If you are part of the 15% of women who suffer from chronic urogenital pain (CUP) and have an upcoming birth, you may be feeling intimidated. Women with CUP experience burning, stinging, itching and stabbing pains in the genital area, and may suffer from urinary urgency and frequency, as well as bowel dysfunction. The two most common CUP disorders include vulvodynia and bladder pain syndrome, also known as interstitial cystitis. Simple activities such as wearing jeans, inserting tampons, having a pap smear, or attempting intercourse can be painful and distressing, and the very thought of giving birth can be terrifying. Most times there are no identifiable medical causes to explain the severity of pain. CUP can affect women of all ages and ethnicities, single, partnered, and with or without children.
There is a lot of conflicting advice relating to mode of birth for women with CUP. Sometimes women are told that having a vaginal birth will “stretch” the vagina and potentially provide a cure, other times they are warned against a natural birth and plan a caesarean due to fears that giving birth might exacerbate the pain. Such advice is not evidence based, and usually reflects the personal preference of the health care practitioner providing the advice.
Unfortunately there has been limited knowledge about CUP, its mechanisms of pain or its origins. Knowing where the pain comes from and what causes the pain is essential to planning effective treatment, and it is this knowledge that is lacking in research. There are many theories that hypothesise the origins of pain, ranging from nerve entrapment, central sensitisation or even suggestions that it may be purely psychological. Treatments based on these theories are usually unsuccessful, and women continue to suffer not only from the pain but also from side effects of medications, surgeries, and the burden of being told that “it might just be in your head.”
Recent pain mapping studies by the author have found where the pain comes from in CUP, and what triggers the symptoms. When examining the external genital area some of the pain can be found originating from the vaginal entrance and urethral opening (where the pain is typically felt), but more intense pain arises from internal soft tissue of the pelvis. Pelvic floor muscles are considered to be the most complex in the human body, representing an integrated unit that provides support and control of pelvic organs. The anatomic and functional integrity of pelvic floor muscles is key to several basic functions of life: storage and evacuation of urine and faeces, support of pelvic organs, and the platform for sexual pleasure and birthing. When pelvic muscle function is compromised, functional capacity diminishes leading to many of the problems seen in relation to chronic urogenital pain.
Women suffering from chronic urogenital pain are frequently found to have dysfunctional pelvic muscles, characterised by increased tension and hypersensitivity. When muscles contract even 20% of their potential, they lose 80% of blood flow. This creates “ischaemic” pain, which is well known as the burning pain felt in the chest and left arm in a heart attack, or in skeletal muscles when exercising hard. When pain is felt in the body, the typical response is to brace and guard the area. As an example, when abdominal pain is present, one tends to hunch over and protect the abdomen. In neck pain, one usually stiffens the neck and raises the shoulder – again a protective action. The burning pain of vulvodynia is felt in the vulvar area, and the instinctive response is to tense the muscles, holding the vaginal opening tightly closed. This is done in a similar way to stopping urine flow, holding wind, or bracing to prevent leakage of urine during sneezing. These responses are designed to be used intermittently, not as a constant state of being. Holding muscles tight for an extended period of time not only causes ischaemic, burning pain, but also reduces elasticity and can result in restrictions such as contractures. A contracture is a very stiff, shortened muscle that can be painful to touch and brittle when quickly stretched.
Pain also provokes anxiety, which increases neuromuscular tension in preparation for the fight or flight response. This can spiral out of control, and is known as the fear tension pain cycle. The more fear there is, the more tension is generated, which creates more pain, which creates more fear and so on.
Decreasing pain in chronic urogenital pain conditions and in labour is based on the same principles. Understanding the cause of pain helps to reduce the sense of threat and danger, which in turn reduces the sense of fear associated with the pain. This minimises the psychological tension associated with pain, which is essential in addressing the physical tension that is held in the muscles and associated soft tissue. Normalising pelvic muscle function involves learning deep relaxation and heightening the mind-body connection, which is a key element in hypnobirthing practice. Techniques that involve diaphragmatic breathing help to regulate pelvic muscle tension, which assists in reducing pain and normalising function.
The good news is that chronic urogenital pain syndromes are functional in nature; meaning that with manual therapy, relaxation practice, and anxiety management relief can usually be achieved. Hypnobirthing provides excellent tools to help with this process, and with the right education, support, and treatment, pain can be relieved and a positive birth experience can be achieved.
Dr Sherie Johns BNurs, MMid, HPCE, PHD Scholar