Book Review: Why Pelvic Pain Hurts

In Pelvic Floor Physical Therapy by pelv_admin1 Comment

By: Rachel Daof, DPT

“Imagine the following: You feel a sudden new, surprising and sharp pain in your thumb while you’re at the office. You look at it and inspect the thumb. You touch it and feel around to see if there is anything out of the ordinary. You move it around. You discuss it with your coworkers and even show it to them. Your coworkers may even share ‘thumb pain’ stories of their own. Once inspected, you reassure yourself all is well with your thumb – it passed the inspection test!

Now imagine this: The next day, again while at work, you experience a sudden pain ‘down there,’ deep in your pelvic area. Will you touch it? Will you look at it? Will you try and move it? Will you show it to your coworkers or even discuss it? Will others be happy to share their pelvic pain stories? Will your ‘inspection test’ be enough to reassure you all is well? What if the pain does not go away?”

— Why Pelvic Pain Hurts by Adriaan Louw, PT, PhD, CSMT, Sandra Hilton, PT, DPT, MS, Carolyn Vandyken, PT Cred MDT, CCMA (acup)1

Pain is an interesting thing. It exists to warn us when there is potential danger to our bodies, but sometimes it persists when there is no danger present. What if the pain is in your pelvis? This adds another layer because, as the authors of Why Pelvic Pain Hurts put it, talking about pelvic pain is on the taboo side of the spectrum. Being unable to talk about your pelvic pain can make a person feel isolated, as if they are going through it alone. However, there is help out there. There are medical professionals, like us at the Pelvic Health and Rehabilitation Center, that are willing to hear you out and rid you of your pelvic pain. Given this, I chose to write a blog on the book Why Pelvic Pain Hurts to provide a few facts and tips to help you understand pain mechanisms specifically in the pelvis. If you are interested in this content, giving the book an actual read is worth your while.

“Understanding your body’s alarm system [and] understanding your extra-sensitive alarm system”

In order to understand pelvic pain, it is important to first nail down the details of pain science, and the authors of this book do a great job in providing readers on simple pain mechanisms. An important rule to pain science is that “pain is 100% produced by your brain. It’s produced when the brain believes you are under threat and need protection.”1 A simple way of looking at this is that pain and tissue damage are two separate things.

Given this, you have nociceptive nerve fibers throughout your entire body, and these fibers are in charge of detecting potential harm to you. As the authors put it, when these fibers reach their threshold of excitability, they send a message to your brain, and your brain “sets off the alarm” alerting you that your body may be in danger (i.e. you experience pain). Some of these nerve sensors detect temperature, stress, movement, immunity, and blood flow. This gives insight as to why your pain increases with increased amounts of stress, when it’s cold out, or when you’re sick, etc.

What if you’re experiencing pain with small triggers that should be harmless? That brings us to the author’s next topic, “your extra-sensitive alarm system.” The authors put it simply: “In some people, the nerves that ‘wake up’ to alert you to the danger in your tissues calm down very slowly. They remain elevated and ‘buzzing.’ In this state, it doesn’t take much activity to make the nerves fire off danger messages to the brain – activities like sitting, typing or driving, or stressful circumstances . . . The nerves become extra sensitive.”1

Interesting, right? Here’s a TedTalk by Lorimer Mosley that further explains the concept.

“Understanding your pelvic pain”

Let’s go back to the quote at the top of the page. The authors illustrate the emotional aspect that accompanies pelvic pain, and they perfectly lay out how pelvic pain fits in its own special box because it is not as readily talked about as any other part of the body. This causes increased amounts of stress and fear, especially if one sees multiple doctors with no solution available. As touched upon previously, stress can exacerbate your pain. Furthermore, the authors note how complicated the pelvis can become once you start considering other parts of the body. The bladder, intestines, reproductive organs, etc. can manifest itself as pain in the pelvis if they become dysfunctional. With this, treatment should be focused on how and why you are in pain and treating the affected tissues. This means an interdisciplinary team is a must if your pain is being caused by organs that physical therapists cannot treat themselves.

“Understanding your treatment options”

I love this section of the book because it offers solutions. Who doesn’t love that? I have included a few of the topics the book goes over; each topic below references the authors’ suggestions to help treat pelvic pain. Along with how they explain how each treatment helps, I am including links to blogs PHRC’s team had written so you guys can further understand pelvic health treatments. With this, it is worthwhile to purchase Why Pelvic Pain Hurts’  to get the full scope on how they recommend treatment should go.


  1. Manual therapy and Soft tissue treatment:

As the authors state, if tissues and joints become stiff, “they send more danger messages” to the brain. This is where manual therapy and soft tissue treatment come into play in which PTs implement “passive movement techniques . . . to the pelvic floor muscles, pelvis, hips, and low back . . . to optimize the movement of your tissues.”1 Below are some articles written by the PHRC team to help you understand a few techniques we may implement here.

  • This blog about trigger points will help you understand more about what a trigger point is and how we treat it.
  • This blog about connective tissue illustrates the importance of addressing and treating dysfunction.
  • Here is a blog about visceral manipulation and how it relates to pelvic PT treatments.

2. Breathing and relaxation:

Diaphragmatically breathing for pelvic floor pain is crucial, and the chances of your pelvic PT teaching you how to use your breath during a treatment session is high. The authors note how it can help calm down nerves and decrease pain. For more information on diaphragmatic breathing and its effects on the pelvic floor, check out this article Nicole Davis wrote.

3. Stress management:

The authors hit the nail on the head when they discuss stress. Along with giving readers tips on stress management, they state how stress management can improve both your pelvic pain and life. The final article I am including is on stress management.


In reviewing Why Pelvic Pain Hurts, we have learned more about how nerves work, what happens if they are overly excited, why pelvic pain is special, and how to manage the pain. Authors have encompassed how visceral organs, nerves, and the pelvic floor play a role into the pain experience as well as the non-tangible (e.g. stress). They also touch upon how certain things in life will take a hit with pelvic pain, such as appetite, fatigue, and sex drive. In all, it may seem as if you are going through pelvic pain by yourself, but we’re here to assure you that you are not alone!

All ideas above are from the authors Adriaan Louw, Sandra Hilton, and Carolyn Vandyken.

Additional Reading:

For more information on how to navigate pelvic pain treatment, check out PHRC’s book Pelvic Pain Explained!



  1. Louw A., Hilton S., Vandyken C. (2014) Why Pelvic Pain Hurts. Minneapolis, MN: Orthopedic Physical Therapy Products.


What are pelvic floor muscles?

The pelvic floor muscles are a group of muscles that run from the coccyx to the pubic bone. They are part of the core, helping to support our entire body as well as providing support for the bowel, bladder and uterus. These muscles help us maintain bowel and bladder control and are involved in sexual pleasure and orgasm. The technical name of the pelvic floor muscles is the Levator Ani muscle group. The pudendal nerve, the levator ani nerve, and branches from the S2 – S4 nerve roots innervate the pelvic floor muscles. They are under voluntary and autonomic control, which is a unique feature only they possess compared to other muscle groups.

What is pelvic floor physical therapy?

Pelvic floor physical therapy is a specialized area of physical therapy. Currently, physical therapists need advanced post-graduate education to be able to help people with pelvic floor dysfunction because pelvic floor disorders are not yet being taught in standard physical therapy curricula. The Pelvic Health and Rehabilitation Center provides extensive training for our staff because we recognize the limitations of physical therapy education in this unique area.

What happens at pelvic floor therapy?

During an evaluation for pelvic floor dysfunction the physical therapist will take a detailed history. Following the history the physical therapist will leave the room to allow the patient to change and drape themselves. The physical therapist will return to the room and using gloved hands will perform an external and internal manual assessment of the pelvic floor and girdle muscles. The physical therapist will once again leave the room and allow the patient to dress. Following the manual examination there may also be an examination of strength, motor control, and overall biomechanics and neuromuscular control. The physical therapist will then communicate the findings to the patient and together with their patient they establish an assessment, short term and long term goals and a treatment plan. Typically people with pelvic floor dysfunction are seen one time per week for one hour for varying amounts of time based on the severity and chronicity of the disease. A home exercise program will be established and the physical therapist will help coordinate other providers on the treatment team. Typically patients are seen for 3 months to a year.

What is pudendal neuralgia and how is it treated?

Pudendal Neuralgia is a clinical diagnosis that means pain in the sensory distribution of the pudendal nerve. The pudendal nerve is a mixed nerve that exits the S2 – S4 sacral nerve roots, we have a right and left pudendal nerve and each side has three main trunks: the dorsal branch, the perineal branch, and the inferior rectal branch. The branches supply sensation to the clitoris/penis, labia/scrotum, perineum, anus, the distal ⅓ of the urethra and rectum, and the vulva and vestibule. The nerve branches also control the pelvic floor muscles. The pudendal nerve follows a tortuous path through the pelvic floor and girdle, leaving it vulnerable to compression and tension injuries at various points along its path.

Pudendal Neuralgia occurs when the nerve is unable to slide, glide and move normally and as a result, people experience pain in some or all of the above-mentioned areas. Pelvic floor physical therapy plays a crucial role in identifying the mechanical impairments that are affecting the nerve. The physical therapy treatment plan is designed to restore normal neural function. Patients with pudendal neuralgia require pelvic floor physical therapy and may also benefit from medical management that includes pharmaceuticals and procedures such as pudendal nerve blocks or botox injections.

What is interstitial cystitis and how is it treated?

Interstitial Cystitis is a clinical diagnosis characterized by irritative bladder symptoms such as urinary urgency, frequency, and hesitancy in the absence of infection. Research has shown the majority of patients who meet the clinical definition have pelvic floor dysfunction and myalgia. Therefore, the American Urologic Association recommends pelvic floor physical therapy as first-line treatment for Interstitial Cystitis. Patients will benefit from pelvic floor physical therapy and may also benefit from pharmacologic management or medical procedures such as bladder instillations.

Who is the Pelvic Health and Rehabilitation Team?

The Pelvic Health and Rehabilitation Center was founded by Elizabeth Akincilar and Stephanie Prendergast in 2006, they have been treating people with pelvic floor disorders since 2001. They were trained and mentored by a medical doctor and quickly became experts in treating pelvic floor disorders. They began creating courses and sharing their knowledge around the world. They expanded to 11 locations in the United States and developed a residency style training program for their employees with ongoing weekly mentoring. The physical therapists who work at PHRC have undergone more training than the majority of pelvic floor physical therapists and as a result offer efficient and high quality care.

How many years of experience do we have?

Stephanie and Liz have 24 years of experience and help each and every team member become an expert in the field through their training and mentoring program.

Why PHRC versus anyone else?

PHRC is unique because of the specific focus on pelvic floor disorders and the leadership at our company. We are constantly lecturing, teaching, and staying ahead of the curve with our connections to medical experts and emerging experts. As a result, we are able to efficiently and effectively help our patients restore their pelvic health.

Do we treat men for pelvic floor therapy?

The Pelvic Health and Rehabilitation Center is unique in that the Cofounders have always treated people of all genders and therefore have trained the team members and staff the same way. Many pelvic floor physical therapists focus solely on people with vulvas, this is not the case here.

Do I need pelvic floor therapy forever?

The majority of people with pelvic floor dysfunction will undergo pelvic floor physical therapy for a set amount of time based on their goals. Every 6 -8 weeks goals will be re-established based on the physical improvements and remaining physical impairments. Most patients will achieve their goals in 3 – 6 months. If there are complicating medical or untreated comorbidities some patients will be in therapy longer.


  1. Love this book! We’ve had this in our clinic for several years. Adriaan and co. make it so much easier for pts to understand pain and how it sets off the “alarm” in our bodies. It’s very worthwhile for pts to read.

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