Chronic Pelvic Pain (CPP) – Introduction
Chronic Pelvic Pain (CPP) is an umbrella term that covers many kinds of pain felt in the pelvic floor area. Contrary to common misconception, It is suffered by both men and women and is much more prevalent than realised probably because many people who have CPP suffer in silence, too embarrassed to seek help.
A World Health Organisation review in 2007 described CPP as being a debilitating condition among women with a major impact on quality of life and work with an annual cost in the USA of $881.5 million and an estimated £158 million to the NHS in the UK. A UK paper in 2002 found that of men presenting with prostatitis 2.3-3% suffered from CPP and that the primary reason for men over the age of 50 consulting a doctor was urogenital pain.
Luzzi found a prevalence of 2.5–3% in men for CPP (2). The primary reason for men over the age of 50 consulting a doctor is urogenital pain (3).
In a study of women between the ages of 18-50 25.4% in New Zealand reported CPP, 14.7% in USA and 24% in UK. 25% of these women remained without a diagnosis for 3-4 years and 30% of women had had their pain for over 5 years.
75% of women with CPP in a trial of 132 demonstrated musculoskeletal involvement (4).
The term CPP covers pain in the front of the abdomen, the pubis, the sacroiliac joint, the vagina, anus, penis, bladder and coccyx. Diagnostic terms that are frequently used include endometriosis, adhesions, cystitis, irritable bowel syndrome, constipation, hernia, vulvodynia, coccydynia, prostadynia or prostatitis and sexual dysfunction. The patient might undergo testing for urological, gynaecological, gastroenterological, psychological, and sexual health problems but frequently the tests are negative.
The aetiology and pathology remain a mystery and it is now commonly thought that central neurological mechanisms are involved (5). However there may have been an initial trauma such as a fall on to the coccyx, friction or vibration of the pelvis from long distance cycling, injury during labour or following a pelvic or abdominal surgical procedure.
Sometimes there is a cause that can be related back to the start of CPP and this might be after having an episiotomy in childbirth to allow a big baby’s head to pass through the birth canal; or it may have been after surgery for a hernia or haemorrhoids (piles), or after a fall on to the bottom which pushed the pelvis or coccyx out of alignment.
In many cases there is no direct cause but stress, excessive sitting, low back pain or an uncomfortable sexual experience can all be factors than can bring on pain. The present view is that CPP is caused by pressure and irritation of the pudendal nerve which is a branch from the nerves of the lower lumbar spine. It supplies the muscles of the pelvic floor including the sphincters for the bladder and the rectum as well as the sense of feeling in the external genitalia of both sexes.
The pelvic musculoskeletal system
The pelvis forms the core of the skeletal system. It needs to be very strong to carry the weight of the body above and cope with the reaction forces from below when we strike the ground with our feet. We sit on it. The ligaments and muscles that support the pelvis are arranged for maximum congruity and strength. The contents of the abdomen such as the bladder, bowel and uterus are supported inferiorly by the levator ani muscles which form a sling, anteriorly by the abdominal muscles consisting of transverus abdominus, internal and external oblique muscles and rectus abdominus and posteriorly by extensor spinae, latissimus dorsi, quadratus lumborum muscles and the thoracolumbar fasica.
The pudendal nerve originates from the lumbo-sacral plexus (L4-S4). It consists of both sensory fibres (80%) and motor fibres (20%). It innervates the external genitalia of both sexes, as well as sphincters for the bladder and the rectum.
The pudendal nerve innervates the penis and clitoris, bulbospongiosus and ischiocavernosus muscles, and areas around the scrotum, perineum, and anus. At sexual climax, the spasms in the bulbospongiosus and ischiocavernous results in ejaculation in the male and most of the feelings of orgasm in both sexes.
The levator ani muscle sling is formed by the coccygeus posteriorly, iliococcygeus laterally and pubococcygeus anteriorly. Piriformis and obturator internus also form part of the sling and involve respectively the sciatic nerve and the hip joint. The more superficial muscles bulbospongiosus and ischiocavernosus are specifically connected to the genitalia. The lumbar spine articulates on the sacrum and the lumbar plexus can refer pain to the pelvis
Neuropathic pain is described by the patient as dull, burning, itchy or pins and needles. It is ill-defined and the patient will usually place the hand over a large area to describe where the pain is, unlike nocioceptive or somatic pain which is localised to a bone, skin or muscle. Sometimes even light touch becomes hypersensitive. The mechanism of neuropathic pain is complex and characterised by central sensitisation involving amplification though the dorsal horn ganglion or higher central nervous centers such as the limbic system. Changes in the afferent (sensory) nervous system and in the efferent system may also occur. Neurochemicals , such as substance P, are released from nerves which releases local inflammatory substances. This can escalate through antidromic transmission of nerve impulses, which travel down affected nerves and spread to other branches of the same or synapsing nerves in other areas of the body. Hence the nasty wind up, continuation and spread of chronic pain.
Involvement of the limbic system and in particular the anterior cingulate cortex provokes feelings of helplessness, hopelessness and fear which can be worse than the actual physical pain and make it very difficult for treatment to break the cycle.
Musculoskeletal causes of CPP
Muscles such as coccygeus can be responsible for pressure on the pudendal nerve that supplies both motor control and sensation to the sexual organs and bladder and bowel sphincter muscles.
Pelvic malalignment can cause muscular overactivity through failure in the normal stability system of pelvic muscular control resulting in a bracing mechanism involving muscles such as coccygeus and piriformis both of which surround nerves such as the sciatic and pudendal nerves. Pressure from muscular overactivity can cause chronic neuropathic pain to develop.
The normal muscular stability system for the pelvis is upset by pelvic malalignment. Malalignment can be caused by a trauma such as a fall on to the pelvis; by incorrect posture altering the muscle balance between such muscles as gluteus maximus and psoas in the hyperlordotic posture or through the birthing process when the ligaments do not tighten up correctly in the weeks following delivery causing symphysis pubis dysfunction (SPD).
Following abdominal surgery, rectal surgery or episiotomy in child birth the resultant scarring and adhesions can cause pain and bracing of local muscles.
Endometriosis and constipation can cause pain and bracing so that in the case of constipation the sphincters are unable to relax to void the rectum thereby making the problem worse.
Constipation over a long period of time can damage and weaken the pelvic floor muscle from too much straining. An imbalance can set itself up further feeding in to the pattern of constipation where the muscle dysfunction becomes the main problem. This needs medical help from your doctor.
How to treat CPP
At esph we have experienced physiotherapists who have worked for many years with patients suffering from chronic pelvic pain. We have built up a team approach which includes pain management with an eminent pain management specialist who has a special interest in CPP, 2 expert cognitive therapists and our esph team of physiotherapists and massage therapists.
We utilise muscle energy techniques to re-align the pelvis, Pilates based exercises for core stability, massage, trigger point work, relaxation techniques, acupuncture for pain relief and education to demystify the chronic pain mechanisms.
There is no need to suffer in silence from the horrible experience of CPP. There are physiotherapy treatments that can help to put the spine and pelvis back in to alignment so that the support muscles can work normally; there are gentle exercise regimes that can get you back to normal activities; there are also specific medications that help you cope with the pain and there is cognitive therapy that can help you find strategies that will help you cope with everyday life and gradually learn to overcome the problem.
- Latthe P,et al. WHO systematic review of prevalence of chronic pelvic pain: a neglected reproductive health morbidity
- Luzzi GA . Chronic prostatitis and chronic pelvic pain in men: aetiology, diagnosis and management. Journal of the European Academy of Dermatology and Venereology. Volume 16, Issue 3, pages 253-256, May 2002
- Fall L et al. EU Guidelines on Chronic Pelvic Pain. European Urology 2010. 57: 35-48
- King PM. Musculoskeletal factors in Chronic Pelvic Pain. JPObs&Gyn 1991
- Nickel JC et al. Chronic prostatitis: current concepts and antimicrobial therapy. Infect Urol 2000. 13: S22-8