Unraveling the Mystery of Adhesions and Pelvic Pain

May is Pelvic Pain Awareness Month, highlighting a critical issue that impacts 25% of women, many of whom come to our clinic seeking relief from pain and dysfunction. Chronic pelvic pain is defined by the American College of Obstetricians and Gynecologists (ACOG) as "nonclinical pain lasting at least six months, occurring in areas such as the pelvis, anterior abdominal wall, lower back, or buttocks, and severe enough to cause disability or necessitate medical attention." Beyond physical discomfort, individuals may also face sleep disturbances, depression, anxiety, and adverse effects on relationships and work capability. In a clinical setting, pelvic pain often presents as symptoms like menstrual cramps, back pain, hip and sacroiliac dysfunction, infertility, or issues with the bladder, bowel, or sexual function. It's crucial to exclude medical causes of pelvic pain, and consulting a urologist or urogynecologist might be necessary.

Adhesions are frequently neglected as a source of pain and dysfunction in the pelvic area. Beyond causing discomfort, adhesions can interfere with core function by constricting the muscles and nerves in the abdominal and lumbopelvic regions, much like a straitjacket. These adhesions are fascial restrictions, similar to a stiff knee following surgery or a scar on a knuckle. To comprehend how adhesions impair function, it is crucial to understand what fascia is.

In recent years, medical researchers claim to have discovered a new organ they renamed the interstitium. What they are describing is fascia, the fluid-filled matrix of connective tissue throughout the body that serves as a scaffolding system and an envelope around blood vessels, nerves, muscles and organs that drains into the lymphatic system. Consisting of 250 million neurons, it is highly neurological tissue. Think of fascia as the white, slippery connective tissue in chicken or roast beef. Healthy fascia is essential for normal organ function, joint mobility, movement and muscle performance. If fascia is unhealthy, it can result in stiffness, myofascial pain syndromes, disease and chronic debilitation. Fascia is made up of collagen and elastin protein fibers and ground substance (a gelatinous watery substance in between the collagen and elastin protein fibers). During the healing process, the ground substance dehydrates while type I collagen lays down in a process called collagen cross-linking. The healing process occurs anytime there is an inflammatory event:

• surgery

• menstruation

• kidney stone

• injury/ fall

• car accident

• radiation

• pregnancy

• irritable bowel, inflammatory bowel disease

• endometriosis (read our blog here)

• chronic inflammation

The likelihood of developing adhesions after gynecological surgery increases with each procedure. A study conducted by autopsy investigators revealed a 90% incidence of adhesions in those with multiple surgeries, a 70% incidence in women who underwent gynecological surgery, a 50% incidence following an appendectomy, and over a 20% incidence in patients with no surgical history. This may account for the presence of adhesions in athletes who frequently fall during sports or in individuals with gut inflammation. Over time, issues may arise as the body adapts. Conditions such as piriformis syndrome or hip bursitis can progress to pelvic floor tightness and fascial restrictions, particularly when estrogen levels decrease, disrupting normal urinary and bowel functions, menstruation, intimacy, and/or core muscle performance. Click here to explore the hormonal connection to fascia.

With over 35 muscles, each muscle fiber encased in a layer of fascia, the pelvis is more prone to adhesions than any other part of the body. Adhesions are more prevalent in females, on the right side of the body where large organs like the liver are located, and in certain individuals due to their unique genetic composition of collagen and elastin. These adhesions contribute to pain because of nerve fibers called nociceptors within the fascia, leading to sensations such as burning, pulling, and deep cramping. Adhesions can attach around nerves, disrupting the function of the nervous and digestive systems, and causing pain or a loss of sensation in certain areas. They also increase the risk of small bowel obstruction (SBO), a potentially life-threatening condition where stool cannot pass through the system. Adhesions interfere with neurological messages as the brain receives altered information due to body tightness. Imagine the brain as a general and the nerves as a reconnaissance team bringing information back to the general. If the information reaching the general is altered, the information sent back to the troops will be inaccurate or distorted. This illustrates what occurs in perpetual holding patterns as muscles and fascia contract to protect vital organs and areas of the body.

There has been increased research and focus on the gut-brain axis, a communication network that operates in both directions between the digestive system (gut) and the brain. This network involves pathways that include the nervous system, endocrine system, immune system, and the gut microbiome. This bi-directional signaling explains how the gut can affect the brain and how the brain and nervous system can impact gut functions like digestion. The gut contains over 100 million neurons, and the enteric nervous system contributes up to nine times more neurons to the body than the brain itself, highlighting a bottom-up rather than top-down influence. Many neurons in the gut are mechanoreceptors, which, when activated, can initiate neuroendocrine changes, including the production of serotonin, a neurotransmitter linked to mood and behavior, and histamine, a substance involved in inflammation. Experts now assert that 90% of serotonin is generated in the gut-brain. Maintaining a healthy gut is crucial for a healthy mind and, naturally, a healthy core.

Structurally, adhesions forming around the organs (viscera) can interfere with various functions, such as the normal mobility of organs. Organs are active and move with each breath and during digestion throughout the day. Fascia restrictions can occur around the bladder, intestines, diaphragm, kidneys, ovaries, uterus, tailbone, pelvic floor, prostate (in males), and nerves. Here are some examples of how adhesions can affect function:

Adhesions around the bladder can limit its ability to expand as it fills with urine. The bladder functions like a water balloon, needing to stretch and rise as it accumulates urine. When the bladder's capacity is reduced, it can lead to frequent urination, urethritis (pain or burning in the urethra), bladder pain, prostatitis in males, urgency to urinate, or nocturia (nighttime urination). Many people are surprised that after just one or two sessions of visceral mobilization, they can sleep through the night. Some women have experienced this issue for over 10 years, believing it was "normal."

Scar tissue around the colon or large intestine can cause pain and dysfunction. The large intestine serves as a passageway for stool. If this passageway is surrounded by adhesions and becomes narrowed, it may result in small stools or a blockage leading to constipation. The cecum (the beginning of the colon on the right side) and the sigmoid (the end of the colon on the left side) run alongside the iliopsoas muscle (hip flexor) on each side. Unresolved adhesions around the large intestine can lead to persistent tightness in the hip flexors. The likelihood of a small bowel obstruction (SBO), which can be life-threatening if untreated, increases following abdominal surgery.

Adhesions around the small intestine can lead to bloating, pain, menstrual cramps, urinary frequency, and/or pelvic organ prolapse. The small intestine, a convoluted tube about 20 feet long, is positioned anatomically above the bladder. If stool remains there, it puts downward pressure on the bladder, occupying space and preventing the bladder from expanding. The ileo-cecal valve plays a role in maintaining muscle tone and facilitating peristalsis (movement) of stool within the colon. If the valve becomes stuck, it can slow down colon transit time, causing constipation or pain when the stool tries to pass through the system.

Adhesions near the tailbone can occur due to trauma, such as a fall or injury, chronic constipation, childbirth, or other abdominal surgeries. When the coccyx (tailbone) is restricted, it can cause the pelvic floor muscles to tense up, affecting penetration, sitting ability, and bladder or bowel function.

Adhesions surrounding peripheral nerves can impair function and lead to pain syndromes. The nervi nervorum is the fascial sheath that wraps around nerves, similar to duct tape around an electrical cord. Adhesions in this sheath can reduce the natural glide of the nerve during movement. A restriction around the sciatic nerve can lead to pain when sitting and cause muscle tightness in the hamstrings and legs. Restrictions in the obturator nerve may result in tightness or pain in the pelvic floor, groin, and inner thigh. The pudendal nerve can become trapped in various structures, including the pelvic floor and hip muscles, leading to pelvic floor tightness and saddle pain.

Adhesions surrounding the kidney can impact hip mobility, breathing depth, and core function. With each breath, the kidneys move vertically up to two centimeters. When the fascia around the kidneys (renal fascia) is tight, it can lead to shallow breathing and interfere with the deep core muscle function via the pelvic floor piston. If the kidneys are restricted, the pelvic floor cannot relax properly or contract and lift during exhalation. This can also result in pain, stiffness, or reduced endurance during exercise.

Adhesions surrounding the uterus can lead to menstrual pain and impact fertility. During each menstrual cycle, histamine is released, causing inflammation. Furthermore, as the uterus sheds its lining and menstruation takes place, menstrual cramping can be intense if the structures around the uterus are restricted. Many women and female athletes we treat experience a reduction or even complete elimination of menstrual pain, even if they initially sought treatment for other reasons. Fertility can also be influenced by adhesions around the ovaries, Fallopian tubes, uterus, and ligaments. Click here to read our blog on menstrual cramps.

Adhesions play a role in muscle pain syndromes. A lot of people experience ongoing tightness and pain in the hip flexors, which is frequently alleviated by mobilizing the renal fascia and respiratory diaphragm. If the fascia referred to as the urogenital diaphragm is restricted, the pelvic floor muscles will stay tight. Furthermore, enhancing flexibility in the hamstrings and hips can be achieved by addressing adhesions around the pelvis.

Scar tissue will not disappear or become flexible over time without intervention. The best way to mobilize fascia is by mechanically loading the tissue, either through manual therapy or specific exercises or movements. Adhesions prevent the core muscles from functioning as intended. The fascia surrounding the organs is continuous with the fascia enveloping the muscles in the lumbopelvic region, including the thighs. Contracting the core muscles can actually reproduce symptoms or pull on the fascia more, perpetuating the issue, creating the "catch 22" that many individuals face.

How can one address fascial stiffness? There are methods to enhance tissue glide and improve fascia extensibility. At Healthy Core, we employ various techniques to tackle adhesions in the pelvic area. We utilize our hands for visceral mobilization, targeting the deep fascia around organs, and employ tools such as vacuum cupping, percussion massagers, kinesiotape, and soft, pliable balls (not hard foam rollers). Visceral mobilization is conducted by a highly skilled provider on the abdomen, thighs, and even internally (vaginally or rectally) to address restrictions around the tailbone, urethra, or pelvic floor. In the United States, physical therapists are among the few professionals authorized to perform intravaginal and intrarectal treatments. After addressing adhesions, we guide you on maintaining your fascia's health for sustained mobility, muscle flexibility, and overall strength. Seeking assistance from the right provider is crucial for alleviating pelvic pain caused by adhesions. If medical screenings have not identified the cause of your pain, adhesions might be responsible. Conduct thorough research and ask questions before booking an appointment to ensure you receive proper care (pun intended). To schedule an appointment with one of our pelvic health experts, call (330)528-0034 or email us at info@healthycorewellness.com.

References:

www.itmonline.org/arts/adhesions.htm.

Schleip R et al. 2012. Fascia - The Tensional Network of the Human Body. Churchill Livingstone.

Callaghan et al. Effects of Patellar Taping on Brain Activity during Knee Joint Proprioception Tests Using Functional Magnetic Resonance Imaging.

written by: Janine Laughlin, PT