Pelvic Pain (Symphysis Pubis Dysfunction)

Pelvic Pain (Symphysis Pubis Dysfunction) Please read the whole article it is quite big and so I just posted the Intro, Symptoms and Causes.


Introduction

One problem that many pregnant women complain about is pubic pain. Yet doctors and midwives often dismiss this pain as either 'inconsequential', 'unfixable', or 'just one of those pregnancy discomforts that have to be endured'. Occasionally, some uninformed doctors have even erroneously told women that such pubic pain means that they would need an elective cesarean section in order not to permanently damage that area during birth, or as a result of prior damage to the area.

Yet none of this is true. Pubic pain in pregnancy is certainly not 'inconsequential'; Kmom knows from experience that it can be very difficult to deal with. Although many doctors and midwives do not know what causes it or how to fix it, many women are able to get improvement or relief with chiropractic treatment or osteopathic manipulation. It is not something that you 'just have to live with'. And although extra care should be taken during labor and birth in order to prevent trauma, it absolutely does NOT mean that you 'have' to have a cesarean!

This purpose of this FAQ is to discuss what causes pelvic/pubic pain, what some of the symptoms are, possible causes, hints for coping with pubic pain, how to prevent further trauma during birth, what kinds of treatments are available, and women's experiences with these treatments.


Anatomy and Structure

Your pelvis is a kind of a circular bone that goes all around and almost meets in the middle in front. The two sides do not quite touch; there is a small gap between them connected by fibrocartilaginous tissue reinforced by several ligaments. This area is called the Pubic Symphysis. This is important for helping your pubic bone to move freely, stabilizing the pelvis while allowing a good range of motion. [An illustration of the pelvis can be found at http://omie.med.jhmi.edu/weblec/templatev1/lec11.html.]

The Pubic Symphysis and the Sacro-Iliac joints (in the back of the pelvis) are especially important during pregnancy, as their flexibility allows the bones to move freely and to expand to help a baby fit through more easily during birth. In fact, the pregnancy hormones relaxin and progesterone help the ligaments of your body to loosen and be even MORE flexible than before, so that there is plenty of 'give' and lots of room for the baby to slip right through.

Because of these hormones, it is normal for there to be some extra looseness and pelvic pressure in pregnancy. This is good---it means your body is getting ready for birth! It's loosening up to give you maximum space and flexibility, and to help make things easy for you and your baby.

However, in some women, either because of excessive levels of hormones, extra sensitivity to hormones, or a pelvis that is out of alignment, this area is extra lax or there is extra pressure on the joint. In 1870, Snelling described this condition: "The affection appears to consist of a relaxation of the pelvic articulations, becoming apparent suddenly after parturition, or gradually during pregnancy; and permitting of a degree of mobility of the pelvic bones which effectually hinders locomotion, and gives rise to the most peculiar, distressing and alarming sensations."

Simply put, significant pubic pain is caused by the pelvic girdle area not working they way it should, probably because of hormones, misalignment of the pelvis, or an interaction of the two.

Although not every provider has a name for this condition, it is most commonly called Symphysis Pubis Dysfunction (or SPD), especially in Britain. Other names for it include:


* pubic shear (osteopathic term)
* symphyseal separation
* pubic symphysis separation
* separated symphysis
* pelvic girdle relaxation of pregnancy
* pelvic joint syndrome.

Diastasis Symphysis Pubis (DSP) is the name for the problem in its most severe form (where the pubic symphysis actually separates severely or tears). For ease of use, in this FAQ the 'milder' form will be referred to as SPD.



Symptoms

The symptoms of SPD vary from person to person, but almost all women who have it experience substantial pubic pain. Tenderness and pain down low in the front is common, but often this pain feels as if it's inside. The pubic area is generally very tender to the touch; many moms find it painful when the doctor or midwife pushes down on the pubic bone while measuring the uterus (fundal height).

Any activity that involves lifting one leg at a time or parting the legs tends to be particularly painful. Lifting the leg to put on clothes, getting out of a car, bending over, sitting down or getting up, walking up stairs, standing on one leg, lifting heavy objects, and walking in general tend to be difficult at times. Many women report that moving or turning over in bed is especially excruciating. One woman wrote, "There were days that I didn't think I was going to be able to get out of bed and actually had to roll out of bed and onto the floor to be able to do so!" [See her story below.]

Many movements become difficult when the pubic symphysis area is affected. Although the greatest pain is associated with movements of lifting one leg or parting the legs, some women experience a 'freezing', where they get up out of bed and find it hard to get their bodies moving right away--the hip bone seems stuck in place and won't move at first. Or they describe having to wait for it to 'pop into place' before being able to walk. The range of hip movement is usually affected, and abduction of the hips especially painful.

Many women also report sciatica (pain that shoots down the buttocks and leg) when pubic pain is present. SPD can also also be associated with bladder dysfunction, especially when going from lying down (or squatting) to a standing position. Some women also feel a 'clicking' when they walk or shift just 'so', or lots of pressure down low near the pubic area.

Many women with SPD also report very strong round ligament pain (pulling or tearing feelings in the abdomen when rolling over, moving suddenly, sneezing, coughing, getting up, etc.). Some chiropractors feel that round ligament pain can be an early symptom of SPD problems, and indicate the need for adjustments. Other providers consider round ligament pain normal, part of the body adjusting to the growing uterus. If experienced with pubic and/or low back pain, it probably is associated with the SPD.


Onset of Pain and Duration

Pubic pain often comes on early in pregnancy, even as early as 12 weeks. One mother reports that she had it at 17 weeks. She says:

When I woke up [from my nap] I could hardly move. It took me forever to walk into the next room. Felt like my hips/pelvis were glued together or something. Already this baby feels sooo heavy inside me, like lots of pressure. I've gained 4 lbs. so far, what's the deal? At night when I wake up to go to the bathroom, sometimes I can't move my legs/hips at all, and sometimes things have to 'pop' back into place. I think, what if there is a fire and I died 'cuz I'm too slow!...I thought this problem in my 1st pregnancy was from gaining so much/swelling and it got worse and worse and stayed till over 3 months postpartum."

Indeed, although pubic pain often does go away after pregnancy, many women find that it sticks around afterward, usually diminished but still present. If treatment to resolve any underlying causes is not done, long-term pain usually sticks around. Anecdotally, this often seems to be associated with long-term low back pain or reduced flexibility in the hips. Even worse, if the mother is mishandled during the birth, the pubic symphysis can separate even more or be permanently damaged. This is called Diastasis Symphysis Pubis (diastasis means gap or separation).



Summary

To summarize, SPD is the mild form of this problem. Its symptoms often include one or more of the following:

* pubic pain
* pubic tenderness to the touch; having the fundal height measured may be uncomfortable
* lower back pain, especially in the sacro-iliac area
* difficulty/pain rolling over in bed
* difficulty/pain with stairs, getting in and out of cars, sitting down or getting up, putting on clothes, bending, lifting, standing on one foot, lifting heavy objects, etc.
* sciatica (pain in buttocks and down the leg)
* "clicking" in the pelvis when walking
* waddling gait
* difficulty getting started walking, especially after sleep
* feeling like hip is out of place or has to pop into place before walking
* bladder dysfunction (temporary incontinence at change in position)
* knee pain or pain in other areas can sometimes also be a side-effect of pelvis problems
* some chiropractors feel that round ligament pain (sharp tearing or pulling sensations in the abdomen) can be related to SPD



Cause

No one knows why SPD occurs for sure, or why it happens in some women and not in others. Some ethnic groups report a high incidence, especially Scandinavian women and perhaps Black women. Other risk factors may include having lots of kids, having had large babies, pre-existing problems with this joint, past pelvic or back pain, or past trauma (car accident, obstetric trauma, etc.) that may have damaged the pelvic girdle area. It also seems logical that women who have broken or injured their pelvis in the past would probably be prone to this problem.

Some sources view SPD simply as a result of pregnancy hormones. As noted, the pregnancy hormones relaxin and progesterone tend to loosen the ligaments of the body in preparation for birth. One theory is that some women have high levels of hormones before pregnancy, and then additional pregnancy hormones cause excessive relaxation of ligaments, especially in the pelvis.

Another theory is that some women manufacture excessive levels of relaxin during pregnancy, causing pelvic laxity. However, although still popular, this theory seems to have been disproven by recent research. Another theory is that women whose joints are especially flexible before pregnancy may be more susceptible to the effect of hormones, or that some women's bodies are just more affected by hormones than others. Traditional medical sources tend to view the problem of pelvic/pubic pain (when they acknowledge it at all) as simply a hormone problem.

A different theory holds that the problem is structural instead, and usually results from a misalignment of the pelvis. In this view, if the pelvis gets out of alignment, the bones don't line up correctly in front, and this puts a lot of extra pressure on that pubic symphysis cartilage. If the two sides are not aligned, it restricts full range of motion, pulling on the connecting pubic symphysis, and making it quite painful. The more out of alignment it is, the more painful this area becomes. It also tends to affect the back, especially in the sacroiliac area, since the pelvis and back are interconnected and work as a unit. And since many areas are affected by back problems, pain can also extend to other areas too.

Kmom's personal opinion is that this condition is probably primarily a problem of misalignment, although hormone levels and sensitivity to hormones may also play a role. In her opinion, the first line of SPD treatment should probably address the possibility of misalignment. Others may not agree. But whatever the cause, SPD is certainly annoying and painful to deal with, and Kmom knows this from personal experience!