Health Organization for Pudendal Education

Hi friends.

About 7 weeks ago I began experiencing a new persistent pain in my pelvis that's not getting any better.

I had been working out for the past 4 months without much difficulty/increase in pain, always doing plenty of pelvic stretches before and after the workouts. On a Monday morning I went to the gym and did an intense chest workout, heavy weights with a lot of squeezing of the pecs (trying to isolate the muscles). A few hours after the workout I began experiencing pain deep inside my rectum on the right side. The pain is persistent, but it's especially made worse with extended sitting. I also tend to stand more on my left foot now so as to avoid sending pressure up to the area by standing on my right foot. My pelvic specialist has evaluated me weekly since the onset: she has confirmed the existence of and released trigger points on the right side along my piriformis muscle and obturator internus. I have been doing lots of piriformis and obturator stretches, yoga, and epsom salt baths since the pain started; I've also stayed away from the gym. Plus I've been using a foam roller on my thighs and glutes as well as releasing trigger points along my glutes with a tennis ball. I sit for many hours a day on a forklift at work, which makes the pain worse. None of the stretches seem to be helping with the pain. I've also been taking 5mg oral Diazepam twice daily for about two weeks. Surprisingly, the Diazepam seems to help a lot with the allodynia/hyperalgesia I've been experiencing in my perineum for about 8 months, but it does nothing to help with this new deep rectal pain. I've watched lots of videos and read many websites about good exercises for piriformis syndrome and sciatica (although re: the latter, the pain doesn't run down my leg underneath my knee).

Any ideas what's going on here? Any suggestions re: stretches/exercises to do?

I just had a pelvis MRI (focused on my sacrum I believe) two weeks ago and I'm seeing my pain specialist for the results on Halloween.

Thanks in advance!

P.S. I'm not sure if this matters but for a few years now, every so often I get abdominal pain (especially when peeing, the harder I push the more it hurts). There's been a spot on the right side of my lower abdomen that hurts a bit from time to time. Should I look into the possibility of a hernia? Are there any tell-tale signs?

Hi Kinec, and welcome
That's the problem with pelvic pain, there are SO many places it could start from that it becomes almost a perpetual quest. You ahve already started off with the right thing, going to a pelvic specialist, I take it though that even the release of the p muscle and other trigger points have not made any difference ??
It can take some time however, I'm sure she has told you this. Can she see any reduction in the trigger points the has discovered when working on you?
What about pelvic floor muscles? The piriformis can be responsible for a great deal of pelvic nerve pain issues and buttock pain of course. However many people (actually most I would say) do get piriformis problems because of, and secondary to pundendal ones, although others (me ) have piriformis which causes pundendal and sometimes other nerve issues. Sciatic pain doesn't always have to go all the way down the leg btw, although obviously it can.
I have read plenty of literature saying that a sciatica related piriformis problem doesn't usually send sciatic type pain lower than the knee, so you may fit right in with that. Who knows at this stage.
All I can say is that sometimes my sciatic pain 'puddles' to the back of my knee (right beside where the common perineal nerve finishes here http://upload.wikimedia.org/wikipedia/c ... ray832.png) and sometimes it goes to either side of my heel. I think that all the medics come up with is it is definitely a nerve problem but then I could have told them that
It is often a process of elimination, but just to throw a spanner in there is NO reason why there can't be a couple of things going on, and the issue of one problem causing a central sensitisation, causing a few pain issues to develop must also be taken into consideration.
HOWEVER, if there is one defining moment where the pain started and didn't spiral I would rule central sensitization out.
I would definitely get your pelvic floor muscles checked out.
In the mean time have a look at medication on the home pages. A combo of anti seizure and anti depressant meds can often work, although a bit of experimentation is sometimes required to find the combo that suits.
Hope this helps but have a good look through the home pages for extra info.
Take care and let us know how you get on.
Helen

Thanks very much for the reply.

I should have included more information:

1. As stated, this pain started a few hours after doing a weight-lifting workout 6 weeks ago. I forgot to mention that for the next few days it felt as if there was a golf ball or foreign object inside me. But within about two days of doing the piriformis stretches suggested by my PT that foreign object sensation went away.
2. I've had chronic pelvic pain and central sensitization (almost body-wide allodynia/hyperalgesia (especially in my groin and legs)) for nearing 3 years now.
3. I've been seeing a pelvic health specialist weekly for a year now. She does trigger release therapy each visit.
4. I've been on tons of meds, including anti-depressants (Cymbalta, Amitriptyline, Nortriptyline), anti-convlusants (Lyrica), opiods (oxycodone, codeine), muscle relaxants (both oral and topical diazepam), and plenty of vitamins (e.g. all the B vitamins, Acetyle-L-Carinitine, etc. etc....all the ones recommended for nerve pain).
5. Generally-speaking, the rectal pain has improved greatly. It's always felt very superficial but I've definitely had tight pelvic floor muscles for a long time.
6. This pain that I'm posting about now, however, is of a different sort. It's very deep-seated, it's a constant ache but it is indeed made worse with long sitting as well as standing since the right foot seems to send pressure up to the problem area. Again, it feels very deep inside my pelvis on the right side. There is a slight throbbing sensation but it's subtle.
7. Since this pain started, I do sometimes get discomfort that seems to wrap around my thigh/hip on the right side. And every so often I do get foot discomfort.

Hi again Kinec,
1.The foreign object feeling is a classic nerve issue. If it is in the rectum (or vagina of course) the pudendal nerve is responsible.(as per Nantes criteria)
2. Do you know what was responsible for the onset of this problem Kinec?
3.Is she treating the pelvic floor mainly? That is a lot of physiotherapy, has it been beneficial and say if you miss a few sessions (hols whatever) can you tell a difference and the need to have more. I would suggest some pain management techniques to run along side the physio if you haven't already got that sorted.
5. It could be that your predisposition to pelvic muscle tightness, previous and current central sensitisation and prolonged sitting at work just needed that extra push in the gym to cause what does seem to be a piriformis problem. It could of course be a totally unrelated piriformis problem which could have occurred regardless. I guess whichever, it is matter less, although at least your physiotherapist was able to help from the onset.

If I get your meaning here

Kinec_121 wrote: 7. Since this pain started, I do sometimes get discomfort that seems to wrap around my thigh/hip on the right side. And every so often I do get foot discomfort.

I can totally relate. I sometimes feel as if I am wearing a 'belt of pain' which is fashionable tilted (SO last millennium!) at the front to include my p muscle hip and groin, It always builds as p pain then hip and then groin. This only happens with too much 'activity'(and not that much or that strenuous) just sitting which does cause piriformis and/or pudendal pain won't do it.
Pacing activities (and tramadol) helps me a lot with this. I can always get back to base line pain with time and rest.
Have you had your hips checked out? There is a lot of talk about labral hip tears and pelvic pain connection. This could even help explain your past pelvic problems ?? What about any SIJD?
I think that because the p stretches had a theraputic effect that muscle has to be part of your issue now. Do the stretches hurt? You will be able to compare sides and ascertain any difference or additional pain on the effected side.
I would get your physio to properly evaluate the piriformis muscle if it is not too painful to do so. A few months after my fall ( causal agent ) I could feel an egg shaped (smaller than a hen's egg) hard lump deep in (what I now know is) my piriformis muscle. I have been told that this was probably a heamatoma that has caused scar tissue which has subsequently compromised the nerves (4) there. I have read some medical literature since confirming this as a rare but medical entity. It is usually caused by a fall onto the bum however and I can't remember any talk of this sort of problem arising from strenuous gym work. However, this may have caused a tightness or spasm in the muscle which physiotherapy could help. I wonder if some anti-inflammatory's would help the situation as it is still relatively new (not sure, worth a try?)
Some people also have the sciatic nerve running thru' the p muscle (aprox 17%) and i have read recently that sometimes the pudendal nerve can too. Obviously those people will be more pre-disposed to nerve pain if the muscle tightens around the nerve.
I would hope that pacing, stretching and extra myofascial release to the p muscle will help you problem Kinec, although it may take some time.
I've had acupuncture etc too and then steroid and botox shots. TBH botox was the only thing that did help (the acupuncture was sheer agony) but then I need decompression surgery for any additional relief.
A pelvic scan can also show any asymmetry in the p muscles which is supossed to be a classic sign of piriformis syndrome, and then of course the MRN scans are supposed to show up nerve entrapments but the sciatic nerve in particular is so thick and tough nothing usually does show. Anyway all of that is a way down the line for you if ever needed at all. . . . .I hope that non invasive conventional treatments will help in the short term, but at least you are aware of the extensive therapies available.
Take care
Helen

Kinec, does your physiotherapist do internal work via the rectum? Maybe he/she can determine the source of the deep pain -- whether it's a muscle or along the course of the nerve. There are so many different nerves/muscles in the pelvic area it is a major trick to figure out the source of the pain. The posterior femoral cutaneous nerve wraps around the lower buttock near the back of the thigh -- you can google images of it. There's piriformis syndrome, paresthetica meralgia, acetablular labral tears, psoas muscle strain (abdominal pain) -- these are just a few of the possible generators of pain that you can consider -- including the possible hernia. Good luck sorting through all of this! Hopefully by avoiding weightlifting your body will heal itself and you will be OK soon.

Violet