Primary Care Liaison Unit

Physiotherapy and Persistent Pelvic Pain

Jennifer Vardy, Senior Clinician Physiotherapist, P5 Persistent Pain Clinic, Mercy Hospital for Women

In the past 12 months, more than 50% of Australian women reported suffering from pelvic pain1 which impacted upon their ability to go to school, study, work and their personal relationships. Patients commonly present with complex bladder, bowel, menstrual and sexual symptoms and it’s common for them to have co-existing pain conditions such as fibromyalgia, migraines and irritable bowel syndrome. It is of note that four of the ten “chronic overlapping pain conditions” are forms of persistent pelvic pain (PPP)2. Whilst guidelines for the management of endometriosis and pelvic pain suggest predominantly surgical and pharmacological interventions 3 these conditions should be managed with a biopsychosocial approach which fits well with our contemporary understanding of the management of persistent pain. PPP patients often present with changes to nervous system sensitisation4 such as hyperalgesia and allodynia, together with evidence of catastrophising, fear/avoidance behaviours and reduced pain self-efficacy on psychometric screening tools.

We can support our patients with PPP best within a biopsychosocial model by firstly listening to their concerns and validating their symptoms. It is important to understand a patient’s beliefs regarding their condition and their goals. Providing early education on both pelvic pain and pain science education is important to ensure all health care professionals are consistent with messaging and treatment approach. It can be helpful to use psychosocial screening tools to determine impact of pain on quality of life and to assist patients to gain a broader understanding of possible contributors to their pain. Screening tools include the:

A thorough biopsychosocial assessment allows a more nuanced and individualised approach to management with referral to other disciplines for appropriate support. Whilst tertiary based interdisciplinary care offers best practice for complex pain patients, long waiting lists and barriers to early access exist and we need to improve referral pathways in primary care.

Pelvic Health Physiotherapists have completed additional training in pelvic health conditions, pain management and trauma informed care to support the management of PPP patients to reduce the burden of disease. These physiotherapists can support the management of the following symptoms:

  • Bladder – incontinence, urgency and frequency or overactive bladder symptoms, voiding symptoms, recurrent urinary tract infections, dysuria and bladder pain
  • Bowel – anal incontinence, constipation and defecation symptoms, anal pain/spasm and dyschesia
  • Prolapse
  • Sexual function – dyspareunia, vaginismus/genito-pelvic pain penetration disorder (GPPPD), vulvodynia and perineal pain

Multimodal physiotherapy management may include:

  • Education on their condition and pain neuroscience concepts5,6 which can help to improve pain self-efficacy and reduce pain catastrophisation.
  • Pelvic floor muscle (PFM) assessment and exercise prescription. Pelvic floor muscles may be tense/non-relaxing with impact on bladder/bowel and sexual function. They may be locally tender and can reproduce a patients primary PPP. Physiotherapy assessment can assist to distinguish between muscular pain and hormonal or centrally driven pain. Patients may benefit from exercise to improve co-ordination or awareness of pelvic floor contraction and relaxation, referred to as pelvic floor muscle down-training. They may also benefit from desensitising strategies to reduce muscle and tissue sensitivity. This may include support with vaginal dilator therapy to reduce pain and sensitivity with penetration for vaginal examination, cervical screening, ultrasound and sexual intercourse.
  • Breath awareness, diaphragmatic breathing and relaxation.
  • General exercise such as yoga and stretching to further assist PFM relaxation and reduce central nervous system sensitivity.
  • Exercise and pacing strategies to improve exercise tolerance and reduce fatigue.
  • Referral for Musculoskeletal physiotherapy for strength/support of other co-morbidities.
  • Referral to Dietitian/Psychologist/Psychiatrist/Pain Physician

Other helpful treatment modalities and resources for patients with PPP include:

The Mercy Hospital for Women Physiotherapy department offers comprehensive assessment, diagnosis and treatment for disorders of pain and dysfunction in conditions specific to women’s health.

Our department excepts internal referrals only.

To find a local Pelvic Health Physiotherapist please use the Continence Foundation of Australia – ‘Victoria Find a Physio’ tool.

Want to learn more about Persistent Pelvic Pain? Mercy Hospital for Women Gynaecology and Physiotherapy departments have recently given a webinar that qualifies for CPD Points. If you would like to receive this recording please email: [email protected]

References

  1. Jean Hailes for Women’s Health. Pelvic Pain in Australian Women. A report from the 2023 National Women’s Health Survey. 2023;
  2. Maixner W, Fillingim RB, Williams DA, Smith SB, Slade GD. Overlapping Chronic Pain Conditions: Implications for Diagnosis and Classification. The journal of pain. 2016;17(9):T93-T107. doi:10.1016/j.jpain.2016.06.002
  3. RANZCOG. Australian Clinical Practice Guideline for the Diagnosis and Management of Endometriosis. 2021. 2021, Sept 20. https://ranzcog.edu.au/news/release-of-australian-endometriosis-guideline
  4. Ryan A, Healey M, Cheng C, Dior U, Reddington C. Central sensitisation in pelvic pain: A cohort study. Australian & New Zealand journal of obstetrics & gynaecology. 2022;doi:10.1111/ajo.13596
  5. Mardon AK, Leake HB, Szeto K, Moseley GL, Chalmers KJ. Recommendations for patient education in the management of persistent pelvic pain: a systematic review of clinical practice guidelines. Pain (Amsterdam). 2023;doi:10.1097/j.pain.0000000000003137
  6. Mardon AK, Chalmers KJ, Heathcote LC, et al. “I wish I knew then what I know now” – pain science education concepts important for female persistent pelvic pain: a reflexive thematic analysis. Pain (Amsterdam). 2024;doi:10.1097/j.pain.0000000000003205

Last reviewed September 23, 2024.

Primary Care Liaison Newsletter

The Primary Care Liaison Unit provides primary care providers with quarterly updates specific to your preferred Mercy Health hospital – Mercy Hospital for Women (Heidelberg) or Werribee Mercy Hospital.

Primary Care Liaison Newsletter

Heavy menstrual bleeding

Our gynaecology team would like to support you and your heavy menstrual bleeding patients. Below you’ll find a heavy menstrual bleeding case study from our gynaecology team to support your referrals to Mercy Hospital for Women. Case Study – Heavy Menstrual Bleeding 42 YO Female Referred for: ‘Persistent heavy menstrual bleeding for a few months...
Heavy menstrual bleeding

Iron infusion

IV iron infusions are administered using Ferinject (Ferric carboxymaltose) and can be rapidly infused over a 15-20 minute period. It requires a period of 30 minutes post infusion observation. When referring a patient for iron infusion or blood transfusion, refer to our website on how to proceed. Please use HealthPathways ‘Iron Deficiency Anaemia‘ or ‘Anaemia...
Iron infusion