Chronic pelvic pain (CPP) is a common clinical manifestation of endometriosis¹ and the most common reason for referral to women’s health services.² Unfortunately, many women continue to experience pain, bladder, bowel and sexual dysfunction despite optimal gynaecological treatment. Pelvic health physiotherapy often has a part to play in a collaborative approach to treatment.

Comorbid symptoms are common and associated with dysmenorrhoea (and its severity) regardless of endometriosis presence.³ Most people with CPP or endometriosis have negative sexual effects⁴ including severe deep dyspareunia, which is associated with bladder/pelvic floor muscle (PFM) myalgia regardless of stage/location of endometriosis.⁵ Poor localisation of tactile input may suggest a degree of neglect or poor motor sensory awareness.⁶

Women with endometriosis have increased prevalence of PFM and obturator internus spasm⁷ and hypertonicity (non-neurogenic). Reduced flexibility, dyssynergia, altered motor control with a habitual holding pattern and reduced capacity to relax their PFM may also be present both in voluntary and functional scenarios.^{8 9 10}

Musculoskeletal symptoms also include extrapelvic and abdominal musculature.¹¹ Apical breathing with a braced abdominal wall is common.¹² CPP severity is associated with abdominal wall and PFM myalgia¹³ and observed in women with endometriosis.¹⁴ Positive Carnett’s sign may suggest abdominal wall or nerve irritation components to pelvic pain.¹⁵ Much of the literature refers to myofascial trigger points, the existence of which are currently debated.¹⁶ PFMs may contract involuntarily in response to threat¹⁷ and occur without conscious awareness.

Trauma-informed care, mindful of possible trauma history, is important. A history of distressing sexual events is associated with an increasing number of pain symptoms in women with dysmenorrhoea.¹⁸

Many women experience pain, fear and anxiety related to pelvic examinations.¹⁹ Pelvic health physios do not perform intravaginal examinations to assess sinister pathology. Management can, therefore, involve a staged and graduated approach not only to therapy but also assessment itself. Subsequent assessments by medical colleagues may then be more comfortable.

There is a growing appreciation that CPP in women with endometriosis may be a manifestation of central sensitisation, regardless of endometriosis-specific factors.^{20 21 22} Amplification, viscerovisceral and viscerosomatic convergence, peripherally or at the spinal cord, explain the link between gynaecological pain and other visceral (such as bladder) or somatic (such as PFM) structures. One may initiate or exacerbate another.^{23 24 25 26 27}

Endometriosis may be considered an initiating event that continues to trigger CPP.²⁸ Thoughts alone may provoke inflammatory responses.²⁹ For example, women often reveal that merely contemplating physical intimacy triggers their pain. Nervous system and myofascial contributions to deep dyspareunia show interindividual variation and may guide treatment, including in women requiring surgery for endometriosis.³⁰

PFM myalgia,³¹ hypertonicity and bladder and bowel dysfunction help identify women who may benefit from referral to pelvic health physio. Physiotherapy management is individualised and widely advocated. Addressing the complexity of pain experiences physiotherapeutically means assessing and managing local tissue issues within a broader context of sensitised protective mechanisms resulting from central nervous system (CNS) sensitivity.^{32 33} This takes time. Allowing a woman to tell her story may be therapeutic in itself, permitting development of woman-centred management plans.^{34 35} Fortunately, pelvic health physio appointments often provide additional time for women with complex pain presentations. Treatment seeks to build self-efficacy and reduce catastrophising, which has been associated with pelvic pain severity.^{36 37 38} A focus on self-management and home-based components of management are essential.

Physiotherapy modalities may include education, PFM relaxation, manual therapy and stretches (within and around the pelvis), graded imagery and motor activity, neural dynamics, optimising bladder and bowel health, breathing and body scanning techniques, exercise, pacing and goal setting. This approach sits nicely within our current understanding of the neuroscience of pain.^{39 40 41} Somatocognitive therapy of CPP, in addition to standardised gynaecological treatment, improves pain, function and psychological distress, which continue to improve beyond the completion of treatment.⁴² This therapy overtly recognises the mind/body relationship and the importance of a positive working alliance,⁴³ shown to predict behavioural change and outcomes.⁴⁴

Education may form the mainstay of treatment. Neuroscience-based pain education is an effective treatment in itself^{45 46} and can be readily understood by patients.⁴⁷ Education and reassurance around normal laparoscopy findings can be important regarding the resolution of pain.⁴⁸ Many women have never seen images of genitalia or looked at their own vulva. Demystifying a woman’s genitalia is powerful and potentially achieved via education about anatomy, function and vulval care. We need to normalise varied presentations as media images are very homogenised. Mirrors, images and visualisation may be helpful for some.⁴⁹

Advice and education around sexual activity and the female sexual response cycle⁵⁰ with a focus on intimacy and pleasure-based, rather than fear-avoidant, activity can be helpful for women who experience dyspareunia. Fear and anticipation of pain negatively impact on the sexual response cycle.^{51 52} We can explain a cycle of pain and protective muscle guarding in response to perceived or real threat.

Physiotherapy aims to rehabilitate and retrain the full range of functional capacity of PFMs, including contraction, holding, relaxing and stretching. Historically, much attention has been placed on PFM contractile activity. The ability of muscles to relax and stretch is also essential for normal function.

Ultimately, women can be assisted to identify and change habitual holding patterns, voluntarily relax PFMs and integrate this into functional activities (bladder and bowel evacuation, tampons, pelvic examinations, penetrative sexual activity). Intrapelvic manual therapy is useful for some.

Manual therapy has the potential to reduce medication requirements in women with CPP;⁵³ however, it may need delaying until some downregulation of a sensitised CNS has occurred.⁵⁴ There is much we still don’t know about the efficacy of specific techniques and monitoring individual responses allows treatments to be individualised.

Commonly, pelvic health physios utilise digital techniques, with or without biofeedback and intravaginal devices, to improve awareness of contraction/relaxation, proprioception, confidence, knowledge and self-awareness of the vagina and PFMs, reduce hypersensitivity and stretch soft tissues. Positive physical experiences can start to modify fear-based reactions.

Adverse neural tension in pudendal, ilioinguinal, iliohypogastric, femoral or obturator nerves may contribute to pelvic pain and gentle neural mobilisation techniques can be helpful.⁵⁵ Posture and movement should be dynamic and varied, rather than static and bracing. Exercise has benefits beyond physical fitness, including regulating sleep, improving energy, mood and inflammation.

Kinesiophobia is frequently observed and fear of a pain flare may lead to reduced activity. Mechanisms by which physical activity may be protective for women with endometriosis include decreasing bioavailable oestrogens and insulin resistance, while increasing anti-inflammatory mediators.⁵⁶ Activity pacing is crucial to achieve patient-centred goals.

Many women with pelvic pain describe their experience not only in terms of physical pain but also detail the profound impact it has on their perception of being able to live a meaningful life. They talk of distress, reduced desire and arousal, avoidance of intimacy, social withdrawal, loneliness, limited employment opportunities, inability to care for those who rely on them, and intimate relationships, both with others and themselves, as crumbling. They often describe intense frustration with multiple visits to consecutive health professionals. They struggle to understand why they continue to attend countless appointments at immense personal and financial cost without any improvement, a meaningful explanation or cohesive management plan.

An interdisciplinary approach is widely recommended in the literature and international guidelines and requires all components of the program.^{57 58 59} Unfortunately, interdisciplinary care remains very difficult for many women to access. We need to examine barriers both within ourselves and our health systems to providing this care. For those who have endometriosis, an interprofessional setting improves pelvic pain severity, quality of life and healthcare utilisation.⁶⁰ Paying equal attention to multifactorial contributors initially and concurrently with an interprofessional approach (rather than only after exclusion of organic pathology) may be more likely to achieve positive results.^{61 62 63}

Pain is complex and working with this population presents many challenges and joys for clinicians. A team can support and inspire each other, provide women with consistent messages, multifactorial evidence-based explanations and management plans that help ensure comorbidities are managed optimally in a timely fashion.

Providing women with the highest possible standard of care is, of course, at the forefront of our minds. Equally, we need to value working with one another in a supportive manner in order that we may therefore continue to serve the women we hope to help. We should therefore seek to develop meaningful interprofessional communication that engenders open, respectful, curious relationships with one another and our patients.

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