Pelvic and Coccyx Pain
Sayer pelvic pain clinics in London are leading Coccyx pain, Pelvic Floor and Pudendal Neuralgia specialist neuro-musculo-skeletal treatment Clinics.
Michael Durtnall first trained as a chiropractor. During the past 12 years his continuing professional development focus has been on the area of the spine known as the coccyx (or tailbone) and on the pelvis, the anchor for many of our joints, muscles and nerves.
This complex neuromusculoskeletal region of the body has been a neglected area of clincial research, yet more of us are suffering pain and dysfunction here due to our increasingly sedentary but pressurised 21st century lifestyles. Michael has undertaken postgraduate training with the leading pelvic pain experts, Dr. Amy Stein and Dr. Rhonda Kotarinos. He has been a member and listed practitioner with the International Pelvic Pain Society (IPPS) since 2006 and has lectured at international coccyx and pelvic pain symposia and conferences. Michael is a leading coccyx and pelvic pain manipulation specialist and has successfully treated many patients suffering coccyx dysfunction, pudendal neuralgia and pelvic pain.
Michael has 40 years experience with expertise in spinal manipulation and spinal, sacroiliac and sacro-coccygeal radiology, and treats pelvic joints, muscles, ligaments, fascia and nerve pathways using manipulation and medical acupuncture. He works closely with his leading pelvic specialist physiotherapy team. He has been trained to treat pelvic pain in both men and women. Michael is a published lecturer on coccyx dysfunction, neuromusculoskeletal pelvic and pudendal nerve compression and entrapment (PNE) and postural rehabilitation.
At Sayer Clinics we specialise in the diagnosis and treatment of Coccyx pain, Pelvic Girdle Pain (PGP), Pelvic Floor Pain and dysfunction, Pudendal Neuralgia (PN) and Pudendal Nerve Entrapment (PNE) as well as unexplained neuromusculoskeletal pelvic pain in our three pelvic pain clinics located in:
Sayer Clinic West London: Kensington W8
Sayer Clinic Central London W1, near Bond Street, West End
Sayer Clinic East London, Moorgate, City of London EC2.
Michael practises and liaises closely with his exceptionally skilled Specialist Pelvic Pain Physiotherapy Team of highly qualified and fully registered health practitioners. Diagnosis using neurological and orthopaedic tests, spinal examination and, where indicated, digital radiology or diagnostic ultrasound is performed in order to treat patients with safe and effective manipulation, physical therapy modalities and postural rehabilitation.
Marta Dias De Oliveira, Karolina Krzaczek and Adele Telenta are skilled specialists in Pelvic Pain with expertise in trigger point and myofascial release for coccyx - tailbone pain, pudendal neuralgia and pelvic floor rehabilitation. They treat women from teenagers to post-menopausal. Treatments are conducted in private treatment rooms with focused hands-on therapy. Our specialist women's health therapists evaluate and treat pelvic pain and dysfunction with the active participation of the patient through the treatment and healing process. We are specialised in rehabilitation treatment programmes for pelvic floor pain, abdominal muscle diastisis, incontinence, pre-natal and post-partum pelvic girdle pain, pelvic organ prolapse, sexual pain and dysfunction. They are not only excellent physiotherapists but also the most caring, experienced and effective in manual and bio-psycho-social treatment of pelvic pain and Pudendal neuralgia.
Michael received practical, hands-on training from the leading USA experts in pelvic pain physical therapy treatment Dr Rhonda Kotarinos and Dr Amy Stein and shares his expertise with his Sayer Clinics Pelvic team for non-surgical and non-drug treatment to resolve chronic and acute musculoskeletal coccyx and pelvic pain. He has conducted research into effective coccyx and pelvic pain manual treatment as well as post-partum coccyx pain (coccyx pain after childbirth), successfully treating cases of coccyx dislocation and sacral fractures following ventouse and forceps hospital deliveries.
Michael studied with New Yorker Dr Amy Stein DPT (author of 'Heal Pelvic Pain') at her workshop at the World Congress of Lower Back and Pelvic Pain in Barcelona in 2007. Dr Stein was clear that all pelvic pain patients should first have their pelvic joints examined and, if necessary, manipulated by a specialist chiropractor. Dr Stein had herself learned from the leading pioneers of the profession as a physical therapy graduate, studying with Holly Herman who with Kathe Wallace had founded the Herman & Wallace Pelvic Rehabilitation Institute in Seattle, USA.
Michael also studied 'hands-on' with American pelvic pain expert Dr Rhonda Kotarinos and was instrumental in inviting her to London 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.
Read the 150 coccyx testimonials for Michael and his team at http://www.coccyx.org/treatmen/docsuk.htm and www.coccyx.org as well as 30 pelvic-pain patient reviews for Michael Durtnall and his team on the UK and Ireland forum of www.Pudendalhope.info
Read here 10 years of Michael's research on coccyx.org at 'Chiropractic and Acupuncture works for acute & chronic Coccyx pain/dislocation and read his 2012 medical statistics on 87 consecutive coccyx and pelvic pain patients at http://www.coccyx.org/medabs/durtnall.pdf on http://www.coccyx.org/medabs/durtnall.htm
While 100% cure may never be guaranteed, we are pleased to report that over the last decade patients with severe, acute and chronic musculoskeletal pelvic pain have reported a sustained improvement in pelvic function along with the ability to live a more normal pain-free life following a course of manipulation and physical therapy with Michael, Marta, Karolina and Adele at Sayer Clinics.
Many GPs and doctors have not heard of pelvic-floor physical therapy. Pudendal neuralgia, coccydynia and vulvodynia can be excruciatingly painful and become chronic. Yet surprisingly the majority of people who suffer neuromusculoskeletal referred pelvic pain are mostly treated with surgery, nerve cauterisation, cortisone injections, painkillers, anti-epileptic and antidepressant drugs which often fail to resolve pelvic dysfunction but cover-up symptoms which later return.
Many gynaecologists, obstetricians and GPs help these patients by referring them to the Sayer Clinic specialist pelvic pain team for a thorough examination and clear diagnosis with effective pelvic rehabilitation therapy.
Healthy connective tissues and muscles cushion and protect blood vessels and pelvic nerves from compression.
Pelvic pain following entrapment neuropathies
Nerve entrapment involves two main variables: the container (pelvis) - a rigid space shaped by bone and ligaments - and the contents - the nerves, connective tissue, tendons and muscles. Pelvic floor muscles attach from the pubic bone to the tail bone (front to back) and "sit" bones (side to side) acting as a trampoline to support the internal organs including bladder, rectum and reproductive organs. These core muscles not only stabilise the lower spine, but support, affect and work with the rest of the body. Dynamic changes in the volume of the container and its contents during stress-inducing postures, movement and oedema can lead to nerve entrapment; regions close to joints are, therefore, predisposed to entrapment syndromes, in which abnormal seated postures and repetitive movements induce progressive, focal compression.
Our manual therapy works on connective tissue restrictions caused by dysfunction or injury in muscles, pelvic nerves and joints or which develop as a reflex from malfunctioning abdominal and pelvic organs. Connective tissue which has become scarred or thickened over time, reduces local blood flow and entraps or sensitises nerve endings, causing pain. When we manually release connective tissue restrictions we relieve trigger point activity and pain referred from bladder, uterus, prostate and other tissues and organs. We manually perform the pinch-roll test of the pelvis, abdomen, buttocks and thighs to finely assess for painful tissue thickening or panniculosis. Our pelvic physiotherapists use skilled connective tissue manipulation to mobilise, improve circulation, desensitise and remove negative reflex effects on muscles, nerves and organs which are ubiquitous in pelvic and coccyx syndromes in both men and women.
If appropriate and indicated, our latest 2017 low-dose, high-definition standing digital x-rays detect and accurately measure significant leg-length difference and compensatory scoliosis, with pelvic assymetry and sacroiliac joint torsion, which can often be seen in patients suffering pubic symphysis dysfunction and coccyx and pelvic neuralgia pain.
Tissue manipulation is normally associated with minor soreness for a few days after the initial treatment, but after the first few treatment sessions, connective tissue pain normally diminishes and finally disappears both during and following treatment.
Cluneal nerve entrapment mimicking sciatic pain.
Branches of the superior cluneal nerve (SCN) passing via the thoracolumbar fascia over the iliac crest can be trapped within adhesions.
The middle cluneal nerve (MCN) with sensory branches from S1 to S3 pass below the posterior superior iliac spine (PSIS) horizontally to supply the skin of the posteromedial buttock. S1 and S2 lateral branch compression explains why MCN disorders can refer leg pain symptoms into the posterior thigh and calf.
A diagnosis of SCN/MCN entrapment can be made by skilled palpation of the iliac crest or long posterior sacroiliac ligament (LPSL) resulting in severe tenderness and aggravation of referred pain symptoms. The SCN trigger point is on the posterior iliac crest about 70 mm from the midline. The MCN trigger point is on the long posterior sacroiliac ligament around 40 mm caudal to the PSIS.
Sayer Clinics’ pelvic pain specialists readily diagnose cluneal conditions by palpation of cluneal nerve pathways and treat it using deep tissue massage to release adhesions and usually extremely contracted fibrotic muscle and fascial tissue compressing cluneal nerves branches.
The initial and essential requirement is efficient neuro-musculoskeletal analysis using, if necessary and indicated, standing low-dose digital x-rays, including assessment of significant leg-length-difference, pelvic torsion and asymmetrical pelvic muscle spasm. Simple causes of cluneal nerve adhesions and compressions include tight belts and lying half-sideways on sofas to watch TV and long-term sitting sideways to avoid chronic coccyx problems.
Sayer Pelvic Physiotherapy Team
Sayer Clinics' specialist pelvic physiotherapists Marta Dias De Oliveira, Karolina Krzaczek and Adele Telenta are rare hands-on experts. Many NHS and private physiotherapists have not been taught these manual techniques even at post-graduate level. Successful treatment depends on experienced therapists with expert connective tissue evaluation and individualised treatment ability.
Michael Durtnall presented the world-first whole-day workshop lecturing on Coccyx and Pelvic pain at the 8th World Congress of Low Back and Pelvic Pain in Dubai in 2013, at the first Coccyx Symposium in Paris in July 2016 and recently at the 2nd Coccyx Symposium in Dordrecht, Holland in July 2018 as an expert in coccyx and pelvic pain manipulation and rehabilitation. He has lectured to international medical audiences at University College London (UCL) and AECC students as well as doctors, therapists, specialists and professors on coccyx and pelvic pain diagnosis and effective manual treatment of chronic musculoskeletal coccyx and pelvic pain without steroid injections, invasive surgery or dependence on opioid prescription drugs.
Sayer Clinic chiropractors and physiotherapists are experienced in working with pregnant women. We understand the demands placed on the body during the different phases of pregnancy with many pregnant women experiencing neck pain, headaches, low back pain and leg pain. We clearly understand postural changes, sacroiliac, SPD or PSD pubic symphysis joint dysfunction and PPGP pregnancy-related pelvic girdle pain. Sayer pelvic floor rehabilitation uses internal and external manual physical therapy techniques targeting connective tissues, muscles and nerves. Our evaluation assesses the external myofascial tissues in the abdomen, inner thighs, low back and gluteal areas in accordance with current research findings. This research confirms a correlation between these external tissues and pelvic floor dysfunction, bladder disorders and pelvic pain.
With written consent and valid verbal patient consent specifically for each area of examination and treatment given by you, the patient, an external and internal exam may be performed to assess the health and function of your pelvic floor muscles because dysfunction here can result in dysfunction elsewhere. 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.
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 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.
When you choose to have treatment with us you are being treated by a uniquely qualified and highly skilled practitioner with uninterrupted treatment and a customized plan of care provided by a Physical Therapist specialised in pelvic floor dysfunction.
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 up to 10 to 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.
Allison Hyman, Doctor of Chiropractic, at our Welbeck Street, London W1 clinic is an experienced chiropractor trained in the specialist Webster technique to help optimise the health of the mother before and after birth.
Causes of chronic & acute pelvic pain and coccyx pain - coccydynia - tailbone pain:
Abdominal muscle pain (trigger points)
Nerve entrapment in Caesarian (c-section) or episiotomy scar tissue.
Spondylolisthesis - forward slippage of one lumbar vertebra on another – treated by regaining mobility/normal function of joints above and below, strengthening core muscles to minimise strain on a spondylolisthetic joint and postural changes.
Poor posture – caused by normal postural adaptation to pregnancy which is unresolved following birth - caesarian section - weak abdominals - obesity, sedentary occupation - poor posture sitting at computers - wearing high-heels.
Mechanical low back pain – lumbar facet joint pain or sacro-iliac joint pain and dysfunction - sciatic referred leg pain - athrosis - leg-length difference, muscle spasm or joint locking.
Sacrococcygeal syndrome – chronic or acute coccygeal pain – coccyx hypomobility (stiffness), minor dislocation or arthrosis causing muscular pain, spasm or weakness to coccygeus, gluteal, obturator externus / internus with typically unilateral Arcus tendinosus tension, piriformis, gluteus minimus, quadratus femoris muscle spasms as well as internal hip rotators, gluteus medius, adductor longus and brevis, pectineus, tensor fascia lata and medial hamstrings.
Coccygeal, sacral or pudendal nerve referred pain - pelvic pudendal neuralgia PN or pudendal nerve entrapment PNE:
In women - rectal or perineum pelvic floor pain, pain in the labia, internal vaginal wall muscle pain with trigger points, clitoris pain and the persistent hypersensitivity genital arousal disorder (PGAD) or clitoral hypo-sensitivity and numbness, lower abdominal and inner thigh pain.
Constant and intense pelvic muscle spasm is central in vulvar pain via hypertonic, over-contracted perivaginal and pelvic floor muscles maintaining vaginal spasm, tension and pain with constant constrictive pressure on pelvic and pudendal nerves. Neurological pudendal nerve compression intensifies pain through pain-anticipation or fear of pain as a conditioned reflex.
In men, chronic referred pain to the inner thigh, groin, pelvic floor, testicles and penis.
Muscular strains and injuries of gluteal medius, gluteus minimus or maximus muscles with hip or buttock pain or piriformis spasms may entrap the pudendal nerve or sciatic nerve. Coccygeus muscles spasm can compress the rectal branch of the nerve causing proctalgia fugax, fleeting, agonising and occasionally long-term rectal spasm and pain.
Chronic pelvic muscle spasm or tightness is often implicated in vulvar pain via hypertonic perivaginal muscles maintaining vaginal tightness and pain. Neurological pudendal and vestibular nerve compression plus arousal stresses may aggravate pain through pain anticipation as a conditioned reflex.
Cluneal nerve conditions respond well to manipulation of sacroiliac and coccygeal joints and specialist deep tissue massage of the involved deep pelvic muscles and myofascia by our excellent and experienced physiotherapists..
Fractures of the sacrum or coccyx following trauma or childbirth - especially after obstetric intervention with Ventouse or forceps delivery in childbirth.
PPGP, SPD OR PSD - Pubic Symphysis Diastasis causing severe pain at the symphysis pubis in the later stages of pregnancy linked to sacroiliac joint dysfunction or subluxation is effectively and efficiently treated with sacroiliac joint specialist manipulation.
Sayer Clinics chiropractors and our leading pelvic pain physiotherapists in London are experts in treating the agony of sacroiliac - SI joint or SIJ dysfunction - PPGP (pregnancy-related pelvic girdle pain) SPD (symphysis pubis diastasis or PSD (pubic symphysis dysfunction) and are able to treat this disabling condition safely and effectively - without pelvic belts, oral analgesics and injections.
We are hearing news stories about TVT trans-vaginal tape and plastic mesh implants 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. http://www.bbc.co.uk/programmes/b09jl9dd. 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.
Tailbone Mobility vs Position - We are frequently asked: 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.
Symptoms of musculoskeletal Coccyx and Pelvic Pain routinely and successfully treated at Sayer Clinics London:
Our patients typically suffer from 2 or more of these symptoms:
Coccyx - tailbone pain
Low back pain
Pain with sitting
Urinary Frequency - Urgency - Hesitancy
Rectal pain / Perineum pain
Male Genital Pain - parasthesia / numbness - gluteals, buttocks, pelvis, perineum, testicles, penis, lower abdomen, inner thighs.
Female Genital Pain or parasthesia / numbness - gluteals, anal pain, buttock pain, pelvic floor muscle tightness or tension or weakness, perineal burning nerve pain, vulval and labial inflammation, one or both sides internal vaginal muscle pain, contraction or weakness, clitoral hypersensitivity PGAD or insensitive, loss of clitoral sensation or pain with anorgasmia, lower abdomen or inner thigh pain or altered sensations - parasthesia.
Lower abdominal pain - parasthesia - tingling altered sensations in lower legs
Pelvic pain during or after sex
Pain or relief after bowel movement
Stress increasing pain
Depression, anxiety or catastrophising about chronic pain
Symtoms persisting while medical tests find no pathology or disease
Reduced quality of life.
We describe and list below in specific detail some of the experiences and symptoms of coccyx and pelvic patients successfully treated at our clinics in London. It will help you to understand how it feels to suffer these musculoskeletal coccyx and pelvic pains syndromes. If you suffer the symptoms below then please ask for our help at Sayer Clinics:
Almost all of us sit constantly throughout every day in cars, trains, all day at work and then socialising or at home for most waking hours. Sitting can trigger or aggravate coccyx and pelvic pain discomfort and flare all pain symptoms which worsen through the day. Travelling, flights and driving aggravate coccyx and pelvic pain.
Coccyx Pain - Tailbone pain - Coccigodynia - Coccydynia
Tailbone / coccyx pain is the most common cause of pelvic floor pain and typically refers sharp or burning pain to the anal area via the rectal nerve branch, and / or via the labial and clitoral branches and also potentially to the lower abdomen and inner thigh via the sacral or coccygeal branches of the compressed, entrapped or inflamed pudendal nerve.
The simple mechanism of pelvic pain progression is that almost everybody with coccyx pain or musculoskeletal pelvic pain sits sideways long-term to avoid the primary pain which then causes thickening and spasm of the pelvic muscles through which the pudendal nerves pass with chronic compression of the pudendal nerve/s with the whole gamut of potential and secondary referred pain along the pudendal nerve pathway.
Coccyx pain is often associated with bowel movement pain.
Low 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 a torsion and imbalance with asymmetrical tension in the pelvic muscles and the lumbar spine which often leads to sacroiliac-iliac pain, facet joint pain, compensatory spinal curvature and poor posture with nerve root irritation.
Coccyx and Pudendal nerve irritation can make the sufferer feel the need to urinate and defecate multiple times a day without resolution of the sensation. This is alleviated by regaining coccyx and pelvic function along with coccygeal and sacral nerve function. It is essential to retrain our patients to stop interfering in the autonomic (automatic) control of their pelvic functions.
We endeavour to heal pelvic pain at Sayer Clinics by assessing and treating the body's entire musculoskeletal structure which includes, posture, mobility, symmetry, tone and strength as well as addressing and dissolving dysfunctional thought patterns. We teach and help every patient perfect the unique 'Sayer Clinics perfect Posture' method of sitting and standing for lifelong postural perfection .
Males: pain in the perineum and at the tip and shaft of the penis or testicular pain felt in one or both testicles.
Females: pain superficially or deep inside the vagina, vulvar vestibulitis, vestibulodynia, labial-vulvar pain on both or one side or Clitorodynia, clitoral burning pain or altered sensation, parasthesia or numbness.
Pain is commonly felt along with urinary frequency and urgency.
Coccyx /pelvic muscle trigger points may refer as perineum, pelvic floor, rectal, inner thigh and lower abdominal pain.
Patients also frequently suffer thigh, calf and foot pains or paraesthesia as altered sensation - formication - like ants crawling or a sensation of water trickling on the skin. These symptoms are usually the first to go once treatment has started.
Genital pain is best resolved using a combination of specialist manipulation to correct pelvic or coccyx joint torsion or dislocation. We treat muscle / nerve compression using specialist physical therapy stretches, trigger point therapy or medical acupuncture.
Groin, pelvic, 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 CAM or PINCER pain.
Bowel movement pain
Relief after a bowel movement is experienced when tight pelvic muscles relax but often pain after a bowel movement may be stronger for many hours afterwards.
The need to defaecate sends a nerve impulse to the internal anal sphincter and puborectalis muscles to relax, triggering a bowel movement. Once the stool passes through the relaxed anal sphincter the internal anal sphincter may reflexively ‘over tighten' into painful spasm.
After-bowel-movement pain occurs less if you can learn to relax and usually resolves fully with specialist pelvic physiotherapy and pelvic muscle tension releases.
Pain symptoms can move or migrate to different parts of the pelvis as the condition progresses with pain and altered sensation in the pelvic floor, genitals, lower abdomen, inner thighs and legs.
Hot baths, showers or heat packs help whereas cold can aggravate symptoms.
Urinary frequency can range from a worry to an overwhelming urge.
A feeling of a constant subtle ache in your bladder/urethra/genitals, not feeling 'empty’ after urination and feeling a need to urinate again despite an empty bladder. The relaxed resolution normally felt after urination is often absent with pelvic pain.
Urgency - difficulty 'holding' once urge starts.
Frequency/urgency means constant worry and planning ahead to be near a toilet for fear of leaking or loss of control when the urge comes.
Urinary urgency and frequency can cause sleep deprivation with frequent waking to urinate throughout the night.
Burning or pain with urination, often with pelvic floor weakness.
When the chronic spasm and myofascial contraction of the pelvic muscles is resolved, in most of our patients, dysuria is also resolved
Pain during or after urination - Dysuria can be severely painful which refers a variety of acute pelvic pains.
Nocturia causes disturbed sleep which quickly impacts on chronic tiredness and exhaustion, irritability with increased stress, tension, guarding and anxiety.
In men a reduced stream or urinary flow may be due to prostate enlargement or neuro-musculoskeletal conditions.
Hesitancy of initiating urination can be worsened when urine is held longer than comfortable and can be a contributory symptom to low self-esteem and hypochondriasis particularly in younger males.
When urinary symptoms are muscular in origin, after relaxing the pelvic floor, the flow of urine usually improves.
Those with neuro-muscular pelvic pain may have to consciously focus on muscle relaxation until urinary flow can start.
Chronic pain in the perineum is very common in females especially after episiotomy where scar tissue is trapping nerves.
The perineum is the focal point of many pelvic floor muscle attachments and may be the endpoint or the source of referred pain.
The perineum is often injured by prolonged cycling with saddle pain and compression of the pudendal nerve/s.
Perineal pain is usually aggravated by sitting but also by standing.
Abdominal and pelvic muscles can refer pain to the perineum (rectus abdominus, adductor magnus, and coccygeus).
Irritation of the perineum and anal sphincter can feel like you're “sitting on a golf ball".
Increased discomfort for hours or even the next day after sexual activity is common as orgasm causes strong contractions of the pelvic, prostate and seminal vesicle muscles with significant nervous system arousal which tightens pelvic muscles, pushing the patient above the symptom threshold
Persistent Genital Arousal Disorder (PGAD)
Persistent genital arousal disorder (PGAD) is felt as spontaneous sensations of clitoral or vulval arousal with engorgement, pulsing or throbbing sensations in the vulva, perineum or anus without sexual thoughts or desire. PGAD ranges from mild to severely incapacitating.
Assessment and diagnosis of PGAD requires care and consideration of the patient. PGAD may be linked with neurological, vascular, physiological, pharmacological and psychologic factors.
PGAD may follow trauma or surgery, pudendal nerve entrapment, spinal disc bulges or compressed nerves and pelvic blood vessels.
Effective Physical Manual PGAD Treatment
Once PGAD has been diagnosed, often with pudendal nerve involvement or local clitoral phimosis or constriction, expert manual release of constrictive tissues around the clitoris and the highly complex pudendal nerve pathway to release tissue entrapment results in rapid resolution of PGAD symptoms in some cases and more gradual improvement in others. Pelvic floor physical therapy and rehabilitation with practical advice and support is essential.
Pain during or after sex - pain is felt on the outside of the vagina, inside or both with potential clitoral hypersensitivity or complete insensitivity or numbness.
Pelvic examination in which trigger points are palpated can recreate symptoms of pain during sex but are resolved by trigger point release physical therapy.
Reduced or a total lack of interest in sex is common with chronic pelvic pain.
In musculoskeletal pelvic pain, there is dysfunction but rarely any pathology of the anatomy involved in sexual activity.
Low libido is often associated with anxiety, low self-esteem and pain in the pelvis which reduces sexual arousal and interest.
Effective physical treatment of pelvic pain and dysfunction of the pelvic muscles may help resolve low libido.
When sex is chronically painful, fear and avoidance of sex follows.
Pain can cause difficulty with erection which worsens already low esteem and confidence. Anxiety with pain and sex is a major reason for performance anxiety and is ‘medicalised’ as erectile dysfunction.
Resolution of pelvic pain sometimes helps the anxiety and erectile dysfunction normalises.
Pelvic and coccyx pain patients are often worried that they will never improve and catastrophise, fixating on the pain which leads to an increasingly powerful and chronic 'centralisation of pain in the brain' which is harder to cure. They often require biopsychosocial practitioner support and focus to break through the fear-pain cycle.
Experiencing severe chronic pelvic pain leads to depression, low esteem and hopelessness, with helplessness and the inability to act to move forward, research, find the right treatment and follow through to resolution.
Sexual and social withdrawal with chronic coccyx or pelvic pain is common and also affects their partners who suffer the loss of sex, socialising, holidays and travel. Preoccupation with pain ruins social enjoyment.
Disturbed sleep with frequent waking during the night to pee or from pain and anxiety means each day starting with tiredness and anxiety.
Normal daily activity as well as unexpected stresses, specific physical activities, such as bowel movements or orgasm, can initiate severe pain flares with deep pelvic muscle protective spasms for many hours after the initial stress has passed. Long term these protective spasms make muscles fibrotic and hypersensitive to pain.
Helplessness naturally follows the seemingly permanent lack of control of the chronic pain which makes you feel demoralised, fearful and banishes your enjoyment of life.
Benzodiazepines and tricyclic antidepressants like Amitryptalline and neural drugs called Gabapentin, Neurontin or Pregabalin have potentially disturbing side effects and, when used regularly for chronic pelvic pain, become less effective with time and can cause tiredness, lethargy and large weight gain.
Inability or difficulty to achieve orgasm is a complex reaction to multiple physical, neurological and emotional factors. Simple neuromusculoskeletal nerve compression and muscle spasm due to pelvic joint and muscle asymmetry may compress or constrict the blood and nerve supply to the pelvis, leading to pudendal neuralgia or neuropathy as one of many pelvic symptoms or signs of pudendal neuralgia. Spinal nerve compression or irritation in the lumbosacral spine may also cause pelvic neuralgia and impede orgasm.
Hypothyroidism, Addison disease, Cushing syndrome, hyperprolactinemia, hypopituitarism, decreased oestrogen and androgen levels and a whole host of commonly prescribed medications commonly negatively affect libido.
Pelvic floor may be impacted by pregnancy, menopause, gynaecologic surgeries and hysterectomy, as well as female genital mutilation (FGM), pelvic trauma, hormonal imbalances, vulvodynia, and childbirth trauma.
Vaginismus, the painful spasm and tightening of muscles at the vaginal opening which prevents or makes intercourse extremely painful, may also follow surgical scars or injury, abuse, chronic infection, childbirth trauma, anxiety and fear.
Nerve damage following surgery: during pelvic surgery and hysterectomy, small nerves may be cut with a resulting decrease in response and sensation.
In our experience, prescription drugs, injections and chemical or electrical burning of nerves (radio frequency ablation) are not the best way to treat 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. The patient may lose control over their health under the influence of these drugs. We help by educating you to understand how to reduce pain logically and to physically regain control and fitness.
Common Symptoms of pelvic pain include:
Vulvar vestibulitis, vaginal pain, clitoral pain, perineal or anal pain
Dyspareunia - pain during sex - pain after sex
Labial, vulvar or genital pain, altered sensation - burning pain or itching
Pain on urination, urinary hesitancy, urgency and/or frequency
Lower abdominal, groin, inner thigh pain or altered sensation
Sacroiliac joint pain, locking or instability
Pain on wearing jeans or underwear
Pain with sitting
Muscular pelvic pain with exercise
Associated or alternate Diagnoses:
Interstitial Cystitis - Painful Bladder Syndrome
Vulvodynia - Vestibulitis - Vestibulodynia
Clitorodynia, clitoral burning pain or altered sensation, parasthesia or numbness
Persistent Genital Arousal Disorder (PGAD)
Proctalgia Fugax - stabbing or shooting rectal pain
Irritable Bowel Syndrome
Tailbone pain - Coccydynia
Sacroiliac Joint Dysfunction
Pelvic Girdle Pain
Evaluation and Treatment at Sayer Clinics:
During your first "evaluation appointment,” we take your extensive medical history and perform a thorough musculoskeletal examination.
Your initial evaluation may include:
- Postural, pelvic joints, spinal and structural assessment
- Evaluation of fascia and connective tissue in the abdomen, back, pelvis and lower extremities
- Myofascial evaluation of the pelvic girdle muscles
- Examination to identify myofascial trigger points in the pelvic girdle and pelvic floor muscles
- Pelvic floor examination by gently assessing muscle tone, motor control and tenderness.
- Evaluation of pelvic floor muscle strength
- Pelvic skin inspection
Following your physical examination, our therapists discuss your physical findings and answer your questions, assess and explain the treatment frequency and probable duration of therapy.
Initially, treatments are 60-90 minutes long over eight weekly sessions. We then re-evaluate in consultation with you to set further treatment plans and goals depending on progress. Patients with pelvic pain are typically seen for up to 12 visits but the duration varies based on the severity, length and chronicity of the problem.
Treatment at Sayer Pelvic Pain Clinics is one-on-one manual physical therapy with a multidisciplinary treatment approach with email access to your therapist to answer questions, address your concerns and provide you with ongoing support. We are committed to ensure that you receive the best treatment possible to help you to get well.
Sayer Clinics Manipulation and Pelvic Physical Therapy Treatments include:
- Trigger point release
- Myo-fascial manipulation
- Musculoskeletal pelvic joints manipulation
- Dry needling, Medical or Japanese Acupuncture
- Scar massage, mobilisation & de-sensitisation
- Re-education of pelvic floor and nerve function
- Restoring tone and function of abdominal core muscles
Sayer Clinics Physiotherapists are HCPC registered with Health & Care Professions Council and registered with most insurers.
Michael Durtnall is registered with Aviva and most international insurance companies.
Please check with us and with your insurers before starting treatment.
Please choose from the three Sayer Clinics in London W8, W1 or EC2, research at www.sayerclinics.com and choose your practitioner/s, choose dates and times and then book and pay online at www.sayerclinics.com for your treatment appointments. We will email you a confirmation email and issue you receipts to help you to reclaim from your insurers.
Book Online 24/7 here for Sayer Clinic Kensington W8, Moorgate EC2 in the City or Welbeck Street W1
Please call Alexandra or Lucie on 020 7937 8978 from 8am-8pm Monday to Friday and Saturdays 9am-2pm or email email@example.com to ask us any questions.
An informative article written 8 years ago, before Sayer Clinics came to the fore in pelvic pain treatment, by Violet Matthews RN, moderator on www.pudendalhope.info, entitled “Taking the shame out of Pudendal Neuralgia can be read if you follow this link: http://www.obgyn.net/pelvic-pain/taking-shame-out-pudendal-neuralgia
Sayer Pelvic Pain Clinics' unique neuromusculoskeletal approach to Pelvic pain.
Pelvic pain is often the result of nerves becoming chronically compressed, irritated and inflamed. This is commonly due to long-term, slumped sitting positions, compressing nerve pathways where they exit the lower sacrum and coccyx, with burning nerve pain into the deep and superficial pelvis, which is served by a multitude of nerves including the rectal, perineal and pudendal nerves. This nerve damage instructs the coccygeus, piriformis and deep gluteal muscles to contract to protect the nerves with resulting self-perpetuating, deep muscle spasms deep in the ischium or “sitting bones” area of the pelvis. Chronic referred pain or neuralgia may be felt in the genitals, perineum, abdomen and buttocks. Pain is increased by sitting, usually one-sided but often both sides become involved. Symptoms may include pain, burning, numbness and paraesthesia in the pelvis near the sacrum and coccyx, which can radiate throughout the pelvic floor, inner thigh, lower abdomen and groin.
N.B. The first step, in consultation with your GP, is obviously 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 often successfully treated by our unique multi-disciplinary team of manipulation therapists and physiotherapists
"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 chiropractic 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 and Clitoral pain, 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 always 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, internal pelvic muscles or ligaments to 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 chiropractic, 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 neuro-musculoskeletal basis. This means that a large proportion of pelvic pain may be physically resolved and effectively treated."
Michael Durtnall DC MSc (UCL) FRCC (Orth)
Chairman Sayer Clinics: London
Sayer Clinics Summary of Intense Treatment
Depending on severity and length of time of symptoms, intense patient treatment visits may range from daily to 2-3 visits per week and if more local, to weekly, fortnightly or monthly.
Sayer Clinics' intense protocol condenses therapy traditionally spread over the course of months into 1-3 weeks, to keep it practicable for those travelling from very distant locations and reducing the need for subsequent trips. The initial intense treatment protocol may comprise one to two or three weeks 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. This protocol is for those travelling from afar with:
• Spinal and Pelvic Manipulative Therapy 5 days/week, depending on patient response and tolerance.
• Manual Physical Therapy and Pelvic Active Release Techniques 5 days/week, depending on patient response and tolerance.
• Lifestyle Modifications.
• Exercises and Dietary Interventions.
• Education of causes, aggravating factors, strategies for management and prevention.
• Biomechanical Correction of lower limb, spinal and pelvic biomechanical gait anomalies.
Our therapies follow scientific evidence in the treatment of pelvic pain syndromes and are combined in a careful, intensive and focussed way, which we find to be successful in patient pain-scores and improvement of tissue and joint function outcomes. Pelvic pain conditions are often of very long duration and are very complex and closely connected with previous injuries or damage to the pelvis, hips, sacroiliac and coccyx joints, groins and lumbosacral spinal nervous system. Our multidisciplinary team will work in partnership with you to alleviate pain and symptoms for the best possible outcome.
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 needs time to respond to your longterm 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.
News: 09/07/2018 Immediate stop to NHS mesh operations
Pelvic pain explained: What everybody needs to know.
Stephanie Prendergast and Elizabeth H. Rummer 2016
Healing Pelvic Pain. Amy Stein 2009
Book your first appointment at Sayer Clinics’ Pudendal Neuralgia, Coccyx pain and Pelvic Pain Specialist Manual Therapy Clinics.
First book at Sayer Clinic: Kensington W8 to see Michael Durtnall for your initial consultation, if indicated x-rays or diagnostic ultrasound, and to start treatment. Michael combines specific spinal and pelvic joint rehabilitation with our highly skilled specialist pelvic and coccyx pain Physical Therapists Marta Dias de Oliveira, Karolina Krzaczek and Adele Telenta at Sayer Clinics EC2, W1 or W8.
If you suffer coccyx or musculoskeletal pelvic pain or dysfunction Michael and his effective and caring team will do everything to help you. If we consider that we are unable to help you ourselves, we will rapidly refer you to specialists best able to help you.
Book online 24/7 here or email firstname.lastname@example.org or talk to Alexandra or Lucie on +44 (0)207 937 8978.
We are always here to help you