Like many sources of pain, pelvic pain is often not something you think about until you have it. However, pelvic pain is a significant issue for many women, with up to 14% of women experiencing pelvic pain in their lifetime.

Pain anywhere in your lower abdomen to the top of your legs can be classified as pelvic pain. In women it can be caused by a wide range of factors and conditions including vaginismus, vulvodynia, endometriosis, irritable bowel syndrome, fibroids and injury.

Finding and addressing the root cause of pelvic pain is an important step towards developing a treatment plan and managing the condition.

How common is pelvic pain in women?

The worldwide prevalence of persistent pelvic pain has been estimated between 5% - 26% in females[1] [2] and it’s more common in females than males[3].

It has been reported that 14% of women experience pelvic pain at least once in their lifetime.[4] Compromised function due to persistent pain conditions lessens productivity due to the physical and psychological burden.[5] In Australia alone, medical costs associated with persistent pelvic pain are estimated to be $6.5 billion annually.[6]

Contributors to pelvic pain

Pelvic pain is a condition that can affect women at different phases of life. It can be from numerous causes which makes management more complex. The pain can present acutely (intermittent, sudden or intense) or chronically (persisting longer than several months).

The contributors to pelvic pain can be gastrointestinal, urinary, gynaecological or musculoskeletal in origin. It’s important to be accurately diagnosed to best manage the condition, as treatment will depend on the underlying cause.

Vaginismus

Vaginismus is involuntary tightness in the pelvic floor muscles which causes pain or difficulty with using tampons or penetration.

The pelvic floor is just like any other skeletal muscle in the body (ie. calf, hamstrings). A lot of women have heard about Physiotherapists teaching women how to strengthen the pelvic floor. But did you know that Women’s Health Physiotherapists can also teach you how to relax the muscles and give them a gentle, regular stretch? This can help treat issues such as Vaginismus.

Vulvodynia

Vulvodynia is persistent pain conditions with unexplained pain in the Vulva (the external female genitals) in the absence of any obvious skin condition or infections.

People who experience this condition describe a burning sensation or sharp pain in and around the Vulva area. This can be ‘provoked’ by touch (underwear, tight pants, sanitary products) and sexual activity; or ‘unprovoked’ by no contact at all, which is more constant. This pain can vary in intensity and from day-to-day.

Physiotherapy can help to reduce/down-regulate the irritated nerves in the pelvic floor which refer pain in the vulva area. We help to desensitise the nervous system to reduce pain and restore normal function to the pelvic floor muscles.

Endometriosis

Endometriosis occurs when tissue that is similar to the lining of the uterus (endometrium) grows in other parts of the body. Most commonly endometriosis is found in the pelvic cavity near the uterus and on ovaries, but it sometimes occurs on the intestines and bladder. [7]

The most common symptom of endometriosis is pain in the pelvis, lower abdomen or back although not everyone with endometriosis experiences pain.

Musculoskeletal causes of pelvic pain

Musculoskeletal structures that can be a source of pelvic pain include muscles, ligaments, bones and joints in the pelvis, lumbar spine, or hip regions. Pain may be associated with specific activities or movements.

Common conditions that can cause pelvic pain include:

Pelvic girdle pain: involving sacroiliac joints (SIJ) or pubic symphysis
Sacroiliitis: inflammation of the SIJs
Piriformis syndrome: muscle tension and spasm, potentially impacting the sciatic nerve
Osteitis pubis: inflammation of the pubic symphysis, aggravated by repetitive high impact movement such as kicking, running, pivoting
Hip joint pathology: arthritis, labral tear, femoroacetabular impingement (FAI)
Muscle strains or tears.

Let’s consider the impact on the pelvic floor muscles from pelvic pain of musculoskeletal origin. The pelvic floor muscles support the pelvic organs in the pelvic cavity to ensure normal functioning of urinary and faecal continence, gynaecological organ support and sexual function. They also contribute to the ‘corset’ effect on stabilising the pelvis with movement and load, alongside the gluteus muscles, piriformis and deep abdominal muscles.

Injury to any of these skeletal muscles can place extra demand on the remaining muscles and lead to pelvic pain. Overuse of any of these muscles can lead to spasms/cramping type symptoms.

Pelvic pain and exercise

Pelvic muscle pain can also be experienced as sharp/stabbing/shooting type pain that radiates up the vagina or rectum. It often gets worse with activities such as exercise, sexual intercourse or inserting tampons.

Keep this in mind when you are doing core strengthening exercises such as Pilates or abdominal workouts. It’s a good idea to talk to your instructor before you start any Pilates or workout program so movements can be personalised to your needs. Once triggered, pelvic pain can often linger afterwards for hours, and in some cases, into the next day.

Addressing pelvic pain

Treatment for pelvic pain of musculoskeletal origin involves a holistic approach. Seeking professional advice to help understand the potential cause will help guide treatment options, and hopefully prevent an acute pelvic injury from progressing to a chronic stage.

A holistic approach to pelvic pain management may include some or all of the following:

Exercise prescription: helps activate and strengthen pelvic muscles to improve posture and endurance. Certain exercises can also downregulate an often heightened nervous system.
Medication: discuss with your GP and specialist about medication for managing pain for you to be able to work/study, exercise and carry out your activities of daily living.
Activity modification and lifestyle management.
Complementary and manual therapies for pain relief and downregulation of the nervous system.
Nutrition review to improve tissue health.
Mapping out a maintenance schedule and a flare-up plan.

How Women’s Health Physiotherapists can help

Women’s Health Physiotherapists are pelvic health professionals. We can assist you in how to manage your pelvic pain and develop exercise prescription to strengthen your pelvic floor and manage pain.

We can also help you to implement strategies to prevent, minimise or settle flare ups, recognise the signs before onset of pain and continue to participate in the activities you enjoy.

Women’s Health Physiotherapy offers an effective non-invasive approach to treating pelvic pain. There is no need to suffer in silence. Book online for an initial consultation with our Women’s Health Physios or call our practices at Currimundi 07 5337 9853 or Forest Glen 07 5391 4929 for more information.

Further information and references

Pelvic Pain Foundation Australia: www.pelvicpain.org.au

Jean Hailes Organisation: www.jeanhailes.org.au

[1] Ahangari, A. (2014). Prevalence of chronic pelvic pain among women: an updated review. Pain Physician, 17(2), E141-147.

[2] Latthe, P., Mignini, L., Gray, R., Hills, R., & Khan, K. (2006). Factors predisposing women to chronic pelvic pain: systematic review. Bmj, 332(7544), 749-755.

[3] Marszalek, M., Wehrberger, C., Temml, C., Ponholzer, A., Berger, I., & Madersbacher, S. (2009). Chronic pelvic pain and lower urinary tract symptoms in both sexes: analysis of 2749 participants of an urban health screening project. Eur Urol, 55(2), 499-507.

[4] Banerjee, S., Farrell, R. J., & Lembo, T. (2001). Gastroenterological causes of pelvic pain. World Journal of Urology, 19(3), 166-172.

[5] Steglitz, J., Buscemi, J., & Ferguson, M. J. (2012). The future of pain research, education, and treatment: a summary of the IOM report “Relieving pain in America: a blueprint for transforming prevention, care, education, and research”. Translational Behavioral Medicine, 2(1), 6-8.

[6] Armour, M., Lawson, K., Wood, A., Smith, C. A., & Abbott, J. (2019). The cost of illness and economic burden of endometriosis and chronic pelvic pain in Australia: A national online survey. PLoS One, 14(10), e0223316.

[7] International Pelvic pain Society, Endometriosis, 2023.