Treating persistent pelvic pain can be complex but can lead to improved outcomes.

Persistent pelvic pain is common but not normal, and recovery is possible, but how do I get this message across to my clients?

Persistent pelvic pain (PPP) is pain in the abdomen, pelvis or perineum. This type of pain is estimated to affect 15–25 per cent of women and 10 per cent of men. Here, I refer to PPP in women as this is my client group.

PPP can occur at any age, for any reason, but some common causes are endometriosis, recurrent thrush or bladder infections, irritable bowel syndrome, interstitial cystitis or painful bladder syndrome, painful periods, and pelvic floor hypertonicity.

PPP is individual, and susceptible to central wind-up in the brain because of the preciousness of the area, in childbearing and bodily functions, and the lack of understanding of the anatomy—school sex education has a lot to answer for. Women report feelings of isolation due to stress, taboo and stigma. No one goes to work and says ‘my vagina is killing me!’

Symptoms can include vaginal or rectal pain, pain with sex, painful orgasms, difficulty with using tampons or a menstrual cup, and painful PAP smears or internal examinations.

Underlying PPP can sometimes present as ‘that weird hip pain’, coccyx pain or glute pain that does not resolve with normal physiotherapy. This is good to have at the back of your mind if clients are not responding as you expect.

My passion for pain treatment began as a physiotherapist working in neurology rehabilitation. In 2004 I did an Explain Pain course with David Butler, and it changed my life. I took those lessons and ran with it. I had a special interest in preventing and managing post-stroke and post-amputee pain.

It was a revelation when some of my patients with neurological insults had problems with their bladder or bowels. When two young women patients confided to me that they were worried about returning to sex, as they were having difficulty with hip abduction, it opened my eyes to a whole new side of rehabilitation.

I knew I had to learn more about women’s health. I completed my continence and women’s health master’s at Curtin University, graduating in 2012, and I am proud to be an APA Continence and Women’s Health Physiotherapist.

Last year, with a large part of my caseload being women with PPP who had already sometimes seen multiple providers, I was driven to improve the consistency of their care and transition to self-efficacy. I had been thinking about how better to support my patients on their recovery journey. I always try to balance the combination of financially viable treatment, clinical excellence, practice according to latest research and supporting the clients between appointments. I had to find something to pull this all together.

Treating PPP is complex, and women recover in different timeframes. Some education is delivered informally; how was I to document this well and deliver this consistently? I required more structure to ensure every client received the basic concepts of pain education, in conjunction with their individual physical treatment plan in a timely fashion. In addition, how was I going to engage clients in their own treatment between visits, especially as they transitioned to self-efficacy with longer gaps between appointments?

With these thoughts in mind, I collaborated with an amazing graphic designer and communicator, Suzy Cooper of Sidecar Studio, and a specialist in engagement in learning. I wrote a program which incorporated the Explain Pain neuroscience and target concepts, clinical experience in treating pain, adult learning principles and the ‘voodoo’ of physiotherapy.

Included in the program is information about the common milestones of pelvic pain recovery (eg, returning to sex). I researched and included quality resources, articles and podcasts to create an engaging email series sent to clients to accompany their treatment sessions. Client review is built into the email cycle, allowing for continuous development.

Working with elements of physiotherapy, technology and graphic design, my goal is to present clinical information in an engaging way. This complete package links a thread through face-to-face treatment, emails and a home program. As well as reinforcing education, and assisting compliance, this helps clients feel supported and allows a deep understanding that PPP is common, not normal, and that recovery is possible.

APA Continence and Women’s Health Physiotherapist Rachel Andrew runs her own business, Pelvic Physio in Hobart, and works collaboratively within a team at TasOGS with an obstetrician/ gynaecologist, doctors, psychologists, and midwives.