Archive for November, 2016

When Stress Causes A “Headache” In The Pelvis

November 26, 2016

Andrew Siegel MD 11/26/2016


Image above attributed to Dr. David Potter, licensed under the Creative Commons Attribution-Share Alike 4.0 International license.

It is virtually impossible to avoid stress in our lives. A small and manageable amount of stress—“eustress”—triggers adrenaline release, which increases pulse, respiratory rate and blood pressure, dilates the pupils and makes one hyper-alert, focused and motivated. All things considered, this can improve performance—think “caffeine on steroids.” However, excessive stress—”distress”—is clearly a bad situation, causing anxiety that can decrease performance, un-motivate and make life rather unpleasant.

The immediate manifestations of stress-mediated adrenaline release are due to the primitive “flight-or-fight” response that causes us to brace, tighten, clench and compress our bodies. Stress triggers rapid, shallow and less efficient chest breathing as opposed to proper breathing from the diaphragm, which is slow, steady deep and efficient. Slouching and poor posture from clenching and muscle tensioning further exacerbates the breathing issues.

Chronic stress—internalized—can have many physical manifestations, often tension headaches involving taut muscles in the head, neck and back. Other signs of stress-turned inwards are insomnia, fatigue, altered immune system function, depression and loss of sex drive. It can also be responsible for high blood pressure, angina, heart attacks and strokes as well as give rise to gastritis, peptic ulcer disease and irritable bowel syndrome. Urinary frequency is a not uncommon urological manifestation of chronic stress.

When stress is internalized within the pelvic floor muscles it can cause pelvic floor tension myalgia, which causes pelvic pain often accompanied by sexual, urinary and bowel symptoms. It can cause knots within the pelvic muscles—discrete sights of hyper-tensioned muscle. This tension myalgia is a very difficult and frustrating situation that often requires a number of different treatment approaches.

Because the pelvis is the site of important functions– urinary, sexual and bowel–it is a particularly bad location for holding tension. Pelvic “hypertension” can cause urinary, genital and rectal pain as well as adversely affect the proper performance of these systems. It can cause difficulty starting one’s urinary stream, a weak stream, incomplete emptying of the bladder and symptoms of overactive bladder (urgency, frequency, etc.). It can be responsible for pain with sexual stimulation and intercourse, sometimes to the extent that sexual intercourse is not possible. It can also cause constipation, hemorrhoids, fissures and other bowel symptoms.

When anxiety expresses itself through tension in the pelvic floor muscles, the physical tension and pain further contribute to emotional anxiety and stress reaction, which creates a vicious cycle. Poor posture, muscle overuse and abnormalities with the nerve pathway that regulates muscle tone are other factors that contribute to the pelvic tension.

Characteristically, the pain waxes and wanes in intensity, may “wander” to different locations and can be perceived to be superficial, intermediate or deep in the pelvic tissues. It can involve the lower abdomen, groin, pubic area, genitals, perineum, anus, rectum, hips and lower back. The pain is often described as “stabbing,” although it can be cramping, burning or itching in quality. Urination, bowel movements and sexual activity can aggravate the pain.

Because the symptoms of pelvic floor tension myalgia can be vague and variable, those afflicted often have difficulty precisely expressing their symptoms, although they usually have many complaints and have typically seen numerous physicians and have had multiple prior interventions. Many patients thought to have interstitial cystitis/chronic pelvic pain syndrome, irritable bowel syndrome, chronic prostatitis, vulvodynia and fibromyalgia in actuality have pelvic tension myalgia. In fact, this pelvic floor issue is probably one of the most common problems that urologists and gynecologists see and is likely one of the most misunderstood, misdiagnosed and mistreated conditions. Many suffering with it are miserable and deeply frustrated after having endured years of episodic agony without relief.

How Is Pelvic Floor Tension Myalgia Diagnosed?

Most important are a rectal exam in men and a pelvic exam in women to evaluate the pelvic floor muscles. Typical findings are tight, tender and weak pelvic muscles, spasticity, and difficulty in relaxing the muscles following contraction. Localized, knot-like bands can often be felt, similar to tension knots that can develop in back muscles. The pain can often be localized by a vaginal or rectal exam that identifies these trigger points, the sites of origin of the myalgia that when manipulated cause tremendous pain, often replicating the symptoms.

How Is Pelvic Floor Tension Myalgia Managed?

The key to treatment is to foster relaxation and “down-training” of the spastic pelvic muscles in order to untie the “knot(s).” By making the proper diagnosis and providing pain relief, the vicious cycle of anxiety/pain can be broken. Managing it often requires multiple approaches including stress management, anti-inflammatory and anti-spasmodic medications, and physical interventions.

Pelvic muscle training can be a useful piece of this multimodal management approach by its focus on developing proficiency in relaxing the pelvic muscles. The emphasis here is not on contracting these already over-contracted and over-tensioned muscles, which could aggravate the problem. This demands a different spin on the usual concept of pelvic training, which in this instance is not to increase tone and strength—rather it is to instill pelvic muscle awareness and enable the capacity for maximal pelvic relaxation, which is considered to be a “meditative” state between pelvic muscle contractions. Those suffering with this problem need to learn to unclench and release the pelvic floor muscles.

Focused therapies include the application of heat and pelvic massage. Pelvic floor physical therapists can be of great benefit to those suffering with pelvic tension myalgia. They use a number of physical interventions that provide pelvic muscle stretching and lengthening to increase muscle flexibility including trigger point therapy, which compresses and massages the knotted and spastic muscles. Those afflicted that are so motivated can pursue self-treatment regimens using internal, manually guided trigger point release wands that aim to relieve or eliminate the knots by self-directed manipulation and massage. These devices may be obtained without a prescription and are available online. Pelvic muscle tension myalgia sometimes requires injections of medication—including anesthetics, steroids or Botox—into the offending trigger points.

Bottom Line: In people afflicted with pelvic pain, the diagnosis of pelvic floor muscle tension myalgia should be a primary consideration. Physical interventions can be extremely helpful in alleviating the pain and untying the “knots” within the over-tensioned pelvic muscles. By making the proper diagnosis and providing pain relief and fostering muscle relaxation, the vicious cycle of anxiety/pain can be broken.

Wishing you the best of health,

2014-04-23 20:16:29

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