Pelvic, Pudendal and Coccyx Pain, Women's health and Pelvic health.
Sayer Clinics in London are the leading neuromusculoskeletal specialists in manual treatment of pelvic and coccyx (tailbone) pain.
Sayer Clinics specialise in the diagnosis and treatment of pelvic and coccyx pain, pelvic girdle pain, pelvic floor pain and dysfunction, pudendal neuralgia and pudendal nerve entrapment.
We have three pelvic pain clinics locations in London:
Sayer Clinic Kensington, West London, W8
Sayer Clinic Welbeck Street, Central London, W1
Sayer Clinic City, Moorgate, East London EC2
About Dr Michael Durtnall
Michael Durtnall DC (AECC University College), MSc (University College London) FRCC (Orthopaedics and Rehabilitation), Founder and Chairman of Sayer Clinics, is a registered chiropractor with over 40 years’ clinical experience in spinal and pelvic manipulation using spinal, sacroiliac and sacro-coccygeal radiology or diagnostic ultrasound. He is able to treat pelvic joints, muscles, ligaments, fascia and nerve pathways using joint manipulation, myofascial mobilisation and medical acupuncture. During the past 13 years, his continuing professional development focus has been on the pelvis and the coccyx and he has been a longterm member and listed practitioner with the International Pelvic Pain Society (IPPS) since 2006 and listed as expert with PelvicPartnership.org as a leading specialist in SPD (Symphysis pubic diastasis) pubic and sacroiliac pelvic pain, before during and after pregnancy.
During his long career, Michael has undertaken specialist postgraduate training with the leading USA pelvic pain physical therapy experts, Dr Amy Stein (author of 'Heal Pelvic Pain') and Dr Rhonda Kotarinos, and shares his expertise with his amazing Sayer Clinics Pelvic team for non-surgical and non-drug treatments to resolve chronic (long-term) and acute (short-term) musculoskeletal pelvic and coccyx pain.
For more details on Michael’s training, scroll to the bottom of the page.
Michael has lectured at University College London (UCL) and to AECC University College students as well as doctors, therapists, specialists and professors. The focus of his talks is pelvic and coccyx pain diagnosis and effective hands-on manual treatment without steroid injections, invasive surgery or dependence on opioid prescription drugs.
He presented over 10 hours of his expertise on pelvic and coccyx pain at the 8th World Congress of Low Back and Pelvic Pain in Dubai in 2013, and again at the first Coccyx Symposium in Paris in July 2016, and recently at the 2nd Coccyx and Pelvic Pain Symposium in Dordrecht, Holland in July 2018.
Michael participated with focus on coccyx-dysfunction-related pelvic floor dysfunction and Pudendal Neuralgia at the Convergences Pelvic Pain conference in Madrid in November 2019.
In addition to this, Michael has also conducted ground-breaking research into effective pelvic and coccyx pain manual treatment as well as post-partum coccyx pain (coccyx pain after childbirth) and recently advising a major London hospital on the mechanism of multiple cases of coccyx dislocation and sacral fractures following hospital deliveries with Ventouse (a cup-shaped suction device) and forceps.
This wealth of academic and practical experience has made Michael Durtnall the international leader in effective manipulation treatment for Pelvic pain and coccyx pain. Michael has successfully treated great numbers of patients from UK, United States, Canada, Australia and all the countries of Europe, the Middle East and around the globe who have experienced coccyx dysfunction, pudendal nerve compression and entrapment, pudendal neuralgia and pelvic pain.
You can read more than 190 testimonials for Michael and his team here: https://www.coccyx.org/personal/index.htm.
At Sayer Clinics, Michael practises in close collaboration with our exceptionally skilled Specialist Pelvic Pain Physiotherapy Team of highly qualified and fully registered health practitioners.
Sayer Clinics Pelvic Pain Physiotherapy Team
Karolina Krzaczek, Marta Dias de Oliveira, Magdalena Krzysik and Esra Koculu are London’s leading specialists in pelvic pain with expertise in trigger point* and myofascial release** for coccyx pain, pudendal neuralgia and pelvic floor rehabilitation.
Our specialist physiotherapists evaluate and treat pelvic pain and dysfunction with the active participation of the patient throughout the treatment and healing process. They are trained to treat women of all ages, from teenagers to post-menopausal, and are specialised in rehabilitation treatment for pelvic floor pain, abdominal muscle diastasis (muscle separation), urinary urgency, urinary frequency, urinary incontinence, faecal incontinence, pre-natal and post-partum pregnancy pain, pelvic girdle pain, PSD, pubic symphysis diastasis, pain or dysfunction, pelvic organ prolapse, dyspareunia, vestibulodynia, sexual pain and dysfunction.
Treatments are conducted in private treatment rooms with focused hands-on techniques that many NHS and private physiotherapists are not routinely taught, even at post-graduate level. They are not only excellent specialist pelvic physiotherapists but also the most caring, experienced and effective in manual and bio-psycho-social treatment of pelvic pain.
* A trigger point is a small knot in your muscle that can cause pain where it originates or further away in another part of the body.
** Myofascial release is an effective manual technique that involves applying gentle, sustained pressure into the myofascial connective tissue to reduce pain and restore motion.
About pelvic and coccyx pain
The pelvis is a basin, served by nerves and blood vessels and moved by muscles with complex stresses shared between joints and ligaments. Within the pelvic region is the coccyx. The coccyx, also known as the tailbone, is a small, triangular bone located at the bottom of the spine. It’s made up of three to five, usually mobile, coccygeal vertebrae or spinal bones. The coccyx is connected to the sacrum by a joint and it’s an attachment site for tendons, ligaments, gluteal and pelvic muscles. It’s also connected to many of the muscles of the pelvic floor where it's function is to flexibly support and protect pelvic organ function and help stability in the sitting position.
This complex neuromusculoskeletal region of the body continues to be a hugely neglected area of clinical research, yet more of us are suffering pain and dysfunction here due to our increasingly sedentary and pressurised 21st century lifestyles.
Coccyx pain – also known as tailbone pain, coccydynia or coccygodynia
Coccydynia is the most common type of pelvic floor pain. It often occurs when you injure or strain your coccyx or the surrounding muscles and ligaments. The result is pain and discomfort felt at the base of your spine that is usually worse when sitting and often aggravated on standing up from sitting where the top Sacrococcygeal joint is straightened like a spike or dislocated backwards. In some cases, the pain disappears within a few days but it can last much longer, becoming chronic and severely impacting your ability to sit, drive, travel and perform daily activities.
Lower back pain is common in patients with pelvic pain as they typically sit or lie awkwardly and twisted sideways on one or other buttock to avoid their pain in the pelvic floor or coccyx. This creates torsion and imbalance with asymmetrical pressure and tension in the pelvic muscles and the lumbar spine which often leads to sacroiliac-iliac pain, facet joint pain, compensatory spinal curvature and painful poor posture.
Pudendal neuralgia (PN)
Pudendal neuralgia is a type of long-term chronic pelvic pain when the pudendal nerves become compressed, damaged or irritated.
The pudendal nerves are the main nerves of pelvic floor control and function, conducting motor control of the pelvic floor and sexual function as well as sensation from genitals, vaginal pain, labial pain, pelvic floor pain, perineal pain, ischial sitting bone pain and anal burning pain, between the buttocks, coccyx sitting burning pain and pain around the back passage.
Pudendal nerve entrapment (PNE)
Pudendal nerve entrapment causes chronic pelvic pain that occurs when the pudendal nerves are compressed by torsioned or asymmetric pelvic obturator internus pelvic muscles, compressed, entrapped or compressed nerves between the sacrotuberous and sacrospinatus ligaments inside the vaginal pelvis at Alcock’s canal.
Cluneal nerve entrapment
The cluneal nerves are nerves of the buttocks. Entrapment or compression of these nerves can cause lower burning lower back and pelvic pain. To read more about nerve entrapment conditions,scroll to the further reading section at the bottom of the page.
Pregnancy related pelvic girdle pain (PPGP)
Also known as pelvic girdle pain (PGP) or symphysis pubis dysfunction (SPD), this condition is caused by a locking or stiffness of your sacroiliac pelvic joints or by the joints moving unevenly either near the sacrum or pubic symphysis joint at the front of your pelvis. It usually occurs in the later stages of pregnancy or in the months after delivery and can cause severe pain in several areas including the pubic /pubis area, clitoris, groin, hips, inner thighs and undrr one or both buttocks.
What causes pelvic and coccyx pain?
If you’re experiencing pelvic or coccyx pain, the first step is to visit your GP to rule out serious conditions such as an infection or – in rare cases – cancer. Most often, this type of pain is neuromusculoskeletal in cause, which means that it can be physically resolved and effectively treated.
Pelvic pain and coccyx pain may be chronic or acute and there are several possible causes:
Fractures of the sacrum or coccyx: This usually occurs following trauma, such as a fall, or childbirth. Fractures from childbirth happen more frequently following intervention using a ventouse (cup-shaped suction device) or forceps with poor technique and exceess force. We can see fractures, even hairline coccyx fractures on our super-advanced, high-definition, low dosage x-ray system.
Poor posture: This can be caused by obesity, weak abdominals, having a sedentary occupation, sitting slumped on sofas and poor quality seating, postural adaptation in pregnancy and after caesarean section (C-section).
Surgical procedures during childbirth: Having a C-sections or an episiotomy (a surgical cut made at the opening of the vagina) can cause scar tissue which may result in nerve entrapment, leading to pelvic pain.
Spondylolisthesis: This happens when a vertebra, usually at the base of the spine, slips forwards over a bone below.
Muscular strains and injuries: Strains or injuries of the gluteal muscles, or glutes (the muscles in your buttocks) may entrap the pudendal nerve or sciatic nerve. Similarly, spasm of the coccygeus muscle (a muscle of the pelvic floor) can compress the rectal (back passage) branch of the pudendal nerve causing fleeting, agonising and occasionally long-term rectal spasm and pain (proctalgia fugax). Chronic pelvic muscle spasm or tightness is often implicated in vulvar pain and reduced clitoral sensation.
Mechanical low back pain: This may result from lumbar facet or sacro-iliac joint pain and dysfunction, lumbar disc referred sciatic leg pain, arthrosis, significant leg-length difference, muscle spasm or joint locking.
What are the symptoms of pelvic and coccyx pain?
At Sayer Clinics London, we are able to effectively treat the symptoms listed below. Patients typically experience two or more of these symptoms:
Pain when sitting: Sitting can trigger or aggravate pelvic and coccyx pain, particularly at work, when driving or travelling. Sometimes, this pain can be made worse by wearing tight jeans or underwear.
Pain or difficulty with bowel movements: In some cases the pain is relieved by a bowel movement, while for others the pain feels worse afterwards. The pain is felt as a result of spasms in the surrounding muscles. You may also feel the need to go to the toilet more often or experience constipation.
Pain or difficulty with urination (dysuria): This is usually a result of spasms in the surrounding muscles. When urinary symptoms are muscular in origin, after relaxing the pelvic floor, the flow of urine usually improves. Males may also experience a reduced stream or urinary flow – this is known as urinary hesitancy – and it can be worsened when urine is held longer than comfortable.
Needing to urinate more frequently: This can range from a worry to an overwhelming urge. There may be a constant subtle ache in your bladder, urethra or genitals. You may not feel 'empty’ after urination and feel a need to urinate again despite an empty bladder. You may also go to the toilet to urinate often during the night – this is known as nocturia.
Thigh, calf or foot pain: Some people may feel pain or paraesthesia (a burning, prickling or itching sensation) in these parts of the body referred through nerves from the pelvis or via ‘central sensitisation’ .
Groin, hip or abdominal pain: Groin pain needs to be diagnosed accurately and not confused with a hernia, muscle, tendon-bone insertion inflammation or hip joint pain.
Genital pain (in males): This is felt at the tip and shaft of the penis or as testicular pain felt in one or both testicles and may be referred via pudendal nerve compression.
Genital pain (in females): Females may experience pain, paraesthesia or numbness superficially or deep inside the vagina, on one or both sides of the vulva (vulvodynia) or in the clitoris (clitorodynia) and may be referred via pudendal nerve compression most typically between the coccyx and sitting bone.
Perineal pain (males and females): The perineum is the area between the genitals and the anus. Chronic pain in the perineum is very common in females especially after episiotomy when scar tissue is trapping nerves. In both males and females the perineum is often injured by prolonged cycling with saddle pain and compression of the pudendal nerve. This type of pain is usually aggravated by sitting but also by standing and increased discomfort for hours or even the next day after sexual activity is common as orgasm causes strong contractions of the pelvic muscles.
Pain during or after sex (dyspareunia): This pain may be felt on the outside as vulvar pain or as vestibular pain just inside the vagina. In some cases there will also be clitoral hypersensitivity or complete insensitivity or numbness.
Loss of interest in sex (low libido): This is common in cases of chronic pelvic pain. In males, pelvic pain can cause difficulty with getting an erection, resulting in anxiety and low self-esteem around sex, which reduces sexual arousal and interest.
Persistent Genital Arousal Disorder (PGAD): This is a spontaneous, persistent, unwanted and uncontrollable state of genital arousal in the absence of any sexual stimulation or desire. PGAD may be linked with neurological, vascular, physiological, pharmacological and psychologic factors. It may follow trauma or surgery, pudendal nerve entrapment, spinal disc bulges or compressed nerves and pelvic blood vessels. Clinically we have successfully treated many women with PGAD who had clitoral adhesions who responded extremely well to our careful clitoral hood mobilisation treatment.
Inability or difficulty to achieve orgasm (anorgasmia):
This is a complex reaction to multiple physical, neurological and emotional factors. Simple neuromusculoskeletal nerve compression and muscle spasm due to pelvic joints and muscle asymmetry can compress or constrict the blood and nerve supply to the pelvis, leading to pudendal neuralgia or neuropathy. Spinal nerve compression or irritation in the lumbosacral spine can also cause pelvic neuralgia and impede orgasm. Clinically we have treated women with anorgasmia and clitoral adhesions who have responded extremely well to careful clitoral hood mobilisation treatment.
Anxiety and depression:
Experiencing chronic pelvic pain can lead to depression, low self-esteem and feelings of hopelessness. As a result, sexual and social withdrawal with chronic pelvic or coccyx pain is common and people experiencing pain may have less desire to have sex, socialise, go on holiday or travel. In addition, problems with sexual performance, worries about needing the bathroom and feeling unable to control the situation can lead to anxiety.
Anxiety and depression can make it hard to move forward, find the right treatment and follow through to resolution. Pelvic and coccyx pain patients are often worried that they will never improve and catastrophize, fixating on the pain which leads to an increasingly powerful and chronic 'centralisation of pain in the brain' which is much harder to cure. They often require biopsychosocial practitioner support and focus to break through the fear-pain cycle.
How is pelvic and coccyx pain treated?
Self-care advice and measures provide important relief. These include avoiding long periods of sitting, using a specially-designed coccyx cushion, applying cold packs to the pelvic area and wearing loose clothing, avoiding straining during defecation or urination, stop trying to control autonomic pelvic function by controlling and overstressing.
GPs and specialists may prescribe pain medication, gabapentin, pregabalin, amitriptyline and even opioids such as codeine phosphate, Co-Codamol or Co-dydramol for pelvic or coccyx pain or injections of anti-inflammatory drugs (corticosteroids) and painkillers into the coccyx or surrounding area. We do not advise this approach which covers-up the pain just to a limited extent, with side-effects, but without resolving the underlying neuromusculoskeletal condition which needs addressing with specialist mobilisation treatment.
In extreme, yet fortunately extremely rare cases, a patient may need to be referred by us to the best surgeon for the coccyx to be surgically removed – a procedure known as coccygectomy.
In our experience, prescription drugs, injections and chemical or electrical burning of nerves (radio frequency ablation) are not good treatment for chronic neuromusculoskeletal conditions. They suppress and cover up pain symptoms, allowing the patient to continue being trapped in a pain-generating cycle with continued inactivity, weight-gain, poor posture and progression of the condition.
We help by educating you to understand how to reduce pain logically and to physically regain control and fitness.
• Pelvic skin inspection
• Trigger point release
• Myofascial manipulation
• Musculoskeletal pelvic joints manipulation
• Dry needling, medical or Japanese acupuncture
• Scar massage, mobilisation & desensitisation
• Re-education of pelvic floor and nerve function
• Restoring tone and function of abdominal core muscles
• Spinal and pelvic manipulation for several days depending on response
• Manual pelvic physical therapy over several days, depending on tolerance
• Lifestyle modifications
• Exercises and dietary interventions
• Education of causes and strategies for management and prevention
• Biomechanical correction of lower limb, spinal and pelvic gait anomalies
What will happen during my treatments at Sayer Clinics?
The first step is to consult your GP to exclude any previous pathological, urological or gynaecological causes of your pelvic pain. Once these have been eliminated as a source or cause of the problem, the persistent symptoms of pelvic pain can be examined and, in most cases, successfully treated by our unique multidisciplinary team of manipulation therapists and physiotherapists. We are committed to ensure that you receive the best treatment possible to help you to get well.
During your first appointment we take your extensive medical history and perform a thorough musculoskeletal examination. Sayer Clinic’s specialist coccyx manipulation and internal mobilisation, if diagnostically indicated, is discussed with benefits and any risks as well as the expected timescale to again pain-free coccyx and pelvic-floor function.
We answer all your questions and proceed with coccyx or pelvic treatment only with your written consent as well as your verbal consent at each visit and at each stage of treatment.
We advise you how to sit uniquely without pain, how to stand to minimise aggravation of tailbone or pelvic pain, the best coccyx cushion for your coccyx or pudendal pain and we give you effective physical and mental strategies to cope with tailbone pain with our unique and specific exercise program to help maximise your effective and successful rehabilitation from coccyx or pudendal burning sitting pain.
Your initial evaluation may include:
• Postural, pelvic joints, spinal and structural assessment
• Evaluation of fascia of abdomen, back, pelvis and lower extremities
• Myofascial evaluation of the pelvic girdle muscles
• Examination for myofascial trigger points of pelvis and pelvic floor muscles
• Pelvic floor examination assessing muscle tone, motor control and tenderness
• Evaluation of pelvic floor muscle strength
Treatment may begin during your first appointment and is geared toward resolving any dysfunction noted. You will be provided with feedback regarding home management, exercises, and behavioural changes as needed.
Our manipulation and physical therapy treatments include:
When you are our patient, you are always in control and receive your physical therapist's undivided attention for the appointment. You may choose to have one or more different therapists who work with you to learn what your body needs and how your body best responds to treatment. Our therapists work in partnership with you and liaise with each other with your consent via shared medical notes. We allow sufficient treatment time to provide you with optimal results. We are specialists with experience in the field of pelvic floor physical therapy. We have a high level of education and attend national and international conferences to stay on top of the latest research to help our patients.
Your length of treatment varies based on the severity and length of time you have had your symptoms, any previous treatment you have received, and your adherence to self-management and home exercise programmes which we will provide for you. It is imperative that you are committed to actively participating in your treatment.
Patients are usually seen for 60-90 minutes of pelvic physical therapy each week for between 8 and 12 weeks, depending on severity and length of time of their condition. In partnership and consultation with you, we re-evaluate every 10 visits to determine if there has been adequate improvement in your symptoms to justify continued therapy. Once you have achieved 75% to 80% improvement in your symptoms your treatments can be reduced to once every 2 weeks. On achieving 90% to 95% improvement in your symptoms, your treatments will be reduced to once a month until you are discharged from therapy.
Frequently asked questions
- Can you manipulate my coccyx back into the right position? 'It's not about a 'right position' but about regaining a pain-free, fully-functional 'range of movement' which also allows the pelvic floor and spine to function properly again to free sufferers from the grip of nerve-pain and protective muscle spasm.
- If you suffer debilitating tailbone or pelvic pain, it is not unusual for a hospital specialist to tell you there is nothing wrong after an x-ray or MRI. Many clinicians are not trained to, and do not, examine the coccyx properly or at all for tailbone injuries and having seen a radiology report which says there is no fracture, tumour or cancer, often dismiss it and label the problem as psychosomatic. Static x-rays and MRIs, with the patient prone, show coccyx position, but not the fixed, limited or disturbed range of motion which causes coccyx pain.
- At Sayer Clinics, we properly examine and, where indicated with digital coccyx x-ray, diagnose and treat you to restore coccyx mobility and normal function of the coccyx, pelvic joints and muscles, together with better posture and fitness.
- The initial intense treatment protocol for patients travelling from abroad may comprise a few days or a week or more of careful daily therapy which is constantly reassessed. If there are early signs of a flare, the frequency and type of therapy is moderated accordingly.
Will the treatment work?
Due to the complexity of these conditions a rapid cure, during a limited treatment time-frame, should not be anticipated as your body and mind always need time to respond to your long-term specific treatment and exercise plan with our biopsychosocial input where we help guide you to think, act and move differently to optimise your eventual outcome.
While 100% cure may never be guaranteed, we are pleased to report that over the decades patients with severe, acute and chronic musculoskeletal pelvic pain have reported sustained improvement in pelvic function along with the ability to live a more normal pain-free life following a course of manipulation with Michael and physical therapy currently with Marta, Karolina and Adele at Sayer Clinics.
To read more than 180 testimonials for Michael and his team, follow this link: https://www.coccyx.org/personal/index.htm
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You can also talk to Alexandra or Lucie on +44 (0)207 937 8978 from 8am to 8pm
For your first appointment we advise you to book first with Michael Durtnall at Sayer Clinic Kensington, West London for standing digital x-rays, if needed, and to be examined and treated with his musculoskeletal expertise in coccyx, sacroiliac, postural and pelvic manipulation in combination with our specialist pelvic physiotherapists. It is this combination of treatment that is unique in the world and a hugely significant factor in Sayer Clinics’ great success in pelvic & coccyx pain.
Following your Initial consultation, you may be advised to book appointments also with our specialist pelvic physiotherapists at any of our three Sayer Clinics: Sayer Clinic Kensington, West London, Sayer Clinic Welbeck Street, Central London, Sayer Clinic City, East London.
Michael Durtnall is registered with Aviva and most international insurance companies. Sayer Clinics’ physiotherapists are HCPC registered with Health & Care Professions Council and registered with most insurers.
Please check with us and with your insurers before starting treatment.
You may book your initial consultation with one of our female pelvic specialist physiotherapists if you prefer.
Stephanie Prendergast and Elizabeth H. Rummer, 2016. Pelvic pain explained: What everybody needs to know
Amy Stein, 2009. Healing Pelvic Pain
Articles and news
Immediate stop to NHS mesh operations
09 July 2018
TVT trans-vaginal tape and plastic mesh implants are used to support a prolapsed uterus and the problems this can cause in many women who suffer compression or cutting-in to nerve pathways and other tissues in the pelvis. Sayer Clinics’ pelvic physiotherapists are experienced in improving your pelvic floor strength and function to try to avoid the need for this type of surgery and to rehabilitate your pelvis. Find out more: The Operation that Ruined My Life
16 December 2017
Taking the shame out of Pudendal Neuralgia! – by Violet Matthews RN, moderator on www.pudendalhope.info
25 October 2011
More about Michael Durtnall
Read about 15 years of Michael’s research into coccyx and pelvic pain: https://www.coccyx.org/treatmen/michael.htm
Read Michael Durnall’s 2012 medical statistics on 87 consecutive coccyx and pelvic pain patients at: http://www.coccyx.org/medabs/durtnall.pdf
"Diagnosis depends on a thorough history and physical examination of the complex interaction between all structures leading inevitably to complex dysfunction throughout the body. Leg-length differences of a centimetre or more, for example, can cause significant pelvic tilt and shearing forces at the sacro-iliac and hip joints which in time can cause degenerative changes in these joints. We can address this with graduated heel-lifts to balance the leg-length and spine.
Following a thorough initial musculoskeletal evaluation and, where necessary digital standing x-rays to diagnose your problem, we use specific connective tissue manipulation, acupuncture or myofascial release to reduce muscle spasm and nerve compression and consequent inflammation. Specific joint manipulation, physical therapy ‘nerve tissue tension releases’, neural mobilisation and local medical acupuncture help regain function. Misalignment or fixation of the pelvis, sacro-iliac joints, facet or sacro-coccygeal joints with associated muscular spasms are usually interrelated factors.
The compression or irritation of obturator, ilioinguinal or genito-femoral nerves can cause intermittent and poorly localised shooting or burning pain in the pelvis, front and inner thighs aggravated even by light touch in the nerve distribution. Treatment with pelvic joint mobilisation, deep muscle trigger points and acupuncture, stretches and exercises help to resolve this nerve irritation. Referral for surgery to release a trapped nerve is extremely rarely necessary.
A variety of medical terms exist to describe Chronic Pelvic Pain Syndromes (CPPS): these include Pudendal Neuralgia; Pudendal Nerve Entrapment; Chronic Prostatitis; Interstitial Cystitis; Proctalgia fugax, Levator Ani syndrome, as well as Vulvodynia, Vulvovestibulitis, Clitoral pain and PGAD, hypo-sensitivity or hypersensitivity. However, these pain syndromes are often over-confidently and simplistically labelled yet poorly understood with vague diagnostic tests and pain-masking treatment.
Sufferers consult urologists, neurologists, gynaecologists, dermatologists, proctologists, rheumatologists and orthopaedic surgeons to treat their symptoms which can often be secondary to inter-dependent neuro-musculoskeletal causes. As a result, symptoms almost always return in some form or are never completely eliminated. Patients have reported that urinary symptoms, for example, are often treated with antibiotics, despite no positive culture, but symptoms return if they are secondary to biomechanical, neurological or visceral dysfunction.
A diagnosis of pudendal nerve entrapment (PNE) by a neurologist usually leads to nerve block injections and drugs to dull the brain's perception of pain. This will temporarily mask symptoms yet allow the patient to keep compressing and damaging their nerves, while unaware of the pain. Invasive surgery may cause fibrotic scar tissue in skin, muscle and fascia and cutting of pelvic ligaments can permanently lessen pelvic stability. There are multiple entrapment sites within the pelvis which are not best addressed by surgery but by expert manual therapy.
Our clinical experience over the years has shown us that these pelvic pain conditions are closely interrelated and associated with often simple factors such as: connective tissue, fascia and ligament laxity; prolonged sitting and physical inactivity (due to job/lifestyle); pelvic asymmetry; previous (forgotten) falls and other injuries from years before. Biomechanical muscular imbalance from prolonged slumped, asymmetrical sitting, cycling, weight-training and repetitive strains to the pelvic floor, sacroiliac and coccygeal joints can cause muscular spasm, hypertonicity and painful thickened, fibrotic myofascial adhesions with the potential to trap the pudendal and perineal nerves within these deep pelvic muscles. The Pudendal nerve is extremely specialised, controlling a complex web of urogenital sensation and function, control of bladder and pelvic floor muscular function plus fascial connections to pelvic and abdominal viscera. The pudendal nerves as well as the urethra pass through pelvic fascial structures and may be compressed or irritated if pelvic fascia or muscles around the bladder, prostate, urethra, rectum, anus, pubis, sacrum and coccyx are in pain and spasm.
We have found that complex and varied pelvic pain syndromes respond best when each and every patient is treated individually and differently at each treatment visit according to their current situation. Some need very specific manipulation of the sacroiliac and coccyx joints, others need firm external treatment to regain flexion of their almost fused and extended sacro-coccygeal joint. Most also need very deep tissue trigger point work to usually one-sided gluteal, coccygeus and deep pelvic muscles which have thickened and are compressing pelvic nerves. These muscles have usually become deeply fibrotic and pain sensitive, after years or decades of sitting sideways (usually on the same side). Some are so exquisitely painful that they can hardly be touched, so we start using light medical acupuncture, gradual and super-gentle soft tissue work and, finally, progress to internal or external pelvic joint, muscle and ligament manipulation.
In partnership with you, the patient, we use a flexible, inquiring approach in our clinical practice without preconceptions or foregone conclusions about how treatment has to be. Our treatment is based on clear musculoskeletal findings following experienced physical examination and, if necessary, digital standing x-rays. We treat in a multi-disciplinary way, with a combination of manipulation, acupuncture and pelvic physical therapy. We use localised medical acupuncture with very specific, frequent and increasingly intensive rehabilitation exercises.
For example, we recommend specific active movement every half hour throughout each day to regain fitness of joints, muscles, ligaments, tendons and nerves. We ask patients to stand and move while working, to adapt so that they stop sitting so much for prolonged hours. “Sofa surfing” after work is discouraged, as is taking prescription drugs to mask pain, putting on weight, becoming morbidly inactive and losing hope.
Our experience over 35 years allows us also to use words, ideas and motivation - what some would now call “mindfulness” - to increase confidence and fitness by degrees, empowering our patients to become as pain-free as possible and regain control over their bodies and general well-being. We certainly do not believe in covering or blocking pain as a short-term goal for short-term pain relief.
Patients describe pelvic pain as like being in an abyss; it is very depressing but the need for mental clarity to climb out of this is an imperative. Our role as therapists is to help in this struggle for recovery. I ask my patients why they think we are successful in treating their pelvic and pudendal pain. They say that Sayer Clinics are incredibly “hands-on”; that we are comprehensive in our musculoskeletal diagnostics; that we ceaselessly re-examine and reappraise the symptoms of joint locking, muscle spasms, asymmetry and range of movement of the pelvis and coccyx; and that we search out and firmly tackle poor health behaviour and bad ergonomics that largely cause the maelstrom of pelvic pain.
Everybody who suffers from pelvic pain is overwhelmed with diagnostic words: pudendal neuralgia, interstitial cystitis, proctalgia, vulvodynia. Let's keep it simple: the pelvis is a basin, served by nerves and blood vessels and moved by muscles with complex stresses shared between joints and ligaments. There are only so many things that can cause pain; if it isn’t infection, if it isn't a skin disorder and if it isn't cancer then the chances are that it has a neuromusculoskeletal basis. This means that a large proportion of pelvic pain may be physically resolved and effectively treated."
Michael Durtnall DC MSc (UCL) FRCC (Orth), Founder and Chairman, Sayer Clinics, London
More about Michael Durtnall’s training
Michael studied with New Yorker Dr Amy Stein DPT at her workshop at the World Congress of Lower Back and Pelvic Pain in Barcelona in 2007. Dr Stein was clear that pelvic symmetrical function was critically important and that all pelvic pain patients should first have their pelvic joints examined and, if necessary, manipulated by a specialist chiropractor.
Michael also studied 'hands-on' with American pelvic pain expert Dr Rhonda Kotarinos and was instrumental in inviting her to London in 2011 to lecture at an intensive specialist workshop at St George's Hospital in London and afterwards they continued their professional development holding consultations and treating their pelvic pain patients together at Sayer Clinic: Kensington.
World-leading Coccyx and Pelvic Pain Specialists
Symphysis Pubis Disorder – SPD.
The Symphysis Pubis joint between the pubic bones at the front of the pelvis may become separated or twisted due to ligamentous laxity during pregnancy causing SPD with pain and difficulty on walking, climbing stairs, dressing, turning in bed and getting in and out of a car.
Pain can be severe in the sacro-iliac joints and sometimes in the groin, inner thigh, hips or buttocks.
SPD can be surprisingly easily and rapidly improved by careful, experienced and skillful unlocking of the sacroiliac joints, thus instantly reducing the torsional strain at the pubis. Acute SPD patients, usually referred by their midwife or obstretician, often in tears, hobbling and supported by friends at their first visit to us, walk out smiling within the hour!
Our specialised treatment tables have adjustable abdominal sections for maximum comfort during treatment allowing you to lie face-down comfortably. Treatment with manual therapy eases painful muscles, decreases oedema and swelling and increases joint motion and flexibility. Post-pregnancy Core stabilisation, pelvic floor exercises and postural re-education are addressed.
Help with Pelvic Pain originating from the Musculoskeletal System
Musculoskeletal pathologies that can cause pelvic pain include sacroiliac dysfunction, symphysis pubis and sacrococcygeal joint dysfunctions, coccyx injury or subluxation and neuropathic structures in the lower thoracic, lumbar, and sacral plexi. The thoracic and lumbar spine, as well as sacro-iliac and hip joints, are linked due to pain-avoidance posture and mobility, and must be considered in the differential diagnosis of pelvic pain.
Pudendal Nerve Entrapment – PNE
The Pudendal nerve can become compressed or inflamed as it passes from the sacral and coccygeal nerve branches within self-perpetuating, deep muscle spasms close to the ischium or “sitting bones” area of the pelvis. Chronic referred pain or neuralgia may be felt in the perineum, abdomen and buttocks. Many patients have increased pain on sitting which is usually one-sided but both sides can be involved.
Symptoms may include pain, burning, numbness and parasthesia in the pelvis near the sacrum and coccyx which can radiate throughout the pelvic floor, inner thigh, lower abdomen and groin.
After a thorough evaluation to confirm your diagnosis we use specific connective tissue techniques, acupuncture or myofascial release to reduce muscle spasm and nerve compression and, therefore, inflammation. Specific physical therapy techniques called ‘nerve tissue tension releases’ and neural mobilisation or acupuncture can help decrease and regain reduced coccygeal range of motion by internal mobilisation to reduce coccyx/spinal cord meningeal tension. Misalignment or fixation of the pelvis, sacro-iliac joints, facet or sacro-coccygeal joints and muscular spasms are usually interrelated factors. We may use acupuncture, manipulative techniques and exercises prescribed with instruction.
It is very important to previously exclude, in consultation with your GP, urological and other potential medical causes of your pain.
Groin Pain in Sportsmen and women
The Groin is anatomically complex, highly mobile and vulnerable to significant stresses generated in sport through the legs, abdomen and pelvis.
Pain can originate from the lumbar spine, sacroiliac joints, hip joints and/or symphysis pubis.
Muscles involved include the hip adductors, hip flexors, gluteal, abdominal and lumbar extensors.
The obturator nerve, ilioinguinal nerve and genitofemoral nerve are potentially involved.
Diagnosis depends on a thorough history and examination of the complex interaction between them all with dysfunction of one structure leading inevitably with time to a multipartite dysfunction throughout the body. Leg-length differences of a centimetre or more can cause significant pelvic tilt and shearing forces at the sacro-iliac and hip joints which, in time, cause degenerative changes in the joints. We address this with graduated heel-lifts to balance the leg-length and spine.
Our aim is to give the athlete a realistic framework for rehabilitation and return to sport.
Pain and inflammation at the insertion of the adductor tendons onto the pubic bones causes pain with running and kicking with tightness and tenderness on resisted adduction of the hip.
Adductor tendon injuries are treated with soft-tissue physical therapy, ultrasound or laser with gradual strengthening of the adductor muscles.
Osteitis Pubis and Pubic Symphysis Diastasis - PSD
The symphysis pubis joint at the front of the pelvis has adductor muscles attaching on either side and abdominal muscles attaching to the top of the pubic bones. The symphysis can shear with sudden and repeated changes of direction during running and kicking and especially if the sacro-iliac joints at the back of the pelvis have sheared or twisted following a fall on the side of the pelvis or due to a significant leg-length difference, often of only a centimetre or so.
PSD pain typically radiates to the inner thigh and lower abdominal region often with clicking at the pubis.
If necessary and indicated a digital x-ray may show degeneration at the pubic symphysis due to chronic inflammation of the joint.
Treatment includes mobilisation of the sacro-iliac joints and deep massage and acupuncture to the muscles of the pelvis, hips and lumbar spine.
Hip Labral Tears
The hip joint is a common source of groin pain. The labrum is the cartilage lip of the acetabulum or hip socket, adding stability to the joint. A labral tear can cause clicking and pain on flexion and rotational hip movements with pain at the front of the hip which may radiate to the front of the thigh.
Examination can show decreased range of abduction and of internal rotation with the hip flexed at 90° and positive grinding tests. There may be associated spasm and pain in Iliopsoas, piriformis, gluteal and lumbar spinal muscles.
Hip and groin conditions can sometimes cause knee pain due to somatic referral of nerve pain from hip to knee.
Treatment of hip labral tears may involve referral to an orthopaedic surgeon for MRI and arthroscopic surgery.
Pelvic Nerve Entrapments
Compression or irritation of obturator, ilioinguinal or genitofemoral nerves within a self-perpetuating, deep muscle spasm can cause intermittent and poorly localised shooting or burning pain in the pelvis or inner thighs aggravated even by light touch in the nerve distribution. Treatment with pelvic joint mobilisation, deep muscle trigger points and acupuncture, stretches and exercises may help to resolve nerve irritation .
Referral for surgery to release a trapped nerve is occasionally necessary.
N.B. There has been very limited large-scale, clinical research carried out in the physical treatment of coccyx and pelvic pain and therefore limited evidence of the efficacy or otherwise of manual and acupuncture treatment for these conditions.
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