Getting to the pointy end of pelvic pain
Patients with pelvic pain or continence issues have often been on the medical merry-go-round before they finally arrive to see a physiotherapist. Their problems can be complex and they’re often sceptical about whether physiotherapy can help them. But, says APA Sports and Exercise Physiotherapist and author Peter Dornan, that’s all the more reason for physiotherapists to step up. Melissa Mitchell reports.
There are many challenges for physiotherapists treating patients with pelvic pain, not least of which is that rarely no two patients are the same and no two treatment approaches may be the same. As such, the variance in conditions and pain presentations can test the mettle of even the most seasoned practitioners. But it is in this space, says Peter Dornan, that physiotherapists can really shine and achieve great results for their patients.
The author of Conquering Incontinence, as well as several military non-ﬁction tomes and two earlier books on sporting injuries, has just released a new book about pelvic pain that is an update of his 2014 publication Pelvic pain: a musculoskeletal approach for treatment. Released in September this year, So you’ve got pelvic pain … here’s how to manage it explores wider perspectives on pelvic pain for both patient and practitioner. The book is the result of four years of research and the collection of evidence for Peter, who says the moving feast of pain knowledge means there is always so much more to know.
‘It takes about four years for a person to be diagnosed with pudendal neuralgia or pelvic pain. In that time they’ve been to about between 10 and 30 professionals, and many of them have been through invasive treatment. So by the time they ﬁnd a real diagnosis they want to get it treated in a real hurry,’ Peter says. ‘Once they’ve had pelvic pain for about three months they may enter the persistent or neural hypersensitivity phase, so they’ve got to treat the pain as much as the cause. They’ve got to ﬁnd the cause, treat it and . . . deal with the flare- ups and the hypersensitivity—and that’s not going to go away in two weeks, two months or maybe even two years. Hopefully what they do is learn to be patient with it, learn to manage it and live with it.’
As he explains in the ﬁrst chapter of his new book, an understanding of the anatomy, biomechanics and pathology that underpin pelvic pain is crucial for both patient and practitioner. Following this chapter in the book are sections on musculoskeletal assessment and treatment as well as text covering a broad range of topics including viscero-somatic reactions, chronic pain management, mobilisation, diet and managing flare-ups. Often those with chronic pelvic pain have developed signiﬁcant central and peripheral sensitisation with the concomitant allodynia and hyperalgesia, have developed an attitude of hopelessness and have become markedly depressed to the point of committing suicide, Peter says.
‘These are generally patients who have a long medical history. Most of them have seen various professionals and they’re sceptical about walking in to see the physio. Once they feel you might be able to help treat the cause, then you’ve got to spend time telling them about persistent pain and about the mechanics of it,’ Peter says. ‘These patients are difﬁcult to treat because of their long, complicated history, and the psychosocial approaches that are required.
‘My book also outlines dealing with pelvic pain once they get a flare-up; it inflames the brain, smudging and transference can occur, and straight away it upsets their memories, emotions and feelings, and they catastrophise. They go straight back to the beginning, saying things like “I’m never going to get better, I’m depressed”, so you’ve got to bring in psychology a great deal.
‘That’s why in the ﬁrst couple of treatments, you spend a lot of time telling these patients about the situation they’re in, and try and tell them that if they understand their condition they’ll lose a lot of their anxiety. Anxiety is a great pain driver and can trigger and feed a flare-up; once they learn that this is a condition they should be able to treat, once they understand the cycle they are in, you are well on the way. But it takes time and patience, and they’re distressed by the time they get to you.’
With a focus on men’s health during November as part of the Movember campaign, Peter says while pelvic pain can be easier to diagnose in men than in women, men can be more reluctant to seek help due to embarrassment, male denial, shame or a misunderstanding or a lack of knowledge of their own anatomy. When Peter was diagnosed with prostate cancer in 1996, not only did the health professional not know of his own prostate or its function, none of his relatives or friends would mention the word.
‘A nun friend even said to me “never mention that you have this condition”—such shock and shame,’ Peter says. ‘The problem relates to the naming of the genital area, the pudenda (and the pudendal nerve), from the Latin pudenda membra, meaning parts to be ashamed of. This is not a recent trend, it’s probably not even Victorian, or maybe not even a religious edict. The ﬁrst mention I could ﬁnd dates from the mid-17th century, but it probably stretches back further.
‘Anxiety is a great pain driver and can trigger and feed a flare-up; once they learn that this is a condition they should be able to treat, once they understand the cycle they are in, you are well on the way.’
‘Regardless, society regards this area as stigmatic, secret, dirty, unmentionable. We are at the same spot in history as incontinence was 20 years ago. There have been tremendous changes now in our understanding, tolerance and empathy of this condition. I like to think physiotherapists, including my 2003 book Conquering Incontinence, may have played some signiﬁcant role in this. I would like to be at the forefront of culture change for understanding pelvic pain. Encouraging correct anatomical language would be a start, instead of accepting colloquial terms such as “willy” etc. Talking about pelvic pain, admitting pelvic pain and educating our health professionals about pelvic pain will slowly turn thinking around.’
So you’ve got pelvic pain … here’s how to manage it is available online through Australian Academic Press at and at peterdornanphysio.com.au.
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