Yoga Therapy and Chronic Pelvic Pain (CPP)

Chronic Pelvic Pain (CPP) is a pain in the area below the belly button and between the hips lasting six months or longer. CPP can be its own condition or symptoms of another disease. Treatment is symptomatic abortive therapy to reduce acute exacerbation. CPP is a problem for health care providers because it is misunderstood and poorly managed. CPP has an unclear etiology, complex natural history and inadequate response to treatment plans of care. There is currently little research on yoga therapy and CPP. CPP has an unclear etiology, complex natural history and poor response to treatment plans of care. Arnold Kegel, in 1950 was the first author to talk about PFM (Pelvic Floor Muscles) and has been recommended for some time. In 1963 Jones suggested that anatomic characteristics could influence the performance of PFM. In 1984 the introduction of biofeedback provided confirmation of the use of Kegel exercise in changing PFM function. In the 1990s randomized control trials began related to PFM training. CPP is a public health problem for women throughout the developed world.

One in seven women suffer from CPP outpatient visits in the United States for CPP is estimated at $881.5 million per year for women between the ages of 18 to 50. Similarly to other chronic pain conditions, CPP may lead to prolonged suffering and a lifetime of therapies while affecting their personal and professional relationships and leading to the loss of employee mental or disability. To optimally manage this condition a variety of healthcare professionals are needed. A CPP patient may see a gynecologist, gastroenterologist, urogynecologist, psychiatrist and physical therapist. It is suggested that the patient and their family be educated on the multifactorial approach to chronic pain. Patients should avoid stressful situations and poor posture. It is recommended that exercise, good sleep hygiene, balanced meals, biofeedback, and relaxation techniques may be beneficial to CPP.

A treatment plan could be tailored to the individual with a goal to reduce symptoms and improve the quality of life. The complexity of the pelvis and the anatomical proximity of pelvic visceral organs means that symptoms frequently overlap traditional medical specialties, leading to diagnostic delay. Inadequate treatment happens to 25% of the women, and often after 3 to 4. years they still do not have a diagnosis. There is no gold standard diagnostic test for CPP; it is a diagnosis of exclusion. Comorbidities for CPP are depression. The association between abuse, psychological morbidity, pathology, and CPP are sufficiently consistent and suggest that they may well be causally related. CPP is challenging treatment strategies most successfully if they are undertaken in a broader scope of an integrated care model. What women want out of a CPP consultation is personal care, to be understood, to be taken seriously, explanation and reassurance. Yoga has been found to be effective in reducing pain intensity and improving function; however, the studies do not mention the sampling methods used.

Having a good working relationship between the clinician and patient is a necessity due to the compounding nature of CPP. A treatment plan should be tailored to the individual with a goal to reduce symptoms and improve the quality of life. While managing the pain using a contemporary approach of both psychological and physical therapy is needed, if a particular cause is found treating this condition as well. The complexity of the pelvis and the anatomical proximity of pelvic visceral means that symptoms frequently overlap traditional medical specialties, leading to diagnostic delay (Vincent, 2008).  Inadequate treatment happens to twenty-five percent of women and often after three to four years they still do not have a diagnosis. During this time these women saw a forty-five percent productivity reduction at work. CPP can present anywhere along a spectrum of organ-specific to regional to systematic pain (Vincent, 2008). 

CPP pain symptoms can range from mild to annoying to severe where the patient is missing work, cannot sleep and cannot exercise. Standing for extended periods of time may intensify symptoms; symptoms may be relieved by lying down. Some symptoms that may accompany CPP are severe and cover a broad range of constant pain, intermittent pain, dull aching pain, sharp pains or cramping, pressure or heaviness deep in the pelvis, pain during intercourse, pain while having a bowel movement or urinating, pain when you sit for extended periods of time.  There is no gold standard diagnostic test for CPP; it is a diagnosis of exclusion (Sherkhane, 2013). Causes for this condition are complex as there may not be one single cause but many amongst a wide range of conditions including reproductive, GI, urologic and neuromuscular disorders. Diagnosis for CPP is usually a process of elimination. A detailed past health history, family history, journal of pain and symptoms, pelvic exam, lab tests (infection, blood count cells and UTI), ultrasound, x-rays, CT scans, musculoskeletal (piriformis syndrome, dysfunction of obturator muscle or fascia, herniated disc, dysfunction of psoas or flexion abduction and external rotation)  and MRI’s (Neis, 2009). What women want out of a CPP consultation is personal care, to be understood, to be taken seriously, explanation and reassurance (Vincent, 2008). 

The pharmacology of CPP generally starts with pain relievers such as aspirin, ibuprofen, and acetaminophen. It is common to prescribe hormone treatment (birth control) and/or antibiotics (tizanidine) and/or antidepressants (doxepin, desipramine, protriptyline, buspirone).  Other therapies prescribed are physical therapy (stretching, massage, relaxation techniques, TENS-transcutaneous electrical nerve stimulation), Neurostimulation (spinal cord stimulation), trigger point injections, psychotherapy (working on root cause cognitive behavioral therapy), biofeedback, acupuncture, meditation, and deep breathing. If surgery is an option the most popular surgeries used are laparoscopy and hysterectomy. Other surgery procedures may be presacral neurectomy (superior hypogastric plexus excision), paracervical denervation (laparoscopic uterine nerve ablation) and uterovaginal ganglion excision (inferior hypogastric plexus excision) (Singh, 2015).  Tizanidine is not a conventional method; the theory is that it may provide improved inhibitory function in the central nervous system. Selective Serotonin Reuptake Inhibitors (SSRIs) such as Prozac, Paxil and Zoloft are commonly prescribed to CPPS patients (Singh, 2015). 

Pelvic floor muscles (PFM) function is a group of muscles and connective tissue that extends as a sling across the base of the pelvis (medical dictionary). It is comprised of two layers, the superficial perineal muscles and the deep pelvic diaphragm providing support for the pelvic organs, the bladder and elements of the spine.  Stiff muscle fibers have a decreased ability to generate power. Overactive pelvic floor muscle (OPFM), experience muscular weakness and early time-to-fatigue. PFM has a higher percentage of slow fibers to maintain its tone and contraction, except during voiding. Alternative methods, such as Pilates and Yoga may be an effective tool to improve the strength of the body’s core musculature (Marques, 2010). 

Leslie Howard and David Wise, Ph.D. And Rodney Anderson, M.D. have done some great work on the Pelvis as well as Eric Franklin. Leslie’s book is super relatable and really helped me write the story of my pelvis through pelvic inquiry allowing me to connect to it an empowering loving way. Eric Franklin with his use of balls, somatic movement, anatomy, and imagery allowed me to build introspection and proprioception with my pelvis. The Wise-Anderson Protocol for healing Pelvic Pain brought it all together for me in a broader perspective and built the bridge for collaborative care. 

Poem by Richard Rosen called “The Pelvis”

It’s something like a bowel but its bottom has a hole and it’s reim’s but halfway round as a bowel it’s quite unsound.

Don’t worry though it’s not made for liquids cold or hot instead it works just fine as a platform for our spine.

From here we’ve all been hatched our legs are here attached when weary on our feet on it we take a seat.

From here we forward bend male privates here suspend and women’s here are too though they’re hidden out of view.

Though pelvis means “a bowl” that’s really not its goal- it's where we store our gut and a place to hang our butt.

All levels of the Kosha model. Anamaya Kosha vigors yoga with lots of sun salutations and lunging is not a good fit for CPP. A treatment plan using gentle yoga, while using the language of letting go, and allowing the nervous system to relax is more efficient. Highlighting characteristics of Chakra 1,2 and 3. Pranamaya Kosha Shallow breath deprives organs and muscles of oxygen and is a common trace in those suffering from chronic pain thus yoga therapy can guide the patient into conscious pranayama. The diaphragm works in coordination with the pelvic floor. Manomaya Kosha Grounding meditation while working on moving beyond survival into thriving, decreasing emotional suppression and feeling thoughts come and go and breaking powerlessness and moving into safety and empowerment. Vijnamaya Kosha Ahimsa does no harm, do not push to discomfort more listening to boundaries of the body. Ishwara Pranichdhana focuses on letting go of control and practicing humility. Swadhyaya focuses on letting go of blame and practicing curiosity through self-study that uncovers strengths. Aparigraha focus on letting of expectations and practicing flowing with whatever comes our way as a way to practice letting go of some of the physical, emotional and mental baggage that we amass during life. When we let go it opens up our energy so that something new can come allowing us to grow. Anadamaya Kosha finding security, self-nourishment, and self-empowerment. Sensations of comfort and bliss can stem from the pelvis while radiance unfolds naturally as inner peace and harmony are obtained.

Quotes:

”Generally change in our society is incremental. Real Change, enduring change happens one step at a time.” - Ruth Bader Ginsburg, Associate Justice, U.S. Supreme Court

”Feminism is the radical notion that women are people.” - Marie Shear

”When I stood before her, this unknown woman in repose, I saw myself, my mother, my grandmother, a woman revealed lovingly by a man’s hand and eye...I wept. I wept at the beauty of naming it so clearly. Origin of the World. We come into this world through women, a woman who is spent, broken open, in awe. No wonder women have been feared and worshipped ever since man first saw the crowning of a human head here, legs spread, a brushstroke of light.” - Terry Tempest Williams “when women were birds: fifty-four variations on voice” 

Resources:

Engeler DS, et al. The 2013 EAU Guidelines on Chronic Pelvic Pain: Is Management of Chronic Pelvic Pain a Habit, a Philosophy, or a Science? 10 Years of Development. Eur Urol (2013), http://dx.doi.org/10.1016/ j.eururo.2013.04.035

Janssen, E. B., Rijkers, A. C., Hoppenbrouwers, K., Meuleman, C., & D'hooghe, T. M. (2013). Prevalence of endometriosis diagnosed by laparoscopy in adolescents with dysmenorrhea or chronic pelvic pain: a systematic review. Human Reproduction Update, 19(5), 570-582. doi:10.1093/humupd/dmt016

Latthe, P. (2006). Factors predisposing women to chronic pelvic pain: a systematic review. Bmj,332(7544), 749-755. doi:10.1136/bmj.38748.697465.55

Marques, A., Stothers, L., & Macnab, A. (2010). The status of pelvic floor muscle training for women. Canadian Urological Association Journal,4(6), 419-424. doi:10.5489/cuaj.963

Mathias SD, Kuppermann M, Liberman RF, et al. Chronic pelvic pain: prevalence, health-related quality of life, and economic correlates. Obstet Gynecol. 1996 Mar. 87(3):3217.[Medline].

Neis KJ, Neis F. Chronic pelvic pain: cause, diagnosis and therapy from a gynaecologist's and an endoscopist's point of view. Gynecol Endocrinol. 2009 Nov. 25(11):75761.

[Medline].

Perineal muscles | definition of perineal muscles by ... (n.d.). Retrieved from http://medical-dictionary.thefreedictionary.com/perineal+muscles

Prosko, S. (n.d.). Optimizing Pelvic Floor Health Through Yoga Therapy. Yoga Therapy Today, Winter(2016), 32-48.

Sherkhane, N. R., & Gupta, S. (2013). Ayurvedic Treatment For chronic prostatitis Chronic Pelvic Pain Syndrome: a Randomized Controlled Study. International Journal of Ayurveda and Allied Science,2(3), 52-57. Retrieved March 1, 2017.

Singh, M. K., MD. (2015, January 13). Chronic Pelvic Pain in Women. Retrieved March 9, 2017, from http://emedicine.medscape.com/article/258334-overview#a6

Sutar, R., Yadav, S., & Desai, G. (2016). Yoga intervention and functional pain syndromes: a selective review. International Review of Psychiatry,28(3), 316-322. doi:10.1080/09540261.2016.1191448

Vincent, K. (2009). Chronic pelvic pain in women. Postgraduate Medical Journal,85, 24-29.   doi:10.1136/pgmj.2008.073494

https://www.amazon.com/Headache-Pelvis-Wise-Anderson-Protocol-Definitive/dp/1524762040

https://www.amazon.com/Pelvic-Liberation-Self-Inquiry-Breath-Awareness/dp/0692944184

WTLG

https://www.amazon.com/Pelvic-Power-Exercises-Strength-Flexibility/dp/0871272598