Why do I still have pain months after endometriosis surgery?
You suffered through your symptoms, finally received an endometriosis diagnosis, scheduled surgery hoping to get relief and now, months later, you are still dealing with pelvic pain, painful sex, bowel or bladder symptoms, abdominal discomfort, or other lingering symptoms.
It can leave you wondering: Did the surgery even help? Did the endometriosis come back?
An important thing to understand is that a successful endometriosis surgery can remove disease, but it does not always resolve every source of pain. Endometriosis pain is often driven by more than the lesions themselves. Pelvic floor tension, myofascial pain, scar and tissue restrictions, bowel or bladder dysfunction, and changes in the nervous system may continue to contribute to symptoms after surgery.
In this blog, we’ll talk about why you may still have pain months after endometriosis surgery, what else may be contributing to your symptoms, and how pelvic floor physical therapy can support your recovery and help address the pieces that surgery alone may not resolve.
Endometriosis Surgery Removes Disease, But Pain Can Have More Than One Driver
Endometriosis is an inflammatory condition in which tissue similar to the lining of the uterus grows outside of the uterus. Surgery may be performed to remove or destroy endometriosis lesions and, when appropriate, address adhesions or other affected tissue.
Not all endometriosis surgeries are the same. Endometriosis may be treated with excision, where identified lesions are surgically removed, or ablation, where lesions are destroyed using heat or another form of energy. Some people may also have a hysterectomy as part of their surgical treatment, particularly when adenomyosis or other uterine conditions are contributing to symptoms. The location and type of endometriosis, the procedure performed, and the experience of the surgical team can all influence surgical planning and outcomes.
Learn more about endometriosis, adenomyosis, and how pelvic health physical therapy can help in our blog: Endometriosis and Adenomyosis 101: Symptoms, Diagnosis, and How Pelvic Floor Physical Therapy Can Help
We’ll dive deeper into the different types of endometriosis surgery in another blog, but for this discussion, we want to cover one important factor: even after a well-planned and successful surgery, pain can continue. That is because the endometriosis lesions may have been one contributor to your pain, but not necessarily the only one.
Removing the disease can make a significant improvement in pain, but if there are other drivers contributing to your symptoms, those may need to be addressed as well for you to experience more complete relief.
For many people with endometriosis, by the time they have surgery, they have been experiencing pelvic or abdominal pain for years. When you live with painful periods, pain with intimacy, bowel or bladder symptoms, or musculoskeletal pain in your back, hips, or surrounding areas, your body adapts. You may begin to move differently, brace your muscles, avoid certain activities, or develop patterns of tension without even realizing it.
It is also important to know that other conditions can occur alongside endometriosis. IBS, bladder pain syndrome, vulvar pain, pelvic floor dysfunction, and other musculoskeletal or pelvic pain conditions can overlap with endometriosis symptoms.
Because of all of these factors, it is possible to still have pain months after a successful endometriosis surgery. The next step is figuring out what may still be contributing to your pain and which of those factors can be addressed.
How Years of Pain Can Change the Nervous System and Pelvic Floor
Your body is designed to protect you from pain and injury. Think about touching a hot stove. Your nervous system immediately tells you to pull your hand away, without you having to plan that movement.
With chronic pain, that protective response can happen over and over, often without you even realizing it. Your nervous system learns to recognize potential threats, and one way your body may respond is by tensing your muscles to brace or protect the area.
With endometriosis, this increased muscle tension may develop in anticipation of pain with periods, intimacy, bowel movements, or certain movements and activities. Over time, what started as a protective response can become another contributing factor to your pain.
We often see hypertonic, or tense, pelvic floor muscles contributing to symptoms such as:
pelvic or vaginal pain
pain with intimacy
difficulty or pain with bowel movements
urinary urgency or frequency
difficulty emptying the bladder or bowels
abdominal, hip, back, or tailbone pain
discomfort with exercise or movement
Your nervous system is also adaptable. With persistent pain, the nerves involved in detecting and processing sensation can become more sensitive. Researchers use terms such as peripheral sensitization, central sensitization, and cross-sensitization to describe some of these changes.
Peripheral sensitization occurs when nerves in an area become more sensitive and respond more strongly to input from the surrounding tissues.
Central sensitization means that the nervous system becomes more responsive to incoming information, so sensations that might not normally be painful can become uncomfortable or painful.
Cross-sensitization helps explain why symptoms from different pelvic organs can overlap. For example, someone with endometriosis may also experience bladder or bowel pain even when endometriosis is not directly involving those organs.
This does not mean that your pain is “all in your head.” Your pain is real. It means that after years of receiving pain signals, your nervous system may continue to respond protectively even after the original source of some of those signals has been treated.
In a small study of people undergoing endometriosis surgery, higher levels of central sensitization before surgery were associated with worse pain outcomes afterward. This is one reason researchers are increasingly looking at endometriosis-associated pain more broadly instead of assuming that surgery alone will resolve every symptom.
The encouraging part is that the nervous system and muscles are adaptable. Just as your body can learn protective patterns in response to pain, it can also learn new patterns. This is one of the areas we address with pelvic health PT.
What Else Can Drive Pain After Endometriosis Surgery?
Every person's experience is different, which is why we do not want to assume that persistent pain has one specific cause. Depending on your symptoms, contributors may include:
Pelvic floor muscle tension or myofascial pain.
The muscles of the pelvic floor, hips, abdomen, and surrounding areas may have been guarding in response to pain long before surgery. Surgery does not automatically teach those muscles to relax again.
Scar and connective tissue restrictions.
Healing from surgery can change the mobility and sensitivity of the abdominal wall and surrounding tissues. Previous surgeries may also contribute.
Changes in movement.
Pain often changes the way we move. You may have learned to brace your abdomen, sit or stand in different postures, limit hip movement, avoid certain positions, or breathe differently because those strategies helped you feel protected.
Bowel or bladder dysfunction.
Constipation, painful bowel movements, urinary urgency, frequency, bladder pain, or difficulty emptying may have pelvic floor or other contributing factors in addition to endometriosis.
Nervous system sensitivity.
After repeated pain signals, the nervous system can remain protective even after tissues have healed.
Other sources of pelvic pain.
Endometriosis frequently exists alongside other conditions. Identifying those additional pain generators is an important part of figuring out why symptoms remain.
If your symptoms are new, worsening, or concerning, additional medical evaluation may be appropriate. But when pain continues after endometriosis surgery, it can be helpful to take a step back and look at the full picture.
A skilled pelvic floor physical therapist can help identify whether pelvic floor tension, muscle guarding, movement patterns, bowel or bladder dysfunction, scar restrictions, or nervous system sensitivity may still be contributing to your symptoms. At Cultivate Your Wellbeing, our goal is to help you better understand what your body needs and give you practical tools to reduce pain, improve function, and feel more confident moving forward.
What does pelvic health PT look like after endometriosis surgery?
The important thing to understand is that your symptoms, your story, and your goals should drive your treatment plan.
At Cultivate Your Wellbeing, we always start by listening to your history and trying to understand what may still be contributing to your symptoms after surgery. We believe the best treatment starts with education, helping you connect the dots between your symptoms so that together we can build the best plan for you.
We commonly work with people after endometriosis surgery who are experiencing:
continued pelvic or abdominal pain
pain with intercourse or penetration
painful bowel movements
constipation or difficulty emptying
urinary urgency, frequency, or difficulty emptying
bladder or urethral discomfort
abdominal or pelvic pulling and tightness
scar sensitivity or restricted scar mobility
hip, low-back, groin, or tailbone pain
difficulty returning to exercise
discomfort with bending, lifting, twisting, or prolonged positions
fear or guarding around movements that previously caused pain
Your pelvic health physical therapy evaluation may include looking at:
how your abdomen and pelvic floor are moving
areas of muscle tension or tenderness
breathing and rib cage mobility
abdominal and surgical scar mobility
hip, pelvis, and spinal movement
how your body manages pressure
bowel and bladder habits
dietary factors that may be contributing to symptoms
movements or activities that reproduce your symptoms
how your pelvic floor contracts, relaxes, and coordinates with the rest of your body
An internal pelvic floor examination can provide helpful information, but it is never required. We explain what we are assessing, ask for consent, and adapt the evaluation and treatment to what feels appropriate for you.
Treatment often looks different from one patient to the next, and it should. We want to uncover the contributing factors that are specific to your body.
Posture and movement patterns often change with chronic pain, so part of treatment may include helping you move with less guarding and more confidence. We may also use hands-on treatment such as visceral manipulation, soft tissue work, myofascial techniques, scar mobilization, and other manual therapy approaches to address restrictions through the abdomen, hips, low back, and pelvic floor when appropriate.
We also work on pelvic floor downtraining, breathing, nervous system regulation, bowel and bladder strategies, and improving the coordination between your pelvic floor and the rest of your body. As symptoms improve, treatment may progress toward strengthening, return to exercise, and getting you back to the activities that matter most to you.
When Should You Begin Pelvic Floor Physical Therapy After Endometriosis Surgery?
The type and extent of your surgery, your surgeon's recommendations, how your incisions are healing, your symptoms, and your overall recovery all matter in deciding when the right time to come in for pelvic health PT.
The timing of when you come in, may change the initial focus of PT to best address what you need at the time. Pelvic health physical therapy does not necessarily have to begin with hands-on scar or pelvic floor treatment.
Earlier in recovery, physical therapy may focus on things such as:
comfortable movement and positioning
breathing
bowel management and reducing straining
gentle mobility
gradually increasing activity
understanding what to expect during recovery
As healing progresses, treatment evolves with you. And if your surgery was months or years ago, it is not too late to have persistent symptoms evaluated.
At Cultivate Your Wellbeing, we love working with people with endometriosis and understand that these symptoms are rarely as simple as one tight muscle or one painful structure. Our pelvic health physical therapists take the time to listen, look at the whole picture, and build an individualized plan around the symptoms and activities that matter to you.
Still experiencing pain months after endometriosis surgery?
We would be happy to help you determine whether pelvic health physical therapy could be part of your next step. We have two convenient locations: right off of I-43 in Mequon between the Mequon Rd and Highland exits and centrally located on Capitol Drive in Brookfield. Contact Cultivate Your Wellbeing or schedule a pelvic health physical therapy evaluation at our Mequon or Brookfield location.