Synonyms
Pelvic Pain
Chronic pelvic pain syndrome
Neuroplastic Pain
Functional Pain
Tension Myostitis Syndrome (TMS)
Centralized Pain
Subdivisions
General Discussion
“Just have a glass of wine and relax!”
This is quite an insensitive comment to hear as someone struggling with pelvic pain, but unfortunately too many patients seeking help for their pain have been told this. It can be traumatizing to have pain dismissed and misunderstood. Telling someone to “just relax”, “have a glass of wine”, or “the pain is in your head” is never appropriate for any cause of pelvic pain, nor accurate or supported by research.
There are many causes of pelvic pain. Sometimes the brain can play a powerful role in causing pelvic pain in the absence of tissue or structural damage. Even in such cases, the pain is never just in someone’s head. It is very real. It’s crucial to recognize that pain isn’t always a direct result of physical damage. Neuroplastic symptoms are any pain or other sensations that are generated by the brain, in the absence of structural or tissue damage. The definition is in the name. Neuro means brain, and plastic, like plasticity, means to learn and adapt. Pain in general acts as a warning signal in order to let us know there is danger, for example when there is tissue damage in the body, like when someone has a papercut. But in neuroplastic pain, this pain signal gets learned by the brain. The good news is that research in neuroscience shows us that it also can be unlearned. (reference 1). Throughout this article there will be illustrations of people who identified their pelvic pain as neuroplastic and were able to become symptom-free after utilizing neuroplastic-targeted approaches.
In this article, we will be discussing what is neuroplastic pain, what are its causes, how to know when pelvic pain is neuroplastic, and what are the treatments.
Signs & Symptoms
Neuroplastic symptoms can create pain anywhere in the body, but the focus of this article is neuroplastic pain in the pelvis. Neuroplastic pain can sometimes be the cause of pain that has been attributed to chronic pelvic pain syndrome, pelvic floor dysfunction, vulvodynia, pudendal neuralgia, endometriosis, overactive bladder, irritable bowel syndrome (IBS), persistent genital arousal disorder (PGAD), and interstitial cystitis. A study of over 300 participants with chronic pelvic pain syndrome found that 49% of these individuals had neuroplastic pain as a cause of their pain (reference 2).
But how does someone know if pain is neuroplastic, especially since there are many causes of pelvic pain including hormone deficiencies, infections, as well as skin, musculoskeletal, autoimmune, and metabolic conditions?
Luckily, there are certain signs we can look for that point to pain being neuroplastic. This includes that symptoms are “FIT”; functional, inconsistent, and triggered (reference 3).
Functional
Functional means symptoms arise despite no injury preceding them, or symptoms started with an injury but endure after an injury has healed. If someone has had thorough testing that rules out the other causes of pain, this may also be a sign that the pain is functional.
Inconsistent
Inconsistent refers to when the sensation of pain turns on and off, migrates, or spreads in a way that is not typical of structural issues or tissue damage. Pain from structural issues or tissue damage in the pelvis itself should reliably cause pain in predictable ways. But when pain is inconsistent, then the timing, location, or intensity of pain may be variable or unreliable. For example, patient advocate Laura Haraka was diagnosed with pelvic floor dysfunction, persistent genital arousal disorder, endometriosis, interstitial cystitis, and pudendal neuralgia. She describes how all her pelvic pain symptoms significantly decreased when she was on vacation and was engaging in and distracted by enjoyable activities with her family. This was an important clue for her to heal from her pain and understand that her pelvic pain was in fact neuroplastic (reference 4).
Triggered
Triggered refers to symptoms that can be switched on and off or change because of exposure to certain stimuli like the time of day, a particular situation, light physical activity, anxiety or fear. Additionally, if symptoms started during a stressful time, this could point to pain being neuroplastic. Also, people with neuroplastic pain often experience symptoms in multiple parts of their bodies. Having 3 or 4 pain conditions such as pelvic pain, back pain, irritable bowel disease, jaw pain, or headaches could point to a single underlying cause - neuroplastic pain (reference 5, reference 6).
Causes
Advancements in neuroscience explain how neuroplastic symptoms are generated by the brain. The brain integrates multiple inputs, including sensory signals, emotional factors, and stress responses, to produce pain. In fact, all of us have experienced symptoms produced by the brain. Think of when someone has been embarrassed and blushed, or has been nervous and had butterflies in their stomach. This is the brain saying “That is dangerous. Avoid it next time.” Although these symptoms come and go quickly, the brain can also produce symptoms that are chronic, meaning they last for a long time (reference 1). Think of a veteran with a phantom limb, in which even after the painful limb has been amputated, that person still has pain that feels like it is coming from the limb.The missing limb cannot cause physical pain anymore, and it’s the brain creating that sensation. Similarly, the source of pelvic pain can also be from signals generated by the brain. Once we understand that the brain can be a key component of causing pain, we can focus on approaches to heal that target the brain.
Affected Populations
There are some things that can predispose people to neuroplastic pain, including past injuries that have healed, past or present stressors, or traumatic memories even as far back as childhood.
Any pain that is learned by the brain, whether it started with an initial injury or not, is neuroplastic. Even after it has healed, the brain can perpetuate the pain at the site of the former injury. For example, in one study, scientists followed people who had recently injured their backs. For most of the individuals, the injury healed, and the pain went away. But for some of the people, even after the injury healed, the pain remained. The scientists took brain scans of these people. When the pain became chronic, it shifted to parts of the brain associated with learning and memory. This shift in brain activity supported that the brain, through neuroplasticity, had learned the pain (reference 7).
Anything that makes someone feel unsafe can cause the brain to activate the pain response discussed earlier. This includes feelings that could be from a job, relationship, or past traumas. For example, patient advocate Andrew describes how different stressors in his life, including people close to him being diagnosed with cancer and the death of his father, were triggers for his pelvic pain syndrome and pudendal neuralgia. He had symptoms of urinary frequency, pain with urination, pain with ejaculation, constipation, pain with sitting, and deep pelvic pain and tightness. He had to go on short term disability from work because of the pain, which fortunately resolved after addressing his pain from a neuroplastic perspective (reference 8).
Fear of continued pain is a common experience among people with chronic pain, and that fear can further contribute to the pain. When someone has pain and is afraid of the symptoms, the brain can interpret this fear as a sign of danger. What starts off as a mild discomfort might flare into more intense pain from fear alone. Fear of pain and also attention to the pain reinforces a vicious cycle of pain, fear, attention, and more pain. Fighting or resisting the pain and putting pressure on symptoms to get better on a timeline reinforces to the brain that symptoms are dangerous. Fortunately, the brain can learn to break free of this cycle and overcome fear, which is key to becoming free from neuroplastic pain. For example, Gabby experienced pelvic pain, diagnosed as pudendal neuralgia. Her symptoms started about 4 weeks after she was sexually assaulted, and also during this time were the COVID lockdowns and her parents’ divorce. She eventually learned about neuroplastic pain, saw that this was relevant to her, and her pain improved when she learned to not fear the pain. She focused on creating messages of safety, such as that her body was not sick or broken. She gradually reintroduced activities that she had stopped because of the pain and she reinforced to herself that movement was safe (reference 9). Addressing the fear she had towards her pain was key in overcoming it.
Data also shows a link between adverse childhood experiences (ACEs) and an increased risk of developing sexual dysfunction in adulthood, with this risk potentially increasing with the number and severity of ACEs experienced. One study showed people with pelvic pain were 3-fold more likely than those without pelvic pain to have been a victim of childhood or adult sexual abuse (reference 10). Data has shown that people with 4 or more ACEs had twice as many pain conditions as those with no ACEs (reference 11). In a study of over 800 participants, increasing ACE severity in people with chronic pelvic pain syndrome (CPPS) was associated with more diffuse pain and more comorbid functional symptoms (reference 12).
There are other factors that can also make people feel unsafe which can contribute to the brain producing pain. These include:
- Perfectionism: Perfection and flawlessness don’t exist. Letting go of perfectionism is a powerful way to communicate safety to the brain. When someone can sit with the discomfort of imperfection, they are teaching themselves that they are safe.
- Overcommitment: Eventually, something’s got to give, and it’s usually someone’s peace (or even health).
- Self-criticism: It’s like having a judge inside who is never satisfied, which can increase feelings of danger. Constantly being on high alert is a helpful strategy for someone trying to avoid being eaten by a crocodile, but for people living in the modern world, excess fear can be a burden that makes pain worse.
- People-pleasing: Whether it’s saying yes to things someone doesn’t want to, not setting boundaries, or putting others' needs first, this can also increase feelings of danger.
- Urgency: It’s okay to slow down especially when someone is healing.
Acknowledging the roles that past experiences, emotions, habits, and fear play in producing symptoms opens up a broader, more empowering approach to healing (reference 1).
Diagnosis
The diagnosis of neuroplastic pelvic pain involves a thorough look at the conditions under which symptoms started, the past and current stressors in someone’s life, an assessment of if symptoms are represented by the FIT criteria, and the presence of co-occurring pain conditions. It also involves ruling out other causes of pain with a thorough history, physical exam, and in some cases lab tests and imaging (reference 1). The Association for the Treatment of Neuroplastic Symptoms has a questionnaire on their website that can help assess if someone’s symptoms could be neuroplastic (reference 19).
Standard Therapies
Shifting from a paradigm that pain is purely physical to one that involves the brain’s ability to cause pain can feel new, weird, and daunting, but it is also empowering. Neuroplastic pain is a learned response, and it can be unlearned too, and thousands of people have done this!
A main strategy to become free from chronic pain is Pain Reprocessing Therapy (PRT). PRT is based on an understanding of the neuroscience of how pain is produced and perpetuated by the brain. It thereby directly addresses the root of neuroplastic pain. Additionally, somatic tracking is about observing sensations without reacting with fear, therefore disrupting the pain-fear-attention-pain cycle. These strategies involve reducing beliefs that pain indicates tissue damage, changing views about the causes and threat value of chronic pain, reinforcing feelings of safety, and being outcome independent. This also involves changing the language around the pain. Instead of using negative or harsh words, finding more neutral or positive words to describe it, such as a “sensation”, can help eliminate fear. Although the most robust research on PRT has been done on patients with back pain, it can be applied to all manifestations of neuroplastic pain (reference 1). In a study of patients with back pain, in the group of people undergoing PRT, 60% became pain-free or nearly pain-free within 4 weeks, with this being maintained after one year, compared with 20% in the placebo group and 10% in the group told to continue the care they already were getting (reference 15).
Instead of fighting the pain like it’s an enemy, as Alan Gordon LCSW the creator of PRT says, “just maybe, we can think of [neuroplastic symptoms] more like a lighthouse.” In this analogy, the symptoms, like a lighthouse, are trying to guide someone, to steer their attention to something important. The things that need to be uncovered could be worries about the future, stress that has been piling up, or past trauma that the brain hasn’t fully processed. For example, Heather was diagnosed with overactive bladder and interstitial cystitis. When she was building evidence that her symptoms were neuroplastic, a key moment was when she noticed that at night, once her son was put to bed and the day was over, her symptoms would go away or decrease significantly. She realized her pain was related to the stressors of being a new mom (reference 20). The core of the healing lies in retraining the brain to learn to see pain as not inherently dangerous and perhaps even as guiding us to further self awareness.
As discussed earlier, unresolved negative emotions (such as fear, anger, shame, grief, guilt) can be a notable factor in producing chronic pain. Subconscious emotions that have not been processed can still trigger fear or feelings of danger. Emotional Awareness and Expression Therapy (EAET) is a form of therapy that targets the trauma and stress that can be found in many people with chronic pain, especially neuroplastic pain. Therefore EAET helps with processing these experiences and emotions to reduce and eliminate pain. Recognition (i.e. through journaling) and verbal expression of previously suppressed emotions can be key to improvement. EAET has been shown to be efficacious for patients with neuroplastic pain, and people with pelvic pain have been included in some of these studies (reference 21).
Investigational Therapies
Other psychological approaches, including Cognitive Behavioral Therapy (CBT) and Acceptance and Commitment Therapy (ACT), can help people learn to live with pain rather than to learn how to overcome it (reference 22, reference 23).
For pelvic pain that is neuroplastic, pelvic floor physical therapy including manual therapy can also be helpful, especially in how it can reinforce safety and reduce fear of the pain. However, if pelvic floor physical therapy reinforces the idea that there are structural issues (such as misalignment or weakness) causing the pain, it likely will have limited efficacy for helping those with neuroplastic pelvic pain. Additionally, nerve blocks and injections may improve pain yet will not address the underlying cause in neuroplastic pain. Getting at the root of treating neuroplastic pain does not involve treating the pain as if it is from a structural issue (reference 1).
To start healing from neuroplastic symptoms, people have to begin challenging and changing some fundamental ideas they hold; it’s important to question the idea that when someone has pain, that the body is fundamentally broken. Clinicians including doctors, psychotherapists, and physical therapists have a role in treating chronic pain, but we must remember that each of us have a profound ability to heal within ourselves. Instead of fighting neuroplastic pain like it’s an enemy, maybe we can think of it more like a lighthouse.
Support Available
There are providers across the country who specialize in diagnosing and treating neuroplastic pain. www.painpsychologycenter.com and www.symptomatic.me can help you find one in your area.
References
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- Till SR, Schrepf A, Clauw DJ, et al. Association Between Nociplastic Pain and Pain Severity and Impact in Women With Chronic Pelvic Pain. J Pain. 2023: 1406-1414. doi: 10.1016/j.jpain.2023.03.004.
- Schubiner H. Unlearn Your Pain. Mind Body Publishing, LLC. 2022.
- Haraka L. Feel to Heal; About Me. Retrieved July 20 2025. https://www.feeltoheal.live/about-me
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- Beyond the Pelvic Podcast. Episode 17: Andrew's journey and the role of stress in pelvic pain. 2024. Retrieved July 20, 2025. https://open.spotify.com/show/7D55ulDFFhvx0luTyiLYR3.
- Pain Free You Youtube Channel. Gabby's TMS / PDP Success Story - Pelvic Pain and Pudendal Neuralgia. 2024. Retrieved July 20, 2025. https://www.youtube.com/@PainFreeYou.
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