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Pelvic Physical Therapy: What's the best treatment?

The exact cause of pelvic pain for many women can be elusive, despite lots of tests and scans. In some cases, the symptoms are related to a problem that is often overlooked, says Dr. Eman Elkadry, an instructor in obstetrics, gynecology, and reproductive biology at Harvard Medical School. Pelvic pain may stem from a pelvic floor muscle problem that can be helped by a specialized form of physical therapy known as pelvic physical therapy.

"Although pelvic physical therapy may not work for everyone, it can be quite effective for certain individuals," says Dr. Hye-Chun Hur, director of the Division of Minimally Invasive Gynecologic Surgery at Harvard-affiliated Beth Israel Deaconess Medical Center and associate faculty editor of Harvard Women's Health Watch. She stresses that pelvic physical therapy is normally undertaken by a trained female practitioner.

An underdiagnosed issue

The pelvic floor is essentially a bowl-shaped set of muscles that supports your bladder, bowel, rectum, and uterus. Pelvic pain sometimes occurs when muscles of the pelvic floor are too tight, says Dr. Elkadry. This causes a condition called myofascial pain, or pain caused by muscle irritation.

Sometimes this pain is mistaken for other conditions or missed entirely. A 2012 article in the Journal of Obstetric, Gynecologic & Neonatal Nursing estimated that myofascial pelvic pain in women may be the underlying cause of chronic pelvic pain in 14% to 23% of cases and up to 78% of cases of interstitial cystitis, which is a type of otherwise unexplained bladder pain.

Myofascial pelvic pain may go undetected because it can only be identified by a focused internal examination, says Dr. Elkadry. "It's very poorly recognized. Doctors often don't understand it and don't look for it," she says. "Before my fellowship, I had never heard of this."

Doctors in the field of gynecology are trained to focus on organs, not muscles. "If someone has unexplained pain in the shoulder, of course we would look at the muscles," says Dr. Elkadry. But when it comes to pelvic pain, doctors tend to ignore the muscles and look for other causes, such as a problem with the bladder, uterus, or vulva.

Diagnosing the problem

Myofascial pain affects women of all ages, from teenagers to women who have already gone through menopause, those who have had children and those who have not. It's not clear why some women are more prone to the condition than others, says Dr. Elkadry. Some women develop it after menopause, possibly because tissue becomes more sensitive as a result of hormonal changes, which can make women more prone to discomfort, she says.

Before making the diagnosis of myofascial pelvic pain, doctors should rule out other potential causes of pain, such as fibroids or bladder problems. Once myofascial pelvic pain is diagnosed, pelvic physical therapy should be considered, says Dr. Elkadry. It can be prescribed separately or alongside other treatments or medications. However, while medications may dull pain temporarily, they don't address the underlying muscle problem as pelvic physical therapy is able to do.

What is pelvic physical therapy?

Pelvic physical therapy can help not only with myofascial pelvic pain but also reduce symptoms of other conditions caused by pelvic floor problems, such as urinary and fecal incontinence, painful intercourse, and sexual dysfunction. For myofascial pain, a specially trained physical therapist uses her hands to perform external and internal manipulations of the pelvic floor muscles, which are accessed through the woman's vagina or rectum.

Relaxing contracted and shortened muscles can help alleviate pain in the pelvic floor, just as it would in other muscles in the body.

"Stretching in general helps muscles relax and prevents excessive cramping and tightening," says Dr. Hur.

The therapist may recommend internal vaginal manipulation and massage. This component of treatment may not be an option for women who have a history of sexual abuse or assault or who have difficulty with internal vaginal exams, says Dr. Elkadry.

An unusual therapy that provides relief

Although pelvic physical therapy may sound a little unusual and invasive to some women, it can be effective. Dr. Elkadry says her patients have seen a good success rate using the procedure. "How effective pelvic physical therapy will always depend on the severity of the case," she says.

Treatment for myofascial pelvic pain using pelvic physical therapy typically takes six to eight hour-long sessions. It can take longer, sometimes several months, to help women with more severe cases. Often women will need to return to physical therapy periodically to keep the problem in check.

If you're hesitant to try the internal component of pelvic physical therapy, external physical therapy could also be an option to strengthen other muscles in the pelvic area, which may also help reduce symptoms. "Pelvic physical therapy can also serve as an adjunct therapy and does not always have to be the sole treatment," says Dr. Hur. It can be performed in conjunction with other types of pain treatments or medications such as muscle relaxants or injections of Botox, a drug best known for its wrinkle-smoothing uses in the cosmetic industry.

Women should know that pelvic pain is not normal in menopause or at any other time. Getting treatment early is important, says Dr. Elkadry. The longer a woman experiences chronic pain, the more likely the nerve receptors will become sensitized to it. This heightens the body's reaction to pain, often making it more severe and more difficult to treat. So, if you're suffering from unexplained chronic pelvic pain, it may be wise to consult a urogynecologist who specializes in pelvic floor disorders.

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