Pelvic Pain Physiotherapy Sydney | Pelvic Floor & Anorectal Pain

Understanding pelvic pain

Pelvic pain covers pain you feel deep in the abdomen around the pelvic organs (bladder, uterus, prostate, large intestine and rectum), as well as pain that sits closer to the skin surface around the inner thigh, lower abdomen, the genitals, and the perineal (between the genitals and anus) and peri-anal (at or around the anus) regions. It might not sound glamorous, but roughly 1 in 4 women and 1 in 6 men experience pelvic pain at some point, most often in their 20s to 40s.

Pelvic pain can come from trauma or surgery to the abdomen or pelvic organs, referred pain from the lower back, and in some cases has no single definitive cause but worsens with certain activities, positions or muscle use. It also includes neurohormonal and metabolic conditions such as PMOS (previously called PCOS) and endometriosis in women, and prostatitis in men, which can go undiagnosed and untreated for long periods. Pelvic pain can also exist only in the context of intercourse or penetration, which is covered more on the painful sex page. Many pelvic pains end up filed under the umbrella of "chronic" or "persistent" pelvic pain, but there are many specific diagnoses under that umbrella that are managed similarly, though not identically, so getting a specific diagnosis and treatment plan is critical to a successful recovery.

What pelvic pain can feel like

Because pelvic pain can present in many ways, symptoms vary between different types of pelvic pain and between men and women, but some of the things you might notice include:

Deep aching or sharpness in the abdomen behind or below the level of the bellybutton
Pain that gets worse around the menstrual period, different from your typical period pain
Tenderness to the touch of the female external or internal genitalia (vulva, labia, clitoris, vagina, perineum)
Tenderness to the touch of the male genitalia (pelvis at the base of the penis, penile head, testes, scrotum, perineum)
Tightness or tenderness in the muscles surrounding the genitalia that make up the pelvic floor
Pain that increases in the groin or pelvic region with certain movements of the lower back (arching or folding)
Pain around the sacroiliac (SI) joints that may or may not refer into the pelvic region
Irregular menstrual bleeding, or rectal bleeding in any capacity
Constipation and straining, or difficulty passing bowel movements
Pain or difficulty passing urine
Pain with intercourse (penetrative or receptive) or with orgasm

Note: masses, or noticeable rapid changes in the size and feel of the abdomen and pelvis, warrant medical review and imaging. If you are unsure, contact your GP before your first session, or contact me and I'll let you know the best way to approach it.

Why pelvic pain happens

Chronic pelvic pain has a significant overlap with neurodivergence (autism / ASD, ADHD, and combined AuDHD), hypermobility (benign or general hypermobility, Ehlers-Danlos, hEDS, Marfan's, and similar) and chronic pain conditions (fibromyalgia, polymyalgia rheumatica), though there is no direct causal relationship. Many pelvic pain conditions have no single cause, but some contributing factors include those listed here.

Contributing factors

Pregnancy, pre-term labour, and miscarriage
Menstrual and endocrine changes (endometriosis, adenomyosis)
Inflammatory conditions of the pelvic organs or bowel (IBS, diverticulitis)
Recurrent UTIs and STIs
Pelvic muscle spasm, tightness, or irritation
Lower back injury with disc or nerve involvement at L1-2 or L4-S3
Surgery to the lower back, abdominal wall, or pelvic organs

How I treat pelvic pain

Assessment & diagnosis

History and pattern of your symptoms
Contributing factors
Triggers and easing factors
Sensitivity and tenderness of the region
Pelvic floor muscle tone, co-ordination and strength

Treatment techniques

Pelvic floor activity normalisation with ultrasound feedback
Desensitisation strategies (dilators, pelvic wand)
Co-ordination of the abdominal and pelvic muscles
Scar and soft tissue manual therapy
Reducing or removing contributing factors

Your home program

Prescribed pelvic floor exercises
Desensitisation and mobility drills for the pelvic floor
Breath work to co-ordinate the pelvic floor
Mobility and strength of the lower back / hips where appropriate

Your first visit

During your first visit, I'll go through what has brought you in, the history and timeline, and the contributing factors that might be present, both lifestyle and medical or surgical, anything you have already tried that did or did not help, and what your main goals are. Where it is relevant, I'll also ask about your bladder and bowel habits if they are affected, and your sexual habits if they are affected.

To diagnose accurately and build a treatment plan when there is pain in or around the pelvic floor or pelvic organs, I'll assess the pelvic floor. In men this is usually done externally for most pains, though a rectal internal examination may be warranted for proctalgia, painful anal conditions, and other pain around the back door. In women it is usually done internally (vaginally), as the muscles are most accurately examined about one knuckle's depth inside the vagina. External examination only is an option if you are not comfortable with an internal one, along with ultrasound to view the deeper tissues and how they move and work in different positions and activities.

After the examination, treatment usually begins in the same session and often involves manual therapy in some form - sometimes soft tissue techniques to relax or desensitise muscle or tissue that is sensitive to touch or stretch, and sometimes activation or co-ordination of the pelvic floor if the muscles are hard to feel working. If I find other contributing factors during our initial discussion, I can talk you through exercises to continue at home, along with what to keep doing, what to modify, and what to temporarily avoid in the early stage of your recovery.

All of this is packaged into a plan to continue at home between sessions, where I continue or adapt the hands-on techniques as you improve, monitor your progress, and increase the intensity or complexity of the exercises as needed.

Consent is ongoing, specific, and yours to withdraw at any time.

Common questions about pelvic pain

What can physiotherapy help with?

Most pelvic pains that are not, at the time, the result of a UTI or STI can be treated with physiotherapy. In some cases I don't treat the source directly (pain from a uterine mass or fibroid, for example), but I treat the resulting symptoms, such as muscular tension and tightness, pressure on the pelvis, pelvic floor weakness, or altered movement habits. In other cases I can treat the affected tissue directly, such as pelvic muscle tension or tightness contributing to scrotal pain, vaginal pain, or SIJ pain. Treatment varies with what is happening, but if it becomes clear that factors are involved that physiotherapy cannot address, I'll tell you and refer you on to a specialist or practitioner who is a better fit.

Is pelvic pain all in my head?

No, pelvic pain is definitely not all in your head. That said, in many cases of ongoing pelvic pain there is a significant psychological component, because of the impact on quality of life: day-to-day activity, toileting, exercise, sitting, and sex. It can become a vicious cycle, where pain affects mindset and activity, which leads to doing less and can make things more tight, tense, sensitive or irritated. For many people there are what I call psycho-physiotherapeutic strategies (psychology strategies wrapped in a physiotherapy bow and tied to your goals) and trauma-informed approaches to help address every corner of the problem.

What does treatment involve?

Treatment depends on what is causing or contributing to the pelvic pain, so there is no one-size-fits-all answer. Some of the techniques I use include:

Soft tissue techniques to the internal and external pelvic floor muscles
Soft tissue techniques to the lower back and hip / groin muscles
Joint mobilisations to the lower back
Ultrasound biofeedback to visualise muscle activity
Internal EMG (electromyography) to assess strength and stimulate the pelvic muscles
Pelvic wands to assist with internal desensitisation
Vaginal and anal dilators to help with tightness and resistance to stretch
Breath work and co-ordination of the diaphragm, midsection and pelvic floor
Pelvic floor strengthening, relaxation and co-ordination exercises
Loaded exercises co-ordinated with the pelvic floor
Gradual, guided exposure to movement, stretch and penetration to return to activity and sex

Book an assessment

Not sure if I'm who you need? Ask me and I'll let you know if physiotherapy is the right fit, or point you to who is.

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