Pudendal and pelvic pain.
Mrs X, who we will call Jane, came to the clinic 6 months ago after suffering a long history of pelvic and pudendal pain. The pain came on 3 years ago after her first child where an episiotomy was performed. She had some pelvic floor physio after and this appeared to sort the issue of pelvic pain, pain during sex and some odd nerve like pain. 3 years later and after a normal delivery with her second child the pain returned. However, her maternity physiotherapy was short lived and once her pains had settled to a certain level she was discharged. Believing that her pain was normal and in keeping with what one might expect with a second child, Jane felt her slight incontinence with increased exertion and discomfort during sex would reduce after a period of 2-3 months. However, as Jane became more active and returned to spinning at 3 months her pains began to worsen and her ‘odd’ nerve like pain was increasing in intensity. It was located in the sitting region of the pelvis or perineum. She would attend for a spin class and then would endure 2-3 days of increased saddle pain. This would settle after the 3 days and she felt that some simple pelvic floor exercises helped. At the same time Jane began to experience some back pain brought on by the spinning and sought the help of a local and recommended Chiropractor. The spinal manipulation was helpful and reduced some of the lower back pain but did little for the pelvic pain.
Jane then spent the next 6 months consulting with her GP, returning to the maternity physio and generally getting nowhere with the pain. She accepted that this 2-3 days of pain was manageable after spinning and provided she did her pelvic exercises this would be sufficient. Jane stopped the spinning began running in an attempt to loose weight and get fitter. She had previously been a runner before children and completed 2 half marathons. The running was going well and after steadily increasing her running mileage to 2 miles x 3 a week she began to notice some new problems.
Increased tightness in the hamstrings and a return of her back pain was her primary complaint and frustrated by yet another problem, she attended Core Body Clinic to get a sports analysis of her posture and running. Interestingly, having stopped spinning she found her pelvic pain had reduced by 75%. However, she was still experiencing pain with intercourse and had a very slight stress incontinence.
Jane was assessed by Sports Physio Adrian Wagstaff.
She was found to have short and weak hamstrings and weakness in the gluteal muscles. There was a dominance of the hip flexors, a reduced lumbar extension (leaning back) and some balance issues when standing on one leg. Her running gait was assessed: she had mal-tracking on landing; shallow hip flexion (bringing her knees up); and, a dominant adductor pattern (knees drawn in). The weakness in the gluteal muscles was evident because of poor pelvic stability. Jane was also assessed on the bike and it was here that she complained about the pelvic pain. On further questioning Jane admitted to the pain she experienced and the stress incontinence. On the Bike the pelvic mal-alignment was evident again with the hips shifting side to side and a poor control of the lower lumbar spine.
Superficial palpation of the pelvic rotator muscles revealed tenderness in the obturator muscles and piriformis. Pelvic floor contractions were also poorly controlled with increased abdominal activation. Adrian, as a pelvic trained therapist himself, identified that these problems were likely to be a contributing factor towards the development of Jane’s pelvic pain and the reason for her hamstring tightness and gluteal weakness. Wanting to treat the cause of Jane’s symptoms, he quickly referred her onto the Clinic’s expert female Pelvic Physiotherapist, Abarna Devi.
Abarna is one of the most qualified and knowledgeable pelvic therapists in the south of England and we are fortunate to have her at Core Body Clinic. Her knowledge and skills quickly identified abnormal contractions and compensations in the pelvic floor and through trigger point release Jane found an immediate relief in some of her pelvic pain associated with intercourse. She also noticed a reduction in the pelvic pain which both Adrian and Abarna agreed was likely to be pudendal neuralgia. Jane was taught the appropriate pelvic floor and abdominal muscle exercises and began to work on these immediately. She was also found to have a very tight abdomen with stress and relaxation techniques through breathing found to be hugely beneficial. At the same time she was given a running program by Adrian and exercises to help strengthen the hamstrings and gluteal muscles. After a period of a few weeks Jane was running better on the treadmill and her gait was more normalised with better pelvic stability. She desired to return to spinning and a graduated exposure program was commenced. This was done in association with her continued pelvic floor physiotherapy to help reduce nervous system sensitivity. After 8 weeks Jane was tolerating spinning with only some slight discomfort the following day. Her hamstring tension was much reduced with running and she had noticed a complete resolution of pain during intercourse. There was a little incontinence remaining but Abarna had advised Jane that given the duration of her symptoms it may take as much as 3 months to clear up……………10 weeks in the end.
We felt that Jane's hamstring and gluteal strength returned more quickly after pelvic floor treamtent because of the improved co-comtractions of the muscles in the region. Jane may have been 'hanging' on when she was running and therefore caused her gait to change. Post pelvic treatment there was a quicker return to normal function than what we might normally see. It is important to consider the impact of these findings on how we treat patients in the future.
Jane had a residue of back pain and while the exercises were really helpful she found relief in the use of spinal manipulation (performed by Adrian at Core Body Clinic) was really helpful in reducing the remaining pain. This was done within the sport physio sessions making best use of Jane’s time. The physiotherapy manipulative techniques are very gentle and highly specific making them useful in instances where the aim of the therapy is to reduce pain while not increasing sensitivity in other regions.
Jane’s posture also improved dramatically over the course of the treatment. Posture is key in the reduction of pelvic pain because it promotes appropriate alignment through the lumbar spine and pelvis. Patient report a reduction in pelvic tension with better postural control. Evidence seems only to find a causal relationship between back pain and posture but we have found clinically this to be improved with treatment.
Jane worked with Coe Body Clinic for over 3 months to resolve her pain and continues to see our Sports Therapist for sports massage to maintain hamstring flexibility. This has helped Jane get back to spinning and running and keep symptom free. She would like to return to distance running once the children are a little older. Janes dedication to resolving her problems was key in achieving a successful outcome. She worked hard with the physiotherapists and because of the sports and pelvic knowledge in the clinic Jane was quickly and painlessly living and exercising again.
This case study is a great example of how people live with pain and really don’t need to. It also highlights the close working of physiotherapists across specialist areas and the benefit of having diverse skills in a clinic. Not everyone is as active but being active really does help get rid of pain quickly!
If you are in pain, have some stress incontinence or pain during intercourse then get in touch and see our pelvic experts! (Abarna – male and female) (Adrian – male).