Medically reviewed by Jenny Blair, MD
A complication of inflammatory bowel disease (IBD) that often goes unaddressed and misdiagnosed is chronic pelvic pain (CPP).
CPP is often defined as pain in the pelvic area that isn’t cyclic and isn’t related to pregnancy and that lasts for three to six months. It may affect from 6% to 25% of reproductive-age women, depending on how it’s defined, as well as men and older women. The condition can arise from a variety of causes.
How I’ve Experienced Pelvic Pain
So how does CPP apply to us as IBD patients? In my case, as someone living with Crohn’s, after many colorectal surgeries and given my perianal disease, I’ve developed CPP that requires constant management.
Several problems are contributing to my pain, which includes rectal, vaginal, perineal, and lower back pain. For instance, I have had peritoneal inclusion cysts, which are a result of fluid build-up in the pelvis due to adhesions. My cysts impinged on my bladder, resulting in urinary urgency and incontinence. More recently, I’ve been facing potential diagnoses of endometriosis and an inguinal hernia.
A Few Ways to Treat Pelvic Pain
Some cases of CPP arise from problems with the muscles that line the floor of the pelvis, a condition called pelvic-floor dysfunction. Pelvic-floor physical therapy and home exercises are sometimes used to treat CPP.
“Pelvic-floor muscles tend to tighten in patients with IBD,” says physical therapist Dr. Kara Mortifoglio of Solstice Physiotherapy in New York City.
By practicing some internal rectal or vaginal manual therapies, a person can increase blood flow to the pelvic floor, thus improving muscle movement and blood supply to nerves, according to Dr. Mortifoglio. This may help with overall movement and pain relief.
It’s important for patients to coordinate with their colorectal surgeon to decide at which point after surgery it may be worth starting pelvic-floor physical therapy, and how quickly to progress with manual therapy and home exercises, says Dr. Mortifoglio.
What should a patient do if physical therapy isn’t delivering the desired results?
If after 4 to 6 pelvic- floor physical therapy visits, a patient doesn’t show significant improvement or hits a plateau in treatment, then it might be time to administer an injection to either block a nerve or to target one set of muscles in the pelvic floor, according to Tayyaba Ahmed, DO, a pelvic pain physiatrist (a doctor of physical medicine and rehabilitation) at Pelvic Rehabilitation Medicine in New York City.
For some people, nerve blocks and trigger-point injections are used as a supplement to physical therapy. They may reduce nerve pain and muscle tension.
Dr. Ahmed also prescribes rectal and vaginal suppositories of diazepam to ease pelvic spasms. If necessary, she uses a variety of oral neuropathic medications instead of opioids to manage CPP.
Along with traditional medicine, Dr. Ahmed says it may be helpful to also use holistic therapies to ease symptoms, like:
- Gentle yoga exercises
Dr. Ahmed says these modalities help to focus the mind on relaxation and work to retrain the brain.
How I Manage My CPP
In addition to regular physical therapy visits and following my home exercise program, I try to alternate between sitting, standing, and walking as much as possible. For me, sitting for long periods of time, especially in cars and planes, results in significant pelvic pain.
I also find that sitting on a cushion prevents intense pain or spasms and at other times, use a TENS, or transcutaneous electrical nerve stimulation, unit machine calms the nerves.
More recently, I’ve started suppositories and oral medications alongside weekly nerve blocks and trigger-point injections, which have significantly reduced the pain and soreness at the pelvic floor site. After 4 to 6 weeks of weekly nerve blocks, Dr. Ahmed encourages patients to follow up with her quarterly to decide whether maintenance injections are needed to prevent CPP flare-ups.
Expert Tips to Help Pelvic Floor Muscles
Kegel exercises, in which women tighten and relax the pelvic-floor muscles, may be better avoided, according to Dr. Mortifoglio.
“Contrary to popular belief, Kegels are not a panacea for patients facing CPP, especially not for IBD patients. If one’s muscles are already tight, Kegels could make the pain worse,” explains Dr. Mortifoglio. Instead, she recommends a comprehensive evaluation by a pelvic-floor physical therapist to determine which exercises may be beneficial for each individual.
Here are a few general tips to prevent aggravation of pelvic floor muscles, according to Dr. Mortifoglio:
- Always sit and urinate on the toilet. Don’t hover over it, as that can strain the pelvic floor muscles. Lean forward to empty the bladder fully.
- For bowel movements, sit upright on the toilet and keep the knees higher than the hips in order to evacuate properly. (Some people use bricks or a footstool to achieve this position.)
- Practice diaphragmatic breathing and gentle yoga as prescribed by one’s physical therapist.
Strengthening the pelvic floor muscles can certainly ease CPP, but it can also ease constipation in addition to decreasing both rectal and bladder incontinence in patients over time, according to Dr. Mortifoglio. This is why it may be important for IBD patients and their physicians to familiarize themselves with CPP and its treatment options to decide whether the above options can help patients in the long-term to manage both the pain and symptoms.
Learn More About This Complex Condition
If you’re interested in reading more about CPP, you can find additional information on the International Pelvic Pain Society site at https://www.pelvicpain.org/. You might also want to check out The Women’s Pelvic Health Podcast by Hannah Matluck. My pelvic pain story appears on episode #14.
Jenny Blair is a writer and journalist covering science, medicine, and the humanities. She earned her MD at Yale University, then completed a residency in emergency medicine at the University of Chicago. After several years in practice, she transitioned to working with words and ideas full-time. Jenny has contributed to Discover, New Scientist, Washington Spectator, and Medtech Insight, among other publications. She lives in New York City.
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