Pain in Women pp 291-308 | Cite as

Physical Therapy for Female Pelvic Pain

  • Jessica McKinney


The purpose of this chapter is to discuss the role of physical therapy in the management of women with pelvic pain disorders. Pelvic pain is a costly, prevalent, yet poorly understood condition, found to disproportionately affect women 4:1 [1]. Annual healthcare costs in the US are estimated in excess of $880 million for physician visits alone, and nearly three billion when out-of pocket expenses and mental health visits are included [2]. Prevalence of pelvic pain is found to be similar to prevalence rates of asthma and low back pain [3], and the 3-month prevalence of chronic pelvic pain is estimated at 24% [4]. The majority of prevalence studies of pelvic pain have excluded women with vulvar pain disorders, as well as women who were pregnant or who had been pregnant within the past year. Therefore, the prevalence of all pelvic pain conditions is likely greater than that commonly cited in the literature. For example, an investigation by Harlow and Stewart identified a 16% lifetime prevalence of unexplained chronic vulvar pain, equating to approximately 14 million US women; a much higher prevalence than that found in earlier studies [5]. This high prevalence of female pelvic pain and the changing healthcare landscape are contributing to the now widely accepted and promoted concept of a multidisciplinary and collaborative approach to diagnosis and treatment that includes physicians of multiple specialties, physical therapists, and mental health professionals [6, 7].


Pelvic Floor Pelvic Pain Pelvic Floor Muscle Physical Therapist Trigger Point 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Sinaki M, Merritt JL, Stilwell GK. Tension myalgia of the pelvic floor. Mayo Clin Proc. 1977;52:717–22.PubMedGoogle Scholar
  2. 2.
    Mathias SD, Kupperman M, Liberman RF, Steege JF. Chronic pelvic pain, prevalence, health-related quality of life and economic correlates. Obstet Gynecol. 1996;87:332–7.CrossRefGoogle Scholar
  3. 3.
    Grace V, Zondervan K. Chronic pelvic pain in women in New Zealand: comparative well-being, comorbidity, and impact on work and other activities. Health Care Women Int. 2006;27:585–99.PubMedCrossRefGoogle Scholar
  4. 4.
    Zondervan KT, Yudkin PL, Vessey MP, et al. The community prevalence of chronic pelvic pain in women and associated illness behavior. Br J Gen Pract. 2001;51:541–7.PubMedGoogle Scholar
  5. 5.
    Harlow BL, Stewart EG. A population-based assessment of chronic unexplained vulvar pain: have we underestimated the prevalence of vulvodynia? J Am Med Womens Assoc. 2003;58:82–8.PubMedGoogle Scholar
  6. 6.
    Gambone JC, Reiter RC. Nonsurgical management of chronic pelvic pain: a multidisciplinary approach. Clin Obstet Gynecol. 1990;33(1):205–11.PubMedCrossRefGoogle Scholar
  7. 7.
    van Lankveld JJDM, Granot M, Schultz WCMW, et al. Women’s sexual pain disorders. Int Soc Sex Med. 2010;7:615–31.Google Scholar
  8. 8.
    Specialty Council on Women’s Health Physical Therapy. Description of Specialty Practice: Women’s Health Physical Therapy. Alexandria, VA: American Physical Therapy Association; 2007.Google Scholar
  9. 9.
    McGowan L, Clark-Carter D, Pitts M. Chronic pelvic pain: a meta-analysis review. Psychol Health. 1998;13:132–44.CrossRefGoogle Scholar
  10. 10.
    Latthe P, Mignini L, Gray R, Hills R, Khan K. Factors predisposing women to chronic pelvic pain: systematic review. Br Med J. 2006;2:16. doi: 10.1136/bmj.38748.697465.55.Google Scholar
  11. 11.
    Stout A, Steege J, Dodson W, Hughes C. Relationship of laparoscopic findings to self-report of pelvic pain. Am J Obstet Gynecol. 1991;164:73–9.PubMedGoogle Scholar
  12. 12.
    Vercillini P, Trespidi L, De Giorgi O, et al. Endometriosis and pelvic pain: relation to disease stage and localisation. Fertil Steril. 1996;65:299–304.Google Scholar
  13. 13.
    Rapkin AJ, Mayer EA. Gasteroenterologic causes of chronic pelvic pain. Obstet Gynecol Clin North Am. 1993;20:663–83.PubMedGoogle Scholar
  14. 14.
    Summit RLJ. Urogynecologic causes of chronic pelvic pain. Obstet Gynecol Clin North Am. 1993;20:685–98.Google Scholar
  15. 15.
    Saravelos H, Li T, Cooke I. Adhesions and chronic pelvic pain. Contemp Rev Obstet Gyneacol. 1995;7:172–7.Google Scholar
  16. 16.
    Cheong Y, Stones WR. Chronic pelvic pain: aetiology and therapy. Best Pract Res Clin Obstet Gyneacol. 2006;20(5):695–711.CrossRefGoogle Scholar
  17. 17.
    Tu FF, Holt J, Gonzales J, Fitzgerald CM. Physical therapy evaluation of patients with chronic pelvic pain: a controlled study. Am J Obstet Gynecol. 2008;198:272.e1–e7.CrossRefGoogle Scholar
  18. 18.
    Smith MD, Russell A, Hodges PW. Disorders of breathing and continence have a stronger association with back pain than obesity and physical activity. Aust J Physiother. 2006;52:11–6.PubMedCrossRefGoogle Scholar
  19. 19.
    Baker PK. Musculoskeletal origins of chronic pelvic pain diagnosis and treatment. Obstet Gynecol Clin North Am. 1993;20:719–42.PubMedGoogle Scholar
  20. 20.
    Srinivasan AK, Kaye JD, Moldwin R. Myofascial dysfunction associated with chronic pelvic floor pain: management strategies. Curr Pain Headache Rep. 2007;11:359–64.PubMedCrossRefGoogle Scholar
  21. 21.
    Chaitow L. Chronic pelvic pain: pelvic floor problems, sacroiliac dysfunction and the trigger point connection. J Bodyw Mov Ther. 2007;11:327–39.CrossRefGoogle Scholar
  22. 22.
    Montenegro MLLS, Vasconcelos ECLM, Candido dos Reis FJ, Nogueira AA, Poli-Neto OB. Physical therapy in the management of women with chronic pelvic pain. Int J Clin Pract. 2007;62(2):263–9.PubMedCrossRefGoogle Scholar
  23. 23.
    Van der Velde J, Everaerd W. The relationship between involuntary pelvic floor muscle activity, muscle awareness and experienced threat in women with and without vaginismus. Behav Res Ther. 2001;39:395–408.PubMedCrossRefGoogle Scholar
  24. 24.
    Rosenbaum TY, Owens A. The role of pelvic floor physical therapy in the treatment of pelvic and genital pain-related sexual dysfunction. J Sex Med. 2008;5:513–23.PubMedCrossRefGoogle Scholar
  25. 25.
    Rosenbaum TY. Physiotherapy of sexual pain disorders. J Sex Marital Ther. 2005;33:329–40.CrossRefGoogle Scholar
  26. 26.
    Fritsch H. Anatomy and physiology of the pelvic floor. In: Carriere B, Markel Feldt C, editors. The pelvic floor. Stuttgart: Thieme; 2006. p. 1–20.Google Scholar
  27. 27.
    Sapsford R. The pelvic floor: a clinical model for function and rehabilitation. Physiotherapy. 2001;87(12):620–30.CrossRefGoogle Scholar
  28. 28.
    Shafik A. The role of the levator ani muscle in evacuation, sexual performance, and pelvic floor disorders. Int Urogynecol J Pelvic Floor Dysfunct. 2000;11:361–76.PubMedCrossRefGoogle Scholar
  29. 29.
    Vleeming A, Stoeckart R. The role of the pelvic girdle in coupling the spine and the legs: a clinical-anatomical perspective on pelvic stability. In: Vleeming A, Mooney V, Stoeckart R, editors. Movement, stability, & lumbopelvic pain: integration of research and therapy. 2nd ed. Edinburgh: Churchill Livingstone/Elsevier; 2007. p. 113–37.Google Scholar
  30. 30.
    Hodges PW, Cholewicki J. Functional control of the spine. In: Vleeming A, Mooney V, Stoeckart R, editors. Movement, stability, & lumbopelvic pain: integration of research and therapy. 2nd ed. Edinburgh: Churchill Livingstone/Elsevier; 2007. p. 489–512.Google Scholar
  31. 31.
    Lee DG. The pelvic girdle. 3rd ed. Edinburgh: Elsevier; 2004.Google Scholar
  32. 32.
    Lee D, Lee LJ. Stress urinary incontinence – a consequence of failed load transfer through the pelvis? In: 5th world interdisciplinary congress on low back and pelvic pain, Melbourne; 2004.Google Scholar
  33. 33.
    Hodges PH, Sapsford RR, Pengel HM. Feedforward activity of the pelvic floor muscles preceded rapid upper limb movements. In: Proceedings of the VI international physiotherapy conference, Sydney; 2000.Google Scholar
  34. 34.
    Sapsford RR, Hodges PW. Contraction of the pelvic floor muscles during abdominal maneuvers. Arch Phys Med Rehab. 2001;82:1081–8.CrossRefGoogle Scholar
  35. 35.
    Pool-Goudzwaard A, van Dijke GH, van Gurp M, Mulder PH, Snijders CJ, Stoeckart R. Contribution of pelvic floor muscles to stiffness of the pelvic ring. Clin Biomech. 2004;19(6):564–71.CrossRefGoogle Scholar
  36. 36.
    Richardson CA, Snijders CJ, Hides JA, Damen L, Pas MS, Storm J. The relationship between the transversely oriented abdominal muscles, sacroiliac joint mechanics, and low back pain. Spine. 2002;27(4):399–485.PubMedCrossRefGoogle Scholar
  37. 37.
    Smith MD, Coppieters MW, Hodges PH. Postural response of the pelvic floor and abdominal muscles in women with and without incontinence. Neurol Urodynam. 2007;26(3):377–85.CrossRefGoogle Scholar
  38. 38.
    Hodges PW, Richardson CA. Inefficient muscular stabilization of the lumbar spine associated with low back pain. A motor control evaluation of transverses abdominus. Spine. 1996;21(22):2640–50.PubMedCrossRefGoogle Scholar
  39. 39.
    Leinonen V, Kankaanpää M, Luukkonen M, Hänninen O, Airaksinen O, Taimela S. Disc herniation-related pain impairs feed-forward control of paraspinal muscles. Spine. 2001;26(16):E367–72.PubMedCrossRefGoogle Scholar
  40. 40.
    Arendt-Nielsen L, Graven-Nielsen T, Svarrer H, Svensson P. The influence of low back pain on muscle activity and coordination during gait: a clinical and experimental study. Pain. 1996;64(2):231–40.PubMedCrossRefGoogle Scholar
  41. 41.
    Radebold A, Cholewicki J, Polzhofer GK, Greene HS. Impaired postural control of the lumbar spine is associated with delayed muscle response times in patients with chronic idiopathic low back pain. Spine. 2001;26(7):724–30.PubMedCrossRefGoogle Scholar
  42. 42.
    Hodges P, Moseley L. Pain and motor control of the lumbopelvic region: effect and possible mechanisms. J Electromyogr Kinesiol. 2003;13(4):361–70.PubMedCrossRefGoogle Scholar
  43. 43.
    Weiss JM. Pelvic floor myofascial trigger points: manual therapy for interstitial cystitis and the urgency-frequency syndrome. J Urol. 2001;166:2226–31.PubMedCrossRefGoogle Scholar
  44. 44.
    Langevin HM, Sherman KJ. Pathophysiological model for chronic low back pain integrating connective tissue and nervous system mechanisms. Med Hypotheses. 2007;68:74–80.PubMedCrossRefGoogle Scholar
  45. 45.
    Spitznagle TM. Musculoskeletal chronic pelvic pain. In: Carriere B, Markel Feldt C, editors. The pelvic floor. Stuttgart, Germany: Thieme; 2006. p. 35–68.Google Scholar
  46. 46.
    Sahrmann SA. Diagnosis and treatment of movement impairment syndromes. St. Louis: Mosby; 2002.Google Scholar
  47. 47.
    Haugstad GK, Haugstad TS, Kirste UM, et al. Posture, movement patterns, and body awareness in women with chronic pelvic pain. J Psychosom Res. 2006;61:637–44.PubMedCrossRefGoogle Scholar
  48. 48.
    Prendergast SA, Weiss JM. Screening for musculoskeletal causes of pelvic pain. Clin Obstet Gynecol. 2003;46(4):1–10.CrossRefGoogle Scholar
  49. 49.
    Meadows JTS. Orthopedic differential diagnosis in physical therapy: a case study approach. New York: McGraw-Hill, Health Professions Division; 1999.Google Scholar
  50. 50.
    Molloy G. NAIOMT 500 localizing and analyzing the site and source of pain. Eugene, Oregon: NAIOMT, Inc.; 2009.Google Scholar
  51. 51.
    Meadows JTS. Level I differential diagnosis. Eugene, Oregon: NAIOMT, Inc.; 2001.Google Scholar
  52. 52.
    Fitzgerald MP, Kotarinos R. Rehabilitation of the short pelvic floor I: background and patient evaluation. Int Urogynecol J Pelvic Floor Dysfunct. 2003;14:261–8.PubMedCrossRefGoogle Scholar
  53. 53.
    Fitzgerald MP, Kotarinos R. Rehabilitation of the short pelvic floor II: treatment of the patient with the short pelvic floor. Int Urogynecol J Pelvic Floor Dysfunc. 2003;14:269–75.CrossRefGoogle Scholar
  54. 54.
    Head H. On disturbances of sensation with especial reference to the pain of visceral disease. Brain. 1893;16:1–13.CrossRefGoogle Scholar
  55. 55.
    Wesselmann U, Lai J. Mechanisms of referred visceral pain: uterine inflammation in the adult virgin rat results in neurogenic plasma extravasation in the skin. Pain. 1997;73:309–17.PubMedCrossRefGoogle Scholar
  56. 56.
    Kendall FP, McCreary EK, Provance GP. Muscles, testing, and function. 4th ed. Baltimore: Williams and Wilkins; 1993.Google Scholar
  57. 57.
    Bo K, Sherburn M. Evaluation of female pelvic-floor muscle function and strength. Phys Ther. 2005;85(3):269–82.PubMedGoogle Scholar
  58. 58.
    Laycock J, Jerwood D. Pelvic floor muscle assessment: the PERFECT scheme. Physiotherapy. 2001;87(12):631–42.CrossRefGoogle Scholar
  59. 59.
    Sadowy AM, Brouwer HL, Finseth DL, Hagener KM, Lawrence AE, Hollman JH. Development of a pelvic floor muscle coordination scale. J Women’s Health Phys Ther. 2010;34(3):81–8.Google Scholar
  60. 60.
    Kaltenborn FM, Evjenth O, Kaltenborn TB, Morgan D, Vollowitz E. Manual mobilization of the joints: joint examination and basic treatment; Volume II, The Spine. 5th ed. Oslo: Norli; 2009.Google Scholar
  61. 61.
    Cantu RI, Grodin AJ. Myofascial manipulation theory and clinical application. 2nd ed. Gaithersburg: Aspen Publishers; 2001.Google Scholar
  62. 62.
    Weiss JM. Chronic pelvic pain and myofascial trigger points. Complement Med Pain. 2000;2:13–8.Google Scholar
  63. 63.
    Dommerholt J, Bron C, Franssen J. Myofascial trigger points: an evidence-informed review. J Manual Manip Ther. 2006;14(4):203–21.CrossRefGoogle Scholar
  64. 64.
    Vleminckx M. Visceral mobilization. In: Carriere B, Markel Feldt C, editors. The pelvic floor. Stuttgart, Germany: Thieme; 2006. p. 230–52.Google Scholar
  65. 65.
    Butler DS. Mobilization of the nervous system. Edinburgh: Churchill Livingstone; 1991.Google Scholar
  66. 66.
    Hodges PW. Low back pain and the pelvic floor. In: Carriere B, Markel Feldt C, editors. The pelvic floor. Stuttgart: Thieme; 2006. p. 81–97.Google Scholar
  67. 67.
    McArdle WD, Katch FI, Katch VL. Exercise physiology: energy, nutrition, and human performance. 5th ed. Baltimore: Lippincott Williams and Wilkins; 2001.Google Scholar
  68. 68.
    Frahm J. Biofeedback and electromyography. In: Carriere B, Markel Feldt C, editors. The pelvic floor. Stuttgart: Thieme; 2006. p. 203–27.Google Scholar
  69. 69.
    Thompson JA, O’Sullivan PB, Briffa NK, Neumann P. Assessment of voluntary pelvic floor muscle contraction in continent and incontinent women using transperineal ultrasound, manual muscle testing and vaginal squeeze pressure measurements. Int Urogynecol J. 2006;17(6): 624–30.CrossRefGoogle Scholar
  70. 70.
    Frahm J. Electrotherapy. In: Carriere B, Markel Feldt C, editors. The pelvic floor. Stuttgart: Thieme; 2006. p. 177–203.Google Scholar
  71. 71.
    Janda V, Frank C, Liebenson C. Evaluation of muscular imbalance. In: Liebenson C, editor. Rehabilitation of the spine: a practitioner’s manual. Baltimore: Lippincott Williams and Wilkins; 2007. p. 203–25.Google Scholar
  72. 72.
    Key J. The pelvic crossed syndromes: a reflection of imbalanced function in the myofascial envelope; a further exploration of Janda’s work. J Bodyw Mov Ther. 2010;14(3):299–301.PubMedCrossRefGoogle Scholar
  73. 73.
    McLaughlin L. Breathing evaluation and retraining as an adjunct to manual therapy. Man Ther. 2009;14(5):S1–54.Google Scholar

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  • Jessica McKinney
    • 1
  1. 1.Center for Women’s HealthMarathon Physical Therapy and Sports Medicine, LLCNewtonUSA

Personalised recommendations