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With Pelvic Pain
Elaine Meadows, PT
Director, Continence and Pelvic Rehab Program, MATRIX
Rehabilitation, Atlanta, GA.
This article is reprinted with permission of Urologic Nursing, March 1999, 19(1) , p. 33-35 (published by Anthony Jannetti Inc.).
An overview of the incidence and types of pelvic pain is presented, followed by some practical information concerning the presentation of patients with pelvic pain. Simple physical therapy techniques that are use in treating patients with pelvic pain are also discussed.
Chronic pelvic pain (CPP) is a vague and confusing term that generally refers to noncyclic pain in the abdominal and/or pelvic area, that has been present for 6 months or longer, and that may have a negative impact on activities of daily living and quality of life. CPP affects predominantly women but men may suffer with pelvic and/or rectal pain as well.
Information related to pelvic pain is limited. Two studies published in 1996 presented staggering statistics. Chronic pelvic pain is most common among women 26 to 30 years old and 39% of women of all ages reported having some form of pelvic pain. Irritable bowel syndrome (IBS) was present in 65% to 79% of referrals of women with CPP and 10% to 15% underwent hysterectomy without resolution of their symptoms (Jamieson & Steege, 1996; Mathias, Kupperman, Liberman, Lipschutz, & Steege, 1996). Patient complaints are often unrelated to an identifiable gynecologic or urologic pathology. Despite this, many patients are treated with surgery and/or medications. There are many different diagnoses associated with CPP including vulvar pain syndromes, interstitial cystitis, levator ani syndrome, piriformis syndrome, vaginismus, anismus, dyspareunia, proctalgia fugax, constipation, pelvic floor tension myalgias, endometriosis, pudendal neuralgia, and/or rectal pain. Many patients seek help for many years until they receive a correct diagnosis and proper treatment.
Symptoms and Relief
Symptoms associated with CPP include low back pain, heavy feeling in pelvis, radiating leg pain, pain with urination and/or defecation, constipation, diarrhea, coccyx pain, supra pubic pain, abdominal pain, bloating, and/or cramping, irregular menstrual cycles, pain with menstruation, and dyspareunia.
Symptoms are aggravated by many factors that may contradict each other. Some patients report increased pain with sitting, standing, supine, or with changes in position. Working with patients to find a position of comfort is essential (Kendall, McCreary, & Proveance, 1993; King Baker, 1998). Pillows can be used to assist with placement of extremities and trunk for proper positioning in supine and sidelying. In sitting position, use lumbar rolls to facilitate lumbar support and use a footstool for hip and knee flexion. Try to maintain hip flexion greater then 90 degrees to facilitate proper lumbar lordosis. Discuss and monitor patient's workstations, home care areas (kitchen, bathroom, bedroom), car seating, and recreational activities for proper body positioning.
Physical activity often exacerbates pelvic pain and patients may choose not to exercise or be active. Lack of physical activity causes patients to become deconditioned. Educate the patient as to the importance of aerobic exercise for overall fitness and conditioning. Suggest the patient exercise 3 to 6 times a week for 20 to 40 minutes at a time. Walking, swimming, and low-impact aerobic activities may be best. Some patients should avoid running, cycling, and high-impact aerobics since they may aggravate the pelvic girdle musculature. Easy stretching or yoga will lengthen chronically tight muscles and help alleviate muscle pain. A simple home exercise program to perform pelvic stability, abdominal exercises, hip strengthening exercises, and extremity exercises is easily accomplished with theraband, rubber tubing, swiss ball, or floor exercises. As a patient's muscles regain strength, function follows.
Keeping a bowel and bladder record will help a patient recognize the importance of regular urination and defecation, and identify problems with regularity. Patients should understand the significance of bowel regularity in the control of CPP. Tension in the pelvic floor muscles (PFM), poor intake of fiber and fluid, and lack of physical activity may cause constipation (Whitehead, 1998). Constipation may increase complaints of CPP. A bowel and bladder retraining program may also be used. Stress the importance of eating 20 to 30 grams of fiber each day to maintain regular and easy bowel movements.
Many patients with painful bladder conditions will limit their daily fluid intake in an attempt to alleviate symptoms, a practice known to worsen symptoms. Teach the patient about proper fluid intake levels and timed voiding intervals. Many people do not consume enough water and are frequently drinking bladder irritants (caffeinated products, acidic fruit juice, spicy foods). Have handouts available with lists of bladder irritants and help patients understand the importance of making choices in their diet and fluid intake. The best fluid for patients to drink is water, especially if they are constipated or have a painful bladder.
Dyspareunia (painful intercourse) is a common complaint of patients with chronic pelvic pain and a frank, open discussion with your patients regarding their sexual function and fulfillment is beneficial. Many patients have not been thoroughly interviewed prior to their referral and may be embarrassed by a discussion regarding their sexual activity. This information is helpful in understanding the nature of their pain and in documenting pelvic muscle dysfunction. Ask questions regarding positioning, use of lubrication, areas of pain, ability to achieve orgasm, type of stimulation needed for orgasm, description of pain during and after sexual activity, and frequency of activity. Offer practical suggestions such as positioning to avoid excessive weightbearing on sensitive tissue, and reading material to facilitate alternative sexual fulfillment.
An initial evaluation should include a thorough musculoskeletal assessment. Consider referring to a physical therapist who treats chronic pelvic pain. Musculoskeletal evaluation includes posture assessment, gait and transfer analysis, active range of motion, and strength tests of the extremities and trunk (American Physical Therapy Association, 1997). Patients are also examined for scar tissue on the abdominal wall and flexibility. A pelvic muscle examination should include grading muscle strength and coordination of slow-twitch and fast-twitch fibers, overall muscle tone, tissue sensation and color, location of tender and trigger points, organ descent, perineal movement, and scarring. Surface electromyographic evaluation of the PFM documents baseline resting and contraction ability.
During the musculoskeletal assessment particular attention should concentrate on the hip rotators, hip flexors, hip adductors, hip extensors, sacroiliac joint function, lumbosacral joint function, leg lengths, upper body position, and general movement patterns. A therapeutic exercise program targeting dysfunctions found in these musculoskeletal groups is very helpful. First, consider a stretching program for tight and painful muscles. As the patient progresses add strengthening exercises for all muscle groups especially the pelvic girdle and trunk muscles. Pelvic stability and abdominal strengthening are significant as well. Pelvic floor muscle instruction is important to regain control and coordination of these muscles.
Biofeedback is useful for monitoring the pelvic floor muscles and accessory muscles for patients with CPP. Biofeedback uses computerized (and other) instruments to relay information to patients about a physiologic activity. Interpreting information about pelvic muscle use through visual displays (such as computer monitors) is very helpful. Biofeedback can be used to strengthen the pelvic floor; facilitate relaxation and reduce resting tone of the pelvic floor; enhance coordination of pelvic muscles; inhibit accessory muscles, which substitute for PFM, to reduce voiding and defecating dysfunctions; and to train for general relaxation techniques (American Physical Therapy Association, 1997; Pauls, 1995). Often, patients with CPP have high resting tone of the pelvic floor muscles and poor ability to properly contract and relax the PFM and accessory muscles. To assist the patient with relaxation techniques, try working with breathing techniques, visualization, massage, and progressive relaxation exercises.
Transcutaneous electrical nerve stimulation (TENS) may be effective for treating patients with chronic pelvic pain. TENS has been used with patients with interstitial cystitis (Kotarinos, 1994). Interferential electrical stimulation is effective in pelvic floor strengthening but may require frequent visits to the clinic. Neuromuscular electrical stimulation (NMES) is used for pelvic floor strengthening and reflex inhibition with patients with pelvic muscle dysfunction (Laycock, Schussler, Norton, & Stanton, 1994). Try to use a vaginal or anal sensor with NMES and have patients use it before bedtime for assistance with sleeping and relaxation.
Manual therapy is another essential component of the treatment plan for patients with chronic pelvic pain. Manual therapy may include visceral mobilization of the pelvic organs and supporting structures, soft tissue massage or myofascial techniques to pelvic girdle musculature, scar tissue massage, internal vaginal and/or anal work to muscles and tissues, and joint mobilization to spine and extremities. Proper training is required to perform these techniques and referral to a skilled physical therapist may be best for your patient. Contact the American Physical Therapy Association Section on Women's Health at (800) 999-APTA, ext. 3237 to locate a regional representative who can refer you to a practitioner in your area.
Written educational materials are beneficial resources to have available for your patients. Maintain a list of professionals who specialize in counseling patients with chronic pain. Many areas have support groups for people with chronic pain that your patient may join. There are several national organizations whose brochures are available to distribute to your patients (see Table 1).
The Internet is a valuable resource for you and your patients to use for education and networking. Several chat rooms are available to patients and families to discuss their problems (see Table 2). Working with patients with chronic pelvic pain can be challenging and rewarding. Be creative and be sincere with your care and treatment plan. Many patients are willing to work with you to improve their conditions and are motivated much more than other patients because of their chronic pain. Document the treatments you perform and monitor for functional outcomes. Most of all, enjoy your work and good luck.
American Physical Therapy Association. (1997). The gynecological manual. Alexandria, VA: APTA
Jamieson, D., & Steege, J. (1996). The prevalence of dysmenorrhea, dyspareunia, pelvic pain, and irritable bowel syndrome in primary care practices. Obstetrics and Gynecology, 1, 55-58.
Kendall, F., McCreary, E., & Proveance P. (1993). Muscle testing and function (4th ed.). Baltimore: Williams & Wilkins.
King Baker, P. (1998). Musculoskeletal problems. In J. Steege, D. Metzger, & D. Levy (Eds.) Chronic pelvic pain: An integrated approach (pp. 205-224). Philadelphia: WB Saunders Co.
Kotarinos, R. (1994). Interstitial cystitis. Journal of OB/GYN Physical Therapy, 18(4).
Laycock, J., Schussler, B., Norton, P., & Stanton, S. (Eds.). (1994). Pelvic floor re-education: Principles and practice. London: Springer-Verlag.
Mathias, S., Kupperman, M., Liberman, R., Lipschutz, R., & Steege, J. (1996). Chronic pelvic pain: Prevalence, health-related quality of life, and economic correlates. Obstetrics and Gynecology, 1(3), 321-327.
Pauls, J. (1995). Therapeutic approaches to women's health. Rockville, MD: Aspen Publishers.
Whitehead, W. (1998). Gastrointestinal disorders. In J. Steege, D. Metzger, & D. Levy (Eds.) Chronic pelvic pain: An integrated approach (pp. 205-224). Philadelphia: WB Saunders Co.
Definition / Description
Coccygodynia is defined as a disabling pain in and around the os coccyx. This pain is usually provoked by sitting or by rising from a seated to a standing position. It is also known as coccydynia or coccygeal neuralgia. The pain caused by coccygodynia is disabling and has a significant impact on the patient's quality of life. The pain can be described as "pulling" or "lancinating," and may also radiate to the sacrum, lumbar spine, and buttocks, or more rarely to the thighs.
Clinically Relevant Anatomy
The coccyx is the most distal aspect of the vertebral column. It consists of three to five rudimentary vertebral units that are typically fused. The ventral part of the coccyx is concave, and the dorsal aspect is convex and features coccygeal articular processes. The coccyx articulates with the sacral cornu of the inferior sacral apex at S5.
The anterior aspect of the coccyx serves as the attachment site of ligaments and muscles important for many functions of the pelvic floor. The levator ani muscle includes m. coccygeus, m. pubococcygeus and m. iliococcygeus. The coccyx supports the position of the anus. Attached to the posterior side of the coccyx is m. gluteus maximus. Muscle weakness, disturbed tonus or damage to muscles or ligaments can cause abnormal positions of the coccyx.
Epidemiology / Etiology
The prevalence for coccygodynia is five times greater in women than in men. This may be related to increased pressure during pregnancy or delivery (post-partum coccygodynia).
The pain in the coccyx can be caused by radiation from a lumbosacral segment, a direct trauma or an overcharge. Congenital deviations can also cause complaints during long sitting.
Coccygodynia may be classified as posttraumatic or idiopathic. Posttraumatic coccygodynia may be due to a fall onto the buttocks, or due to a difficult childbirth. Some studies question the possibility that coccygodynia could be caused by a direct trauma, because of protection by the ischiadic bones.
Often, a positional change of the coccyx is caused by overtension of the anal levator muscle. In more than one third of cases, coccygodynia has an idiopathic cause.
Characteristics / Clinical Presentation
The patient may complain of pain in the coccyx region during, going into, or coming out of a seated position - this is a first indication of coccygodynia. Tenderness over the coccyx is likely present, and the location of tenderness may help to discern between different forms of coccygodynia:
- Referred or radiating pain is caused by a lumbar disc lesion, irritation of lower pelvic structures or deviations of the lower lumbar and/or sacroiliac joints.
- Local pain or coccygodynia is usually caused by a direct trauma to the coccyx bone, or may be idiopathic in nature.
- Local coccygodynia
- Traumatic coccygodynia
- Idiopathic coccygodynia
- Referred or radiated coccygodynia
- Psychogenic coccygodynia
- Chronic proctalgia
- Chronic pelvic pain and pudendal neuralgia
Local coccygodynia presents as pain felt in the coccyx during sitting, and does not spread in any direction. The pain can be relieved by sitting on a hard surface or with the buttocks over the border of the chair. Only pressure point pain is present. Depending on the exact location of the pain, walking, stair walking or getting up from sitting can be painful.
Other movements are painless and examination of lumbar spine and sacroiliac joints and hips are normal. Trauma or overtension of the levator ani muscle can shift the coccyx into an abnormal position. These contributing factors can be distinguished based on the affected tissues.
Psychogenic coccydynia features a less specific pain location, and usually a vague and radiating pain in various directions. Lumbar and hip movements are painful.
- Pain Measures
Coccygodynia can be diagnosed during a physical examination. Patients may take a guarding seated position, in which one buttock is elevated to shift weight from the coccyx and to prevent and/or minimize discomfort and pain. With referred or radiated pain, the pain will also arise during lumbar movements. Coughing is painful. Physical examination will show an increased pain during a straight leg raise test. There may be radiating pain around the buttocks and going to the back of the thighs. Women may have pain during menstruation. Palpation at the sacrococcygeal junction will elicit a tender point and will be painful.
There is growing evidence that supports the efficacy of coccygectomy as treatment for coccygodynia. Coccygectomy showed a high percentage of patients with good results, and this outcome is durable over time.
Physical Therapy Management
Patients with coccygodynia are initially advised to avoid provocative factors. Initial treatment includes ergonomic adjustments such as using a donut-shaped pillow or gel cushion when sitting for a long period of time. This reduces local pressure and improves the patient's posture. There is however no significant evidence that these minor changes reduce the patient's complaints.
Mobilizations can be used to help realign the position of the coccyx. The first choice for mobilization is postero-anterior central vertebral pressure (first gently oscillating). Given that there is tenderness to palpation, it might be best to start with rotation mobilization. It is advised to begin mobilizing only one side at one treatment.
Another option for manual therapy is to apply deep transverse frictions (DTF) to the affected ligaments. The patient lies in prone position with a pillow under the pelvis and the legs in slight abduction and internal rotation. The therapist places his thumb on the affected spot, and, depending on the location of the lesion (direction DTF), the DTF are administered.
Manipulation of the coccyx can be performed intrarectal with the patient in lateral position. With the index finger, the coccyx is repeatedly flexed and extended. This is performed for only one minute, to avoid damage or irritations of the rectal mucosa.
Massage of the levator ani muscle and coccygeus muscles has also been found to relieve pain. To exclude the possibility of muscles pulling on the os coccyx, relaxation of the pelvic floor muscles can be integrated by using biofeedback.
In 16% of the patients (Wray et al) daily ultrasound followed by two weeks of short-wave diathermy (no settings were given) was found beneficial.
There are only a few studies/reviews available concerning the ?ideal? physiotherapy treatment for coccygodynia, more research is needed and the techniques described are insufficient.
- Chronic proctalgia and chronic pelvic pain syndromes: new etiologic insights and treatment options (2011)
Recent Related Research (from Pubmed)
- ? 1.0 1.1 1.2 Wray CC, Easom S, Hoskinson J. Coccydynia: aetiology and treatment. J Bone Joint Surg 1991;73(B):335-8.
- ? 2.0 2.1 2.2 2.3 2.4 2.5 Kerr EE, Benson D, Schrot RJ. Coccygectomy for chronic refractory coccygodynia: clinical case series and literature review. J Neurosurg Spine 2011;14:654-663.
- ? 3.0 3.1 3.2 3.3 Patel R, Appanagari A, Whang PG. Coccydynia. Curr Rev Musculoskelet Med 2008;1:223-226.
- ? 4.0 4.1 4.2 4.3 4.4 4.5 4.6 Ombregt L, Bisschop P, ter Veer JH. A System of Orthopaedic Medicine. Elsevier Science Limited, 2003, p.968-969.
- ? 5.0 5.1 5.2 5.3 5.4 5.5 5.6 Gregory P. Grieve, De wervelkolom, veel voorkomende aandoeningen (The spine), 1984, p. 320-321.
- ? Maigne R. Douleurs d?origine vertébrale et traitements par manipulations, medicine orthopédique des derangements intervertébraux mineurs, 2e editie, p. 473-476.
- ? Chiarioni G, et al. Chronic proctalgia and chronic pelvic pain syndromes: New etiologic insights and treatment options. World J Gastroenterol 2011;17(40):4451-4455.
- ? Maitland GD, Brewerton DA. Vertebral manipulation. Butterworths, 1973, p.236-239.
- ? Thiele GH. Coccygodynia: cause and treatment. Diseases of the Colon and Rectum, 1963, p.422-436.
- ? 10.0 10.1 Wu C, et al. The application of infrared thermography in the assessment of patients with coccygodynia before and after manual therapy combined with diathermy. J Manipulative Physiol Ther 2009:287-293.
- ? Physiotherapist UZ Brussels, internal physiotherapy and gynecology.
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