Unlocking the Mystery behind Chronic Pelvic Pain

A case study in pudendal neuralgia.

This is a true story involving several medical specialties, a plethora of doctor’s visits, multiple prescriptions of medication, and one depressed, anxious and nearly hopeless lady. I met Beverly nine months into her journey of chronic pain.

By that time, she had been to doctors in each of the following practices: family medicine, urology, gynecology, gastroenterology, emergency medicine, pain management, chiropractics and orthopedic physical therapy. It took her nine months to finally reach a pelvic health specialist.

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History

Beverly’s journey started in 2020 after losing 60 lbs. and incorporating daily exercise into her lifestyle.

In January 2021, she started to feel symptoms of a urinary tract infection (UTI)  – burning and irritation in the urethra. Naturally, she went to her primary care physician, who then referred her to a urologist. Despite multiple negative UTI tests, she was put on antibiotics. Soon she finished her treatment of pills, with no reduction in symptoms. She went back to her urologist who put her on another dose of antibiotics.

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This time, her symptoms were not only worse, but she also began to experience abdominal pain and GERD. After another course of medication, the urologist wanted to put her on another dose of antibiotics, but she refused. She then visited the gynecologist for further insight. A cystoscopy was performed which revealed no significant findings. Shortly following, she obtained a referral to gastroenterology for severe abdominal pain.

A colonoscopy was performed, which revealed no significant findings. At this point, she also developed restricting back pain, which prevented her from participating in daily physical exercise. Additionally, her pelvic pain would cause her to wake up several times a night. She was referred to an orthopedic physical therapist with no relief in symptoms.

Her symptoms continued to worsen overtime until she admitted herself to the emergency department for severe pelvic pain. CT scans and MRIs were performed on the pelvic region which revealed no significant findings. Was this in her head? Was she drug-seeking? Was it some sort of psychosomatic reaction? She was then referred to a pain management doctor who finally put a name to her symptoms: pudendal neuralgia.

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What is Pudendal Neuralgia?

The pudendal nerve originates from the sacral plexus and branches off to innervate the muscles of the pelvic floor. It passes between ligaments, bone and the muscles of the hip in order do so. Pudendal neuralgia occurs when there is compression at any point along the pudendal nerve pathway. This can be caused by: surgery, trauma, muscular tightness, fascial tension or chronic compression (from sitting – i.e. cycling)

Due to the extensive distribution of the nerve pathway, patients who experience pudendal neuralgia may complain of the following: increased urinary frequency, urgency or hesitance, painful voiding and/or bowel movements, rectal pressure, difficulty evacuating urine or feces, painful orgasms and pain with sitting or standing.

Suggested Treatments: nerve blocks or physical therapy

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Ultimately, Beverly was referred to pelvic physical therapy, where I entered her next chapter. Upon performing an initial evaluation, objective and subjective examination revealed congruent findings of pudendal neuralgia as mentioned by the pain management doctor.

Objective examination revealed hypertonicity and trigger points throughout the pelvic floor muscles with reproduction of pt abdominal and pelvic pain including her initial “UTI” symptoms of burning and irritation in the urethra. Beverly also demonstrated decreased hip range of motion.

Reduced flexibility and tension throughout the tensor fascia lata, gluteus medius, and IT band was also found, which tension can affect pelvic alignment and therefore relates to pelvic floor muscle tension. She also demonstrated shallow breathing pattern with increased rib angle and decreased diaphragm excursion.

Physical therapy prescription and treatment plan:

• Diaphragmatic breathing to downregulate the nervous system in combination with meditation and progressive relaxation
• Hip, pelvic floor and back stretching
• Pudendal nerve glides
• Hip mobilizations to improve range of motion and reduce tension throughout the connective tissue
• Pain neuroscience education
• Desensitization of the pelvic floor muscles
• Graded exposure to imagery
• Graded exercise program
• Intravaginal pelvic floor muscle release (not yet attempted)
• Fascial mobilizations to reduce tension in the connective tissue surrounding the pelvic organs and musculoskeletal layers
• Recommendation for Theraseat (not a donut, rather it is specific to pudendal neuralgia).
• Education in defecation and urination dynamics to promote evacuation by relaxing the pelvic floor muscles

Results: In process

I have been seeing Beverly for three weeks now and she is already off her pain medication (tramadol and hydrocodone), no longer has pain the pelvis when bending over and reports relief of pain for up to two days after therapy sessions. She has returned to mild stretching and strengthening. She reports having less anxiety about her symptoms and is better able to manage her symptoms at home. She is now able to sleep through the night.

Is she completely better? No. She continues to have pressure and burning during bowel movements and can only sit for 10 minutes and walk for about 15 minutes before she begins to feel an increase in her symptoms. Furthermore, she continues to have good days and bad days entailing painful flare-ups (though not as intense as before starting physical therapy) of her symptoms with increased physical activity.

Providing relief of symptoms of pudendal neuralgia is a long process. It took nine months before Beverly was referred to me, and her symptoms are not going to go away overnight. I continue to work with her twice a week as we make slow and steady, but gradual improvements in her symptoms.

Assessment:

Based off these results and because I was able to reproduce her symptoms through palpation of the pelvic floor muscles, I speculate this whole journey started because of increased physical activity causing muscle tension around nerve resulting in initial symptoms of burning and irritation around the urethra.

How much time and money could have been saved had other professions knew of the pelvic health specialty and referred Beverly there? No one is at fault for Beverly experiencing nine months of pain.

However, I cannot help but believe that the specialists in pelvic health physical therapy should be doing more to advocate for their profession and establish their role in continuity of care for patients like Beverly. My purpose in sharing this case study is to make a difference in the life of one patient at time through educating one doctor at time.