Pelvic pain is often complex because the pelvis contains many overlapping systems in a small space, including the bowel, bladder, reproductive organs, pelvic ring, hips, spine, nerves, blood vessels, muscles, and connective tissue. At Manhattan Pain Medicine, we evaluate pelvic pain by looking beyond the painful area to understand whether symptoms are being driven by pelvic floor guarding, joint instability, nerve irritation, visceral inflammation, vascular congestion, spinal pathology, or nervous system sensitization.
Pelvic pain can have many causes. Dr. Siefferman explains what may be behind your symptoms and how treatment can help.
Our team organizes conditions and treatments into related zones of expertise to make it easier to explore the care paths most relevant to your symptoms and goals.
Use the zone tags above to browse dedicated pages for each focus area, including services, providers, and what to expect during treatment.
Hi, I’m Dr. Jason Siefferman and I’d like to speak with you about one of our zones of expertise, pelvic pain. Pelvic pain and dysfunction is often more complex than most people realize. And the reason for this is the pelvis is a complex area. There are many anatomic structures in a small defined space. And our sensory awareness of these structures is often mixed. Within the pelvis, there’s a combination of pain sources. One major pain source is the viscera. And when we say the viscera, that’s the internal organs. It can be the uterus, the bladder, the colon, or the vasculature inside the pelvis. It can be the skeleton, meaning the pelvic ring itself or even the hips. It can be the spine or it can be any of the nerves running through the pelvis. And of course, there’s all the connective tissue that holds it together, which can also be strained or herniated.
So when we evaluate pelvic pain, we really have to think in every domain to understand which things may be causing pain and figure out which things actually are causing pain. The other thing that happens in the pelvis is that there’s often referred pain. Referred pain means that the pain is felt in an area where it’s not generated. A good example is if someone has a heart attack, they may feel it in the left arm. Pain’s not coming from the left arm, it’s just sensed in the left arm. The same thing happens in the pelvis. So recognizing when a pain is from a direct anatomic structure and felt directly in that structure versus when it’s referred from another structure is one of the first steps in diagnosing pelvic pain.
Pelvic pain is a zone of expertise because it requires many different provider subtypes’ input to comprehensively diagnose and treat. And that’s because there may be an inflammatory process from the rheumatology side like sclerosis or sacroiliitis. There may be a mechanical problem like sacroiliac joint hypermobility or hip impingement. There may be a neurologic problem. There may be a visceral problem. There may be a vascular problem like pelvic congestion syndrome. And there may be secondary processes like TMJ dysfunction or dysautonomia arising from these primary pelvic issues.
Often there’s more than one thing causing pain in the pelvis. We comprehensively as a team fully understand the reasons for the pelvic pain and develop a robust treatment plan to address everything for the patient to get through this process and have a future maintenance plan. We consider pelvic pain to be a zone of expertise because it requires multiple different provider types to thoroughly diagnose and make sure we’re not missing anything. Specifically, pelvic pain may be from inflammatory conditions, spine conditions, peripheral nerve entrapments, visceral pain, or vascular issues. And then there can be secondary conditions such as dysautonomia and headache. We want to comprehensively diagnose, understand the reason behind it, and come up with a treatment plan that covers all of the bases.
Pelvic pain is complex because it sits at the literal core of the body and contains every system within the body. Pain may be related to pelvic ring instability, hip issues, vascular issues, visceral issues, spine issues, and there may be some combination of all of these. We often serve as the quarterback for pelvic pain because so many different systems are involved. We don’t treat every system. If there’s pelvic congestion syndrome, for example, or hernias, we help diagnose them and we help coordinate your care with other providers that are necessary. So you can rely on us to understand the breadth of complexity of pelvic pain, develop a treatment plan, and coordinate with any other providers that you may need to come to resolution.
Pelvic pain may be felt in the lower abdomen, pelvis, bladder, rectum, vagina, vulva, perineum, scrotum, hips, sacroiliac joints, tailbone, or low back. Because these structures sit close together and share overlapping nerve pathways, pain may be felt in one location even when it is generated somewhere else.
At Manhattan Pain Medicine, we do not assume that pelvic floor dysfunction is always the primary problem. In many patients, pelvic floor tightness is a guarding response to another driver, such as hip or sacroiliac instability, pudendal nerve irritation, endometriosis, interstitial cystitis, spinal nerve irritation, pelvic congestion, occult hernia, or connective tissue laxity.
Our goal is to identify which systems are involved, which pain generators are primary, which symptoms are referred, and what treatment sequence may help the pelvis become less reactive and more stable.
Pelvic pain often requires collaboration across pelvic pain medicine, interventional pain, rehabilitation, rheumatology, pain psychology, regenerative medicine, and outside specialists when needed. At Manhattan Pain Medicine, care is coordinated around the full pelvic pain pattern, including pelvic floor symptoms, visceral pain, nerve pain, joint instability, spine involvement, vascular concerns, and systemic contributors.
Patients may benefit from evaluation when pelvic pain is persistent, difficult to explain, worsens with sitting, affects the bladder or bowel, causes pain with intercourse, feels burning or electric, overlaps with hip or low back pain, follows endometriosis or pelvic surgery, or continues despite pelvic floor physical therapy, urology, gynecology, or gastrointestinal evaluation.
Pelvic pain is rarely solved by treating one structure in isolation. We work to understand the pelvis as a dynamic crossroad where the hips, sacroiliac joints, spine, pelvic floor, nerves, organs, blood vessels, connective tissue, and nervous system may all contribute to the pain pattern.
Your evaluation may include a detailed review of pelvic pain location, sitting intolerance, bowel and bladder function, sexual pain, menstrual or hormonal history, prior surgeries, spine and hip symptoms, imaging, pelvic floor therapy response, and previous injections or procedures. The team may evaluate whether pain is local, referred, nerve-driven, mechanically driven, visceral, vascular, inflammatory, or part of a broader sensitization pattern.
Pain felt in the pelvis is not always generated by the exact structure that hurts. A spinal nerve, sacroiliac joint, hip, hernia, vascular issue, bladder, uterus, bowel, or pelvic floor muscle may refer pain into another pelvic region. Understanding referred pain helps prevent treatment from focusing on the wrong target.
I cannot say enough good things about Manhattan Pain Medicine. From the moment I walked in, I felt truly cared for and taken seriously. Dr. Nino Mikaberidze, Director of Rheumatology, is exceptional — knowledgeable, compassionate, and incredibly thorough. She takes the time to listen, explains every...
The best care I've received as a chronic pain patient. I traveled from out of state to visit Manhattan Pain Medicine because I could not find knowledgeable doctors in my hometown for my hypermobility, and Ehlers-Danlos syndrome symptoms and comorbidities. Let me tell you, it was worth every travel e...
I was injured in a bicycle accident over 8 years ago. I’ve suffered throughout the years since my accident with nothing seeming to work. PT, Yoga, lifestyle changes, NOTHNG! I finally made an appointment with Dr Kane and I’m feeling an improvement in my life. I no longer stay up all night in pain, a...
One of the best experiences, if not the best, I have ever had at the doctor’s office. From the front desk to the nurses to the PA assisting the doctor this was a great experience. Dr.Nino actually listened to me and came up with a game plan. Would recommend this practice to as many people as I could...
I have very unique & severe nerve pain from CRPS which has no known specific cure. Dr. Siefferman has a huge tool box, far greater than the other 23 Drs. I have seen. He saved me from jumping off a bridge and continues to help me with both treatments and advice. Dr. S. is in a different league!
After two years of searching and feeling lost and let down, I finally found real help at Manhattan Pain Medicine. With Dr. Siefferman, Adam Rosenberg, Dr. Mikaberidze, and the whole team, I feel heard, supported and understood. Every symptom is being considered and I’m finally getting answers with m...
Why is Dr Dr. Tayyaba Ahmed one of the top pevic Floor specialists - 1- She wants to know a full history of what led the patient to get to this point. 2 - She listens intensley to the patient 3- She does not rush you 4- Extremely skilled at giving pelvic floor injections 5- I thank my luck stars she...
The staff was friendly and helpful. Dr. Siefferman was thoughtful, listened, asked questions and proposed simple safe ways to come to further conclusions regarding my pain and discomfort. The office staff including Dr. Siefferman is responsive even after the initial in-person visit. Very pleased.
Dr. Siefferman is a brilliant provider. While my pain is still a work in progress, Dr Siefferman always gives me options and explains his reasoning behind things. He listens to my feedback and concerns. I never feel rushed; and am grateful he works to meet me where I am. I highly recommend him.
What a great find! They listen to me, I listen to them and the diagnosis is made and a plan developed to develop an approach to treat all of my chronic pain. I wish I could have discovered this type of treatment sooner. This doctor and group give me hope.
Chronic pelvic pain can come from many structures, including the pelvic floor muscles, pudendal nerve, sacroiliac joints, hips, spine, bladder, bowel, uterus, connective tissue, blood vessels, or abdominal wall. In many patients, more than one system is involved.
No. Pelvic floor dysfunction is often a guarding response rather than the original cause. The pelvic floor may tighten to protect an unstable hip, irritated sacroiliac joint, inflamed organ, compressed nerve, spinal problem, or painful visceral condition. Identifying the driver helps determine whether pelvic floor treatment alone is enough.
Pudendal neuralgia is pain involving the pudendal nerve, which supplies sensation to parts of the vulva, clitoris, penis, scrotum, perineum, and rectum. Symptoms may include burning, stabbing, electric pain, pins and needles, numbness, or sitting intolerance.
Sitting can increase pressure and shear forces through the sacroiliac joints, pelvic floor, pudendal nerve, tailbone, hips, and pelvic ligaments. If one of these structures is irritated or unstable, sitting may compress or tension the painful pathway.
Yes. When the hips or sacroiliac joints are unstable, pelvic floor muscles may tighten to create stability. Over time, this guarding can become painful and may irritate nearby nerves, including the pudendal nerve.
Yes. Endometriosis and related inflammatory conditions can create chronic visceral pain and nervous system sensitization. Over time, this may contribute to pelvic floor guarding, pain with intercourse, bladder symptoms, bowel symptoms, allodynia, and increased sensitivity to touch, pressure, or clothing.
Bladder pressure, urgency, burning, or frequency can occur even when urine testing is normal. Possible drivers may include bladder pain syndrome, pelvic floor guarding, pudendal nerve irritation, visceral sensitization, sympathetic nervous system overactivity, occult hernia, or referred pain from nearby structures.
Yes. Nerves from the lower spine and sacrum contribute to pelvic sensation and function. Disc irritation, inflammation, scar tissue, or nerve root compression may refer pain into the pelvis, genitals, rectum, bladder region, or pelvic floor.
Double crush syndrome means a nerve is irritated in more than one location. In pelvic pain, a nerve may be affected near the spine and also compressed or tensioned in the pelvis by muscle guarding, scar tissue, ligament strain, or joint instability.
Yes. Occult inguinal, femoral, obturator, or abdominal wall hernias may irritate nerves that travel toward the pelvis, groin, genitals, bladder region, or hip. These hernias may be difficult to identify on standard imaging and may require careful clinical suspicion and appropriate referral.
Pelvic congestion syndrome involves enlarged or backed-up pelvic veins that may create deep pelvic pressure, heaviness, aching, or pain that worsens with standing, activity, or certain positions. It may overlap with low back pain, vulvar symptoms, hip discomfort, or autonomic symptoms.
Evaluation may include a detailed symptom history, physical examination, review of imaging, assessment of hip and sacroiliac mechanics, spine review, nerve pattern mapping, bowel and bladder history, medication response, and targeted diagnostic blocks. The goal is to identify which structures and systems are contributing.
A pudendal nerve block is an image-guided injection that numbs the pudendal nerve temporarily. The response can help determine whether the pudendal nerve is a major contributor to the patient’s familiar pain or whether symptoms may be referred from another source.
Treatment depends on the driver. Care may include medication support, compounded vaginal or rectal suppositories, bowel optimization, sympathetic nerve blocks, pudendal nerve blocks, Botox or Xeomin for selected muscle spasm patterns, regenerative medicine for pelvic instability, epidural procedures, pelvic floor physical therapy, pain psychology, and coordination with outside specialists when needed.
Before care begins, our team helps patients understand the practical side of treatment, including insurance verification, out-of-network benefits, cost-share estimates, self-pay options, and billing questions. We believe patients should have as much clarity as possible before moving forward.
Pelvic pain is complex because the pelvis contains many structures in a small space. Pain may come from the bladder, bowel, uterus, ovaries, prostate, pelvic floor muscles, sacroiliac joints, hips, spine, nerves, blood vessels, abdominal wall, connective tissue, or hernias. These structures share overlapping nerve pathways, so the brain may feel pain in one location even when it is generated somewhere else.
At Manhattan Pain Medicine, we evaluate pelvic pain by looking at the pelvis as a dynamic crossroad. We ask whether the pain is local, referred, nerve-driven, mechanically driven, visceral, vascular, inflammatory, or part of a broader sensitization pattern. Often, more than one answer is true.
Pelvic floor dysfunction is commonly described as a diagnosis, but in many patients it is a response. The pelvic floor may tighten to protect the pelvis, hips, sacroiliac joints, spine, nerves, or irritated organs. This guarding can become painful and can create symptoms that seem primary, even when the original driver is elsewhere.
For example, unstable hips or sacroiliac joints may cause the obturator internus, piriformis, levator ani, or other deep pelvic muscles to contract as functional splints. Over time, these muscles may become enlarged, tight, painful, and crowded around nearby nerves. The pudendal nerve may become irritated, creating genital, perineal, rectal, or sitting-related pain.
Pelvic pain can be driven by multiple systems at once. A patient may have endometriosis, sacroiliac instability, pelvic floor guarding, pudendal nerve irritation, constipation, dysautonomia, and medical trauma all feeding into the same pain pattern. Treating only one piece may help, but it may not be enough.
MPM’s role is often to help organize the full pattern and determine what needs to be treated directly, what needs referral coordination, and what needs to be calmed before the next step can work.
Pudendal neuralgia may cause burning, stabbing, electric, pins-and-needles, or numb sensations involving the vulva, clitoris, penis, scrotum, perineum, or rectum. Sitting intolerance is common. Some patients feel better standing or walking because sitting increases pressure or tension through the nerve pathway.
Endometriosis, adenomyosis, interstitial cystitis, painful bladder syndrome, bowel inflammation, and other visceral conditions can place the nervous system in a high-alert state. Over time, the body may become more sensitive to pelvic signals, leading to pain with intercourse, clothing sensitivity, bladder urgency, bowel flares, pelvic floor guarding, and cross-organ symptoms.
Some patients feel constant bladder pressure, burning, urgency, or frequency despite normal urine testing. These symptoms may be related to bladder pain syndrome, pelvic floor guarding, sympathetic nervous system sensitization, pudendal nerve irritation, occult hernia, or referred pain from nearby structures.
The pelvis depends on the hips, sacroiliac joints, pubic symphysis, ligaments, and deep stabilizing muscles. When these structures are unstable, the pelvic floor may tighten to protect the region. This can create pain in the pelvis, low back, groin, rectum, vagina, perineum, hip, or tailbone.
Pelvic nerves are influenced by the lower spine and sacral nerve roots. A disc herniation, inflammatory irritation, scar tissue, or tethered nerve root may contribute to pelvic pain. A nerve may also be irritated in two locations, such as near the spine and again within the pelvis. This double crush pattern can make symptoms more severe and more difficult to interpret.
Pelvic pain may also come from vascular congestion, occult hernias, abdominal wall defects, or variant anatomy such as Bertolotti syndrome. These conditions can mimic pudendal neuralgia, bladder pain, hip pain, low back pain, or genital pain. When suspected, the team helps coordinate appropriate imaging, referrals, or procedural evaluation.
Discovery begins by separating the symptoms. We ask where the pain is felt, what it feels like, what triggers it, what relieves it, whether sitting changes it, whether bowel or bladder function is involved, whether intercourse is painful, and whether symptoms change with the menstrual cycle, posture, hip motion, spine motion, or activity.
We also look for referred pain. A structure may generate pain in one area while the patient feels it somewhere else. This is common in the pelvis because the organs, nerves, muscles, joints, and connective tissues share overlapping pathways.
Diagnostic blocks may help isolate variables. A pudendal nerve block may clarify whether pudendal neuralgia is a major contributor. Superior hypogastric plexus or ganglion impar blocks may help evaluate visceral or sympathetic pain. Hip, sacroiliac, spine, or pelvic ligament injections may help determine whether mechanical instability is driving pelvic floor guarding.
When hypermobility or instability is suspected, diagnostic fluid distension or targeted joint testing may help determine whether stabilizing a joint reduces pelvic floor guarding or referred nerve pain. Imaging may be reviewed carefully, and dynamic or specialty imaging may be considered when standard studies do not explain the symptoms.
Treatment depends on the driver and the sequence. Pelvic pain treatment often works best when the nervous system is calmed, bowel and bladder contributors are addressed, mechanical instability is treated when present, and the pelvic floor is retrained after the upstream drivers are better controlled.
Pelvic pain often persists when treatment focuses only on the most obvious symptom. Pelvic floor therapy may flare if the sacroiliac joint remains unstable. Pudendal nerve treatment may be incomplete if the nerve is also irritated at the spine. Bladder treatment may fail if the driver is pelvic floor guarding, hernia, or sympathetic sensitization. Surgery may not solve pain if the nervous system has become sensitized.
MPM works to identify what should be calmed first, what should be repaired, what should be referred, and what should be retrained. This order of care helps the pelvis move from alarm and guarding toward better function.
Maintenance begins when the patient has a clearer map of the pelvic pain pattern and the major drivers are more stable. The goal is to help the patient recognize familiar flares, understand what system is likely involved, and know which tools to use before symptoms escalate.
Patients may continue pelvic floor physical therapy, bowel support, strengthening, pacing, medication strategies, periodic procedures, or coordinated care with gynecology, urology, gastroenterology, vascular specialists, or hernia specialists when needed.
Pelvic pain can feel overwhelming because so many systems may be involved. With a structured diagnostic process, the pain pattern can become more understandable, and the treatment path can become more precise.
