Pelvic Pain: What It Is, Why It Lingers, and What Physical Therapy Can Do

Pelvic Pain:What It Is, Why It Lingers, and What Physical Therapy Can Do About It

By Kelly Brown Gross, PT, MPT, WCS  |  Ashworth Chiropractic, Physical Therapy & Acupuncture  |  West Des Moines, Iowa

Pelvic pain is one of the most undertreated conditions in women’s health. Not because effective treatment doesn’t exist — it does. But because women are often told that pelvic pain is normal, that it’s just part of their cycle, that it’s anxiety, that it will probably improve on its own.

Sometimes it does improve on its own. More often, it doesn’t. And the longer it goes unaddressed, the more it shapes the way a woman moves, sleeps, exercises, works, and experiences intimacy. The longer it goes, the harder it becomes to unwind.

In over 20 years of working with pelvic pain patients, the pattern I see most often is this: a woman has been in pain for months or years, has seen multiple providers, has been told her imaging is normal or her labs are unremarkable — and has been sent home without a clear path forward. She doesn’t know that what she has is treatable. And she doesn’t know that pelvic floor physical therapy is often the missing piece.

This post is for her.

What Is Chronic Pelvic Pain?

Chronic pelvic pain is broadly defined as pain in the lower abdomen, pelvis, or perineum that persists for 6 months or longer. But that definition undersells how varied and complex it actually is.

Pelvic pain looks different in different people. It might be:

• A constant, deep aching in the lower pelvis that is always present and worsens by end of day
• Sharp, stabbing pain with specific activities — sitting, standing, exercising, or during or after sexual intercourse
• Burning or rawness in the vulvar region that makes clothing uncomfortable
• Heaviness or pressure deep in the pelvis — the sense that something is falling out or pushing down
• Pain that cycles with the menstrual period but extends beyond it
• Pain during urination or bowel movements that doesn’t have a clear urological or gastrointestinal cause

Pelvic pain frequently involves multiple overlapping sources — uterine, ovarian, bladder, bowel, muscular, neurological — which is exactly why it is so often missed in a system designed to evaluate one organ at a time.

A gynecologist examines the reproductive organs. A urologist examines the bladder. A gastroenterologist examines the bowel. If each specialist finds their organ unremarkable, the patient is sent home without an answer. What often goes unevaluated is the pelvic floor — the muscular system that surrounds and supports all of those organs simultaneously.

The Conditions Behind Pelvic Pain — and Why the Pelvic Floor Is Almost Always Involved

Pelvic pain rarely has a single cause. The conditions most commonly associated with it include:

Dyspareunia — Pain During or After Sex

Pelvic pain is much more common that many people think and highly treatable with the right approach.

Dyspareunia is one of the most common presentations in my practice and one of the most under-discussed. Pain during intercourse — whether superficial (at the vaginal entrance) or deep (deeper in the pelvis) — has a high likelihood of having a pelvic floor muscle component. Pelvic floor muscles that are hypertonic (too tight, too guarded) produce pain with penetration, pressure, and friction in ways that have nothing to do with relationship quality or psychological state. They are muscles in spasm. They respond to specific physical therapy techniques designed to release them.

Endometriosis

Endometriosis — the presence of endometrial-like tissue outside the uterus — affects roughly 10% of women of reproductive age. It is associated with chronic pelvic pain, painful periods, and dyspareunia. The relationship between endometriosis and the pelvic floor is direct: chronic inflammation and pain drive protective muscle guarding, which becomes its own source of pain even when the underlying endometriosis is treated or managed. Addressing the pelvic floor component is frequently the missing piece in endometriosis pain management.

Vulvodynia and Vestibulodynia

Vulvodynia is chronic vulvar pain without an identifiable cause — burning, stinging, rawness, or irritation in the external genital area. Vestibulodynia is localized to the vestibule, the tissue at the vaginal opening. These conditions are closely associated with pelvic floor hypertonia and respond meaningfully to targeted pelvic floor physical therapy. The pelvic floor muscles attach directly to the vestibular tissue — tension in the muscles creates tension and sensitivity in the surrounding tissue.

Interstitial Cystitis / Bladder Pain Syndrome

IC/BPS is a chronic bladder pain condition characterized by pelvic pressure, urgency, frequency, and pain with bladder filling. The pelvic floor is intimately involved — hypertonic pelvic floor muscles increase tension around the bladder and urethra, exacerbating symptoms. Pelvic floor physical therapy is now recognized as a first-line treatment for IC/BPS by major urology organizations.

High-Tone Pelvic Floor Dysfunction

This is the underlying mechanical driver in many cases of pelvic pain — regardless of which condition is attached to it. The pelvic floor muscles are held in a state of chronic tension. They don’t relax fully. They don’t coordinate normally. The sustained muscle guarding produces pain, pressure, and the cascade of symptoms that looks like bladder pain, sexual pain, bowel dysfunction, and generalized pelvic heaviness — all at once.

The critical point: high-tone pelvic floor dysfunction is not fixed by strengthening. It is fixed by release, re-coordination, and retraining. Telling someone with high-tone dysfunction to do kegels is like telling someone with a leg cramp to flex harder.

What the Research Shows

Based on articles retrieved from PubMed, the evidence for multimodal physical therapy in chronic pelvic pain is strong and growing.

38 RCTs, 2,168 Women — High Certainty of Evidence

The most comprehensive review of the evidence to date was published in 2024 in the American Journal of Obstetrics and Gynecology (Starzec-Proserpio et al.) — a systematic review and meta-analysis of 38 randomized controlled trials covering 2,168 women with chronic pelvic pain. The conclusion: multimodal physical therapy resulted in significantly lower pain intensity compared to inert or non-conservative treatments in both the short term (high certainty of evidence) and the intermediate term (moderate certainty of evidence).

The GRADE certainty rating matters here. ‘High certainty’ is the highest level the evidence grading system awards. This is not a marginal finding from a small pilot study. It is the strongest possible research conclusion from nearly four decades of randomized controlled trials.

Starzec-Proserpio M, et al. Effectiveness of nonpharmacological conservative therapies for chronic pelvic pain in women: a systematic review and meta-analysis. Am J Obstet Gynecol. 2024;232(1):42-71. DOI: https://doi.org/10.1016/j.ajog.2024.08.006

Pelvic Floor PT for Endometriosis — RCT Evidence

A randomized controlled trial published in Ultrasound in Obstetrics & Gynecology (Del Forno et al., 2021) enrolled 34 women with deep infiltrating endometriosis and superficial dyspareunia and randomized them to pelvic floor physical therapy or no intervention. At four-month follow-up, the physical therapy group showed significantly improved pelvic floor muscle relaxation on 3D/4D transperineal ultrasound, a marked reduction in superficial dyspareunia scores (median change of -3 on the numerical rating scale vs. 0 in the control group), and significant improvement in chronic pelvic pain.

The ultrasound findings are particularly meaningful — the therapy produced measurable, objective changes in the pelvic floor muscle architecture, not just subjective pain score improvements. The tissue actually changed.

Del Forno S, et al. Assessment of levator hiatal area using 3D/4D transperineal ultrasound in women with deep infiltrating endometriosis and superficial dyspareunia treated with pelvic floor muscle physiotherapy: randomized controlled trial. Ultrasound Obstet Gynecol. 2021;57(5):726-732. DOI: https://doi.org/10.1002/uog.23590

The research is clear: multimodal pelvic floor physical therapy is effective for chronic pelvic pain with the highest possible certainty of evidence. For specific conditions like endometriosis-related dyspareunia, RCT evidence shows both subjective pain relief and measurable objective changes in pelvic floor structure. This is not experimental. It is evidence-based first-line care.

Why ‘Just Do Kegels’ Is Often the Wrong Advice for Pelvic Pain

This is one of the most important things I want to communicate to anyone reading this who has pelvic pain.

Kegel exercises — pelvic floor contractions — are strengthening exercises. They are appropriate when the pelvic floor is weak, underactive, or poorly coordinated in the direction of insufficient contraction.

But the most common pelvic floor finding in women with pelvic pain is the opposite: a pelvic floor that is too tight, too guarded, too unable to relax. High tone. Hypertonicity. The muscles are working too hard, not too little.

Strengthening a hypertonic muscle does not relieve its pain. It amplifies it. Women who have been doing kegels for pelvic pain and finding that things are getting worse — or not improving — are often doing exactly the wrong exercise for their presentation.

This is why evaluation matters before treatment. A thorough pelvic floor assessment tells us which direction the problem actually lies — and whether the approach should be strengthening, releasing, re-coordinating, or some combination. That assessment cannot be replaced by a handout of standard pelvic floor exercises.

What Pelvic Floor Physical Therapy for Pelvic Pain Actually Looks Like

The first appointment is an hour. We talk about your history — when the pain started, what makes it better and worse, how it affects your daily life, your relationship, your ability to work, your sleep. We talk about what you’ve already tried. I want to understand the whole picture before anything else.

A pelvic floor assessment follows. This is a thorough evaluation of the pelvic floor muscles — their tone, their strength, their coordination, their trigger points, and the surrounding tissue. An internal assessment is often the most informative, though it is always explained clearly, always your choice, and always done with your full comfort in mind.

Treatment for pelvic pain typically involves:

• Manual therapy — hands-on release of hypertonic muscles, trigger points, and restricted connective tissue. This is not painful by design — the goal is progressive release, not force.
• Neuromuscular re-education — retraining the pelvic floor to contract and relax fully and in the right timing with movement, breathing, and functional activity.
• Visceral mobilization — gentle manual techniques to address the mobility of the pelvic organs and their surrounding connective tissue, which is relevant in conditions like endometriosis and IC/BPS.
• Breathing and pressure management — the diaphragm, pelvic floor, and abdominal wall work together as a pressure system. Dysfunctional breathing patterns contribute significantly to pelvic floor tension and pain.
• Nervous system regulation — chronic pelvic pain involves central sensitization — the nervous system has been in a heightened state and needs specific approaches to calm the amplified pain response.
• Education and home program — the goal is for you to understand what is happening in your body and have the tools to maintain progress on your own.

Most patients with chronic pelvic pain require 8 to 12 sessions. Some need more, some significantly less. Progress is assessed continuously and the plan adapts accordingly.

Who Should Come In

The honest answer is: most women with chronic pelvic pain should at least have a pelvic floor evaluation. The list of conditions that have a pelvic floor component is long, and the conditions that definitively do not have one is much shorter.

You should come in if:

• You have pain during or after sex that has not been explained or resolved
• You have been diagnosed with endometriosis, vulvodynia, vestibulodynia, or interstitial cystitis and are still in pain
• You have chronic lower abdominal or pelvic pain that worsens with sitting, standing, or activity
• You have pelvic heaviness or pressure that increases throughout the day
• You have been told your pelvic pain is ‘normal’ or ‘stress-related’ and it doesn’t feel right
• You have painful periods that extend beyond the period itself
• You have pain with tampon use or pelvic exams

You do not need a specific diagnosis to come in. You do not need a referral — Iowa is open access for physical therapy. If something in your pelvis doesn’t feel right and you haven’t found answers, that is enough reason to call.

When Pelvic Pain Is More Complex — Coordinated Care

Pelvic pain often requires more than physical therapy alone. Endometriosis requires ongoing gynecological management. IC/BPS may need concurrent urological care. Vulvodynia sometimes has a dermatological or hormonal component. Significant central sensitization may benefit from pain psychology support.

At Ashworth Chiropractic, pelvic pain patients benefit from the integrated care model that surrounds my work. Chiropractic care from Dr. Matt Wilson addresses the musculoskeletal components that frequently contribute to pelvic pain — lumbopelvic alignment, sacroiliac joint function, and the hip mechanics that load the pelvic floor. Acupuncture provides additional neuromodulation for the central sensitization component. The team communicates.

For the most complex cases, I also coordinate with referring gynecologists, urogynecologists, and pain specialists. I will tell you clearly when I think additional evaluation is needed, and I will support you in getting it.

Questions I Hear Most

Is pelvic pain during sex normal?

No. Painful intercourse — dyspareunia — is common, but common is not the same as normal. Pain during sex is a signal that something is wrong. It is not a character flaw, it is not a relationship problem, and it is not something you should simply endure. In most cases it is highly treatable with targeted pelvic floor physical therapy.

I’ve been told my endometriosis is the cause of my pain. Is physical therapy still relevant?

Yes — and often critically so. Endometriosis produces chronic inflammation and pain, and the body responds with protective muscle guarding that becomes its own source of pain independent of the endometriosis itself. Women who have had successful surgical management of endometriosis but still have significant pain often have a substantial pelvic floor component that was not addressed by the surgery. Pelvic floor PT addresses exactly this.

I’ve tried multiple treatments and nothing has worked. Is this worth trying?

In my experience, the patients who present having tried many things without success are often those who haven’t yet had a pelvic floor physical therapy evaluation — or who received a generic pelvic floor program that didn’t match their specific presentation. The 2024 systematic review of 38 RCTs found high-certainty evidence for multimodal PT even in the context of chronic, complex presentations. If you haven’t worked with a WCS-certified pelvic floor PT who specializes in pain presentations, you have not exhausted your options.

Do I need a diagnosis before I come in?

No. You need symptoms and a willingness to be evaluated. Many of the most treatable pelvic pain presentations are under-diagnosed or mis-labeled. A thorough pelvic floor evaluation often provides more clinically useful information than imaging or labs for this population.

Is this covered by insurance?

Pelvic floor physical therapy is covered by many insurance plans including Medicare. Coverage varies by carrier and plan. We recommend calling your insurance provider to confirm your benefits before your first appointment and are happy to assist with that process.

Clinical References

The following peer-reviewed studies were retrieved from PubMed and cited in this article.

1. Starzec-Proserpio M, et al. Effectiveness of nonpharmacological conservative therapies for chronic pelvic pain in women: a systematic review and meta-analysis. Am J Obstet Gynecol. 2024;232(1):42-71. DOI: https://doi.org/10.1016/j.ajog.2024.08.006
2. Del Forno S, et al. Assessment of levator hiatal area using 3D/4D transperineal ultrasound in women with deep infiltrating endometriosis and superficial dyspareunia treated with pelvic floor muscle physiotherapy: randomized controlled trial. Ultrasound Obstet Gynecol. 2021;57(5):726-732. DOI: https://doi.org/10.1002/uog.23590
3. Del Forno S, et al. Effects of Pelvic Floor Muscle Physiotherapy on Urinary, Bowel, and Sexual Functions in Women with Deep Infiltrating Endometriosis: A Randomized Controlled Trial. Medicina (Kaunas). 2024;60(1). DOI: https://doi.org/10.3390/medicina60010067

About Kelly Brown Gross

Kelly Brown Gross, PT, MPT, WCS is a physical therapist at Ashworth Chiropractic, Physical Therapy & Acupuncture in West Des Moines, Iowa. She holds the Women’s Health Certified Specialist (WCS) designation — one of fewer than 700 in the United States, and one of only about five in Iowa. Kelly has over 20 years of experience in pelvic health, chronic pelvic pain, postpartum rehabilitation, and orthopedic physical therapy. She sees one patient at a time, every visit, and has received referrals from Mayo Clinic and the University of Iowa Hospitals and Clinics for complex pelvic floor presentations.