Pelvic Pain Syndrome

by Beate Carriére, PT, CIFK

Assessment and treatment of the hyperactive pelvic floor.

Men and women can suffer—sometimes silently—for a long time from various pain syndromes of the pelvic region. They do not dare to talk about it out of fear of being misunderstood and because some physicians who are unfamiliar with such pain syndromes are uncomfortable discussing these problems with their patients. Patients may describe pain or pressure in the bladder, rectum, anus, and tailbone—often in the lower abdomen and sometimes in the muscles surrounding the pelvis, back, and legs. The pain’s origin is rarely known.

The emotional strain this pain causes is tremendous. When asking the patients what their goals are, they answer, “I want to have my life back. I cannot walk, exercise, eat what I want, and do all of the things that I liked to do.” Frustration, depression, and hopelessness are involved in having constant pain.

Often, the pain began after a bladder infection or prostate inflammation and the patients were treated with antibiotics or other medication, sometimes several times. Patients usually report that after the inflammation was gone and the medicine was discontinued, the pain remained and often intensified. Acute prostate pain turned into chronic prostatitis, without the presence of bacteria. Continuous pain in the bladder is finally diagnosed as urethral syndrome or inflammation of its lining. The mucosa inside the bladder becomes inflamed, a condition called interstitial cystitis (IC).

As a result of this condition, the individual develops intolerance to many foods and drinks containing acid, such as orange juice and alcohol. Frequent urination, sometimes combined with the urge to have to go to the bathroom (symptoms associated also with overactive bladder syndrome), accompanies the pain. Some patients have to urinate every 30 to 60 minutes during the day (normal voiding is six to eight times per day). Often, they also develop nocturia, which means that they wake up several times at night with the urge to go to the bathroom (normal occurrence is zero to one urge) and they get sleep deprived. Deferring going to the bathroom frequently increases the pain in the bladder and lower abdomen. The patients get little rest, worry a lot, and tend to get depressed—the bladder and pain rule their lives.

If the patient does not drink enough because of fear of having to go to the bathroom so often, the bladder tends to shrink. The volume that the bladder can hold decreases and causes more frequent urges.

Constipation can also result from drinking less. In order to improve constipation, patients tend to eat more fiber, not knowing that this could further increase constipation, especially if the patient is not drinking much fluids. Certain medications contribute to constipation as well. Prescribed antidepressants sometimes cause considerable weight gain and affect the patient’s self-image. The seemingly endless spiral into the abyss of pain and frustration is set into motion.

Running from one physician to another until finding one who understands the condition may lead the patient to feel hopeless. Add to that the inappropriate recommendations by some practitioners to strengthen and tighten (sometimes with biofeedback) the pelvic floor muscles, which are already too tight.

Pelvic floor dysfunction is the general term for part or all of the above symptoms. All of these symptoms require a careful evaluation and treatment by a physician and a PT who are knowledgeable in the field of pelvic floor dysfunctions and who understand these pain syndromes.

Most of these pain syndromes have a common culprit described as hyperactive pelvic floor syndrome (HPFS).1 Known symptoms of HPFS in women and men are:

  • Chronic pelvic pain
  • Irritable bowel syndrome
  • Constipation
  • Urethral syndrome
  • Overactive bladder
  • Interstitial cystitis
  • Dyspareunia
  • Sexual arousal problems
  • Perineal pain
  • Perianal pain
  • Hemorrhoids
  • Coccygodynia
  • Sacral pain
  • Hyperventilation

Obviously, any of these symptoms can be devastating. If a patient has at least three of the above symptoms, it may be an indication that the pelvic floor is hyperactive and the muscles may be stiff and painful.Very specialized treatments are required because many systems of the body are involved. Patients with constipation can learn to perform colon massage and hot-roll treatments to the abdomen or back to relax the autonomic nervous system.2 With scars and congestion in the abdomen, manual lymph drainage3 may be a choice of treatment, if there is autonomic dysfunction.

Read our September 2006 article, “Changes During Menopause—Implications for SUI.” to find out how understanding the basics of estrogen can help PTs assess and treat stress urinary incontinence.The patient may have poor posture for many reasons, including pain,4,5 which may contribute to tight pelvic floor muscles. Good breathing techniques and the ability to allow oxygen to get into the pelvic region may improve the condition, because it improves muscle function. Breathing has to be coordinated with pelvic floor muscle activity. The patients have to learn to be aware of the pelvic floor muscles (through sensory-awareness training) and then learn to relax the muscles.

When patients experience leakage, strengthening exercises can be indicated, but the patient should learn to relax the pelvic floor muscles as well. The pelvic floor muscles do not have to be active all the time. Just like other muscles, they need a rest period. Patients also should avoid exercises such as crunches that apply increased pressure to the bladder. Exercising in unloaded positions may be more beneficial.

Patients who experience leakage when coughing or sneezing have to learn to do a quick contraction of the pelvic floor muscles when inhaling prior to a cough or sneeze. This precontraction eliminates the problem in a high percentage of patients6; repetitive exercises are contraindicated, especially if they are not coordinated with relaxation. Therapists also must have an understanding of treating the abdominal compartment with massage and visceral mobilization,7 by restoring muscle balance and mobility to the organs of the abdomen of the hips and spine. Trigger points inside and outside the pelvic region have to be treated as well.8

Therapists have to work closely with their patients to address each system of the body involved and help the patient to relax the tight muscles in the pelvic floor. Of all of the problems of the body, pelvic pain may be the most challenging treatment. We are treating a muscle group that is not easily visible or palpable. More than 30 muscles are attached to the pelvis and may directly or indirectly influence the pain. Orthopedic problems, such as a fall, can affect/injure the sympathetic or parasympathetic nervous system, causing leakage. Nerve damage can cause invisible problems as well. A multisystem approach is warranted most of the time.

Therapists should empower patients and teach them what they can do for themselves to improve their conditions. Thorough education about the pelvic floor is a must. It can reduce the feeling of guilt and frustration. This is a change from disablement to empowerment.

The Interstitial Cystitis Association ( provides information to patients with IC as well as a list of therapists. PTs treating pelvic floor problems can also be found through the women’s section of the APTA Web site (

The encouraging news is that most of the time, the condition can be improved or cured with treatment. Since it usually took a while for it to get into such a desperate state, there is no quick fix, either. It takes good cooperation of the patient, physician, and therapist to make a difference. Every system of the body that is involved has to be restored to improve function.

Almost always, the pelvic floor muscles are hyperactive and Kegels would not be the exercise of choice—in fact, it usually worsens the condition. Often, patients are extremely stressed, taking care of everybody else but themselves. They have to learn to find a quiet moment for themselves and make life changes.

Beate Carriére, PT, CIFK, is a therapist at Hollywood Physical Therapy Associates in Hollywood, Calif, and a published author. For more information, please contact linkEmail(‘PTPEditor’);


  • Ramaker M, van Lunsen R. The hypertonic pelvic floor. In: Carriere B, Feldt C, eds. The Pelvic Floor. New York: Thieme Verlag; 2006:117–121.
  • Carriere B. Heat application, the hot roll. In: Carriere B, Feldt C, eds. The Pelvic Floor. New York: Thieme Verlag; 2006:228–230.
  • Rosenberg MK. Therapy for lymphedema. In: Carriere B, Feldt C, eds. The Pelvic Floor. New York: Thieme Verlag; 2006:35–67.
  • Carriere B. Interdependence of posture and the pelvic floor. In: Carriere B, Feldt C, eds. The Pelvic Floor. New York: Thieme Verlag; 2006:68–80.
  • Rock CM. Reflex incontinence caused by underlying functional disorders. In: Carriere B, Feldt C, eds. The Pelvic Floor. New York: Thieme Verlag; 2006:98–116.
  • Miller JM, Ashton-Miller JA, DeLancey OL. A pelvic muscle precontraction can reduce cough-related urine loss in selected women with mild SUI. J Am Geriatr Soc. 1998;46:870–874.
  • Vleminckx M. Visceral mobilization. In: Carriere B, Feldt C, eds. The Pelvic Floor. New York: Thieme Verlag; 2006.
  • Kusunose RS. Strain and conterstrain for the pelvic floor. In: Carriere B, Feldt C, eds. The Pelvic Floor. New York: Thieme Verlag; 2006:149–163.

Recommended Reading

Interstitial Cystitis Association. Treatment guidelines. Available at:www.ichelp.comAccessed August 9, 2007.

Spitznagle TM. The Musculoskeletal Chronic Pain. In: Carriere B, Feldt C, eds. The Pelvic Floor. New York: Thieme Verlag; 2006:35-67.

Wise D, Anderson R. A Headache in the Pelvis. Occidental, Calif: National Center for Pelvic Pain Research; 2003.

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