Pelvic Pain

Stress Induced Changes in Cortisol Levels can Impact Pain Tolerance

Stress triggers the sympathetic nervous system, leading to heightened levels of adrenaline and cortisol, which can cause inflammation and increase the perception of #pain.

Prolonged stress can deplete cortisol levels, leading to adrenal fatigue, which makes it difficult to manage chronic pain. Additionally, stress can lower #testosterone levels, further exacerbating the experience of pain. Testing cortisol levels through saliva or serum can provide insights into how stress is impacting the body.

Lack of sleep can also increase cortisol levels, contributing to heightened pain sensations. Establish a consistent and relaxing routine. Consider activities like spending time in nature, exercising, taking a warm bath🛁 , reading a book📖, journaling, or meditating🧘‍♀. @insighttimer is a great relaxation app!

Strive to get 7-9 hours of sleep😴 per night. This helps down-regulate the sympathetic nervous system, leading to improved pain sensitivity, energy levels, and tissue healing. Aim to wake up at the same time every day (including weekends) and expose yourself to bright natural light☀️ in the morning. Falling asleep between 9 and 11 PM is a helpful guideline as it often aligns with natural circadian rhythms.

Self-Lymphatic Drainage for Pelvic Pain

1. Diaphragmatic Breaths (Stimulating the Autonomic Nervous System): Breathe in and allow 360-degree ribcage expansion, with the belly rising slightly, the ribs moving laterally, and the chest remaining steady. Exhale slowly through your mouth. This helps stimulate the autonomic nervous system, influencing pain perception.

2. Clockwise Abdominal Circles with Light Touch: Gently make clockwise circles on your abdomen with light pressure. This aids in promoting lymphatic flow. 

3. Lymphatic Pumps: Perform gentle pumping motions just above the collarbone, at the armpit, and in the groin area. This helps facilitate lymphatic drainage and circulation.

4. Resisted Inhalations (Elastic Recoil): Place your hand on your abdomen. Inhale deeply, and as you reach the top of your breath, resist the urge to exhale immediately. Lift your hand off your abdomen, engaging elastic recoil for respiratory and lymphatic benefits.

5. Pelvic Floor Muscle Contractions (Coordinated with Exhale): Coordinate pelvic floor contractions with your exhale. These contractions act as a sump pump, aiding in lymphatic drainage, especially in the pelvic region where numerous lymph nodes are present.

6. Diaphragmatic Breaths (Enhancing Lymphatic Flow): Revisit diaphragmatic breathing to enhance lymphatic flow. Focus on creating a pressure differential during inhalation and exhalation, promoting the movement of lymphatic fluid while inducing deep relaxation.

Remember to perform each technique mindfully and listen to your body. If you experience any discomfort or have specific health concerns, it's advisable to consult with a healthcare professional before starting this self-lymphatic drainage routine.

This does not replace pelvic floor physical therapy. I highly encourage finding a therapist near you for an individualized treatment plan. Many people do not perform pelvic floor muscle contractions (kegels) correctly and not everyone benefits from performing them. 

Connective Tissue

Fascia is loose connective tissue connected head to toe🦶. This tissue is located under the skin and over muscle and forms a cable knit full body leotard👯‍♀️. Imagine a knit🧶 sweater - if you pull a loose string, you can get puckering at another place. You can have tension, scar tissue, tightness, or poor blood flow to one area that can cause pain or pelvic floor symptoms elsewhere. When prior pelvic floor therapy has been unsuccessful, connective tissue restrictions are often the missing piece.

Connective Tissue Functions:

▪️Protects and compartmentalizes muscles, nerves, and organs

▪️Provides space and lubrication between bodily structures

▪️Creates pathways for nerves, blood vessels, and lymphatic vessels

▪️Offers mechanoreceptor input for kinesthetic awareness

▪️Facilitates the transfer of forces 

Connective tissue restrictions are dense fascial thickenings that cause discomfort upon examination. They reduce blood flow🩸to underlying muscles and hinder their normal movement. Connective tissue must remain mobile to fulfill its functions and prevent pain and pelvic floor symptoms. These restrictions can also impede the response to therapies, especially for tight muscles or trigger points. Individuals with connective tissue restrictions may experience increased sensitivity to underwear/clothing👖 and sitting surfaces, contributing to discomfort. 

Connective tissue restrictions develop and persist due to visceral, joint, muscular, and neural dysfunction. Pelvic floor physical therapy aims to address the underlying causes of these restrictions! Reduced blood flow🩸in restricted areas can lead to pain and heightened sensitivity to touch, limiting movement and function. This can result in urinary and bowel💩 symptoms, as well as pelvic pain, which may also affect pelvic organs like the bladder. Connective tissue restrictions can also compress nerves, impeding their normal mobility and causing symptoms of peripheral neuralgia such as tingling and numbness, burning🔥, stabbing or shooting⚡️pain, and muscle weakness.

Benefits of connective tissue manipulation:

✔️Enhances circulation, improving blood flow and lymphatic drainage

✔️Increases lubrication and hydration of the collagen matrix

✔️Improves mobility, hypersensitivity, and function of surrounding muscles, nerves, and organs

✔️Induces a neuro-reflexive response, reducing abnormal muscle tone and pain 

Connective tissue restrictions have a strong association with trigger points and can refer pain to distant sites or organs such as the bladder. In pelvic floor physical therapy, we assess the connective tissue in the abdomen, attached to the bony pelvis, back, buttocks, and thighs. Restricted connective tissue reduces local blood flow🩸, making tissues overly sensitive to touch. Pelvic floor physical therapists employ a manual therapy technique called connective tissue manipulation, often referred to as skin rolling. This technique aims to improve mobility, sensation, and blood flow in impaired tissues, reducing inflammation, pain, pelvic floor symptoms, and negative effects on surrounding muscles💪 , nerves⚡️, and organs. Cupping, which utilizes suction to lift fascia, can also be used. The movement of cups on the body helps tissues move more freely. With connective tissue work we are trying to affect the nervous system! When restrictions are present our body receives mixed signals (can go haywire) which can contribute to symptoms.

⚠️ During treatment some people experience eye dilation, increased heart rate, as well as the feeling of ants, running water, vision change, or nausea/dizziness since we are affecting the nervous system.

What are trigger points?

Trigger points are hyperirritable spots in muscle💪 that are painful on palpation/compression.

▪️Active trigger points: pain upon palpation reproduces pain you are familiar with

▪️Latent trigger points: painful only upon palpation

A low level of non-purposeful electrical activity⚡️in the muscle (thought be be from excessive release of the neurotransmitter acetylcholine) causes a hypersensitive palpable “knot” 🪢. The sustained contraction leads to decreased blood flow and oxygen to the area. These proinflammatory knots can cause pain locally or at distant locations.

Tight muscles can be weak muscles since they don’t rest at a normal length. This can lead to compensation from other muscles. Physical therapists👩‍⚕️ trained in manual therapy, dry needling, and personalized exercise prescription can help decrease muscle tension, retrain mechanoreceptor input, decrease pain, improve blood flow/oxygenation, and improve motor recruitment.

Causes of trigger points include:

- Sustained postures

- Muscle fatigue

- Muscle overload/overuse

Increased likelihood can come from:

- Stress &/or anxiety

- Insufficient sleep 😴

- Endometriosis

- IBS 

What is dry needling?

During dry needling a sterile needle (as used in acupuncture) is inserted into skin, fascia, muscles, and in the vicinity of ligaments, tendons, and peripheral nerves.

Dry needling normalizes chemical balance and pH of skeletal muscles and restores blood flow/oxygenation to the area.

Dry needling can improve:


✅Muscle tension

✅Muscle recruitment

✅Scar tissue

✅Nerve function

✅Function, activity & participation

✅Biochemical and electrical⚡️dysfunction of motor end plates

The most common use for dry needling is trigger points. See last week’s post to learn more about these! 

Use a Foam Roller or Massage Gun Prior to Exercise to Reinforce Optimal Tone & Retrain Muscles

We want muscles to have optimal length/tone while exercising to train them to stay that way! The shaking that the massage gun provides can help muscles soften. You can also just shake your muscles with your hands🤚

TMJ and Pelvic Pain

There is a high correlation between people with TMJ and pelvic pain. This is because of embryological connections resulting in fascial connections between the jaw and pelvic floor muscles. When we clench one, we often clench the other! People who grind their teeth at night are also creating tension in the pelvic floor muscles. When we relax the jaw, it also helps to relax the pelvic floor. 

Overactive Pelvic Floor Muscles can "Pinch" the Pudendal Nerve

The pudendal nerve is responsible for sensation of the genit@li@ and skin around the anu$. Tight pelvic floor muscles can tighten around pudendal nerve ➡️ pain

Symptoms of peripheral neuralgia can include:

▪️Tingling and numbness


▪️Stabbing or shooting⚡️pain

▪️Muscle weakness

Pelvic floor PT can help!

Lichen Sclerosus is an Autoimmune Vulvar Dermatological Condition that can cause Shiny White Patches on the Vulva

Symptoms may include vulvar itching, tearing or bleeding🩸with s3x or wiping, urinary urgency/frequency, pain with s3x, or no symptoms at all. Some people may also experience atrophy (shrinkage) of their labia minora as well as clitoral hood scarring over the clitoris. The vulvar skin may also look like leather and the v@gin@l opening may appear smaller with less elasticity.

🔎 I hope to motivate you to get out a hand mirror🪞 and learn your anatomy - many doctors don’t spend time performing a proper vulvar exam. As a pelvic floor physical therapist👩‍⚕️I see it as my duty to perform a comprehensive vulvar exam to catch anything that may have been missed!

Pelvic floor physical therapy is an integral part of interdisciplinary care for those with lichen sclerosus! We can help with:

▪️pelvic floor muscle dysfunction

▪️scar tissue management

▪️pain management

▪️education and lifestyle modifications

It's important to treat lichen sclerosus! Left untreated, it can increase the risk of vulvar cancer. These conditions can be diagnosed with a punch biopsy from genital tissue. Make sure to ask your doctor to distinguish between lichen sclerosis and lichen planus when sending the biopsy to the pathologists. If lichen is not present, it is important to avoid potent steroid cream as it can thin the tissue.

Vestibulodynia Presents as Pain Where the Labia Minora Meets the Opening of the Urethra & Vagina 

The vestibule is a specific part of the vulva where the labia minora meets the urethral meatus and v@ginal introitus. Vestibulodynia (a form of vulvodynia) is pain/irritation at the vestibule. This can feel like burning, stabbing, fire🔥, and ripping apart. People can experience pain/irritation from sitting, s3x, wearing tight clothes👖or underwear, exercising 🏃‍♀️, sweating💦, wearing tampons, and urinating. People may also feel like they get urinary tract infections a lot or like they have lots of issues with their bladder. Pelvic floor PT can help!

Chronic inflammation can increase the density of nerve endings⚡️and decreased pain threshold ➡️ increased discomfort. 

Potential contributing factors:

▪️Use of Monistat (a commonly used medication to treat yeast infections) - Monistat may increase the number of mast cells, which are immune cells that play a role in inflammation and pain and may also disrupt the natural balance of vaginal bacteria and fungi, leading to inflammation and pain.

▪️History of chronic inflammation caused by extreme allergies

▪️Recurrent UTIs

▪️Autoimmune conditions

▪️Congenital - born with excessive nerve endings

Decreased vulvovaginal estrogen and testosterone can make the vestibule irritated🔥The vestibule is dependent on estrogen and testosterone so if it has reduced hormones you can feel like the bladder is acting up.

This drop in hormones may be related to the use of:

As well as with:

Fun fact: the clit0ris is also testosterone dependent (it can shrink in size with low hormone levels)

The pudendal nerve is responsible for sensation of the genitalia and skin around the anus. Tight pelvic floor muscles can tighten around pudendal nerve ➡️ pain

Symptoms of peripheral neuralgia can include:

▪️Tingling and numbness


▪️Stabbing or shooting⚡️pain

▪️Muscle weakness

Reach out to a Pelvic floor PT near you!

Pelvic Floor Therapy for Overactive Bladder and Interstitial Cystitis

Overactive bladder (OAB) is often characterized by bladder spasms leading to urgent and frequent urination. Signs of OAB include voiding more frequently than every two hours and waking up to urinate more than twice during the night. Some individuals may also experience chronic bladder or pelvic discomfort/pain and have a diagnosis of interstitial cystitis (IC) In cases of OAB, the pelvic floor muscles are typically tight or in spasm (tight muscles can also be weak). Pelvic floor physical therapy, combined with bladder retraining, has proven effective in managing these symptoms.

The pannicular layer, the most superficial layer of fascia, can play a role in various issues, including an inappropriate urge to urinate that mimics bladder signals. Fascia plays a significant role in our pelvic PT work!

Mechanoreceptors lining the bladder communicate with the brain, signaling when it's time to urinate. Giving in to every urge to urinate can lead these receptors to recalibrate, perceiving it as normal to empty the bladder when it's not full. These receptors become less sensitive to pressure, continually signaling the brain to urinate even when it's unnecessary.

May is Ehlers Danlos Syndrome (EDS) and Hypermobility Spectrum Disorder (HSD) Awareness Month

Ehlers Danlos Syndrome (EDS) encompasses a group of connective tissue disorders characterized by skin and connective tissue laxity, alongside various complications. Hypermobility Spectrum Disorder (HSD) falls within this spectrum, featuring joints with increased range of motion, often leading to heightened pain and instability. Not everyone with HSD has EDS.

Common characteristics include stretchy, semi-transparent skin, heightened joint instability (with dislocation/subluxation being more prevalent), joint pain, arthritis, and soft tissue overuse injuries such as tendonitis, bursitis, and muscle pain. Individuals with EDS may also experience debilitating pain and fatigue, significantly impacting daily activities. As of now, there is no cure for EDS, and treatment primarily revolves around symptom management.

The most effective approach is prevention through enhancing functional mobility, stability, and adhering to a consistent physical therapy regimen. Building muscle stability is crucial to prevent injuries - maintaining an active lifestyle in safe ways is key. Initially, it may be beneficial to avoid certain exercises or extreme motions until stability is achieved. Collaborating with a physical therapist for personalized guidance is highly recommended.

Stress urinary incontinence, urinary tract infections (UTIs), and prolapse are more prevalent in this population. Pelvic floor physical therapy is beneficial for EDS patients by strengthening and stabilizing pelvic floor muscles, improving bladder and bowel function, and reducing pelvic region pain and discomfort.

Physical therapy can consist of:

✨Muscle strengthening

✨Core, trunk stabilization, and joint awareness exercises

✨Manual therapy/soft tissue mobilization for overactive muscles

✨Posture re-education

✨Proprioceptive training

✨Transcutaneous electrical nerve stimulation (TENS) to block pain signals via gate control theory

✨Durable medical equipment such as cushions, compressive garments, and braces

✨Relaxation training

There is a strong EDS community! Check out @ehlers.danlos @thezebranetwork @eds__awareness

Individuals with EDS may be more susceptible to developing POTS (Postural Orthostatic Tachycardia Syndrome) due to the underlying connective tissue abnormalities affecting blood vessel function. POTS is characterized by an abnormal increase in heart rate upon standing up from a seated or lying position, often accompanied by symptoms such as lightheadedness, palpitations, fatigue, weakness, and fainting.

Pacing yourself is crucial to help minimize flare-ups, and adopting an anti-inflammatory diet can provide additional support. Remember, limitations should not be viewed as failures - utilizing aids and seeking assistance when needed are essential self-care. It's important to advocate for yourself and secure the accommodations necessary for your well-being.

Maintaining a sense of normalcy in daily life is often beneficial for mental health. While adjustments may be necessary in navigating physical tasks or managing mental health, staying calm, seeking support, and remaining open to new opportunities are key. Embracing the journey of adaptation, seeking assistance when needed, and continuing to pursue personal growth and fulfillment are vital aspects of living with EDS and related conditions.

Self-talk is incredibly important. There's a significant difference between thinking,

"What if I twist my ankle and suffer severe consequences?” versus "What if I strengthen my body to prevent such incidents?" Positive self-talk can empower individuals with EDS to focus on achievable goals and foster resilience in the face of challenges.

SI Belt

SI belts provide pelvic compression and can offer benefits for conditions such as back pain, SI joint pain, pubic pain, hip pain, and pregnancy-related discomfort. Brands like @serolabiomechanics have demonstrated effectiveness, particularly when addressing joint instability or increased mobility.

To maximize its effectiveness, wear the SI belt low around your hips; this can reduce SI joint motion by up to 30%.

During pregnancy and breastfeeding, increased ligament laxity can exacerbate symptoms. Consider using an SI belt to alleviate discomfort. Some individuals have found relief by wearing it at night while pregnant, especially if they experience pain when moving in bed.

It’s important to note that an SI belt should not replace physical therapy. If you are experiencing symptoms, reach out to address the root of your condition.

Pelvic Congestion/Varicose Veins

Pelvic congestion and varicosities (distended veins) can occur when pelvic veins become lax/enlarge to the point that there is no longer just one way movement of blood flow. Blood pooling can put pressure on parts of your pelvis or nerves⚡️ leading to discomfort. The appearance can fluctuate (can look like little freckles and can go away).

Symptoms can include:

▪️Pressure in the abdomen/pelvis

▪️Pain in the legs

▪️Asymmetrical/swelling of the labias

▪️Pain with intercourse (increased blood flow can pool)

▪️Pain with periods

▪️Urinary urgency/frequency

▪️Veins in the pelvis easily visible

▪️Spider veins in the legs

Symptoms are typically worse at the end of the day, with prolonged standing, and when pressure is applied to the abdomen or when bearing down (Valsalva/straining on the toilet). Typically, there is improvement with lying down.

Some other ideas to help relieve symptoms include:

▪️Bridge positioning while lying down (can elevate hips under a pillow)

▪️Massage labia up towards groin

▪️Compression garments/biker shorts – wearing a V2 supporter can help

▪️Apply a cold compress (ex: frozen peas)

▪️Lymphatic drainage & lymph foam pads in underwear

▪️Walk regularly & do ankle pumps

▪️Avoid prolonged sitting/standing & crossing legs

▪️ Ask your doctor about sclerotherapy

✨These tips don’t substitute pelvic floor PT. Feel free to reach out if you are experiencing symptoms✨