Common Causes of Pelvic Pain in Women: When Physiotherapy Helps

Pelvic pain affects many women in Burlington and beyond, often persisting for months or years despite multiple medical appointments. At Burlington Pelvic Physiotherapy, we frequently see women who've been told their test results are "normal" despite experiencing daily discomfort that significantly impacts their quality of life. Understanding the various causes of chronic pelvic pain is the first step toward finding effective treatment.

Chronic pelvic pain is defined as pain in the pelvic region lasting six months or longer. Rather than having a single cause, this condition typically involves multiple contributing factors—including physical, neurological, and psychosocial components—that interact in complex ways. According to clinical practice guidelines from the American College of Obstetricians and Gynecologists (ACOG) and the Society of Obstetricians and Gynaecologists of Canada (SOGC), effective management requires addressing all these factors through a comprehensive, multidisciplinary approach.

The Most Common Causes of Chronic Pelvic Pain

Pelvic Floor Muscle Tension and Myofascial Pain

One of the most overlooked causes of chronic pelvic pain is tension in the pelvic floor muscles themselves. These muscles can develop areas of tightness, tenderness, and dysfunction—known as myofascial trigger points—that create both local pain and referred pain to other areas of the pelvis, abdomen, and lower back.

This condition, sometimes called pelvic floor tension myalgia or levator ani syndrome, occurs when the pelvic floor muscles go into protective spasm. Research shows that pelvic floor muscle tenderness is present in a significant percentage of women with chronic pelvic pain. One study found that simple palpation tests identifying pelvic floor muscle tenderness correctly identified 85% of patients with chronic neuromuscular pelvic pain.

The pelvic floor muscles—particularly the levator ani and obturator internus—may become hypertonic (excessively tight) due to various factors:

• Injury or trauma to the pelvic area
• Chronic protective guarding around areas of pain
• Poor posture and movement patterns
• Prolonged sitting or repetitive strain
• Stress and anxiety that manifests as muscle tension

Research has demonstrated a correlation between the severity of pelvic floor myofascial pain and the degree of symptom bother reported by patients. Many women describe a constant ache, pressure, or burning sensation that worsens with sitting, standing for long periods, or during intimate activities.

Endometriosis

Endometriosis affects an estimated 60-70% of patients with chronic pelvic pain. This condition occurs when tissue similar to the endometrium (the uterine lining) grows outside the uterus—on the ovaries, fallopian tubes, bowel, bladder, or other pelvic structures.

These endometrial implants respond to hormonal changes during the menstrual cycle, triggering an inflammatory response in the pelvis. The classic presentation includes extremely painful periods, but many women also experience:

• Pain during or after intercourse
• Painful bowel movements or urination during menstruation
• Chronic pelvic discomfort between periods
• Lower back and abdominal pain

An important connection exists between endometriosis and pelvic floor dysfunction. When uterine pain or pain from endometriosis adhesions and lesions persists, surrounding muscles may protectively contract to guard the area. Over time, this protective response creates additional areas of muscle tightness and pain throughout the pelvis, abdomen, and back—sometimes causing referred pain in areas where there is no endometrial tissue.

Evidence suggests that patients with endometriosis experience improved pain relief when treated with pelvic floor physiotherapy after surgery. A recent systematic review found that physiotherapy techniques were effective in reducing pain compared to non-physiotherapy treatments, especially when applied locally.

Pudendal Neuralgia and Nerve-Related Pain

Chronic pelvic pain can also result from irritation or damage to the pudendal nerve, which runs from the back of the pelvis to all muscles and skin in the genital area, including the anus, vagina, and external genitalia. This condition is known as pudendal neuralgia.

The classic symptom of pudendal nerve entrapment is perineal pain that is exacerbated by sitting and relieved by standing or sitting on a toilet seat. This distinctive pattern is reported in over 50% of cases and can be a key diagnostic clue.

Pudendal neuralgia can occur when the pudendal nerve is damaged or compressed by surrounding tissues or muscles. Common causes include:

• Activities that place constant strain on the pelvic area (cycling, squatting exercises, horseback riding)
• Chronic constipation and straining
• Tension on the nerve from surrounding muscles and ligaments
• Complications from pelvic surgeries
• Trauma during childbirth

For women dealing with sitting discomfort and nerve pain, understanding the role of the pudendal nerve can be transformative in finding effective treatment approaches.

Post-Surgical Complications

Injury to the pelvic floor from surgery or trauma can result in painful, hypertonic muscles. Pelvic surgical procedures—including mesh placement, permanent sutures in the muscles, hysterectomy, and procedures for pelvic organ prolapse—have been reported to result in muscular pain and hypertonicity of the pelvic floor.

Post-surgical rehabilitation is crucial for individuals recovering from pelvic surgeries, aiding in pain management, scar tissue mobilization, and restoring normal function. C-section recovery, in particular, may benefit from specialized scar tissue work and pelvic floor assessment, as caesarean delivery involves cutting through multiple layers of tissue that can develop adhesions and restrictions.

Research demonstrates that postoperative physiotherapy helps women undergoing pelvic floor reconstructive surgery by addressing pain, improving mobility, and preventing long-term complications.

Other Associated Conditions

Chronic pelvic pain frequently coexists with other conditions that may contribute to or be affected by the pain experience:

• Bladder pain syndrome/interstitial cystitis: At least one in five women with chronic pelvic pain experiences bladder-related symptoms, including frequency, urgency, and pain with bladder filling
• Irritable bowel syndrome: Gastrointestinal symptoms are common, with altered bowel patterns and abdominal discomfort contributing to the overall pain experience
• Chronic constipation: Straining and incomplete emptying can worsen pelvic floor muscle tension

Healthcare providers following ACOG and SOGC guidelines are encouraged to have a systematic approach to identify and address possible factors initiating and perpetuating pain, including gynecologic, urologic, gastrointestinal, myofascial/musculoskeletal, and psychosocial contributors.

When Pelvic Physiotherapy Can Help

At Burlington Pelvic Physiotherapy, our team specializes in assessing and treating the neuromuscular and biomechanical factors that contribute to chronic pelvic pain. Evidence shows that physical therapy helps approximately 60% of women with chronic pelvic pain and levator ani syndrome by:

• Aligning bone or muscular imbalances
• Decreasing abnormal muscle tension and soft tissue restrictions
• Strengthening core muscles to prevent further injury
• Identifying other contributing factors such as poor posture, positioning, and habits

Our treatment approach may include:

Internal and External Manual Therapy: Gentle techniques to release trigger points, reduce muscle tension, and improve tissue mobility throughout the pelvis, abdomen, and lower back.

Pain Neuroscience Education: Understanding how chronic pain works in the nervous system can significantly reduce pain-related fear and help patients regain confidence in movement. Research supports pain neuroscience education as a moderate to strong evidence-based intervention for chronic pelvic pain.

Therapeutic Exercise: Customized programs to address muscle imbalances, improve coordination, and gradually restore normal function—while avoiding the "just do Kegels" approach that often oversimplifies pelvic floor rehabilitation.

Postural and Movement Retraining: Addressing habits and movement patterns that may perpetuate pain or place excessive strain on the pelvic floor.

Modalities for Pain Relief: Evidence suggests that physiotherapy modalities—including electrotherapy devices like TENS (transcutaneous electrical nerve stimulation) units and therapeutic laser—can provide significant pain reduction when used appropriately.

Physical therapists are trained in functional restoration of the whole body and uniquely positioned to assess and treat chronic pelvic pain with the goal of restoring transitional movement ease, improving tolerance for daily activities, and promoting overall wellness.

The Importance of Multidisciplinary Care

Multidisciplinary care is essential for chronic pelvic pain because central nervous system sensitization of the chronic pain process makes it unlikely that pain will resolve through a single intervention. According to updated ACOG guidelines, treatment should include pelvic floor physical therapy, behavioral health support, and medical pain management, alone or in combination.

Interdisciplinary management that includes psychological support, physiotherapy, and medical treatment based on a biopsychosocial model offers more comprehensive and effective care than any single approach alone. This is particularly important because chronic pain often coexists with depression and anxiety—conditions affecting at least one in five patients with chronic pelvic pain.

At Burlington Pelvic Physiotherapy, we work collaboratively with your healthcare team, including gynecologists, pain specialists, mental health professionals, and other providers, to ensure you receive comprehensive, coordinated care.

Next Steps: Getting an Assessment

If you're experiencing chronic pelvic pain, know that you're not alone and that effective treatment options are available. Many women find that addressing the neuromuscular components of their pain—even when other conditions like endometriosis are also present—significantly improves their quality of life.

A comprehensive pelvic physiotherapy assessment can help identify:

• Areas of muscle tension, tenderness, or weakness
• Movement patterns that may contribute to pain
• Postural habits that place strain on the pelvic floor
• Connections between your pelvic symptoms and other areas of your body, such as chronic back pain or hip and groin discomfort

Whether you're dealing with pain after surgery, living with endometriosis, experiencing nerve-related symptoms, or simply haven't found answers despite multiple medical tests, pelvic physiotherapy may offer valuable support on your healing journey.

This content is for educational purposes and does not replace professional medical advice. Chronic pelvic pain should always be evaluated by qualified healthcare providers to rule out serious conditions and develop an appropriate treatment plan.

Ready to start your journey toward relief? Our team at Burlington Pelvic Physiotherapy is here to support you with evidence-based, compassionate care tailored to your unique needs. Book an appointment today at our Burlington location at 960 Cumberland Ave, or call 905-635-5711 to learn more about how we can help.

Reviewed by: Juhi Israni, Pelvic Health Physiotherapist