Q&A: Painful Sex, the Bladder-Back Pain Connection, Male Pelvic Pain and More

In Male Pelvic Pain by Stephanie Prendergast and Elizabeth Rummer2 Comments

In this, our latest Q&A post, we tackle some important pelvic floor issues, including painful sex, the connection between bladder and back pain and the proper PT for someone with prolapse and pain.

Prolapse + Pelvic Pain = What kind of PT?

Dear Liz,

I get e-stim done, but I have both prolapse and pelvic pain/trigger points. What is the protocol in this case?


Prolapse Plus Pain

Dear Prolapse Plus Pain,

In certain cases, a patient may present with what we endearingly call a “hybrid pelvic floor.” This means that certain pelvic floor muscles are tight or “hypertonic” (trigger points may or may not be present) while other pelvic floor muscles are weak or over-lengthened. As a result, this patient can have both prolapse and pain. (Prolapse, for its part, is caused by a combination of factors, such as loose connective tissue and/or weak and overstretched pelvic floor muscles, while pain is typically caused by tight muscles and trigger points.)

As we discuss at length in this blog post about the appropriate use of e-stim, e-stim can help “up-train” or strengthen the pelvic floor if it’s truly weak or overstretched. The patient who needs e-stim for this purpose likely has either incontinence or organ prolapse, not pain. If the patient does have pain,  e-stim may exacerbate that pain by contributing to further hypertonus and/or trigger point irritation.

In your case, you’ve pointed out that you do indeed have pain along with prolapse.

So first and foremost, you have to be aware of the fact that not all patients with prolapse have muscle weakness and excess length. And e-stim should only be administered if, in fact, this is the case. So an important question for you to ask your PT is: “Do I have muscle weakness and/or excess length?”

The second consideration for your PT is to figure out which symptom is causing you the most distress.

If your pain is worse than the symptoms of your prolapse (typically pressure and/or incontinence) then treatment should focus on the impairments your PT believes are causing your pain first. Treatments for pain involve down-training and manual therapy. Then as your pain improves, the goals of your therapy can evolve to address the impairments associated with the prolapse. This may be accomplished through e-stim (again, only if there is weakness and excess length) and/or manual therapy, among other techniques.

Through communication you and your PT can figure out how to achieve maximum improvement for both situations with managed flare-ups.

Thank you for submitting this question. A patient with a hybrid pelvic floor such as yours  is a great example of why treatment plans must be individualized to be effective. PTs should always focus on a patient’s impairments and responses to treatment when designing a treatment plan. One-size-fits-all is never the way to go with pelvic floor PT.

Be well,

Pain with Sex: Is Surgery the Answer?

Dear Melinda,

I had a hysterectomy many years ago. Ever since, I have had painful intercourse. I kept my ovaries, so it’s not menopause. The doctors believe that scar tissue from the surgery is causing my pain. I was told that the only way to find out is to have surgery again, and if they see the scar tissue they can remove it, but it will probably return. I have stopped having sex because of the pain in the upper part (in the far back) of my vagina. Is there anything that can help with this pain without having surgery?


Painful Sex after Surgery

Dear Painful Sex,

There are many possible causes for pain with intercourse. Possible post-surgery scar tissue is only one possibility. A thorough physical therapy exam will help determine exactly what issue/issues are causing your pain. For instance, tight pelvic floor muscles and trigger points  may cause painful sex. Trauma to the pelvic floor can cause either of these impairments to occur, and any type of surgery, a hysterectomy included, qualifies as trauma to the pelvic floor. Both tight pelvic floor muscles and trigger points can be treated with manual physical therapy.

If the problem is indeed scar tissue, manual therapy can also be helpful. Take a look at this blog post that describes how manual PT helps treat scar tissue.

As far as the option of having surgery to remove any existing scar tissue, as with any surgery, this would carry the risk of creating its own scar tissue. So that is definitely something you have to consider before opting for surgery.

All my best,

What Doc Treats Male Pelvic Pain?

Dear Steph,

I am a 20-something male with pelvic pain. My main symptoms are perineal pain and pain with sitting. I do not have any urinary symptoms. In the research that I’ve done, it seems that the majority of pelvic floor specialists are gynecologists. What sort of doctor should a male with pelvic pain see?


Guy with Pelvic Pain

Dear Guy with Pelvic Pain,

Most men with pelvic pain consult with a urologist first. With both men and women who start experiencing pelvic pain it is best to rule out other causes of pain first, such as infection. If infection, or other pathology, is ruled out a urologist who specializes in male pelvic pain (they are out there) can refer you to a physical therapist if it seems as though there are musculoskeletal causes of your pelvic pain. A urologist can also prescribe medications, if appropriate, to decrease your symptoms. There are two well-known gynecologists who also treat men with pelvic pain. They are Michael Hibner, MD and Mark Conway, MD. They are two of the surgeons in the U.S. who perform the pudendal nerve decompression surgery, that’s why they see both men and women. In your case, however, it seems very premature to consult with either of these physicians.

For more information about male pelvic pain, please click here.

Can my Bladder Hurt my Back?

Dear Stephanie,

I’ve been diagnosed with IC and I also have chronic back pain. I’ve been to a couple of doctors about this and it always seems to be this mystery of why my back hurts the way that it does, especially since it doesn’t look that bad on MRI’s and X-rays. The pain is in my lower back.  There are times that I move and I can feel that area immediately tense up, leaving me out of commission for a couple of days. Is there a link between the bladder and lower back pain as far as trigger points go?  Have you seen this before?


Bladder and Back Pain

Dear Bladder and Back Pain,

Yes, your pelvic pain could be contributing to your back pain particularly if other sources of back pain have been ruled out (lumbar spine pathology upon MRI/X-ray). The reason for this is that when your pelvic floor musculature is impaired (tight, weak, has trigger points, etc.), it’s going to affect the surrounding muscles. Indeed, if the pelvic floor muscles are not able to work optimally the surrounding muscles have to compensate, or work a little harder.

The muscles that may have to work harder include the muscles in your pelvic girdle, hip, low back, and legs. When muscles have to overcompensate for dysfunction somewhere else in the body they can develop trigger points or dysfunction themselves, which can cause additional pain. I think this is likely what is happening in your case.

A good pelvic floor PT should treat not only the muscles of the pelvic floor, but all the surrounding muscles as well. You should find relief with this type of comprehensive treatment plan.

All my best,

The Role of a Pain Management Doc

Dear Liz,

What is the role of pain management physicians in the treatment of pelvic pain? How important is this provider, and how would you describe high quality pain management?


Curious about Pain Doc

Dear Curious,

Pain management MDs play an integral role in the treatment of pelvic pain for those patients who require interventional pain treatment (nerve blocks, trigger point injections, Botox, etc.) and/or pharmaceuticals.

Also, it is important for patients who require pain medication to be managed by a pain doc because that is their area of expertise. They are the drug experts. Also, pain docs are very skilled at putting needles in the right place because they do it all day, so they are often the best person to do nerve injections.

High quality pain management is a hard situation to evaluate, but in my opinion and experience, it’s an MD who works closely with the other members of the treatment team, such as the patient’s PT, ob/gyn, urologist, among others, someone who is willing to try different treatment strategies until they get success, and lastly, and maybe most importantly for pelvic pain, someone with some experience with pelvic pain.

Be Well,

If you have a question of your own, please take the opportunity to post it in the “comments” section of this blog, email it to us at [email protected], post it on our Facebook page or tweet it to us. We want to hear from you!

All our best,
Steph, Liz and Melinda


  1. I am currently 33 weeks into my 2nd pregnancy. I had slight pelvic during 26th week but it seems ok now. The issue is my pelvic has gotten quite low since 2nd trimester. This week when I visited my gynae, she checked and said it’s quite bad that the muscle (i’m not sure if she meant pelvic muscle) had dropped. Now I have my vagina area with a muscle slightly bulging out. She said a repair is probably necessary 6 months after baby is out, even though if i choose to do nothing, it’s only an aesthetic issue, not risking my health in any way. I also did ask if pelvic exercises after my delivery will help to retract this bulging muscles and she said it’s no use.

    I am quite concerned about delivery particularly I like to go for natural vaginal birth without epidural, same like what i did for the 1st delivery. However, the gynae kept telling me that I should go for epidural to avoid further injury to the vaginal/ pelvic drop. I don’t know if epidural will really do the magic since I know epidural or not, pushing is still necessary in any delivery. I’m also cautious about what gynaes in SG say because often, they offer quick, fast (and inevitably costlier) solutions which may not be the best options all the time.

    Please advise if epidural is really necessary for my case. And, is it true that it’s really only an aesthetic issue and besides surgery, no exercise can help to retract?

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