Pelvic Prime's Anatomy Academy Series

Pain

Pain Theory

In recent years, brain research has taught us a lot about pain. Instead of focusing on where pain comes from, the new approach looks at where pain is felt. Pain is created by the brain as a response to a perceived threat, even if there's no actual damage. Pain is a very personal experience, and tissue damage does not always result in pain, and vice versa. Sometimes, the brain can prioritize other needs over pain, but it might also create pain when it sees normal signals as a threat.


International Association for the Study of Pain

The International Association for the Study of Pain (IASP) is a group made up of scientists, doctors, healthcare providers, and policymakers. Their goal is to study pain and use that knowledge to improve pain relief worldwide. 

The IASP first defined pain in 1979, and in 2020, they updated their definition to: "An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage." This definition is important because it acknowledges that pain is personal and influenced by biological, psychological, and social factors. 


Pain is different from nociception (the body's response to harmful stimuli) and is not just about physical sensations. Pain can be learned from life experiences, and how a person describes their pain should be respected. While pain usually helps protect us, it can also negatively affect our physical, social, and emotional well-being. Even if someone can't express their pain, that doesn't mean they aren't feeling it.

Neuro Orthopaedic Institute

The Neuro Orthopaedic Institute created a program called Explain Pain. They believe that pain is produced by the brain, even if there's no damage to the tissue or organs. By helping people understand their pain, they hope to reduce fear and, as a result, reduce pain. 


According to their view, pain is a construction of the brain in response to a perceived threat, influenced by biological, psychological, and social factors. The brain produces pain as a protective response to prevent further harm.

European Association of Urology

The European Association of Urology (EAU) is an organization for urologists. They created the Guideline on Chronic Pelvic Pain, which is often used in discussions about pelvic pain. Chronic pelvic pain is defined as persistent pain in the pelvic area of men or women. The EAU also focuses on categorizing chronic pelvic pain by describing the condition (phenotyping), using specific terms (terminology), and organizing these into a hierarchy (taxonomy).

International Classification of Diseases

For the first time, the International Classification of Diseases (ICD) has recognized chronic pain as its own disease in its latest version. Chronic pain is categorized into two types: 

Pain Mechanisms

Visceral vs. Somatic Pain


In pelvic pain, both types can be involved. Visceral pain is often hard to pinpoint, which is why pain felt in the bladder, for example, doesn't necessarily mean there's something wrong with the bladder.

Peripheral Pain

Peripheral pain happens when the body responds to tissue damage, like an infection or surgery, by creating substances that start the healing process. These substances also send pain signals to the brain. Specific receptors in the body can increase pain sensitivity and expand the area where pain is felt.

Central Pain

In the central nervous system, pain pathways work together to process information and create pain signals. In chronic pain, the balance between pain signals going up to the brain and coming back down can become distorted, making pain worse. The brain processes both physical and emotional pain, which can contribute to chronic pain and related issues like depression and anxiety.

Psychosomatic Pain

The relationship between pain and the mind is important in understanding chronic pain. The brain can react to different types of stress, leading to pain. This understanding helps explain the connection between pain and emotions and can guide how we manage pain, especially in conditions like pelvic pain.

Pain Management

Acute Pain

When someone experiences acute pain, it often brings them to a doctor's office or the emergency room. Acute pain starts suddenly, stops the person from doing normal activities, and can cause a lot of anxiety. 


If the pain is due to something obvious, like an injury, the cause is clear right away. For example, if someone has pain while urinating, it might be due to a urinary tract infection (UTI). In this case, a urine test is done, and if an infection is found, antibiotics are given. The pain usually goes away, and urination returns to normal. 

When dealing with acute pain, it's important to identify and treat any known diseases that could be causing the pain. This not only helps relieve the pain quickly but also prevents any long-term problems. The brain remembers the details of the pain, like when it happened, where it was, and how it was treated. Successfully treating the cause of the pain helps the brain store a positive outcome in its "file" on that pain. Quick and accurate diagnosis is especially important when there are signs that something more serious might be wrong, requiring immediate medical attention.

From Acute to Chronic Pain

Sometimes, pain doesn't go away as expected, and doctors need to look deeper to find out why. Neurobiology has shown how pain can shift from being a short-term (acute) issue to a long-term (chronic) one. During this "subacute" stage, it's important to consider how well the pelvic floor muscles are working and think about any psychological or social factors that might be affecting the person. For instance, if someone has recently lost a family member to bladder cancer, they might be more sensitive to pain in their bladder. If the person has had other pain issues before, this can also increase the risk of the pain lasting longer. 

Negative thinking, like assuming the worst (catastrophizing), can make the pain feel even worse. Understanding these risk factors can help doctors plan the best way to approach treatment. If the risk is low, a simple investigation might be enough, and it's important to explain the results positively to the patient. If the risk is high, or if the pain becomes chronic, the patient should be referred to a specialist team that can address all aspects of the pain—physical, psychological, and social.

Chronic Pain

When pain becomes chronic, the focus should shift away from the specific organ where the pain is felt and towards understanding the pain itself. It's important for patients to know that pain can be treated even if no clear physical cause is found. Educating patients about pain helps them understand what is happening in their mind and body, and it keeps the communication open between the patient and the healthcare provider. This approach, called motivational interviewing, helps create a positive environment for discussing pain, especially when it's not linked to an obvious physical cause. It can also help patients stick to their pain management plan.

Conservative Management

There are many conservative (non-surgical) treatment options for managing chronic pain.  Psychologists play a crucial role in managing chronic pain. Cognitive behavioral therapy (CBT), mindfulness-based CBT, and acceptance and commitment therapy are some of the approaches psychologists use. Other treatments include eye movement desensitization and reprocessing (EMDR) and hypnotherapy. EMDR is particularly useful for treating trauma and helping patients focus on their pain without feeling tense or anxious. 

Hypnotherapy has shown promising results in reducing chronic pain in many conditions. It works by helping patients access the subconscious part of the brain, where feelings of safety and past experiences are stored. During hypnosis, positive suggestions from the therapist can be implanted in this subconscious part of the brain, helping to reduce pain.

Self-Management

Not all pain can be completely eliminated, so it's important to give patients tools for managing their pain on their own. Self-management is crucial because patients spend most of their time away from healthcare providers, managing their pain on their own. Physical therapists can teach patients how to manage their muscles when pain flares up, and psychologists can help with techniques for preventing relapses and managing stress. Mindfulness, meditation, and self-hypnosis are useful techniques that patients can learn to use whenever they need them. Social support is also important, as is having regular check-ins with a doctor to review the patient's situation and provide reassurance.

References: Bo, K., Berghmans, B., Mørkved, S., & Van Kampen, M. (Eds.). (2023). Evidence-Based Physical Therapy for the Pelvic Floor (3rd ed.). Elsevier.