The Pros and Cons of Exercise When You HaveEndometriosis
Part 2: How to diagnose and begin treatment for pelvic floor pain
Endometriosis does not have an exclusive on pelvic pain from pelvic floor spasm.
Almost any unpleasant sensation—physical or even emotional—can cause these muscles to spasm over time, since they unconsciously contract as a natural defense in our fight-or-flight response. This means that any of the following can evoke this type of muscle overuse that leads to cramping:
- Migraine headaches
- TMJ (temporomandibular joint) dysfunction
- Irritable bowel syndrome
- Inflammatory bowel disease
- Painful bladder syndrome (previously called “interstitial cystitis”)
- Chronic constipation
- Pelvic adhesive disease
- Adenomyosis (endometriosis-like changes in your uterus)
- History of sexual abuse
- Other PTSD
Pelvic pain: the perfect storm
The web site, Ova.academy, calls pelvic pain “the perfect storm,” because it is usually an overlap of several conditions. It’s not that the typical woman has several things wrong with her, but that her abdomen encloses several organs which can get caught up in the expanding inflammatory process. There are 3 things that cause the confusion encountered when trying to diagnose the cause of chronic pelvic pain.
- The peritoneum. This is the enclosure of tissue surrounding your abdominal cavity; the pelvic cavity is confluent with the abdominal cavity and part of it. The peritoneum also folds over the organs as well, and it is thought that inflammation in one tissue type provokes inflammation along this peritoneal covering, thereby spreading to the organs in contact with it elsewhere or everywhere else.
- Pelvis as the center of gravity. The pelvic ring anchors muscles and ligaments both above it and below it, so any chronic dysfunction can impact the muscles of the pelvic ring, from abdominal strain from too many sit-ups to one leg being shorter than another. All of these pain sensations land at the same point in your spinal cord, and the pain signal can often flip back out to the other areas that share this spinal segment. Thus, abdominal wall pain may be—not from those sit-ups—but from spasm of internal pelvic muscles resulting from defensive clenching after a history of sex abuse. Even a gynecologist could miss that!
- The complex nature of the pelvic musculature. The pelvic floor isn’t just one big floor of muscle, but several muscles working together to support your pelvic organs, maintain continence of urine and feces, move your hips and thighs, flex your abdomen, and even provide sexual tone during intercourse. If you think this is complicated, it is. Although a large combination of muscles can be involved, it is entirely possible tha just one muscle can be the villain.
For example, spasm in one of the two bilateral puborectalis muscles can cause nerves within them to transmit pain to the vulva, causing vulvodynia.
What are the muscles we’ve been talking about?
On each side between the top of your pelvic ring to your coccyx (tailbone) are the following:
- Levator ani muscle (as the Latin indicates, its contracting lifts the anus): made up of two muscles, the puborectalis (responsible for continence of urine) and the ileococcygeus.
- Obturator internus from the lower portion of your pelvis to the head of your upper leg bone (femur): it causes rotation of your hip/leg, either toward or away from the pelvis, depending on whether the thigh is flexed of not.
- Pyriformis: nearer the top of your pelvis, toward the back, running from your spine to the head of your femur. It rotates the hip, turning the leg and foot outward.
You don’t have to know these muscles, but the person diagnosing and treating your pain does!
It is only included here for completeness. What is important is how this complexity figures into the diagnosis. The exam that is used to evaluate all of these muscles and thereby becomes a basis for therapy is not your typical GYN exam:
Palpation: It requires a palpation (pressing on and feeling) each of these internal muscles or muscle groups to assess for spasm and pain.
Pain mapping: It also requires something called “pain mapping,” which is a Q-tip touch test to see which areas are over-sensitive to touch. This information is useful for diagnosing neuropathic pain that has developed as part of the progression.
The endometriosis specialist knows how to do this exam.
Whether endometriosis is the cause of pelvic floor muscle spasm or not, the spasm is the same. Worse, it can persist even after the most exacting surgery to remove endometriosis, using the robotic technique Dr. Bozdogan at NYCEndometriosis uses.
After years of clenching these muscles defensively, they can persist in this abnormal tone even after removal of the problem. This is why Dr. Bozdogan will refer you to a pelvic floor physical therapist after definitive surgery for endometriosis or infertility. Although he knows how to do this exam, the PT is an important member of the team to carry out the maneuvers to get these painful muscles back to a normal (non-painful) tone and instruct you on follow-up exercises you can do at home.
Your pelvic floor physical therapist is not your typical physical therapist.
Strangely enough, it’s not because your pelvic floor muscles are any different from any other muscles that can spasm. It’s because of where they are. They can only be accessed through your vagina. This puts up a big roadblock for some PTs who are sensitive to the privacy involved in such an approach. Thus, many do not have the facilities to ensure that privacy and simply decline to do that type of therapy. But if you’ve been referred to a “pelvic floor” physical therapist, you should ask them (before the appointment) if they even do that type of PT and whether there are provisions for the appropriate privacy required.
What treatments are available for pelvic floor muscle pain?
As stated above, all skeletal muscle is basically the same. What makes the pelvic muscles different is not only the vaginal access required for proper examination, but a knowledge of the important nerves and blood vessels that are associated with these muscles. Things like nerve entrapment and neuropathic pain can originate from pelvic floor disease. Nevertheless, the treatment of spasm in these muscles involves the following:
- Eliminating the initiator of the pelvic floor spasm—for our purposes, we’re talking about endometriosis or other pelvic pathology (fibroids, adhesions, etc.)—the things treated by an endometriosis specialist like Dr. Bozdogan. No treatment can be successful if the initiator is still present to provoke muscle spasm.
- A recognition that the muscle spasm can persist as its own disease, even after eliminating the cause. Many surgeons stop at eliminating the cause, ignoring that it can persist. (A common mistake is a sentiment like, “I don’t know what’s causing your pain—I took out all of your endometriosis.”)
- Trigger-point release: this is part of the “myofascial release” that consists of massaging out the hypersensitive areas to break up the trigger points into a normal resting state for the muscle fibers.
- Biofeedback: useful for educating you on when you are clenching these muscles unconsciously. This is an important key to success.
- Specific exercises for specific spasming muscles [SEE Part 3: Exercises that can help with endometriosis pain, next article in this 3-part series.]
Does this treatment hurt?
It can. Certainly, muscles that are exquisitely sensitive to touch can make treatment prohibitive. But there are remedies even for these extreme presentations. For example, an outpatient sedation will allow injection with Botox to relax these muscles for long enough to carry out a successful treatment. The problem is that many patients give up when the treatment proves too painful. This is when the strategy should move “outside the box” and consider things like Botox injections or temporary muscle relaxants.
Tragically, doctors not familiar with the pelvic floor connection can move on to other surgeries in a desperate attempt to stop your pain, including removal of your tubes and ovaries and even your uterus—which is the ultimate tragic irony on someone with infertility having pelvic pain from endometriosis.