What is Visceral Manipulation and How Does it Relate to Chronic Pelvic Pain?

It is commonly accepted that our bodies require movement to function well, and this concept extends to all structures in the body. These structures move upon one another with the help of fascia, a type of connective tissue that is intricately woven throughout the body. Fascia envelopes everything within the body including arteries, nerves, bones, muscles and organs. In a healthy and well functioning system this fascia has a fluid quality to it. This allows for slide and glide between neighbouring structures

Fascia is primarily laid down in vertical sheets throughout the body. These sheets of connective tissue envelope each structure they encounter, and then continue onwards, enveloping many more structures along the way. This means that one single, continuous sheet of fascia can encloses many structure and span many areas of the body.

If this fascia becomes restricted and loses its fluid quality, it can not only cause a local dysfunction, but can cause dysfunction elsewhere in the body. Let's look at the example of a Cesarian section to see how this comes to be.

In a C-section, an incision is made through the superficial layers of skin and adipose (fat) tissue, and then subsequently through the layers of abdominal muscles to reach the uterus. In order to access the uterus, nine different layers of fascia must be cut. As the incision site heals, new connective tissue is laid down. Unfortunately, this new fascia has a slightly less elastic composition than the original tissue, which can create a pattern of restriction.

Initially, this area of restriction can cause dysfunction locally. The mother may begin to unknowingly change her posture, flexing her torso forward to hug around the tender incision site. This can lead to more obvious initial symptoms such as low back pain and tension through the hip flexors.

Over time however, the symptom picture may begin to shift as this fascial restriction causes a lack of movement in nearby structures. A common example is a lack of mobility in the connective tissue that serves as a bridge between the uterus and the sigmoid colon. If the motion of the sigmoid colon is altered, this can lead to dysfunction of the rectum. This may show up in the form of altered function of the muscles of the pelvic floor, leading to urinary incontinence, constipation or pain during intercourse. Given the relationship between the sigmoid colon and the iliac vessels, this could also lead to vascular symptoms such as hemorrhoids or varicose veins. From a musculoskeletal point of view the sigmoid colon sits directly on top of psoas major and minor muscles, two of the muscles that help flex the hip, as well as the left sacroiliac joint. Over time, this dysfunction could lead to seemingly unrelated symptoms such as SI joint pain, sciatica or lower extremity joint dysfunction.

This is a view of the female pelvis from the side, which shows the relationship between the abdominal musculature, uterus and colon.

So what do we do with all of this? Well, there are many therapeutic techniques that can help get to the root of pelvic pain and more importantly, dysfunction. This brings me to my topic of interest, visceral manipulation (VM). This gentle technique assesses the structural relationships between our organs and their connective tissue attachments to the muscles and bones. By encouraging movement of the specific connective tissue or fascia that is restricted, VM helps restore the physiological motion of the organ itself...which brings us back to the idea that motion within and between the body structures is key for health.

References:

Barral, Jean-Pierre, and Pierre Mercier. Visceral Manipulation. Revised ed., Eastland Press, 2006

Netter, Frank. Atlas of Human Anatomy., 7th Edition., Elsevier Inc., 2019