Pelvic Pain: Why Does My Pelvis Hurt? It’s Not Always Your Pelvic Floor

If you're dealing with pelvic pain, you may have already done what so many people do: you started Googling.

Maybe you've seen your doctor. Maybe you've seen more than one. You've had tests that came back normal, or you've been told that nothing concerning showed up. Maybe you've been given a diagnosis and are being treated for it, but you're still in pain and aren't sure what else can be done. Maybe you've been told your pain is something you'll just have to live with.

And yet, you're still hurting.

So you start looking for answers yourself. You read about pelvic floor physical therapy and begin wondering, “Could my pelvic floor be tight?”

It could be. Pelvic floor muscle tension is one potential contributor to pelvic pain—but it isn't the only one, and it isn't always the starting point.

Pelvic pain can have many different contributors. Endometriosis, pelvic venous disease, bladder or bowel conditions, nerve irritation, hip or low-back problems, previous abdominal or pelvic surgery, pregnancy and birth, and problems involving the neuromusculoskeletal system can all play a role. And sometimes, there's more than one piece to the puzzle.

This is why I don't approach pelvic pain by assuming that the painful area tells me exactly what is wrong.

Your pain is real. The question is not simply, “What hurts?” but “What is contributing to why it hurts?”

Could It Be Your Pelvic Floor?

If you've been searching for answers about pelvic pain, you've probably come across the pelvic floor.

And for good reason. These muscles do much more than help with bladder and bowel control. They support the pelvic organs, contribute to sexual function, work with your abdominal and back muscles during movement, and respond to changes in pressure throughout the body.

When these muscles are holding too much tension, they can absolutely contribute to pain.

But here's where things can get confusing:

A painful pelvis does not automatically mean you have a tight pelvic floor.

Your pelvic floor may be part of the problem. It may also be responding to something else going on in your body.

For example:

• With endometriosis, ongoing pain can lead to muscle guarding and tension.

• After abdominal, pelvic, or hip surgery, scar tissue and changes in how your tissues move can contribute to ongoing symptoms. Surgery can also change how you move or use your muscles, creating new patterns of tension or compensation.

• If your hip, low back, or SI joint isn't moving well, the muscles around your pelvis may compensate.

• If you've experienced pain with intercourse, your pelvic floor may tighten as part of a protective response.

In these situations, the muscle tension is real. But simply telling the muscles to relax doesn't necessarily address why they became tense in the first place.

This is one reason I don't approach pelvic pain with a one-size-fits-all treatment plan.

I want to understand what your body has been dealing with, what makes your pain better or worse, how you move, how you breathe, how your muscles are functioning, and what else may be contributing to your symptoms.

Because sometimes the most helpful question isn't “How do we relax your pelvic floor?”

It's “Why is your pelvic floor working so hard in the first place?”

Pelvic Pain Is Bigger Than the Pelvic Floor

The pelvic floor is only one part of the picture. Pelvic pain can come from—or be influenced by—many different systems and structures, and sometimes there is more than one contributor.

Gynecologic conditions

Endometriosis is one example. So are adenomyosis, fibroids, ovarian cysts, pelvic inflammatory disease, and pain associated with your menstrual cycle.

These conditions require appropriate medical evaluation and management, but pelvic physical therapy can still have an important role in addressing the neuromusculoskeletal pieces that contribute to your pain.

Pelvic venous disease

Changes in the veins around the pelvis can contribute to pelvic pain and pressure. Pelvic PT doesn't treat the underlying vascular condition, but it can help address the neuromusculoskeletal and functional contributors that may be adding to your symptoms.

Think of it as turning down the pain dial while the underlying condition is also being addressed.

Bladder and bowel

Your bladder and bowel can also be part of the picture.

Bladder pain syndrome, constipation, and pain with bowel movements can all occur alongside pelvic pain. But sometimes the bladder or bowel symptom is actually related to how the pelvic floor is functioning.

Dyssynergic defecation, for example, occurs when the pelvic floor muscles don't coordinate properly during a bowel movement, making it difficult to empty the rectum.

Urinary and bowel symptoms can have multiple causes, which is why understanding how the pelvic floor is functioning can be an important part of the evaluation.

The neuromusculoskeletal system

The neuromusculoskeletal system—including your muscles, joints, nerves, and the way they work together—can also contribute to pelvic pain.

Your hips, low back, SI joints, pelvic girdle, abdominal muscles, and tailbone can all contribute to pain that you experience as pelvic pain. Nerve irritation, including irritation of the pudendal nerve or contributions from the lumbar spine or sciatic nerve, can also create symptoms that are felt in the pelvic region.

This is one reason I don't want you to assume that because you feel pain in your pelvis, the source must be inside your pelvis.

Your history matters, too

Pregnancy, childbirth, abdominal or pelvic surgery, hip surgery, an injury, or years of dealing with pain can all change how your body moves and how your muscles respond.

Sometimes, there is more than one contributor, and figuring that out is an important part of the evaluation.

What About Pain With Sex?

Pain with sex is another place where the pelvic floor can be involved—but again, it isn't always the whole story.

If penetration is painful, your pelvic floor muscles may be tense or guarding. This can happen with vaginismus, after childbirth or injury, following surgery, or when you've been experiencing pain in the pelvis for another reason. Scar tissue can also affect how tissues move and how comfortable certain positions or types of touch feel.

But pain with sex can also be associated with conditions such as endometriosis or other gynecologic conditions, as well as hormonal changes that affect the tissues and their elasticity. Changes in estrogen, for example, can affect the vaginal and vulvar tissues and contribute to dryness, irritation, and pain with penetration.

The goal isn't to assume that your pelvic floor is the problem. The goal is to understand why sex is painful for you and what factors are contributing.

Pain with sex can feel uncomfortable or embarrassing to talk about. But it is an important part of your story, and it deserves a place in your evaluation.

When Pain Has Been Going On for a While

When pain persists, the brain and nervous system can develop protective responses that change how you move, breathe, and use your muscles—even when you're not consciously trying to protect the painful area.

You may notice that you hold your breath, brace your abdomen, tense your pelvic floor, move differently, or avoid activities that used to feel normal.

This doesn't mean your pain is “all in your head.” Pain is a real experience produced by the nervous system, and the nervous system is constantly taking in information from the body and its surroundings.

This is one reason chronic pelvic pain can become complicated. There may be an original source of pain—endometriosis, surgery, an injury, a gynecologic condition, or something else—and additional neuromusculoskeletal factors can develop around it.

When we can address some of the things turning the pain dial up, we can work toward turning it back down.

Looking at the Whole Picture

If you've been dealing with pelvic pain, you may be wondering what a pelvic PT would actually do.

First, we talk. A lot of information comes from your history:

• When did the pain start?

• Where do you feel it?

• What makes it better or worse?

• Does it change with your menstrual cycle, bowel movements, urination, movement, exercise, or sex?

• Have you had children, surgery, an injury, or another medical condition that may be relevant?

Then we look at the bigger picture.

I may assess your breathing, posture, movement, hips, low back, abdomen, pelvic region, and the way different parts of your body are working together. Depending on your symptoms and your comfort level, an internal pelvic floor assessment may be appropriate—but it is not automatically the first thing we do, and you don't have to have one simply because you're coming to pelvic PT.

I'm looking at how all of these pieces fit together.

Where are you moving well? Where are you compensating? What is contributing to your symptoms, and what can we actually change?

Sometimes the pelvic floor is one contributor among several. Sometimes another part of the neuromusculoskeletal system is playing a bigger role. And sometimes your symptoms point toward something that needs medical evaluation or care beyond physical therapy.

Pelvic physical therapy doesn't replace treatment for conditions such as endometriosis or pelvic venous disease. It fits alongside that care, addressing the neuromusculoskeletal and functional contributors that are within our scope to treat.

You don't need to come to your evaluation knowing what's wrong or whether your pelvic floor is tight.

You just need to come with your story.

We'll start there. Schedule an Evaluation.