Perineum Pain (Perineal Pain) 

ischial-tuberosity-pain-pelvicThe Perineum is the area located between the anus and vaginal opening in women and between anus and scrotum in men. The anus, scrotum and vagina are included in the perineum. The lateral or side to side extent is formed by two bony prominences under the buttocks called ischial tuberosities.

Pain can arise from almost all pelvic organs, muscles, ligaments and nerves.  Since each of the pelvic organs itself can be affected by innumerable disorders, there are a large number of causes of perineal pain. Perineal pain (pain in the perineum) can present not only as pain but more of a discomfort, aching, burning, fullness, squeezing, tightness, sharp or dull sensation. It is often exacerbated when sitting and may include a host of other symptoms. Typical symptoms include one or more of the following:

  • Genital pain, anal and rectal pain, suprapubic  pain, pain in bladder area, tail bone pain, groin pain, low back pain
  • Discomfort when sitting (many say that it feels like they are sitting on a golf ball), pain after bowel movements
  • Urinary frequency, urgency, hesitancy, burning, frequent night time urination
  • Sexual pain including orgasm and post orgasm discomfort (can even be the next day)
  • Anxiety, depression, helplessness regarding symptoms, as there seems to be no end to it

According to ePainAssist, these are the following Gynecologic Causes of Perineal Pain or Perineum Pain

According to ePainAssist, these are the following Abdominal Causes of Perineal Pain or Perineum Pain

  • Colitis – Inflammation or infection of colon.
  • Proctitis – Inflammation or infection of rectum or anus.
  • Appendicitis – Inflammation or infection of appendix/bowel.

What Can Be Done to Relieve Perineum Pain

Pain in the perineum is commonly the result of trigger points that form in muscles up inside the pelvis. These trigger points are extremely tight, and can remain in place for years. According to the Wise-Anderson Protocol, their pain can be felt in places relatively far away from them and their pain can be caused by contracted muscles that are far away from them.

The good news is…pain in the perineum, even when it lasts for years, can get better with proper treatment. You may want to consider checking out The Wise-Anderson Protocol. It trains patients to release perineum pain related trigger points and to relax the muscles related to perineum pain. A detailed description of the Wise-Anderson Protocol treatment for perineal pain can be found in the sixth edition of A Headache in the Pelvis

According to this case report – Patients with chronic perineal pain may have co-existing multiple different pathogenic pain mechanisms. Various modalities such as acupuncture, physical therapy, psychological interventions, local use of botulinum A toxin, systemic use of analgesic drugs including opiates, neuromodulation, and nerve blocks have been advocated. Each modality seems to be effective in a particular subset of patients. Clinical studies to test existing therapies have not always been successful. A combination of different pharmacological agents or treatment modalities might be required to obtain an optimal result.

Perennial Massage

The true perineum is called the Central Tendon. It is the center point at which almost all the muscles of the superficial layer of the pelvic floor converge. However, most people refer to the skin and muscles between the vaginal opening and the anus as the perineum. Perineal massage is a massage of these muscles for the purpose of creating more “stretchiness” and flexibility to the area. Many therapists recommend this approach to pregnant women. It can cause some stinging sensation which is believed to help the mother become familiar and comfortable with the intense stinging that occurs as the baby’s head is crowning. Perineal massage can also be a good opportunity for women to learn how to relax the pelvic floor muscles.

A recent review of randomized, controlled studies of complementary and alternative medicine Medio-lateral-episiotomypractices used during pregnancy showed that perineal massage may truly be helpful, says Frank Anderson, MD, MPH, an assistant professor of Obstetrics and Gynecology at the University of Michigan Medical School. Anderson states that a mother already having birthed one child, has a higher chance of re-tearing if she had torn in from previous births or had an episiotomy. This is because the scar tissue is weaker, thicker, and not as pliable as normal tissue due to lack of blood supply. Both studies see women over 30 years of age benefiting more from perineal massage. Anderson believes this could be due to older tissues being stiffer than younger tissues. 

Perineal Massage Techniques

The following directions are  a suggested guideline for a Perineal Massage. Wash hands, and find a relaxing place to do the massage where you will not be interupted. You may want to have a warm bath beforehand, or warm your stomach with a heating pad to induce relaxing. This may be a nice time to get out the candles, relaxing music and some aromatherapy. Why not make it as nice as possible?

  • Sit in a comfortable position. 
  • Put a water-soluble lubricant or Vitamin E oil on thumbs and perineum.
  • Place thumb just inside the vagina.
  • Press downward towards the rectum and to the sides at the same time until a very slight burning, stinging, or tingling sensation is felt.
  • Hold the pressure for aproximatley 1 minute
  • Breathe deeply, and try to consciously relax the muscles. Consider using the restorative breathing technique by Lois Laynee, breathing in and and out as quietly as possible with diaphragmatic breathes
  • Keep pressing down with the thumb and slowly and gently massage back and forth over the sides of the vagina in a ‘U’ movement for 3 minutes.
  • Relax and repeat once.

Caution: Avoid pressure at the top of the vaginal opening. Massage gently as forceful massage could cause bruising or swelling. Warning: DO NOT USE PERENIAL MASSAGE IF YOU HAVE ACTIVE YEAST OR OTHER VAGINAL DISEASES OR INFECTIONS.

Perineal SMFR – is a massage technique that you can also consider to reduce pain.

Perenial Cleansing Bottle

Perineal Cleansing bottle

I call it my small bidet. The one I use you can get from amazon. Fill with warm water and keep it within reach of the toilet. After urinating and/or elimination, hold the bottle between your legs and squeeze slowly from front to back the area from your vagina to your rectum. The water will cleansing and soothe your private areas. Wait a minute or so and then pat the area dry with clean gauze, or I keep organic, non-bleach face cloths at hand. Do not wipe, as it seems to agitate the delicate tissues. This feels especially good if you have recently had an episiotomy. 

Pelvic Floor Massage – The Tennis Ball

This exercises can be performed on the floor but seems to be easier to hit the perineum muscle when you use a chair. Discuss with therapist before doing this, as they have reasons they don’t want you to do trying this at home.

  1. Warm up before this exercise, either with a quick walk,  or heating pad just to warm up the muscles before massage. 
  2. Place the tennis ball on your perineum and gently ease your body weight (very gently) onto it.
  3. Breath deeply and relax into the ball focusing on relaxing your perineum and surrounding muscles
  4. You may feel involuntary contractions try to focus and prevent these from occurring.
  5. Stop after 3-5 minutes. Do it daily and maybe aim for 10 minutes max. It will be uncomfortable at first. But many people swear it helps.

SYMPTOMS AND TREATMENT OF PERINEUM PAIN USING THE WISE-ANDERSON PROTOCOL – Excellent article – talks about their 6 day treatment.

The Wise-Anderson Protocol is a training of patients who suffer from pelvic pain that often includes pain in the perineum, and centrally includes training in how to rehabilitate their chronically contracted and spastic muscles of the pelvic floor and to relax the nervous system that feeds the pelvic tension and perpetuates chronic pelvic pain. The immersion clinics are offered privately to eligible patients in a monthly 6-day immersion form at held in Santa Rosa, California.

The clinic is limited to 14 patients who learn the protocol in private and group sessions. The aim of these clinics is to train patients in how to reduce or resolve their pelvic pain and related symptoms without the need for ongoing professional assistance.

Treatment Plan Suggestions For Male Pelvic Pain

My treatment plan included connective tissue manipulation, myofascial release, myofascial trigger point release, neuromuscular reeducation, pain physiology education, home exercise program (HEP) prescription and management, therapeutic exercise and activity, activity modification, and stress relieving exercises. During his initial evaluation, we discussed how chronic pain can affect the nervous system and the relationship between heightened stress/anxiety and increasing pain. Ben was given handouts on the mind/body connection and ideas to facilitate change. We practiced pelvic floor drops/relaxations while incorporating diaphragmatic breathing, and this was given as the first part of his home exercise program. (taken from Shannon Pacella – at Pelvic Pain Rehab)

Research and Articles for Perineal Pain

Chronic Perineal Pain Caused by Pudendal Nerve Entrapment: Anatomy and CT-Guided Perineural Injection Technique

Evaluation and treatment of perineal pain in vaginal postpartum

Male Pelvic Pain: It’s Time to Treat Men Right

Pelvic Pain Support for Men

Self Myofascial release for chronic pelvic floor pains

Male Pelvic Pain and Chronic Nonbacterial Prostatitis: A Story of Hope and Determination

 

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