed may • Chronic pain means that an injury has not healed
not even be relevant to the presenting condition. properly;
So how can the therapist explain CPP to their
• Worse injuries always result in worse pain;
patient and what makes one patient more susceptible
to chronic pain than another? As outlined previously, • All pain must go before they can resume work or
the aetiology is unclear but it is apparent that multi- their hobbies;
ple factors somehow contribute to the pain experi- • Exercise will hurt;
ence. With this belief system in mind, a ‘10 points • Something is terribly wrong with their back/
for pain’ model is one concept that a number of pelvis/pelvic organs, it is just that no-one has
patients and clinicians have found useful (Jones performed the right tests;
2003) (Figure 1.3). It is an easy way to demonstrate • They are unable to help themselves overcome their
that pain can develop through many different reasons pain, and think that someone else has to fix it.
