Challenge the Uncomfortable Silence

Every patient you see is likely to have a pelvis.  Roughly 1/4 of women will have had some pelvic pain in the course of sport, childbirth, sex or urinating.  Men are harder to pin down for exact numbers as it gets poorly diagnosed along with back pain and prostate problems but they have pelvic pain as well.  Jane Bowering did a great job pointing out the need for health professionals to ask the difficult questions and screen for pelvic pain in her write-up following the NOI2012 extravaganza found here: Pelvic Pain: all the fun stuff.

Doing a quick screen for pelvic pain conditions is fairly easy.  Start with the original Oswestry Low Back Pain Disability Questionnaire – it has a functional and practical question about sex.[1]  Interestingly, that question was removed in 2001 and replaced with little discussion in a revised edition.[2]  From what I can track down, it was done because therapists weren’t comfortable asking the question when patients left it blank.    I don’t think the discomfort of a therapist should form the quality of the screening process.  I think we can address pelvic function with the same kindness and compassion used with CRPS, CLBP and other life changing difficulties.

It may take a variety of professionals to unravel the complex contributions to persistent pelvic pain.  It may be that you are comfortable screening for pelvic pain but have no intention of treating it.  Happily there are physiotherapists, MDs, social workers and other professionals that can be part of an interdisciplinary team for these patients.  The study and treatment of persistent pelvic pain is a growing area needing robust discussion and critical thinking. The pelvis isn’t weird and mysterious. It is merely complex, with multiple social implications and psychological/biological complications.  A good portion of the fine research on CRPS and CLBP may be just the thing we need to help these patients.

It would be grand to accept the challenge that Jane proposed back in May.  Talk to your patients, listen to the answers as you do, and listen to what they aren’t saying.  Go ahead and ask them about sex, and sitting comfort and peeing/pooping.  For more information on persistent pelvic pain and what might be done about it, check out this short article in The Pain Practitioner (PDF).

About Sandy Hilton

Sandy Hilton PhysiotherapistSandy is a physical therapist in private practice, currently in the outer reaches of Chicago, USA.  Sandy is the Director of Programming for the Section on Women’s Health of the American PT Association and is supported by the Section to bring top-notch speakers on such things as Pain Neuroscience to the conferences.  She is curious about the application of Graded Motor Imagery in pelvic pain and has been stretching the CRPS and GMI research to extreme lengths in clinical practice.


[1] Fairbank JC et al. (1980) The Oswestry low back pain disability questionnairePhysiotherapy 66(8):271-3.

 [2] Fritz JM, & Irrgang JJ (2001). A comparison of a modified Oswestry Low Back Pain Disability Questionnaire and the Quebec Back Pain Disability Scale. Physical therapy, 81 (2), 776-88 PMID: 11175676


  1. Thanks for your ongoing contributions to the world of pelvic pain, Sandy! It is my hope that orthopaedic therapsits who read Lorimer’s site and consider the work of GMI for chronic low back pain also recognize that the pelvic floor is part of core training, functional movement and low back dysfunction. Hypertonicity is just as likely to be a cause of pelvic floor dysfunction as hypotonicity, and like all other body parts, we need to assess the pelvic floor fully before prescribing one more exercise (including core exercises- how will you know that they are engaging their pelvic floor- or does it matter? If it doesn’t, then let’s stop pretending that it does and stop telling them to squeeze as if stopping a mid-stream urine. If it does matter, then PLEASE assess the muscle first to see if they are doing it correctly, or if they should be doing it at all because they are tight and not weak!) Failed low back pain, or chronic non-specific low back pain as the literature likes to refer to it may be very specific after all! Pelvic floor dysfunction is a very likely cause of chronic low back pain. Eliasson (2008) reported that 78% of women with chronic low back pain had pelvic floor dysfunction. Perhaps the cure for chronic low back pain is addressing the correct tissue dysfunction, and of course, unravelling the nervous system’s involvement in the entire process. The concept of threat and the need for the nervous system to produce pain to protect is perhaps no more significant anywhere else in the body than in the pelvis. What other group of muscles have five major functions- storage of bladder/bowel, organ support, musculoskeletal support of the trunk and hips, sexual function and circulatory function? No wonder things go so wrong when we are not functioning well “down there”. Let’s get our heads out of the sand, start asking the difficult questions in a professional manner with as much comfort as, “Does your knee give out?”. As a physical therapist, you do not have to treat the pelvic floor, but it is your professional responsibility to identify all of the factors contributing to your patient’s presentation, and facilitate their recovery by referring them to someone who does. When their tissues do not respond in a predictable fashion (SI joint, facet joint or disc pain) start asking the questions: Do you have pain in your vagina/rectum? Do you have pain with intercourse? Do you have frequency or urgency? Do you have incontinence? Do you have heaviness or pressure in your vagina? Are you constipated or have difficulty passing stool? Positive answers should tell you that there is a pelvic floor dysfunction component. Or better yet, ask those difficult questions during the assessment, not just when the patient fails to respond to your treatment. Save your patients endless frustration and expense and refer them to someone who can address these issues. Your patients will thank you and you will cultivate huge fans out of your patients for correctly identifying the problem and refering them to someone who can help them. There is no other part of the body that physical therapists absolutely fail to assess yet presume to treat on a regular basis every time they give their patients core exercises. You don’t assess the knee through a pair of jeans. Don’t treat the pelvic floor (or the core) without palpating it either!

    soula Reply:

    Perfectly PERFECT Carolyn! Can I add to my website please? I’m building a resource for pudendalneuralgia (

  2. Did someone say pelvic pain? After almost 6 years of this hellish scenario I have a story to tell and awareness to create (just hit my avataar) and some extra questions that might help with diagnosis:
    does the vibration of your voice cause pain,
    does any vibration such as transport, someone tapping their knee next to you set you off?
    is the car hell?
    does it hurt when you’re in a pool, getting out of the pool,
    is the pain like you have your finger stuck in a power point? like someone is screaming in your ears and its vibrating down your spinal column?
    do your legs go weak?
    is it a toothache like pain in the butt?
    is there zing, burning, itching?
    does warmth bring on a flare?
    does weight, (including shoes or a coat) cause more pain?
    is your heel to the ground like stepping on a wire?
    but of course you take ages to realise all the above and have no idea where the pain is coming from exactly?
    does no one understand you and say its crps? do they say ‘go home, get comfortable’, or think you’re crazy?…
    it’s PN and it’s treatable. i’m proof thanks to this brilliant group and the great knowledge of my physiotherapist, Anne-Florence Plante.

    Sandy thank you so much for your post. I’ll copy it to my website for my followers.

    Sandy Hilton Reply:

    Thanks Soula. You’ve clearly been through what reads like a tough road. Totally cool that you’ve taken to sharing the info to help others maybe not get frustrated. Hope is a good thing.
    Pleased that you are sharing this around!

  3. Fabulous, Sandy! As a devotee of Butler, Moseley and the crew with NOI and BIM, and a somatic practitioner as well as PT, who specializes in Pelvic Pain, I am so happy to read your blog post. I am always wondering how we might “mirror box” the pelvis….and experiment daily with imagery, sound, breath, micro-movements etc to work with these challenging patients. Clinically, I am ticking off successes (some small, some bigger) with GMI…for not only those with pelvic pain, but voiding dysfunctions such as urge/frequency, poor evacuation. The brain is where it’s at. And I want to re-emphasize the “OK-ness” of asking patients (in a professional way) about pain or problems with sex, voiding, or pooping. If we are asking folks to engage their pelvic floors for, say core stab work, we can ask them if it ever hurts. And just like we hold tension in our shoulders, just as many of us hold tension “down there.” Thanks Lorimer and BIM for such a great blog site.

    Sandy Hilton Reply:

    Excellent Lizanne, I’d love to hear more about your thoughts and successes, as well as the clunkers – I learn as much from what didn’t help. I agree the brain is astonishingly cool without forgetting the periphery and context etc. As for holding tension, I like Diane Lee’s phrase “butt gripper”.