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Figures
- Figure 1
Pelvic floor anatomy. During the pelvic examination, the levator ani muscles should be directly palpated for tone and tenderness, and the pelvic floor should be evaluated with attention to any tenderness of the bladder and musculoskeletal structures.
Tables
Differential diagnosis Associated historical feature Physical examination Musculoskeletal Pelvic floor dysfunction Complicated delivery, dyspareunia Vaginismus, point tenderness, or high tone of pelvic floor Myofascial pain or fibromyalgia Tender points, chronic somatic pain Tender points Stress fractures Pain with repetitive movements, improved with rest Degenerative disk disease Burning, paresthesias Radicular signs, muscle weakness Gastrointestinal Constipation Inflammatory bowel disease Bowel urgency, hematochezia Irritable bowel syndrome Bowel symptoms; may increase premenstrually Gynecologic (often cyclic with menses) Adhesions Surgical history Immobile uterus, nodularity Adenomyosis Menorrhagia, dysmenorrhea Enlarged, irregular tender uterus on bimanual examination Adnexal mass Localized to 1 area Localized adnexal mass Chronic pelvic inflammatory disease Dysmenorrhea Uterine cramping with menses Endometrial or cervical polyp Intermenstrual or postcoital bleeding Visual inspection Endometritis Uterine tenderness on bimanual examination Endometriosis Diffuse pelvic pain with menses, deep dyspareunia Fixed or immobile uterus, nodularity Leiomyomata Menorrhagia, pressure or heaviness Uterine nodularity, enlargement Pelvic congestion syndrome Multigravid patient; deep dyspareunia, post-coital pain, worse after prolonged standing Varicosity of labia, uterine tenderness on bimanual examination Vulvar vestibulitis Vulvodynia, dyspareunia Exquisite localized tenderness Urologic Interstitial cystitis Urgency, increased frequency of urination Urinary tract infection Dysuria Urolithiasis Localized sharp pain Radiation cystitis History of radiation Other Psychiatric (depression, somatization) Concurrent mood disorder Neurologic (herpes zoster, nerve entrapment) Hot, burning, electric shock-like pain; shingles Type of therapy Examples or description Comments Medications Simple analgesics Acetaminophen, nonsteroidal anti- inflammatory drugs (NSAIDs) Avoid prolonged use of NSAIDs due to potential toxicities Neuropathics Amitriptyline, gabapentin Gabapentin may be more efficacious than amitriptyline Hormonal therapies Oral contraceptives, gonadotropin- releasing hormone (GnRH) analogues, progestogens, danazol GnRH analogues are more effective for pain relief than oral contraceptive pills Antispasmodics Dicyclomine May worsen constipation Neuromodulators Botulinum toxin A Very effective for pelvic floor spasm Other Pentosan polysulfate sodium First-line therapy for interstitial cystitis Pelvic physical therapy Strengthening (up-training) Contracting the pelvic floor in isolation Improves symptoms of pelvic heaviness and discomfort Relaxation (down-training) Stretching, meditation, internal and external manual release of involved muscle groups Improves symptoms of chronic pelvic pain due to overactive pelvic muscles Biofeedback Surface electromyography in conjunction with strengthening and relaxation Allows visual feedback on muscle control; useful for strengthening or relaxation and treatment of reflexive pelvic floor spasm Vaginal dilators Tool for stretching, pain-free vaginal insertion Restores flexibility and coordination of pelvic floor Psychosocial interventions Collaborative goal-setting Identify what has improved patients’ current symptoms to develop goals Very individualized and specific
Short-term goals
Assess progress during each visit and modify goals as neededProgressive muscle relaxation Systematic tensing and relaxing of each large muscle group progressing from toes to head Establish a practice goal (number of practices per week)
Allows for partner participation
Can be done with other relaxation techniques (eg, visualization, deep breathing)Individual Couple My goal is: Our goal is: I will: We will: When: When: I will do this first: We will do this first: Challenges that may arise: Challenges that may arise: I will handle them by: We will handle them by: I will reward myself when: We will reward ourselves when: My reward will be: Our reward will be:
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