Persistent pain after a c-section: when is it muscle pain and what can you do?

I am really surprised by the number of hits I get from people trying to find out more about chronic pain post c-section. Although I suppose I shouldn’t be, because I see women with chronic pain every day and it takes years for most to get an answer (i.e. they don’t get an answer until they’ve been referred to me). It’s really so very sad, because many times the treatments are not very hard.

The two main causes of post c-section pain are nerve pain (covered here) and muscle pain. Muscle pain is actually the most common cause of chronic pain overall. Muscle pain can happen spontaneously; however, it can also be triggered by trauma (like surgery or childbirth). Throw in the hormonal changes of pregnancy and delivery as well as the lack of sleep and the stress of caring for a newborn and you have many of the ingredients for a chronic pain condition.

The formal medical term for this kind of muscle pain is myofascial pain syndrome, or MPS for short. It happens when (for whatever reason) a muscle tenses and contracts too much, forming tight bands (ever felt a knot of muscle in your neck? That is the kind of tight band or knot that happens with MPS, except with MPS the knot won’t go away). The spasms cause severe pain by reducing blood flow and squeezing nerves.

After a c-section, this kind of myofascial pain syndrome can affect the belly wall or it can affect the muscles of the pelvic floor (those are the muscles that you squeeze to stop your flow of urine and the muscles that contract during orgasm).

Muscle pain can be very severe and is often (but not always) worse with physical activity (including sex). Frequently I hear it described as the feeling of “a bowling ball” or a “fist” in the vagina.” I have also heard it described as “my insides are coming out.” Some women say it is a squeezing or a cramping sensation. Everyone has a unique pain experience, so descriptions certainly vary. Because these muscles surround the bladder and bowel, pelvic floor MPS can also cause the need to empty your bladder a lot and urgency (difficulty holding your urine) as well as pain with or after bowel movements.

There are no specific tests for muscle pain or MPS, it is diagnosed by exam. It can be hard for someone who isn’t used to diagnosing muscle pain to know if the pain is coming from the belly or the pelvic floor. However, if you lay flat on your back, press on your belly, and lift your head off the bed and your pain is worse, then the belly wall is probably involved (lifting your head flexes the belly muscles, and worsening of pain while the muscles are working can be a sign of MPS). Your doctor should also feel for specific tight bands in the muscle as well as specific points of pain called trigger points.

MPS of the pelvic floor requires a pelvic exam. The examiner will feel tight bands of muscle (like a violin string) and touching them will reproduce the pain. Many women feel as if their partner is hitting “a wall or blockage” during intercourse – that is actually contact with these tight bands of muscle.

The good news is once MPS is diagnosed most women respond to treatment. The first step is seeing a pelvic floor physical therapist. You can find one at in the International Pelvic Pain Society (enter your country, state and city and a list of providers will appear, you will be able to tell who is a physical therapist and who is not). The physical therapist will do manual therapy on the muscles and help release the tight bands (they may do other kinds of treatments as well). Other therapies may include some of the following:

• A TENS unit. A small device that sends an electic impulse to the muscles of the belly wall. This should be set up by a physical therapist (there are specific settings). A TENS can be very helpful for belly wall pain.
• Trigger point injections. Using a needle to mechanically break down the bands and knots in the muscle. Some local anesthetic is given to make this less painful (it sounds worse than it is). Trigger point injections are not stand alone treatment, they work in conjunction with physical therapy
• Ibuprofen or other anti-inflammatory pain relievers. If there are no contraindications, a 10-14 day course of prescription strength ibuprofen every 8 hours may help reduce inflammation and break the cycle of pain
• Nerve pain medications. When pain has been going on for several months the signalling in the nervous system starts to change and this can amplify pain (think of it as the volume being turned up too loud in the nervous system). Nerve pain medications, such as nortriptyline or gabapentin, can help reverse or dampen these changes. The medications don’t have to be permanent. Many times reducing the pain helps the nervous system get re-organized and the medications can be stopped with time. Nortriptyline can be used during breastfeeding if needed.
• Botox injections. Yes, you read that correctly. When physical therapy has been ineffective at relieving muscle spasm, Botox injections are a highly effective way to break the cycle of muscle spasm. They only work for about 12 weeks and have to be combined with physical therapy. Once the cycle of spasm is disrupted, the physical therapist can help you re-educate the muscles so the effect becomes long-lasting. Botox can’t be used while breastfeeding.
• Weight loss. The mechanical strain of extra weight (not uncommon after having a baby) makes muscle pain worse. In addition, belly fat churns out inflammatory chemicals that can make pain worse.
• Physical activity. Even though it might be painful, muscles are meant to be worked. The less they are used, the less blood flow and the worse the pain will become. Muscles also shorten over time when you don’t move. Some tips for getting started are walking in a pool (the water helps to carry your body weight, putting less strain on the muscles), walking around the block, or a gentle yoga class. When first starting it is important to only exercise every other day to give the muscles time to recuperate.
• Managing constipation. Straining will over work the pelvic floor muscles. Talk with your health care provider about the best way to manage your constipation. Fiber supplements or changing your diet (we need 25 g of fiber a day) is a good place to start.

If your doctor has never heard about muscle pain, print this page out and give it to them and point them to this article in UpToDate. In my experience, myofascial pain is the most common cause of post c-section pain. If your doctor is unsure, they can easily have you see a pelvic floor physical therapist who can be invaluable in confirming the diagnosis (as well as starting treatment).

Remember, this post does not represent medical advice.