Persistent Pelvic Pain (PPP) is defined by the International Association for the Study of Pain (IASP) as ''pain in the area of the pelvis, present on most days for more than six months.'' PPP affects one in five Australian women and has numerous potential causes. We spoke to Pelvic Floor Physiotherapist, Amy Steventon, Bachelor of Physiotherapy and Post Graduate Certificate Continence and Pelvic Floor Rehabilitation, from Jean Hailes for Women’s Health. Amy has worked with and supported numerous women who experience PPP.

What is pain?

The IASP defines pain as ''an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.''

Pain is part of your body’s protective system to keep you safe. ‘Danger’ detectors in the body send

information via nerves to the brain when a body part (or tissue) is under threat of damage or has been injured. This information is processed and interpreted together with all the other information available to the brain. This includes past experiences, general health, attitudes and beliefs around pain, your mood, stress levels and the environment around you. Combining all this information together, the brain then determines whether the tissues are at threat of damage or have been injured. If your brain decides the tissues are at risk of, or have been injured, pain will be produced so that you act to protect yourself.

There are different types of pain and the pain experienced may be a combination of the following:

Acute (nociceptive) pain is felt when a body part is at risk of being damaged (e.g pulling your finger away from a hot object before it gets burnt) or when there has been an injury (e.g spraining your ankle). This pain improves quickly as the tissues heal.

Neuropathic pain is pain resulting from nerve injury such as a spinal cord injury or multiple sclerosis.

Persistent/Chronic (nociplastic) pain occurs when pain becomes persistent. This is long-lasting pain that goes on for more than three months or past normal tissue healing time. When pain has occurred for this long, the nervous system changes and the ‘danger’ detectors in the body become much more sensitive.

They can send more messages of ‘danger’ to the brain, even when the tissues are actually safe.

When this happens, the nervous system becomes overprotective. This occurs because over time the pain system learns to be more effective at protecting a certain body part. It’s like a car alarm that is oversensitive or triggered by the slightest movement or noise. In this situation, pain doesn’t mean there is any tissue damage. It is the sensitivity of the nervous system (of which the brain is a part) that is creating the pain, not any actual damage or harm in the tissues.

When your pain system becomes over sensitive or overprotective, pain can be experienced with things that don’t normally hurt (allodynia) or greater pain can be felt with something that would normally cause mild pain (hyperaesthesia). This can occur in the part of the body where the pain first started (peripheral sensitisation) or pain can become more widespread (central sensitisation). People with central sensitisation often experience pain in more areas of their bodies and/or more often. For example, the pain was initially in the pelvis and is now also felt in other parts of the body, or the pain may have started just with menstrual periods but is now felt on most days of the month.

By understanding the involvement of the nervous system in pain perception, i.e how you feel pain and your response to pain, it helps to explain some of the individual differences we see in people with PPP. Hypersensitivity to noise, light, temperature, clothing and stress are other indicators of an oversensitive nervous system.

Psychological factors such as stress and trauma, social factors (such as relationships, family situation and work), as well as past experiences, can powerfully influence how the brain produces pain. These factors usually have a greater influence on persistent pain, compared to acute pain.

The encouraging thing to realise about persistent pain is that because so many factors affect pain, there are many things that can be done to change pain. Just as the nervous system has learnt to be overprotective and produce pain, it can also unlearn pain and become less protective again. By understanding that pain is more than a physical sensation; it is also influenced by sleep, exercise, general health, attitudes, beliefs, mood, environment and the people around you, it allows you to understand there are many ways you can affect your pain – both moment to moment and over time. This can be a very empowering feeling to know that you can take control of changing your pain.

What are the most common initial causes of persistent pelvic pain?

PPP is a complex condition and many things may contribute. This may include biological factors such as period pain, endometriosis, adenomyosis, irritable bowel syndrome (IBS), pelvic floor muscle (PFM) dysfunction, painful bladder syndrome (PBS), urinary tract infections (UTIs), vulvodynia, chronic pelvic pain syndrome, inflammation and hormonal changes.

PPP can be impacted by psychological factors such as how a person thinks about their pain, stress, past trauma and the bi-directional effects of pain on sleep and mood. Social factors may also play a role in a person’s experience of pain, including relationships, social connections, work situation, family dynamics etc.

Pain may have started with a physical cause, but this initial cause of pain may no longer be present. However, for some people, the pain persists and then becomes the disease or condition. This is because the changes over time in the nervous system make it ‘overprotective’ or ‘over sensitive.’

What impact can persistent/chronic Pain have on your health?

Persistent or long-term pain can have a significant impact on your mental health and emotional wellbeing. It can cause or add to your stress levels, result in anxiety and/or depression and lead to social withdrawal or avoiding people and activities. Living with any chronic condition can be debilitating and draining. Chronic pain in particular, can impact the quality of your sleep, your mood, appetite, energy, concentration and motivation. It can also place significant stress on your relationships, both intimate and other.

This can become a vicious cycle, particularly if people become more socially isolated, depressed, less active and able to function due to pain, which can all contribute further to anxiety, depression and reduced activity levels.

Many body systems can be involved in PPP, including the bowel, the urinary tract, the reproductive and immune systems. Often other persistent or chronic pain conditions co-exist with PPP e.g chronic fatigue syndrome, fibromyalgia, chronic migraines, chronic tension headaches, chronic lower back pain and temporomandibular disorders.

How do you help people to better understand their pain and what techniques/approaches do you use when working with a client withpersistent pelvic pain?

I work as part of a multidisciplinary team. We aim to build a supportive team around the person in pain, using a biopsychosocial approach (BPS). This approach places the person’s pain story, their symptoms and goals at the centre of the picture. It takes into consideration not only the possible biological (physical) causes of pain, but also and just as importantly the psychological and social issues that may be impacting their experience of pain.

Firstly, it’s important to validate the pain. That is, acknowledging the experience of pain as real no matter the cause. It is important to reassure the person that their pain does not necessarily indicate tissue damage by explaining that their oversensitive nervous system will be involved in producing their pain. Then, we look at realistic goals, pain reduction if possible and ongoing pain management.

One of the important aims of treatment is to improve function and quality of life. It may not be completely removing the pain, but working with techniques and approaches which empower the person to better self-manage.

Trauma-informed care is also part of all assessment and treatment. This allows the person to feel emotionally and physically safe, build trust with their healthcare professionals and collaborate with them to make informed choices and decisions.

Pain education is a very important first step in treatment. It’s important for me to understand what the person believes is causing their pain. This can create opportunities to talk about how pain is produced, and the many ways pain perception or experience can be altered. By explaining the concept of central sensitisation, it helps people to think differently about their pain and understand that pain doesn’t mean their body is damaged, that pain doesn’t equal harm. This can be reassuring and build a more positive perception of pain, replacing thoughts of ‘being broken’, catastrophising and hypervigilance (constantly assessing or checking for threats or pain) with more positive thoughts and hope for recovery.

It’s important to empower people with strategies that help manage their pain. I feel my role is to be their coach, to teach skills so they can manage their pain rather than be dependent on a healthcare professional. This helps to improve self-efficacy, that is an individual’s belief in their ability to cope, self-manage their symptoms and their effects. Research and clinical evidence both demonstrate that higher self-efficacy is a positive predictive factor of treatment success. Enablement is another powerful tool. This can be achieved once the person understands that how they think and feel about their pain can make it better or worse. They can be empowered to use this in a positive way to change their pain, slowly, gradually, over time.

Treatment techniques that can be useful for persistent pelvic pain:

  • Pain education. Pain education changes pain more than any other treatment modality. Teaching pain science (how pain is made) empowers people to understand their pain and not be threatened by it. Pain education teaches skills to manage pain; understanding what makes their pain better or worse.
  • Downregulate the sympathetic nervous system (SNS) with diaphragmatic breathing techniques, meditation, mindfulness and mindful movement, such as yoga, Qi gong and tai chi. All these can reduce the sensitivity of the overprotective or over sensitive nervous system. This can help to ‘turn the pain down.’
  • Pelvic floor muscle exercises. Usually with persistent pelvic pain the pelvic floor muscles become overactive, tight and painful. Relaxation or ‘down training’ exercises can help to restore the normal function of these muscles.
  • Movement. Many people are often scared to move because of pain. This is called ‘fear avoidance,’ but this in turn increases stiffness and weakness and can make pain worse, becoming a vicious cycle. I teach clients that it is safe to move and how to move correctly. Regular movement and exercise also increase endorphin (happy hormone) levels, helping us to feel better. It’s important to pace exercise at a rate and level that is suitable for the individual, so they avoid a ‘boom and bust’ cycle.
  • Stretches for the internal and external pelvic muscles, as well as stretches for other parts of the body that have become stiff through disuse, poor posture or maladaptive holding patterns because of prolonged pain.
  • Encouraging a relaxed posture helps the pelvic floor and abdominal muscles to relax. Using regular ‘body scanning’ can help to improve awareness of muscles that are held habitually tight, which can increase muscle overactivity and pain. Once the person is aware of which muscles they are holding tightly, they can consciously work to relax them.
  • Hot or cold applications, e.g heat or cold packs.
  • Transcutaneous electrical nerve stimulation (TENS) machine. This is a method of pain relief where small electrical currents are sent across the skin.
  • Toolkit for ‘speedhumps.‘ Speedhumps are when a person experiences a temporary increase in pain. It is helpful to have a toolkit of skills that can help to manage or reduce this. Tools in the toolkit may include stretches, deep breathing and relaxation exercises, walking in fresh air, support from family/friend/healthcare provider, rest, heat/ cold or TENS. Speedhumps may also require increased pain medication for the short-term relief of pain.

Depending on the individual’s needs, I may use hands-on treatments such as massage and/or stretches, gentle touch to desensitise tissues, teach diaphragmatic breathing techniques and improved body awareness and relaxation. I may also utilise equipment such as vaginal trainers. These help to desensitise tender vaginal tissues, promote safety through touch, reduce pelvic floor muscle spasm, encourage pelvic floor muscle relaxation and reduce fear or pain around this region. Biofeedback (information to help a client understand how their body is functioning), can also be helpful to retrain the pelvic floor muscles.

Graded exposure to activities or situations that may have been avoided due to fear of bringing on pain is used to help reduce the threat of these activities by experiencing them in a safe way with minimal discomfort. If required, treatment for difficulties with sexual function, plus bladder and bowel symptoms such as incontinence or difficulty emptying are also included.

How can someone live well with persistent/chronic pain?

There are so many things you can do to change pain, even if the pain cannot be completely removed. These are my top recommendations for living well with pain:

  1. Education and understanding of how the brain produces pain. Knowing pain does not equal damage can reduce the perceived threat of pain and turn down the ‘danger’ messages going to the brain.
  2. Desensitising the nervous system with techniques such as meditation, movement such as yoga or Qi gong, general exercise and breath work.
  3. Support. Having a strong support network is crucial. This may include but is not limited to family/friends/partner and a supportive medical team as well as allied healthcare professionals. Build a team around you to support you.
  4. Recognising and understanding what turns up the ‘danger’ messages for you and what turns up the ‘safety’ messages and learning how to manage these.
  5. Toolkit. Ways to help you manage a ‘speedhump’ or pain flare:
  • Gentle exercise
  • Stretches/yoga
  • Heat/cold
  • Massage
  • Sleep
  • Focus on joy – sunshine
  • Friends
  • TENS
  • Talking.

What resources can be useful to help people manage their pain?

Working with a supportive multidisciplinary team of healthcare professionals who focus on client centred care, i.e where you, the client are at the centre of the care plan and management. Understanding your pain and the importance of pacing, graded exercise and exposure, as well as setting realistic and achievable goals.

Healthcare professionals who can help:

  • General practitioner, gynaecologist, urologist, colorectal/gastroenterological specialist, vulval dermatologist
  • Pelvic health physiotherapist
  • Pain psychologist, psychotherapist or psychiatrist
  • Nurses, such as a nurse continence specialist and other allied health practitioners including a dietitian, nutritionist and occupational therapist
  • Sexual medicine specialist, sexologist or sexual health physician
  • Pain medicine physician.

Useful websites and resources: