Physical Therapy Guide to Pelvic Pain
Pelvic pain is pain felt in the lower abdomen, pelvis, or perineum. It has many possible causes and affects up to 20% of the population in the United States, including women and men. Pelvic pain is considered "chronic" when it lasts for more than 6 months. Physical therapists help people experiencing pelvic pain restore strength and flexibility to the muscles and joints in the pelvic region, and reduce their pain.
Pelvic pain can be caused by:
Pregnancy and childbirth, which affect pelvic muscles and cause changes to pelvic joints
Pelvic joint problems from causes other than pregnancy and childbirth
Muscle weakness or imbalance within the muscles of the pelvic floor, trunk, or pelvis
Changes in the muscles that control the bowel and bladder
Tender points in the muscles around the pelvis, abdomen, low back, or groin areas
Pressure on 1 or more nerves in the pelvis
Weakness in the muscles of the pelvis and pelvic floor
Scar tissue after abdominal or pelvic surgery
A shift in the position of the pelvic organs, sometimes known as prolapse
The pain in your lower abdomen and pelvis may vary; some people say it feels like an aching pain; others describe it as a burning, sharp, or stabbing pain, or even pins and needles. In addition, you may have:
Pain in the hip or buttock.
Pain in the tailbone or pubic bone.
Pain in the joints of the pelvis.
Tender points in the muscles of the abdomen, low back, or buttock region.
A sensation of heaviness in the pelvic region or even a sensation as if you are sitting on something hard, like a golf ball.
Inability to sit for normal periods of time.
Reduced ability to move your hips or low back.
Difficulty walking, sleeping, or performing daily activities.
Pain or numbness in the pelvic region with exercise or recreational activities, such as riding a bike or running.
Pain during sexual activity.
Urinary frequency, urgency, or incontinence, or pain during urination.
Constipation or straining with bowel movements, or pain during bowel movements.
Difficulty using tampons.
Imbalance when walking.
Your physical therapist will complete a thorough review of your medical history, and perform a physical examination to identify the causes of your pelvic pain and any joint issues, muscle tightness or weakness, or nerve involvement. The exam may include:
Pelvic girdle screening.
Soft tissue assessment.
Visual inspection of the tissues.
Internal assessment of pelvic floor muscles.
Your physical therapist also will determine whether you should be referred to a physician to assist in your interdisciplinary plan of care.
Based on the examination results, your physical therapist will design an individualized treatment program to meet your specific needs and goals. Your physical therapist may:
Show you how to identify the appropriate muscles, such as the pelvic floor, deep abdominals, and diaphragm.
Educate you on how to use these muscles correctly for activities like exercise, posture correction, getting up from a chair, or squatting to pick up a child or pick something up from the floor.
Teach you exercises to stretch and strengthen the affected muscles and retrain them, so they work together normally.
Teach you techniques to improve blood flow and tissue function in the pelvic area.
Teach you appropriate pelvic floor muscle exercises.
Depending on your symptoms and level of discomfort, your physical therapist may decide to use biofeedback to help make you aware of how your pelvic floor muscles work, and how you can control them better. Your physical therapist may attach electrodes to the area to measure your muscle activity as it displays on a monitor, and will work with you to help you understand and change those readings. Your physical therapist also may use gentle electrical stimulation to improve your awareness of your muscles.
Some risk factors, such as aging, smoking and associated coughing, inactivity, obesity, or childbirth, affect general health and may affect core trunk and pelvic strength. Exercises, such as core stabilization, pelvic floor, and deep abdominal wall exercises, muscle flexibility training, and body awareness may help improve muscle function and lower the risk of pelvic injury or pain. See other resources to help you maintain health, such as Fitness Across the Lifespan, Fit After Fifty, Five Ways to Prepare Your Body for Pregnancy, and Nine Physical Therapist Tips to Help You Age Well.
Cindy is a 45-year-old computer programmer who spends hours a day sitting in front of a computer. Last winter, when Cindy was heading to her car after work, she slipped on a patch of ice and fell, landing on her tailbone. She got an x-ray the next day that, thankfully, showed no broken bones.
The week after her fall, Cindy began to feel pain in her lower pelvic area after sitting at the computer for an hour. She also began experiencing constipation, and even had some difficulty urinating. When pain interrupted her during her exercise class, she decided to call her physical therapist.
Cindy's physical therapist reviewed her medical history, and learned the details of her recent fall. She performed a thorough examination, including an orthopedic screening of Cindy's pelvis and spine, and an assessment of her pelvic floor and core muscle flexibility, strength, and coordination. She noted muscle weakness and tender points in the muscles in and around Cindy's pelvis. She also noted an imbalance in Cindy's walk. She diagnosed pelvic pain, and explained that Cindy’s fall aggravated the joints and tissues in her tailbone area.
Cindy's physical therapist designed a treatment program that included exercises to stretch and strengthen the involved pelvic muscles, and to retrain them to work together. She explained that this treatment should help reduce Cindy's urinary and constipation challenges, and also help relieve her pain.
Over Cindy's next several treatments, her physical therapist taught her a few movement techniques to improve blood flow and tissue function in the pelvic region, and some pelvic floor muscle exercises as well. She performed biofeedback exercises with Cindy to help her learn to use her pelvic floor muscles more effectively, and also designed a home-exercise program for her.
Two months later, Cindy is feeling much better. She uses the strategies her physical therapist taught her for sitting, and can now complete a full workday without limitation due to pain. Cindy has recently started performing a yoga program at home based on some of the exercises her physical therapist gave her. She is able to walk for 45 minutes a day, and plans to start jogging soon. Just today, she signed up for a gentle yoga class at her community center, and looks forward to making new friends there.
This story was based on a real-life case. Your case may be different. Your physical therapist will tailor a treatment program to your specific case.
All physical therapists are prepared through education and experience to treat a variety of conditions or injuries. You may want to consider:
A physical therapist who is experienced in treating people with pelvic pain or women's health problems.
A physical therapist who completed a residency or fellowship in women's health physical therapy. This therapist has advanced knowledge, experience, and skills that may apply to your condition.
You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.
General tips when you're looking for a physical therapist (or any other health care provider):
Get recommendations from family and friends or from other health care providers.
When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping people with pelvic pain.
During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and say what makes your symptoms worse.
The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions and also prepare them for a visit with their health care provider.
The following articles provide some of the best scientific evidence related to physical therapy treatment of pelvic pain. The articles and resources report recent research and give an overview of the standards of practice for treatment both in the United States and internationally. The article titles are linked either to a PubMed abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.
Anderson RU, Wise D, Sawyer T, Nathanson BH, Nevin Smith J. Equal improvement in men and women in the treatment of urologic chronic pelvic pain syndrome using a multi-modal protocol with an internal myofascial trigger point wand. Appl Psychophysiol Biofeedback. 2015 December 31 [Epub ahead of print]. Article summary on PubMed.
Singh MK, Rivlin ME. Chronic pelvic pain in women. Medscape. Updated January 13, 2015. Accessed January 6, 2016.
Anderson RU, Wise D, Sawyer T, Nathanson BH. Safety and effectiveness of an internal pelvic myofascial trigger point wand for urologic chronic pelvic pain syndrome. Clin J Pain. 2011;27(9):764–768. Article summary on PubMed.
American College of Obstetricians and Gynecologists. Chronic pelvic pain. Published August 2011. Accessed January 6, 2016.
Ortiz D. Chronic pelvic pain in women. Am Fam Physician. 2008;77(11):1535–1542. Free Article. Accessed January 6, 2016.
Fisher KA. Management of dyspareunia and associated levator ani muscle overactivity. Phys Ther. 2007;87:935–941. Free Article.
Borello-France DF, Handa VL, Brown MB, et al. Pelvic-floor muscle function in women with pelvic organ prolapse. Phys Ther. 2007;87:399–407. Free Article.
Stuge B, Holm I, Vollestad N. To treat or not to treat postpartum pelvic girdle pain with stabilizing exercises? Man Ther. 2006;11:337–343. Article Summary on PubMed.
Depledge J, McNair PJ, Keal-Smith C, Williams M. Management of symphysis pubis dysfunction during pregnancy using exercise and pelvic support belts. Phys Ther. 2005;85:1290–1300. Article summary on PubMed
* PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI). PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine’s MEDLINE database.
Authored by APTA's Section on Women's Health; Kendra Harrington, PT, DPT, board-certified clinical specialist in women's health physical therapy (original author). Revisions by Stephanie Fournier, PT, DPT, PhD(c), board-certified clinical specialist in women's health physical therapy; Lorien Hathaway PT, DPT, board-certified clinical specialist in women's health physical therapy; and Venita Lovelace-Chandler, PT, PhD, board-certified clinical specialist in pediatric physical therapy. Reviewed by the editorial board.
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