Many patients do not realize that pelvic pain can actually be due to muscle problems in the abdominal wall or even back problems of the spinal discs or bones that are referred or perceived as being in the pelvic area.
This type of pain is broadly categorized as myofascial pain. Some doctors fail to thoroughly evaluate this possibility as a cause of chronic pelvic pain.
How can pain actually be "referred" from another site to the pelvis?
The spinal cord is a complex electrical connection system. The nerve roots of the spinal cord send off neurons that sense pain from skin, muscles, bones, ligaments and internal pelvic organs.
The same spinal nerve roots that innervate the ovaries
may also innervate abdominal wall muscles. Low back pain can
arise from pain in the uterus, bladder, fallopian tubes, and
cervix because the same nerves innervate those organs as well as
the lumbar discs, ligaments and muscles. Conversely, abdominal
wall pain, especially around an incision, may actually feel as if
it is arising from the uterus or deeper in the pelvis when its
origin is from the skin near an incision. Neurologists think that
sometimes the spinal cord just gets confused when there are many
pain impulses coming in and by the time your brain perceives the
pain, it cannot tell whether the source is in the internal organs
or the external muscles.
There are also internal muscles lining the pelvic bone such as the piriformis, puboccocygeus, obturator internus and externus muscles. The muscles can present with cramps and achiness and a patient perceives the pain as uterine or ovarian.
How is musculoskeletal pain differentiated from pain arising in the pelvic organs?
Certain questions help to categorize the pain as more likely to be musculoskeletal in origin rather than urogenital organ in origin if:
* you have a history of musculoskeletal injury to the back, hips or knees.
* your occupation is sedentary or labor intensive.
* you have repetitive musculoskeletal or postural stressors.
* physical activity worsens or lessens the pain.
* positional changes (lying to sitting, sitting to standing) worsen or relieve the pain.
* the pain changes with the time of day.
* there is noticeable muscle weakness or numbness or tingling.
* there is a history of inflammatory or collagen vascular disease such as rheumatoid arthritis or lupus.
On physical exam, what findings suggest musculoskeletal dysfunction?
If there is any abnormal curve in the spinal canal such as a curvature to the right or the left (scoliosis), excessive curve of the thoracic spine like a hunch-back (kyphosis) or increased arching of the small of the back (lordosis), these changes make it more likely for the pain to be musculoskeletal.
The doctor will also have you lie flat on an exam table,
raise your knee and will rotate the knee from side to side
to see if any of the internal and external hip rotators are
tight and cause pain with rotation.
Sources: Musculoskeletal factors of chronic pelvic pain.
OBG Management 1999; Feb:10-12,Myers CA
This type of pain is broadly categorized as myofascial pain. Some doctors fail to thoroughly evaluate this possibility as a cause of chronic pelvic pain.
How can pain actually be "referred" from another site to the pelvis?
The spinal cord is a complex electrical connection system. The nerve roots of the spinal cord send off neurons that sense pain from skin, muscles, bones, ligaments and internal pelvic organs.
The same spinal nerve roots that innervate the ovaries
may also innervate abdominal wall muscles. Low back pain can
arise from pain in the uterus, bladder, fallopian tubes, and
cervix because the same nerves innervate those organs as well as
the lumbar discs, ligaments and muscles. Conversely, abdominal
wall pain, especially around an incision, may actually feel as if
it is arising from the uterus or deeper in the pelvis when its
origin is from the skin near an incision. Neurologists think that
sometimes the spinal cord just gets confused when there are many
pain impulses coming in and by the time your brain perceives the
pain, it cannot tell whether the source is in the internal organs
or the external muscles.
There are also internal muscles lining the pelvic bone such as the piriformis, puboccocygeus, obturator internus and externus muscles. The muscles can present with cramps and achiness and a patient perceives the pain as uterine or ovarian.
How is musculoskeletal pain differentiated from pain arising in the pelvic organs?
Certain questions help to categorize the pain as more likely to be musculoskeletal in origin rather than urogenital organ in origin if:
* you have a history of musculoskeletal injury to the back, hips or knees.
* your occupation is sedentary or labor intensive.
* you have repetitive musculoskeletal or postural stressors.
* physical activity worsens or lessens the pain.
* positional changes (lying to sitting, sitting to standing) worsen or relieve the pain.
* the pain changes with the time of day.
* there is noticeable muscle weakness or numbness or tingling.
* there is a history of inflammatory or collagen vascular disease such as rheumatoid arthritis or lupus.
On physical exam, what findings suggest musculoskeletal dysfunction?
If there is any abnormal curve in the spinal canal such as a curvature to the right or the left (scoliosis), excessive curve of the thoracic spine like a hunch-back (kyphosis) or increased arching of the small of the back (lordosis), these changes make it more likely for the pain to be musculoskeletal.
The doctor will also have you lie flat on an exam table,
raise your knee and will rotate the knee from side to side
to see if any of the internal and external hip rotators are
tight and cause pain with rotation.
Next you will be asked to bring the one knee up to the
chest. If the straight leg whose knee is not being raised comes
up off the table or gives pain, this means the iliopsoas muscle
and/or the rectus femoris (hip flexor) muscles are tight and may
actually be the source of deep pelvic pain mistaken for internal
organ pain.
The doctor will also check for any pain in the abdominal muscles and touch the skin of the abdomen and back to see if there are places on the skin that "trigger the pain".On pelvic exam the doctor will have you try to tighten the muscles around two fingers placed in the vagina and will palpate the muscles of the interior pelvic wall to see if any of them are exquisitely tender. All of these screening exams can be checked for by you at home to see if they are abnormal.
If pelvic pain is actually coming from the back and spine, how is it treated?
Certain postural problems, especially kyphosis and lordosis,
have been clinically correlated with pelvic pain as have other
muscle weaknesses and spasms. Treatment of those problems
has also been shown to help the pelvic pain.
If there is any suspicion that pelvic pain has a myofascial cause,
a woman should be referred to a physical therapist for a more
in-depth evaluation and plan for treatment. Physical therapy
and muscle exercises can significantly help these problems.
What are trigger point injections and are they helpful?
Trigger points are areas of skin on the abdominal wall that follow along one dermatome, the area of skin innervated by one specific nerve root. When touching them lightly even with a Q-tip, pain is elicited that feels as if it arises deep in the pelvic organs.
chest. If the straight leg whose knee is not being raised comes
up off the table or gives pain, this means the iliopsoas muscle
and/or the rectus femoris (hip flexor) muscles are tight and may
actually be the source of deep pelvic pain mistaken for internal
organ pain.
The doctor will also check for any pain in the abdominal muscles and touch the skin of the abdomen and back to see if there are places on the skin that "trigger the pain".On pelvic exam the doctor will have you try to tighten the muscles around two fingers placed in the vagina and will palpate the muscles of the interior pelvic wall to see if any of them are exquisitely tender. All of these screening exams can be checked for by you at home to see if they are abnormal.
If pelvic pain is actually coming from the back and spine, how is it treated?
Certain postural problems, especially kyphosis and lordosis,
have been clinically correlated with pelvic pain as have other
muscle weaknesses and spasms. Treatment of those problems
has also been shown to help the pelvic pain.
If there is any suspicion that pelvic pain has a myofascial cause,
a woman should be referred to a physical therapist for a more
in-depth evaluation and plan for treatment. Physical therapy
and muscle exercises can significantly help these problems.
What are trigger point injections and are they helpful?
Trigger points are areas of skin on the abdominal wall that follow along one dermatome, the area of skin innervated by one specific nerve root. When touching them lightly even with a Q-tip, pain is elicited that feels as if it arises deep in the pelvic organs.
Sources: Musculoskeletal factors of chronic pelvic pain.
OBG Management 1999; Feb:10-12,Myers CA
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