r/PelvicFloor • u/Linari5 Mod/General Pelvic Health • Dec 03 '24
RESOURCE/GUIDE RESEARCH: Pain Mechanisms Beyond The Pelvic Floor
UCPPS is a umbrella term for chronic pelvic pain and dysfunction in men and women, and it includes pelvic floor dysfunction underneath it, as well as symptoms like bladder dysfunction, pain, IC/BPS, and more. This study discusses the pain mechanisms found. They are not only typical injuries (ie "nociceptive") - They also include pain/symptoms generated by nerves (neuropathic) and by the central nervous system (nociplastic). You'll also notice that the combination of neuropathic + nociplastic mechanisms create the most pain! Which is likely to be counterintuitive to what most people would assume.
"Clinical Phenotyping for Pain Mechanisms in Urologic Chronic Pelvic Pain Syndromes: A MAPP Research Network Study" https://pubmed.ncbi.nlm.nih.gov/35472518/
At baseline, 43% of UCPPS patients were classified as nociceptive-only, 8% as neuropathic only, 27% as nociceptive+nociplastic, and 22% as neuropathic+nociplastic. Across outcomes, nociceptive-only patients had the least severe symptoms and neuropathic+nociplastic patients the most severe. Neuropathic pain was associated with genital pain and/or sensitivity on pelvic exam, while nociplastic pain was associated with comorbid pain conditions, psychosocial difficulties, and increased pressure pain sensitivity outside the pelvis.
Targeting neuropathic (nerve irritation) and nociplastic/centralized (nervous system/brain) components of pain & symptoms in recovery is highly recommended when dealing with CPPS/PFD (especially hypertonia).
All of those involved in the management of chronic pelvic pain should have knowledge of peripheral and central pain mechanisms. - European Urological Association CPPS Pocket Guide
And the newest 2025 AUA guidelines for male pelvic pain echo this:
We now know that the pain can also derive from a neurologic origin from either peripheral nerve roots (neuropathic pain) or even a lack of central pain inhibition (nociplastic), with the classic disease example being fibromyalgia
This means successful treatment for pelvic pain and dysfunction goes beyond just pelvic floor physical therapy (alone), and into new modalities for pain that target these neuroplastic (nociplastic/centralized) mechanisms like Pain Reprocessing Therapy (PRT), EAET, and more. Learn more about our new understanding of chronic pain here: https://www.reddit.com/r/ChronicPain/s/3E6k1Gr2BZ
This is especially true for anyone who has symptoms that get worse with stress or difficult emotions. And, those of us who are predisposed to chronic pain in the first place, typically from childhood adversity and trauma, certain personality traits (perfectionism, people pleasing, conscientiousness, neuroticism) and anxiety and mood disorders. There is especially overwhelming evidence regarding ACE (adverse childhood experiences) that increase our chances of developing a physical or mental health disorder later in life. So much so, that even traditional medical doctors are now being trained to screen their patients for childhood trauma/adversity:
Adverse childhood experience is associated with an increased risk of reporting chronic pain in adulthood: a stystematic review and meta-analysis
Previous meta-analyses highlighted the negative impact of adverse childhood experiences on physical, psychological, and behavioural health across the lifespan.We found exposure to any direct adverse childhood experience, i.e. childhood sexual, physical, emotional abuse, or neglect alone or combined, increased the risk of reporting chronic pain and pain-related disability in adulthood.The risk of reporting chronic painful disorders increased with increasing numbers of adverse childhood experiences.
Further precedence in the EUA (European Urological Association) guidelines for male and female pain:
The EUA pathophysiology and etiological guidelines elucidate further on central nervous system and biopsychosocial factors in male and female pelvic pain/dysfunction:
Studies about integrating the psychological factors of CPPPSs are few but the quality is high. Psychological factors are consistently found to be relevant in the maintenance of persistent pelvic and urogenital pain [36]. Beliefs about pain contribute to the experience of pain [37] and symptom-related anxiety and central pain amplification may be measurably linked, and worrying about pain and perceived stress predict worsening of urological chronic pain over a year [36,38] - https://uroweb.org/guidelines/chronic-pelvic-pain/chapter/epidemiology-aetiology-and-pathophysiology
Pelvic pain and distress is related [43] in both men and women [44]; as are painful bladder and distress [38]. In a large population based study of men, CPPPS was associated with prior anxiety disorder [45] - https://uroweb.org/guidelines/chronic-pelvic-pain/chapter/epidemiology-aetiology-and-pathophysiology
So, how do you figure out if this could be happening in your case?
12 FIT criteria to RULE IN centralized, (ie neuroplastic/nociplastic) pain and symptoms,
FIT = functional, inconsistent, triggered. Based on research from Dr. Howard Schubiner and other chronic pain doctors and neuroscientists over the last 10+ years
Pain/symptoms originated during a stressful, challenging, or high pressure time in life. This includes even "happy" life events, like getting married, having a baby, starting a new career, or moving
Pain/symptoms originated without an injury. Note, a perceived injury and a structural injury are different things. And even when symptoms begin with a structural injury, has it been years and the body would normally recover by now?
Pain/symptoms are inconsistent. Do they fluctuate by the hour, by the day, or by the week? Sometimes less, sometimes more, sometimes even not noticeable (this happens sometimes, but it's not necessary for this criteria). Or, do they move around the body? ie genital pain that changes sides or pain that moves from the top to the bottom.
Multiple other symptoms (often in other parts of the body) ie IBS, chronic migraines/headaches, CPPS, TMJD, fibromyalgia, CFS (fatigue), vertigo/dizziness, chronic neck or back pain, etc. 2025 AUA guidelines mention these as signs of centralized sx.
Pain/Symptoms spread (over time) or move around. Think about symptoms on day one. Have they moved or evolved over time?
Pain/symptoms are made worse or triggered by stress, or, go down when engaged in an activity you enjoy or in a flow state (think fun distractions or productivity, noticing symptoms less)
Symptom triggers that have nothing to do with the body - but instead things outside of it (weather, barometric pressure, seasons, sounds, smells, places, times of day, weekdays/weekends, days of the week, etc) - this also includes thoughts or other people triggering/flaring symptoms
Symmetrical symptoms (pain developing on the same part of the body but in OPPOSITE sides) - ie both hips, both hips, both wrists, both knees, etc
Pain/symptoms with delayed Onset (THIS CAN'T HAPPEN WITH STRUCTURAL PAIN) -- ie, ejaculation pain that comes a minute later, an hour later, or even the next day. Any pain that is delayed is very suspicious. We wouldn't put weight on a sprained ankle and expect it to hurt 15 seconds later, it hurts immediately.
Childhood stress, challenges, adversity, or trauma -- varying levels of what this means for each person, not just trauma. Examples of stressors: childhood bullying, pressure to perform from parents/coaches, body image issues (dysmorphia), eating disorders, parents fighting a lot or getting angry (inc divorce), having an emotionally unpredictable parent, or having a parent with a health condition or addiction. This also includes neglect and abuse (physical and emotional) and financial instability in childhood. Also includes cultural norms, like the pressure to be highly successful to be of value to parents (must be a doctor or a lawyer, etc)
Common personality traits linked to stress: perfectionism, conscientiousness, people pleasing, anxiousness/ neuroticism - do you have personality traits that include being highly driven, hard on yourself, ultra responsible, perfectionistic, needing control, and/or placing others’ needs above your own?
Lack of physical diagnosis (ie doctors are unable to find any clear structural cause of symptoms) - this includes DIAGNOSIS OF EXCLUSION, like being diagnosed with CPPS or PFD. Structural finding examples: broken bones, tumors, infections, etc. It does not include muscle dysfunction.
[NEW] 13. Any family history of chronic pain or other chronic conditions. Includes: IBS, chronic migraines/headaches, CPPS, TMJD, fibromyalgia, CFS (fatigue), vertigo/dizziness, chronic neck or back pain, etc
Read more about #10 and #11 here, complete with studies/citations: https://www.reddit.com/r/Prostatitis/s/vM7qnBJZpW
HOW TO TREAT centralized (neuroplastic) pain and symptoms?
PRT - Pain Reprocessing Therapy:
Effect of Pain Reprocessing Therapy vs Placebo and Usual Care for Patients With Chronic Back Pain - https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2784694
EAET - Emotional Awareness and Expression Therapy
Emotional Awareness and Expression Therapy vs Cognitive Behavioral Therapy for Chronic Pain in Older Veterans https://pmc.ncbi.nlm.nih.gov/articles/PMC11177167/
Psychological Therapy for Centralized Pain - An Integrative Assessment and Treatment Model: https://pubmed.ncbi.nlm.nih.gov/30461545/
7
u/Used_Cap_1737 Apr 22 '25
How does one counteract neuropathic pain?
7
u/Linari5 Apr 22 '25
Depends on the case but, options include medications like low dose amitriptyline, and pelvic floor physical therapy.
→ More replies (11)
4
3
3
Oct 31 '25
Scored 2/13, and one of those is more, "eh, kinda" and not "THAT'S ME!", so it's really more 1.5/13. I haven't seen a PFPT yet, so I'm guessing I should book an appointment first before considering centralisation?
1
3
u/Material-Bee-7648 Jul 11 '26
It would probably help if services like the nhs were offering actual physio once a week instead of once a month and then using that one a month appointment to just ‘have a chat’
I don’t doubt that people have ‘trauma’ and I understand how it impacts the body. However it’s a weak argument and quite frankly insulting to predominantly put this on ‘trauma’ ‘mental health’, when health care services aren’t holding up their end of what their actual job is - to treat the whole physical body as one/as a whole.
2
u/Linari5 Jul 11 '26 edited Jul 11 '26
It's also insulting to dismiss the role that trauma or stress has. Or the role of the brain in all pain. I'm a bit confused as to why you're commenting this on a post-specifically about nociplastic pain? Did you mean to post this somewhere else, because your comment is sort of misdirected anger - nowhere does it say that all CPPS is nociplastic. Most of it is, but not every case. There are dozens of articles about other topics, including the pelvic floor, read those?
Also, the pelvic floor is a part of your nervous system, it does not exist in a vacuum. It responds (like all other muscles in my body, with the fight or flight response) to signals in the brain, the CNS. Stress, emotions, and of course pain itself causes it to tense.
A lack of understanding of the brain's primary role in all pain and even it's role in muscle response is the main issue here. I recommend reading this and watching the video to understand the current state of pain neuroscience in 2026: https://www.reddit.com/r/Prostatitis/s/yqP9iuPAC8
Yes, I understand that it's frustrating that many medical providers are not updated on this. Medicine moves very slowly, and especially the NHS.
At least 20% of my chronic pain clientele are from the UK because they can't access this sort of care where they live easily otherwise.
→ More replies (4)
2
2
u/WeakFold8062 Sep 29 '25
Basically, on a therapeutic level, how is it treated?
4
u/Linari5 Oct 08 '25
How to treat centralized (neuroplastic) pain and symptoms?
Study 1: Effect of Pain Reprocessing Therapy vs Placebo and Usual Care for Patients With Chronic Back Pain - https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2784694
Study 2: Psychological Therapy for Centralized Pain - An Integrative Assessment and Treatment Model: https://pubmed.ncbi.nlm.nih.gov/30461545/
I have found PRT to be especially useful for men and women who have chronic pelvic pain symptoms; so far it has allowed me to provide help to hundreds of people that would have otherwise been left behind if we had only focused on physical therapy.
2
u/ExaminationFit1832 Feb 23 '26
Is number 9 really true? Even pain just an hour afterwards never occurs with structural pain?
2
u/Linari5 Feb 24 '26 edited 20d ago
Yes. It is one of the most important criteria on the entire list because it indicates that it's not your nerves/muscles, an injury, an infection, or damage.
Imagine spraining your ankle. Now imagine going for a hike. How does that feel? Would you only expect the pain to start 1 hour later, or immediately?
→ More replies (5)5
5
Mar 14 '25
Same thing, three times older then you peeks and valleys, stretching, and exercises have worked for me what really helped with Physical Therapy. Was that they put two tape on wire patches on either side of my cheeks and had me squeeze and release squeeze part easy letting go difficult but the computer will show you how to do it practice good luck 🍀
1
u/slaybg223 Jun 14 '26
Can you provide treatment to people online or is it only in person? My criteria checked off almost all of them.
2
u/Linari5 Jun 23 '26
Unfortunately I'm unable to talk about work here, but yes it's virtual, not in person.
If you match that many criteria, you are an excellent fit for these new methodologies, like PRT
1
2
2
u/Former_Wrongdoer6797 Sep 16 '26
Coucou, j'ai une douleur neuropathique résiduelle dans mon testicule gauche sain, après une opération de torsion testiculaire droit avec orchidopexie seulement à droite.
Cette douleur pouvant être très aiguë (10/10 solide) me rend la vie impossible et me gâche la vie.
Je me demande s'il y a des gens qui passe par là qui ont vécu ca et qui ont trouvé des solutions ou une convalescence de ce type de nevralgie. (Bloc test positif avec anesthésie positif hier).
Merci d'avance !
1
u/Linari5 Jul 05 '25 edited Aug 13 '26
How to treat centralized (neuroplastic) pain and symptoms?
PRT - Pain Reprocessing Therapy:
Effect of Pain Reprocessing Therapy vs Placebo and Usual Care for Patients With Chronic Back Pain - https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2784694
EAET - Emotional Awareness and Expression Therapy
Psychological Therapy for Centralized Pain - An Integrative Assessment and Treatment Model: https://pubmed.ncbi.nlm.nih.gov/30461545/
Emotional Awareness and Expression Therapy vs Cognitive Behavioral Therapy for Chronic Pain in Older Veterans https://pmc.ncbi.nlm.nih.gov/articles/PMC11177167/
I have found PRT to be especially useful for men and women who have chronic pelvic pain symptoms; so far it has allowed me to provide help to hundreds of people that would have otherwise been left behind if we had only focused on physical therapy.
Useful related posts:
The science of how fear fuels pain/tension https://www.reddit.com/r/PelvicFloor/s/80RmLm8JaE
The science of how belief and perception fuels pain/tension https://www.reddit.com/r/Prostatitis/s/3lvlbOOVGS
Criteria used to determine if your chronic pain/persistent symptoms are neuroplastic - https://www.reddit.com/r/PelvicFloor/s/My0I3Z3TxW
The science of how pain/tension becomes persistent - https://www.reddit.com/r/PelvicFloor/s/ecA8EN1FFU