Chronic Pelvic Pain Syndrome (CPPS) is pain in the area below the belly button and between the hips lasting six months or longer. Chronic Pelvic Pain Syndrome can be its own condition or symptom of another disease. CPPS is a complicated situation requiring a combination approach to healing. Treatment is symptomatic abortive therapy to reduce acute exacerbations. There is currently little research on yoga therapy and chronic pelvic pain syndrome. Overall research on chronic pelvic pain syndrome appears to be lacking rigger. Chronic pelvic pain syndrome is a problem for health care providers because it is misunderstood and poorly managed. CPPS 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 have 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 1990’s randomized control trials began related to PFM training. CPPS is a public health problem for women throughout the developed world.
One in seven women suffer from CPPS outpatient visits in the United States for Chronic Pelvic Pain Syndrome (CPPS) is estimated at $881.5 million per year for women between the ages of eighteen to fifty (Mathias, 1996). Similar to other chronic pain conditions CPPS may lead to prolonged suffering and a lifetime of therapies while affecting their personal and professional relationships and leading to loss of employment or disability. To optimally manage this condition a variety of health care professionals are needed. A CPPS patient may see a gynecologist, gastroenterologist, urogynecologist, physiatrist, and a 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 suggested that exercise, good sleep hygiene, balanced meals, biofeedback and relaxation techniques may be beneficial to CPPS (Singh, 2015).
The Literature Review
Having a good working relationship between the clinician and patient is a necessity due to the compounding nature of CPPS. 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. CPPS can present anywhere along a spectrum of organ-specific to regional to systematic pain (Vincent, 2008).
CPPS 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 CPPS 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 CPPS; 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 CPPS 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 fascial, herniated disc, dysfunction of psoas or flexion abduction and external rotation) and MRI’s (Neis, 2009). What women want out of a CPPS consultation is personal care, to be understood, to be taken seriously, explanation and reassurance (Vincent, 2008).
The pharmacology of CPPS 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 (SSRI’s) such as Prozac, Paxil and Zoloft are commonly prescribed to CPPS patients (Singh, 2015).
Pelvic floor muscle (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 have 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 core musculature (Marques, 2010).
Comorbidities for CPPS are depression. The association between abuse, psychological morbidity, pathology, and CPPS are sufficiently consistent and suggest that they may well be causally related (Latthe, 2006). CPPS is challenging treatment strategies most successfully if they are undertaken in a broader scope of an integrated care model (Engeler, 2013).
Yoga therapy can be used as a self-treatment tool for CPPS. Three part breath and letting go breath, works well with this condition. Shallow breathing deprives organs, and muscles of oxygen and is a common trait in those suffering from chronic pain thus the yoga therapist can guide the patient into conscious pranayama. Muscle guarding is a sign of a tight pelvic floor and is a self-protection maladaptive process that leads to injury and increased pain. Nerve pain leads to muscle atrophy causes less blood flow. The diaphragm works in coordination with the pelvic floor. Think of the autonomic nervous system as yin and yang. The sympathetic nervous system is our flight, fight, and freeze pain is overactive here as our run from the bear chemicals are in overdrive. The parasympathetic nervous system is our rest, and digest and our chill out chemicals are working.
Vigorous yoga with lots of sun salutations and lunging is not a good fit for CPPS. A treatment plan using gentle and restorative yoga, using language on letting go, relaxing and allowing the nervous system to relax is more efficient. There is a decrease in Apana vayu energy along with chakras one, two and three. Focusing on expelling exhalation and what is not needed, grounding and cleansing to support the need for becoming calm and rooted. Discussing ahimsa “do no harm” teaching the patient to not push to discomfort because they will gain more by listening to the boundaries their body is tell them. Poses such as knees to chest, twists, pigeon, child’s, supine butterfly, happy baby, third world squat are a few asana to start with. A yoga therapist can help by addressing a four process treatment plan creating awareness, releasing and relaxing the PFM, engaging PFM, and using the chakras and koshas (Prosko, 2016). Yoga has been found to be effective in reducing pain intensity and improving function; however, studies do not mention the sampling methods used (Sutar, 2016).
Even though research is scarce for CPPS it is important that every female who presents to a health professional with pain at whatever age be taken seriously. Validating the experience, managing chronic pain, managing musculoskeletal and psychological secondary consequences must be maintained and is best done within a multidisciplinary setting, will reduce the burden of chronic pelvic pain in women. Chronic pelvic pain is a common disabling condition that has been poorly studied. There is uncertainty about the causes and best treatment (Latthe, 2006). Studies designed with long-term follow-up would be useful in establishing yoga-based intervention as a treatment modality for functional pain disorders.
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: 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, healthrelatedquality 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