What's Actually Causing Your Pelvic Pain?

If you've been passed from your OB to your GI to your urologist and back without a clear answer, and you're trying to figure out what's actually behind your pelvic pain — you are in good company. Chronic pelvic pain affects an estimated 15 to 26 percent of women worldwide [1], and the right pelvic pain treatment almost always depends on which of several overlapping causes are actually driving it.

I'm Dr. Lesley Rivera, a pelvic floor physical therapist in Anaheim Hills. Here are the most common causes of pelvic pain I see in clinic, what each one tends to feel like, and what the most recent evidence says about what actually helps.

First — what counts as "chronic" pelvic pain?

Chronic pelvic pain is generally defined as noncyclic pelvic pain lasting six months or longer [1]. Important framing: it's a symptom, not a single disease. The most up-to-date 2026 review in Obstetrics & Gynecology makes this clear — most patients have multiple contributing conditions across more than one body system: gynecologic, gastrointestinal, musculoskeletal, urologic, and neurologic [1].

That's why "what's wrong with me?" is the wrong question. The better question is: "what are all the things contributing to my pain, and which ones can we actually address?"

The cause almost no one gets told about — pelvic floor muscle pain

This is the one I want you to leave with, because it's by far the most under-recognized cause of pelvic pain and one of the most treatable.

Pelvic floor muscle pain — also called myofascial pelvic pain — is when the muscles of the pelvic floor get stuck in a tight, overactive, or trigger-pointed state. It feels like dull, aching pelvic pressure, sometimes burning in the perineum, often worse with sitting, sex, or long days. It can refer pain to the low back, hips, tailbone, or even down the legs.

A 2024 review in Current Opinion in Obstetrics and Gynecology called myofascial pelvic pain "the forgotten player in chronic pelvic pain" — and noted it's commonly missed because most providers don't routinely screen for it [2]. The same review reports that myofascial pain is present in roughly 23 to 78 percent of chronic pelvic pain cases, depending on the population — highest in patients with bladder pain syndrome.

The strongest current evidence: a 2025 systematic review and meta-analysis in the American Journal of Obstetrics and Gynecology pooled 38 randomized trials and over 2,100 women and concluded that multimodal physical therapy is effective for chronic pelvic pain with a high certainty of evidence [3].

And the trigger isn't always something dramatic. Sometimes it's something you'd never think to connect to your pelvic floor — like sucking your belly in to button your jeans every day for ten years. (Yes, really. I wrote about that one here.)

Bladder pain — interstitial cystitis (IC) and bladder pain syndrome

If your pelvic pain comes with bladder pressure, burning, urgency, or that "I just peed and I have to pee again" feeling, IC/BPS may be in the mix. Between 4 and 12 million Americans may have it [4]; it used to be labeled a "women's condition", but the numbers are starting to show that men also experience it at pretty similar rates.

IC is one of the clearest examples of why the wrong kind of pelvic floor exercise can make things worse. The 2022 American Urological Association guideline is explicit: for IC patients with pelvic floor tenderness, manual pelvic floor physical therapy should be offered, and Kegel-style strengthening should be avoided [5]. That's a Grade A evidence recommendation — the strongest the AUA gives.

Translation: if you have IC and you've been doing Kegels, you may be making it worse. That doesn't mean you did something wrong. It means you needed someone to tell you the difference.

Endometriosis — and the pain that often persists after treatment

Endometriosis is its own disease and needs gynecologic care first. But many women with endometriosis develop secondary pelvic floor muscle pain that persists after surgery or hormonal treatment — and that secondary pain is often what's still bothering them years later.

Honest framing on the evidence: the European Society of Human Reproduction and Embryology's 2022 endometriosis guideline noted there wasn't yet enough evidence to make a formal physiotherapy recommendation [6]. Newer 2023-2024 work is changing that. A 2023 randomized trial in the Journal of Clinical Medicine found that a manual therapy protocol significantly improved pain intensity, lumbar mobility, and physical quality of life in women with endometriosis-related pelvic pain [7], and a 2024 review of comprehensive endometriosis care places pelvic floor physiotherapy squarely inside the multimodal treatment model [8].

So while pelvic floor PT isn't a cure for endometriosis, it can meaningfully reduce the muscle-driven pain that often persists alongside it.

Pudendal neuralgia — when it's actually nerve pain

Pudendal neuralgia is nerve pain in the territory of the pudendal nerve — the perineum, vulva, scrotum, or anal area. It typically feels burning, electric, or stabbing. It's often worse with sitting and sometimes better when sitting on a toilet seat (which takes pressure off the area).

Diagnosis is clinical, using the Nantes criteria, and conservative treatment including pelvic floor physical therapy is considered first-line [9]. The honest caveat: the research base for PT in pudendal neuralgia is small, and study quality is generally weak [9]. That doesn't mean PT doesn't help — it means we don't have large randomized trials. What I see in clinic is that releasing the muscles around the pudendal nerve and addressing posture, sitting habits, and pelvic floor tension does reduce symptoms for many patients who try it.

If you suspect pudendal neuralgia, working with a pelvic floor PT who has experience with nerve-driven pain is more important than starting with any specific exercise.

Tailbone pain (coccydynia)

Coccydynia is localized tailbone pain, classically worse with sitting or with the act of standing up from sitting. It's sometimes triggered by a fall, a difficult delivery, or chronic poor sitting posture, and sometimes it shows up with no clear cause.

Be careful what kind of "PT" you accept here. The most recent 2025 systematic review found that pelvic floor biofeedback and muscle exercises alone did not significantly improve coccydynia [10]. What did show better outcomes was manual therapy targeting lumbopelvic posture and the surrounding muscles (piriformis, iliopsoas), combined with cushion modifications and other conservative care.

PT for coccydynia means the right kind of PT — not a generic Kegel program.

Men get pelvic pain too

Pelvic pain in men is real, common, and badly under-recognized. Chronic pelvic pain syndrome (also called chronic prostatitis / CPPS) is the most common form and often involves a strong pelvic floor muscle component.

The brand-new 2025 American Urological Association guideline on male chronic pelvic pain places pelvic floor physical therapy front and center for the myofascial subtype — most clearly indicated when pain happens with ejaculation [11]. Quoting the guideline's co-chair Dr. Michel Pontari: "We usually think of pain in response to tissue injury that resolves with healing, but we now know that pain can also derive from a neurologic origin" [11].

If you're a man with chronic pelvic, perineal, testicular, or post-ejaculation pain and no one has examined your pelvic floor — that's a gap worth closing.

Post-surgical and scar pain

Any pelvic surgery — C-section, hysterectomy, hernia repair, prostatectomy — can leave behind scar restrictions, fascial adhesions, and protective muscle guarding that drive pain months or even years later. It often gets dismissed as "normal recovery" that just never resolved.

A 2024 systematic review on pelvic floor physical therapy after hysterectomy found moderate-quality evidence for sexual function benefits, with pain-specific evidence still developing [12]. The 2025 AJOG meta-analysis [3] supports physical therapy for chronic pelvic pain broadly, including post-surgical populations. If your pain started after a pelvic surgery and never went away, scar and muscle work should be on the table.

Why it's not "in your head" — but your nervous system IS part of the story

Here's what the most recent research is unanimous about: chronic pelvic pain is not made up, AND chronic pain often involves a sensitized nervous system that keeps amplifying pain signals long after any tissue injury has healed.

The 2026 Obstetrics & Gynecology review describes three pain types that operate on a continuum: nociceptive (tissue-driven), neuropathic (nerve-driven), and nociplastic (nervous-system amplification) [1]. A 2025 systematic review in BJOG and the 2024 Society of Obstetricians and Gynaecologists of Canada guideline both endorse a biopsychosocial approach that includes pain education, physiotherapy, and psychological treatments alongside medical care [13][14].

In plain English: the pain is real. Your nervous system is part of the story. And that's actually good news — because it means there are more levers to pull than just "treat the tissue and hope."

This is also why pelvic floor physical therapy works for so many people. We address the muscle and the nervous system at the same time, through manual therapy, breathwork, graded movement, and pain education.

So what actually helps?

Effective pelvic pain treatment is almost always multimodal. The 2025 AJOG meta-analysis was clear: physical therapy works best when it combines education, manual therapy, and graded movement — not when it's just exercise alone [3].

What pelvic floor PT specifically brings to the table:

• Identifying the muscle component (the part most providers miss)

• Releasing trigger points and tight muscles, internally and externally

• Restoring nerve mobility and joint mobility

• Retraining coordination and breathing

• Pain neuroscience education

What we work alongside:

• A good gynecologist or urologist for medical workup

• Pain medicine when needed

• A pelvic-pain-aware therapist for the nervous-system side

• Sometimes acupuncture, dry needling, or trigger point injections

If you want a fuller picture of what pelvic floor physical therapy looks like and what conditions we treat, here's What is Pelvic Floor Physical Therapy?.

When pelvic pain is an emergency

Pelvic pain that's chronic and frustrating is one thing. Pelvic pain with any of the following needs immediate medical attention, not a PT appointment [15]:

• Sudden, severe pain that won't ease with rest

• Heavy vaginal bleeding (filling a pad every hour for several hours)

• Blood in your urine or stool

• Difficulty peeing or pooping

• Fever and vomiting along with the pain

• Pregnancy and any sudden severe pain

If any of those are happening, skip the appointment booking and head to urgent care or the ER.

A last note

If you've been told there's nothing wrong but you know something is — there's almost always a reason. Finding it usually takes the right team and the right kind of evaluation, not more time.

If you're dealing with chronic pelvic pain and want to know whether pelvic floor PT belongs in your plan, book a free 15-minute discovery call. I'm happy to talk through what you've already tried and what's worth trying next.

Related reads: What is Pelvic Floor Physical Therapy? · An Unexpected Source of Pelvic Pain · Help for Painful Periods

This article is for general education and is not medical advice. Please consult a healthcare provider for guidance specific to your situation.

References

1. As-Sanie S, Ross WT, Till SR. Evaluation and Treatment of Chronic Pelvic Pain. Obstetrics & Gynecology, 2026;147(1):21-43. https://journals.lww.com/greenjournal/fulltext/2026/01000/evaluation_and_treatment_of_chronic_pelvic_pain.5.aspx

2. Namazi G, Chauhan N, Handler S. Myofascial pelvic pain: the forgotten player in chronic pelvic pain. Current Opinion in Obstetrics and Gynecology, 2024;36(4):273-281. https://pubmed.ncbi.nlm.nih.gov/38837702/

3. Starzec-Proserpio M, Frawley H, Bø K, Morin M. Effectiveness of nonpharmacological conservative therapies for chronic pelvic pain in women: a systematic review and meta-analysis. American Journal of Obstetrics and Gynecology, 2025;232(1):42-71. https://www.ajog.org/article/S0002-9378(24)00827-5/fulltext

4. National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Definition & Facts of Interstitial Cystitis. https://www.niddk.nih.gov/health-information/urologic-diseases/interstitial-cystitis-bladder-pain-syndrome/definition-facts

5. Clemens JQ, Erickson DR, Varela NP, Lai HH. Diagnosis and Treatment of Interstitial Cystitis/Bladder Pain Syndrome (AUA Guideline 2022). American Urological Association. https://www.auanet.org/guidelines-and-quality/guidelines/diagnosis-and-treatment-interstitial-of-cystitis/bladder-pain-syndrome-(2022)

6. Becker CM, Bokor A, Heikinheimo O, et al. ESHRE guideline: endometriosis. Human Reproduction Open, 2022;2022(2):hoac009. https://academic.oup.com/hropen/article/2022/2/hoac009/6537540

7. González-Alvarez ME, et al. Effectiveness of a Manual Therapy Protocol in Women with Pelvic Pain Due to Endometriosis: A Randomized Clinical Trial. Journal of Clinical Medicine, 2023;12(9):3310. https://www.mdpi.com/2077-0383/12/9/3310

8. Mick I, Freger SM, et al. Comprehensive endometriosis care: a modern multimodal approach for the treatment of pelvic pain and endometriosis. Therapeutic Advances in Reproductive Health, 2024. https://journals.sagepub.com/doi/10.1177/26334941241277759

9. Conic RRZ, Kaur P, Kohan LR. Pudendal Neuralgia: A Review of the Current Literature. Current Pain and Headache Reports, 2025;29(1):38. https://pubmed.ncbi.nlm.nih.gov/39873912/

10. Mazzoleni MG, Maffulli N, Bardazzi T, et al. Management of coccygodynia: talking points from a systematic review of recent clinical trials. Annals of Joint, 2025;10:9. https://pmc.ncbi.nlm.nih.gov/articles/PMC11836747/

11. Lai HH, Pontari MA, Argoff CE, et al. Male Chronic Pelvic Pain: AUA Guideline (Parts I & II). Journal of Urology, 2025;214(2):116-137. https://www.auanet.org/guidelines-and-quality/guidelines/male-chronic-pelvic-pain

12. Pelvic floor muscle training for urinary symptoms, vaginal prolapse, sexual function, pelvic floor muscle strength, and quality of life after hysterectomy: systematic review with meta-analyses. International Urogynecology Journal, 2024. https://pmc.ncbi.nlm.nih.gov/articles/PMC11513449/

13. Johnson MJ, et al. Biopsychosocial Approaches for the Management of Female Chronic Pelvic Pain: A Systematic Review. BJOG, 2025. https://pmc.ncbi.nlm.nih.gov/articles/PMC11704080/

14. Society of Obstetricians and Gynaecologists of Canada. Guideline No. 445: Management of Chronic Pelvic Pain. SOGC, 2024. https://www.sciencedirect.com/science/article/abs/pii/S1701216323006461

15. Cleveland Clinic. Pelvic Pain: Causes, Diagnosis, Treatment & Relief. https://my.clevelandclinic.org/health/symptoms/12106-pelvic-pain