Pain, The Nervous System & The Pelvic Floor
Chronic Pelvic Pain and Pelvic Floor Tension: Why Your Muscles Guard
Written by Dr. Fiona Callender, ND and Pelvic Therapist.
If you’ve been dealing with chronic pain, whether that’s related to your period, sex, or even digestion, you may have found yourself asking a frustrating question:
Why am I still in pain… and where did this pain come from?
For many experiencing chronic pain, their pain lingers even after treatment. This may be the case for those with endometriosis - surgery may help alleviate pain, but for others it persists. This may also happen postpartum - you are 6 months postpartum and everything is healed but you are still experiencing pain with intercourse. Tests and imaging might not be lining up with how much pain you are experiencing, and nothing seems to be able to explain what’s happening to you.
None of this means your pain isn’t real or that it’s all in your head.
One of the most important things to remember about chronic pain is that pain isn’t simply a measure of how much tissue damage is happening in the body. There are different forms of pain, but ultimately, pain is a protective signal. Sometimes, after experiencing pain repeatedly or for a long time, our nervous system can get really good at protecting us.
As we begin to understand our nervous system, our different pain pathways and how this impacts our pelvic floor muscles, we can start to explain why pain sometimes persists, and why treating chronic pelvic pain often means looking beyond the original trigger. Central sensitization of our nervous system, nociplastic pain and pelvic muscle guarding are some concepts we’ll dive into below!
Pain is there to protect you (in theory)
Pain gets a bad reputation, but it exists for a very important biological reason - protection and safety.
Imagine touching a hot stove. Your nervous system detects a potential threat, sounds the alarm, and gets you to move your hand. That’s exactly what we want it to do.
Physical damage or injury is a common pain trigger. For endometriosis, this might be the inflammation, for pain with intercourse, it might be tissue damage. Either way, your nervous system gets the message:
Something is happening here. Let’s protect it.
One of the ways your body may try to protect the pelvis is by tightening the muscles surrounding it, including the muscles of your pelvic floor. Initially, this makes a lot of sense, but when pain starts to stick around long-term, the alarm system itself can start to change. We call this central sensitization.
What is central sensitization?
I often explain central sensitization using the analogy of a volume knob on a stereo.
Your nervous system is constantly receiving information from all over your body. Normally, it’s pretty good at deciding what information is important enough to bring to your attention, and what we can safely ignore.
With central sensitization, the volume on that system has essentially been turned up.
The brain and spinal cord become more responsive to incoming signals. Things that used to register as mildly uncomfortable can become quite painful. Sometimes sensations that shouldn’t normally hurt at all, like pressure or light touch, start to be perceived as pain.
You may hear terms like hyperalgesia, meaning a painful stimulus feels more painful than we would expect, or allodynia, when something that wouldn’t normally hurt becomes painful. Perhaps one of the most frustrating and confusing aspects of this is that pain may also begin to extend beyond where it originally started.
Even when pain moves to a new location, this still does not mean the pain is imagined or “all in your head.” There are very real changes happening in the way the nervous system processes information. Part of this phenomenon has to do with a type of pain we call nociplastic pain.
What is nociplastic pain?
Another term you may come across is nociplastic pain. Traditionally, we may have thought about pain in two main categories.
Nociceptive pain happens when tissues are injured, irritated or inflamed.
Neuropathic pain happens because of a lesion or disease affecting the nervous system.
We now recognize a third pain mechanism: nociplastic pain.
Nociplastic pain occurs when the way our nervous system processes pain has changed, and the amount of pain someone is experiencing cannot be adequately explained by ongoing tissue damage or a nerve lesion alone. Central sensitization and nociplastic pain are closely related, but they aren’t exactly the same thing.
A simple way to think about it is:
Central sensitization describes a process happening within the nervous system. The nervous system can become sensitized with other types of pain too - nociceptive and neuropathic! Nociplastic pain is more the descriptor for the diagnostic category of pain - one in which changes to central nervous system processing is the predominant driver of pain. Pain doesn't always fit neatly into one category.
It’s possible to have nociceptive, neuropathic and nociplastic contributing to our pain at the same time.
Endometriosis is a great example of this.
As I discuss in my blog about endometriosis and chronic pain, endometriosis pain can involve inflammation, nerve-related pain, changes in how the central nervous system processes pain and muscular responses to ongoing pain.
The concept of central sensitization can help us understand how many of our common - but seemingly unrelated - conditions can tend to cluster together.
Why do IBS, migraines, TMJ and pelvic pain often occur together?
This is something I see all the time in practice. Someone comes to see me for pelvic pain and, as we start talking through their health history, we realize they’ve also experienced migraines - or digestive changes, or TMJ pain, or bladder symptoms, or even chronic fatigue.
Conditions including endometriosis, irritable bowel syndrome (IBS), temporomandibular disorders (TMJ), migraines, fibromyalgia, vulvodynia and bladder pain syndrome commonly overlap.
There probably isn't one single explanation for why, and each of these conditions deserves appropriate investigation and treatment in its own right. That said, one of the shared pieces of the puzzle appears to be how the nervous system processes pain and sensory information. This can also help us understand why some people living with chronic pain experience symptoms that seem to extend beyond the area that hurts: poor sleep, fatigue, brain fog or increased sensitivity to things like light, noise or smells.
Rather than thinking of every symptom as an entirely separate problem, sometimes it helps to zoom out and look at the systems connecting them.
How does chronic pain affect the pelvic floor?
Let’s bring this back to the pelvic floor. If you are consistently experiencing pain with intercourse, your nervous system might learn quite quickly: penetration = potential threat.
Now imagine someone is about to poke a bruise on your arm. What would you do? You might tense your arm before they even touched you. Muscle guarding is a protective mechanism.
Your pelvic floor might do the same. When your nervous system anticipates pain, your pelvic floor muscles may contract or guard in an attempt to protect the area. The problem is that over time, if we keep experiencing pain, that protective response can become part of what keeps the pain going.
The pelvic pain → tension → guarding cycle
This is where we can get caught in a bit of a cycle.
Pain → pelvic floor guarding → increased muscle tension and sensitivity → more pain → anticipation of pain → more guarding.
Over time, your pelvic floor can become very good at bracing for that pain. This isn’t necessarily something you're consciously doing and you might not even realize this is happening. When you can’t see those muscles, it’s not exactly easy to get them to relax.
Our whole goal isn't necessarily to force those muscles to relax either. Part of our goal is to give your nervous system enough experiences or inputs of safety that those muscles no longer get signals that they need to protect you all the time. We essentially want to turn down the volume on our alarm system.
This is one of the reasons pelvic floor therapy can be helpful for people experiencing pain with sex.
What can pelvic floor tension feel like?
A tight or overactive pelvic floor doesn't always feel like obviously “tight muscles.”
Depending on the person, pelvic floor muscle tension and guarding may contribute to things like pain with penetration or sex, vaginal or vulvar pain, pelvic aching or pressure, difficulty comfortably emptying your bowels, urinary urgency, frequency or burning, tailbone pain or discomfort around the hips and pelvis.
These symptoms can have many different causes, which is why assessment still matters. Pelvic floor tension is one possible piece of the puzzle but not an explanation that we should automatically apply to every pelvic symptom.
Think about chronic pain like a spinning wheel
I recently shared this analogy on Instagram, and it's one of my favourite ways to explain chronic pain. Imagine your pain as a big spinning wheel. Something got the wheel moving.
Whether that was endometriosis, an injury, maybe a UTI or pain with sex - something started it. Once the while starts spinning, other factors might keep it going. It might be the pelvic floor guarding, or poor sleep. It could be consitpation that requires straining and contributes to more pain. Maybe it’s the fear or anticipation that gives it another push. The more pain we experience, the more the nervous system is sensitized and pushing the wheel faster.
Then the wheel keeps spinning.
Eventually, addressing the thing that originally started the wheel may not immediately stop it. For those with endometriosis, this is sometimes why we can remove the lesions with surgery, but still have significant pain that lingers.
That can sound discouraging, but it can also be reframed as a more hopeful view of chronic pain. We don’t need to find the root cause or the magical break on pain. There may actually be multiple places where we can intervene.
We don't have to approach chronic pelvic pain from just one direction
We might approach pain through the lens of “what is keeping my pain system activated?” versus “what is the thing that is causing my pain?”
Often, I’m trying to approach from both sides. This might mean supporting endometriosis or another underlying medical condition.
It could mean addressing pelvic floor tension and guarding directly.
It could mean looking at sleep, nutrition and exercise to support safety and resilience in our nervous system.
It might mean addressing vaginal dryness or irritation so that penetration isn't repeatedly painful. This is especially true for my postpartum or perimenopausal folks.
It can include pain education, psychotherapy, medication or strategies that help shift the nervous system's response to perceived threat.
Often, it's a combination of strategies. We're not trying to convince your nervous system that your pain isn't real, but rather helping a protective nervous system learn that we are safe and that it doesn't need to protect you quite so much.
Pelvic floor therapy isn't always about strengthening
When most people hear “pelvic floor therapy,” they think Kegels, but if your pelvic floor muscles are already spending much of the day gripping or guarding, more squeezing isn't necessarily what those muscles need.
Instead, pelvic floor therapy for chronic pelvic pain may involve learning how your pelvic floor moves with your breath, recognizing patterns of tension, improving coordination and mobility, gradually introducing movements or sensations that have become uncomfortable, and helping your nervous system experience those sensations without immediately sounding the alarm.
Does central sensitization mean we stop looking for the cause of pain?
In short? No. I never want our discussions about the nervous system to leave those with chronic pain feeling dismissed. Understanding central sensitization doesn’t mean we stop appropriately investigating symptoms.
We might talk about how our different conditions overlap and have a conversation about the role of the nervous system, but we still want to investigate your endometriosis. We will always still want to rule out infections and other causes of urinary symptoms. Pain with sex also deserves a deeper investigation that looks at all the possible factors that could be contributing.
Pain education isn't a replacement for medical investigation. We can investigate and treat the factors that might be contributing to pain, while also treating the systems that have adapted in response to that pain.
Can a sensitized nervous system change?
Yes! This is one of the reasons I think pain education is so important in my practice. Our nervous systems are so adaptable. As we just discussed, that adaptability is part of how sensitization developed in the first place.
Your nervous system isn’t broken or stuck this way, it has just learned a way to protect you that doesn’t make sense anymore. We need to start feeding our system new cues of safe movement and comfortable touch. We need to teach our nervous system and pelvic floor muscles that it is safe to release and relax.
If pain has been present for years, it can take some time to teach these signals of safety, but you - just like your nervous system - are adaptable and resilient.
If you are a person who has been navigating chronic pelvic pain or symptoms for years on your own, it might be time to talk to someone about support. I’m Dr. Fiona Callender, Naturopathic Doctor and Pelvic Floor Therapist. I work with those experiencing chronic pelvic pain and/or endometriosis everyday in my practice. If you would like to chat to see if I might be a good fit for your needs, you can feel free to book a meet and greet appointment with me at Crafted Balance.