What is the role of pelvic floor therapy (PFT) in managing endometriosis pain in a female patient of childbearing age?

Pelvic Floor Therapy for Endometriosis Pain

Pelvic floor physical therapy should be incorporated as an adjunctive treatment for endometriosis-related pain, particularly when pain persists despite hormonal therapy or surgery, as pain in endometriosis is multifactorial and often involves pelvic floor dysfunction, peripheral/central sensitization, and myofascial components that hormonal and surgical treatments alone do not address. 1, 2

Understanding the Pain Mechanism

The pain experience in endometriosis extends beyond simple nociception from endometrial lesions:

• Nerve involvement occurs through direct invasion, irritation, neuroangiogenesis, peripheral and central sensitization, and scar tissue formation 2
• Pelvic floor disorders can cause or significantly contribute to symptoms in many individuals with chronic pelvic pain 1
• Pain severity correlates poorly with laparoscopic appearance of lesions but does correlate with lesion depth 3
• Trauma, especially sexual trauma, can amplify pain perception and should never be overlooked as a contributing factor 1

When to Consider Pelvic Floor Therapy

Pelvic floor physical therapy becomes particularly relevant in these scenarios:

• Persistent pain despite medical management: When 11-19% of patients experience no pain reduction with hormonal medications 4
• Post-surgical pain: When up to 44% of women experience symptom recurrence within one year after surgery 3, 5
• Deep dyspareunia: Particularly when caused by fibrotic lesions infiltrating the posterior compartment, where myofascial dysfunction commonly coexists 1
• Myofascial trigger points: When physical examination reveals pelvic floor muscle tenderness or dysfunction 2

Integrating Pelvic Floor Therapy into Treatment Algorithm

First-Line Approach

• Start with NSAIDs for immediate pain relief 5, 6
• Initiate hormonal therapy (combined oral contraceptives or progestins) as first-line treatment 5, 4
• Simultaneously refer for pelvic floor physical therapy evaluation if deep dyspareunia, pelvic floor tenderness, or myofascial pain is present 1, 2

Second-Line Approach

• Escalate to GnRH agonists for at least 3 months with mandatory add-back therapy if first-line hormonal therapy fails 5, 4
• Continue pelvic floor therapy as hormonal suppression alone does not address muscular dysfunction or central sensitization 1, 2

Surgical Consideration

• Surgery plus postoperative hormonal therapy should be considered when medical treatment is ineffective 1
• Pelvic floor therapy remains essential post-operatively, as surgery addresses lesions but not the neuromuscular and sensitization components 1, 2

Complementary Interventional Techniques

When standard treatments prove insufficient, evidence supports specific interventional approaches:

• Myofascial trigger point release has shown positive patient outcomes for persistent pain 2
• Peripheral nerve hydrodissection may be beneficial when nerve involvement is suspected 2
• Acupressure at Large Intestine-4 (LI4) or Spleen-6 (SP6) points may reduce cramping pain 6

Critical Clinical Pitfalls

Never assume endometriosis is the sole cause of pain - trauma, pelvic floor disorders, and central sensitization frequently coexist and require separate attention 1

Avoid lesion-focused treatment alone - treatments should be symptom-oriented rather than lesion-oriented, as pain severity does not correlate with visible disease extent 3, 1

Do not delay multidisciplinary referral - comprehensive care by a team including physiotherapists, psychologists, and pain specialists improves outcomes beyond what medical or surgical treatment alone can achieve 1

Recognize that no single treatment cures endometriosis - hormonal drugs induce remission but not cure, and surgery does not prevent recurrence (10% per postoperative year), making ongoing multimodal management essential 1