"Although the concept of a muscle spasm is not foreign, the location is unexpected. Patients and physicians alike may forget that there is a large complex of muscles that completely lines the pelvic girdle....Although a muscle spasm may be the cause of the patient’s pain, it’s important to realize that an underlying process may have triggered the original spasm. To provide effective treatment of pain, therefore, you must identify the fundamental cause, assuming that it is reversible, rather than focus exclusively on symptoms.
"Physical therapy of the pelvic floor—otherwise known as pelvic myofascial therapy—requires a therapist who is highly trained and specialized in this technique. It is more invasive than other forms of rehabilitative therapy because of the need to perform transvaginal maneuvers (FIGURE 1).
This pilot study by the Urological Pelvic Pain Collaborative Research Network evaluated the ability of patients to adhere to pelvic myofascial therapy, the response of their pain to therapy, and adverse events associated with manual therapy. It found that patients were willing to undergo the therapy, despite the invasive nature of the maneuvers, because it was significantly effective.
"Nevertheless, patients who suffer from chronic pelvic pain may take heart that there is a nonpharmaceutical alternative to manage their symptoms, although availability is likely limited in many areas. Given the nature of the physical therapy required for this particular location of myofascial pain, specialized training is necessary for therapists. Despite motivated patients and well-informed providers, it may be difficult to find specialized therapists within local vicinities. Referrals to centers where this type of therapy is offered may be necessary.
Weighing the nonpharmaceutical options for treatment of myofascial pelvic pain
| Treatment | Pros | Cons |
|---|---|---|
| Physical therapy | Minimally invasive Moderate long-term success | Requires highly specialized therapist |
| Trigger-point injection | Minimally invasive Performed in clinic Immediate short-term success | Optimal injectable agent is unknown Botulinum toxin A lacks FDA approval for this indication Limited information on adverse events and long-term efficacy |
| Percutaneous tibial nerve stimulation | Minimally invasive Performed in clinic | Requires numerous office visits for treatment Lacks FDA approval for this indication Limited information on long-term efficacy |
| Sacral neuromodulation | Moderately invasive Permanent implant | Requires implantation in operating room Lacks FDA approval for this indication Limited information on long-term efficacy |
See more at: http://www.obgmanagement.com/home/article/update-on-pelvic-floor-dysfunction/9f178df5dcf8707bc5a96f880f75deee.html
"A plethora of various terms/diagnoses encompass pelvic pain
as a symptom, including but not limited to: chronic pelvic pain (CPP), vulvar
pain, vulvodynia, vestibulitis/vestibulodynia (localized provoked
vestibulodynia or unprovoked vestibulodynia), vaginismus, dyspareunia,
interstitial cystitis (IC)/painful bladder syndrome (PBS), proctalgia fugax,
levator ani syndrome, pelvic floor dysfunction, vulvodynia,
vestibulitis/vestibulodynia dyspareunia, vaginismus, coccygodynia, levator ani
syndrome, tension myaglia of the pelvic floor, shortened pelvic floor, and
muscular incoordination of the pelvic floor muscles.1
"Vulvodynia is associated with other pain conditions such as:
fibromyalgia, irritable bowel syndrome, tempromandibular joint dysfunction, and
interstitial cystitis/painful bladder syndrome. Pelvic floor over activity is
found in 80-90% of these patients....3
"Interstitial cystitis (IC) or painful bladder syndrome (PBS)
is defined as pelvic pain associated with urinary frequency, urgency, and irritable
voiding. It can be associated with
vulvodynia, irritable bowel syndrome, endometriosis, fibromyalgia, and chronic
fatigue syndrome. It is estimated that
50-87% of patients with IC/PBS have pelvic floor muscle overactivity.3
The sensation of the need to void is associated with the pressure from the
pelvic floor muscle over activity.
Pelvic floor physical therapy is more successful with this population
compared to treatment directed at the bladder. 3
"Proctalgia fugax and levator ani syndrome are two anal
region pain conditions that are associated with hypertonic pelvic floor
musculature. Proctalgia fugax is a
sudden, severe, transient attack of pain in the rectum lasting less than five
minutes. Levator ani syndrome is defined
as a near constant pain of a dull ache nature in the anal and rectal
region. Because of the presence of pelvic
floor muscle over activity, the failure of the pelvic floor muscles to relax
can lend to incomplete defecation and post defecatory pain inside the anus.3
"Varying mechanisms can also contribute to the
maintenance and evolution of CPP. One
hypothesis is: neuroplastic changes that occur in the posterior horn of the
spinal cord, which can lead to neurologic inflammation and cross-sensitivity of
the viscera and muscles, share innervation. Due to these aforementioned
mechanisms, an overlap of symptoms including: dyspareunia, dysmenorrhea,
gastrointestinal complaints, genitourinary complaints, and musculoskeletal
complaints can occur with CPP.5 In particular,
irritable bowel syndrome (IBS), fibromyalgia, and interstitial cystitis are common
co-morbidities of patients with CPP. 2 Furthermore, there is strong
evidence that currently demonstrates the involvement of the musculoskeletal
system in CPP.5 Over activity in the pelvic floor musculature is
found in up to 80-90% of patients with vulvodynia.3, 6 Dysfunction
of the musculoskeletal system can lead to the adoption of abnormal postures
which contribute to increased tension, spasm, and adaptive muscle shortening
that can exacerbate or perpetuate the pain.5
"...when
treating this population, it is important to address the myofascial component
of pain to be successful in treatment. 3 Physical therapists are treating
a specific musculoskeletal dysfunction such as muscle spasm, myofascial
restriction, muscle incoordination, and impaired activities of daily living in
patients with vulvar pain.
2
Indications for
Treatment: 8
- Increased
pain (including vaginal, rectal,
suprapubic, vulvar region)
- Urinary urgency/frequency/incontinence
- Impaired muscle performance
- Impaired functional mobility
- Increased joint mobility
- Impaired boney alignment
- Impaired posture
Contraindications / Precautions for Treatment: 8
The following
precautions/contraindications refer to the performance of an internal pelvic
floor examination:
- Pregnancy (must receive written consent
from patient’s obstetrician)
- Active pelvic infections of the vagina
or bladder
- Active infectious lesions (i.e.: genital
herpes)
- Current yeast infection
- Immediately post pelvic radiation
treatment (within 6-8 weeks without physician approval)
- Immediate post pelvic surgery or
postpartum (within 6-8 weeks without physician approval)
- Severe atrophic vaginitis
- Severe pelvic pain
- History of sexual abuse
- Lack of patient consent
- Pediatric patients
- Absence of previous pelvic exam
- Inadequate training on the part of the physical therapist
The following
precautions/contraindications refer to patients who are currently pregnant:
9
- Deep
heat modalities (ultrasound) and electrical stimulation
- Manual
therapy techniques that may increase laxity
- Maintaining
supine positions longer than three minutes after the fourth month of
pregnancy
"
Oral contraceptives have been
recently linked as a possible contributor to the development of pelvic pain.14
A lifetime risk of 6.6 of developing localized provoked vestibulodynia when
using oral contraceptives has been found.15 Topical medications
are often used with vulvar pain. Topical
gabapentin has also been shown to reduce vulvar pain. Topical steroids are
another class of medication that are used if the patient has an accompanying
inflammatory skin condition, such as lichens sclerosis.16 Lidocaine applied
topically to the vulva is a commonly used treatment strategy. Local estrogen has also been used in cases
where there is a specific lack of local estrogen, as in post-menopausal
conditions and thyroid disorders.15
Tricyclic antidepressants are typically used as first line treatment for
vulvar pain (amitriptyline, desipramine, and nortriptyline are commonly used
and used at lower doses that would be used for depression).15,16 Furthermore, anti-epileptic drugs
including gabapentin or pregabalin have also been used to decrease pain,
especially associated with unprovoked vulvodynia.15
"Examination:
Most pelvic floor exams include a detailed medical history,
posture assessment, pelvic floor muscle exam, sensory, coordination, and
neurological testing, pelvic girdle and associated structure exam, bowel and
bladder function including voiding diaries, digital and surface electromyography,
hip, sacroiliac, and spinal mobility, abdominal, and lower extremity strength
testing.2
Observation/Visual
Inspection:
- Gait- The patient may present with
an abnormal or antalgic gait pattern.5 Decreased or increased
pelvic mobility may be observed during gait by observing quantity of
movement of the pelvis in both the sagittal and transverse planes.
- Function- Patients may have
difficulty with prolonged sitting, standing, ambulation, activities of
daily living, as well as bladder and bowel functioning and intercourse.
- Posture/Alignment:
o
AROM
of the spine, quadrant tests, passive segmental mobility may reveal specific
facet joint dysfunction, facilitated segments, and motion restrictions.2
o Head alignment,
shoulder positioning and symmetry, scoliosis, as well as pelvis and lower
extremities should be analyzed for postural deviations.5
o Muscle
imbalances may occur in and around the pelvic girdle, hips, and trunk because of
muscle pain and become chronic once established.
o Typical pelvic
pain posture has been found in 75% of women with CPP which includes:
exaggerated lumbar lordosis, increased anterior pelvic tilt, increased thoracic
kyphosis.17
o Abnormal sitting
postures may also be found such as increased weight distribution on the sacrum
instead of ischial tuberosities.18 Patients may exhibit
shifting and frequent changes of position while standing. Patients may favor
weight bearing on one side, which may contribute to muscle imbalances between
the gluteus medius and the tensor fascia lata.
o
Toileting and intercourse positions should
also be reviewed.
- Pain:
Pain location can be in the
vagina, vulva, rectum, suprapubic region, or lower abdomen. Pain can also
radiate into the back and hips. Pain reports associated with pelvic floor
muscle (PFM) over activity are often vague and poorly localized and
defined as aching, throbbing, pressure-like or heavy. Pain can be provoked
as the day progresses or during activities specifically involving the
pelvic floor such as walking, sitting, exercise, intercourse, urinating,
and defecating.3
Examination/Palpation:
(Please refer to Hand
Washing Protocol for details)
- External Trunk and Abdominal Palpation:
o
The
clinician may start with an observation and examination of the pelvic bones and
lower extremities to determine the presence of pelvic obliquities, innominate
rotation or shear dysfunctions, and sacral positional or movement dysfunctions.2,
8 Please refer to the Pelvic Girdle Pain Standard of Care and the Special
Tests Task Force document of preferred tests to examine this area.
§ Testing may
include: sacroiliac joint compression/distraction,
FABER, Gaenslen’s test, standing forward bend, spring rests, and stork test
(see Special Test Task Force SI Tests for details)
o A lower quarter
screening examination including reflex testing and dermatomal testing for
sensation impairment is conducted, assessing for possible adverse neural
tension of the lower quarter nerves. This
would be revealed with specific positional testing to help determine if the
pain in the pelvis is resulting from pudendal, obturator, sciatic,
ilioinguinal, or genitofemoral nerve compression, adherence, or restriction.2
o External palpation of the abdominal wall, including any scarring or
deformities and assessment of any abdominal trigger points or adhesions should
be made. 2 Palpation of
the bilateral iliacus, psoas, abdominal obliques, rectus abdominis, and
quadratus lumborum muscles should also be performed, as these muscles can be
commonly involved with those with pelvic pain. 7 Carnett’s test can
be conducted to differentially diagnose between visceral and musculoskeletal causes
of pain in this region.4,5 Diastasis
recti testing should also be conducted to determine any separation and possible
reduced stability of the rectus abdominis muscles.4
o
Evaluative
findings in this area may include: thoracolumbar and sacroiliac joint
dysfunction, pubic bone malalignment, coccyx dysfunction, hip impairments,
lower quarter flexibility and strength impairments, pelvic ligamentous tautness
or laxity, and dysfunctional muscle firing or movement patterns.2
- ROM:
Assessment of the range of motion of the lumbar spine, hips, and
sacroiliac joints, and coccyx is also conducted.
- Strength:
Manual muscle testing of the
abdominal region and lower extremities is conducted. The pelvic floor
muscles are tested for strength as well, using the Modified Oxford Laycock
scale for assessment described in a later section.2
Rehabilitative ultrasound imaging
(RUSI) can also be used to assess the timing and accuracy of the pelvic floor
muscles as well as the transverse abdominis contraction to facilitate its
correct timing during functional and strengthening activities (described
later).2
- Sensation:
Lower extremity and perineal sensation should be assessed for any
alterations or deficits.
- External Pelvic Floor Palpation:
o
A
physical therapy exam of the pelvic floor starts with observation of the
external perineum to assess for swelling, asymmetry, color, and skin changes. If dermatoses are noted, the patient may be referred
back to MD for further evaluation of such conditions. Also,
external examination of the vulva, vestibule, urethra, and external pelvic
floor (pelvic clock) should be assessed for injuries, irritation, adhesions,
scarring, or trigger points.
o External
observation of a pelvic floor muscle contraction and relaxation is observed to
see recruitment, coordination, and symmetry of the pelvic floor and anal
sphincter activity. Neurological exam including reflex testing of the anal wink
and bulbocavernosus reflex can occur, along with external palpation of the
superficial PFM for pain and trigger points, shortening and spasm.2
o The cotton swab
test can be conducted. This test helps
to determine the patient’s irritability and tolerance to pressure or contact on
the vestibular tissue and is considered to be a hallmark of localized provoked
vestibulodynia. A cotton swab moistened with water is applied lightly,
deflecting the skin 1 mm, around the areas of the vestibule at the following
locations: 12:00, 12-3:00 quadrant, 3-6:00 quadrant, 6-9:00 quadrant, and
9-12:00 quadrant. These are tested in random order and the posterior fourchette
is tested last as this area has a high probability of provocation. Pain is rated on the Numerical Rating Pain
Scale from 0-10, where 0 is no pain and 10 is the greatest pain one can
imagine. The test is repeated during re-evaluation following procedural
interventions.2
From
this assessment, the therapist can determine where symptoms are perceived
versus where they can be provoked.3
o Pelvic and
visceral adhesions may be seen and detected with visceral manipulation
techniques, although they lack validity, reliability, and effectiveness, it may
prove to be a useful tool in the evaluation and treatment of this population.2
- Internal
Palpation/Exam (vaginal):
o
An
examination of the middle and deep pelvic floor muscles should then commence
and is best conducted via transvaginal or transrectal palpation. From this
exam, the clinician can evaluate the
pelvic floor musculature for the presence of trigger points, spasm, vaginal vault
size, symmetry, muscle activity, and muscle strength.2 Manual muscle testing, using the modified
Oxford scale, is done to determine PFM strength and excursion.2,8
o A cleaned, well glove, and lubricated finger is used to enter the vaginal
(or rectal) vault to assess presence of pain and vaginal/rectal coordination
and strength (Please refer to Hand Washing Protocol for more details).
o Common findings
for patients with CPP and PFM tension myalgia include: tenderness of PFM, spasm
of the PFM, trigger point presence, shortened muscles, overactive PFM, poor
posture, and/or deconditioned pelvic floor muscles. With shortened muscles,
pain and weakness may be present and will have a decreased ability to lengthen,
elongate, or bulge their PFM downwardly, which is needed to allow voiding or
penetration to occur without pain.2 With pelvic
floor muscle over activity, the musculature has tension at rest, and these
patients are often unable to demonstrate much more of a contraction and will
rarely show a release of the muscle between attempts at contraction. Consequently, the attempt to contract the
pelvic floor musculature will often be ineffective.3
§ The
aforementioned possible findings of altered muscle activity can be evaluated
with palpation, surface electromyography (sEMG), observation, and RUSI.
·
Surface Electromyography (sEMG): For diagnostic
studies, objective determination of pelvic floor muscle over activity or under
activity can be obtained through various techniques, one of which is sEMG.
Either internal vaginal or rectal sensors or external superficial adhesive
sensors may be used. The examination will likely reveal at least 3 of the 5
following findings: elevated and unstable resting baseline activity, poor
derecruitment after contraction, poor return to baseline after contraction,
spasms with sustained contractions, and poor overall recruitment.2,3
·
Rehabilitative
Ultrasonic Imaging (RUSI): Overuse of abdominal oblique muscles or valsalva
maneuver during the execution of a PFM contraction may be seen on RUSI which
may be worsening symptoms2
o Less likely to
be observed is under activity or weakness of PFM, yet still possible and should
not be overlooked.2
·
Functional Outcomes:
It is important to recognize that no single measurement can capture the entire scope of pelvic floor symptoms or impairments; therefore, the use of health related quality of life measures as an adjunct to clinical examination and evaluation offers a more accurate means of demonstrating and understanding the impact of pelvic floor dysfunction, including vulvar pain, on a woman’s daily life. 2
It is important to recognize that no single measurement can capture the entire scope of pelvic floor symptoms or impairments; therefore, the use of health related quality of life measures as an adjunct to clinical examination and evaluation offers a more accurate means of demonstrating and understanding the impact of pelvic floor dysfunction, including vulvar pain, on a woman’s daily life. 2
o
Health-related
quality of life questionnaires refer to a person’s total sense of well-being
and consider multiple dimensions including: social, physical, and emotional
health.
o
Vulvar
Functional Status Questionnaire (VQ): provides a measure of physical function
among women with vulvar pathology
o
Pelvic
Organ Prolapse and Incontinence Sexual Function Questionnaire (PISQ): assesses
the impact of POP or UI on the sexual function of sexually active women.2
Differential Diagnosis:
- Non-musculoskeletal
gynecological and/or urological or colorectal disorders (i.e.: endometriosis)
should be considered.19
- Hip
pathology, lumbosacral radiculopathy, plexopathy, or peripheral neuropathy
including pudendal neuralgia should also be examined in the differential
diagnosis process.19
- Lumbar
source of pain: Current reports of or a history of lumbar pain, pain
located above the sacrum, decreased ROM in the lumbar spine, pain with
lumbar motion, pain with palpation of erector spinae muscles, and negative
PGP special testing should be examined as part of the differential
diagnosis.
- Pelvic
girdle pain: Pelvic girdle pain (PGP) is defined by pain experienced
between the posterior iliac crest and the gluteal fold, particularly in the
vicinity of the sacroiliac joints (SIJ). PGP is a specific form of low
back pain (LBP) that can occur separately or concurrently with LBP. The pain may radiate in the posterior
thigh and can occur in conjunction with/or separately in the symphysis, a
similar location to that of vulvar region pain. PGP generally arises in
relation to pregnancy, trauma, or reactive arthritis. The pain or
functional disturbances in relation to PGP must be reproduced by specific
clinical tests.20
- Rupture
of the symphysis pubis: A pubic symphysis rupture is characterized by
tenderness and swelling over the symphysis pubis. Separations greater than
1 cm are considered to be symptom producing. Palpation of gapping in the
joint may occur. Patients may report difficulty with ambulation. Patients
may have PGP in addition to rupture.21
- Vulvar
skin condition (such as lichens sclerosis)16
- Tumor
or infectious process
"...
The
main goal of physical therapy for pelvic pain is to rehabilitate the PFM by:
increasing awareness and proprioception, improving strength, speed, endurance,
and muscle discrimination, decreasing over activity and improving voluntary
relaxation, increasing elasticity of the tissues at the vaginal opening, and
decreasing the fear of penetration.10
Treatment should
focus on the cause of the dysfunction, not just the source of pain. The goal of
therapy is to address any musculoskeletal imbalances that are causing or
perpetuating the pain.19
Patient Education:
Patient
education must always occur first and is one of the most important factors in
treating this population.3 Specifically, educating the patient about
the physical therapy examination findings, the specific nature of their pain,
and how treatment strategies correlate with improvement in their condition.2,
3 The role of the pelvic floor
muscles in posture, sexual appreciation, bowel, and bladder control, physiology
of micturition/defecation, proper bowel and bladder habits/techniques, proper
postural techniques, role of hormonal changes, and proper skin care techniques
should all be addressed.3 Education regarding proper
posture and use of support devices such as lumbar rolls and perineal support
cushions may be included. Recommended vulvar care practices such as: avoiding
irritants, wearing only cotton underwear, and cleaning the area only with water
may be provided to the patient.2
Furthermore, education to avoid
provocating activities initially (i.e.: intercourse, tampon usage) or changing positions with painful activities may
also be warranted.12, 22 Finally, a comprehensive program should always include
instruction in a home exercise program to promote patient/client independence
and continuity of treatment.2
Manual Therapy:
Specific manual soft
tissue mobilization techniques to address scar tissue, adhesions, trigger
points, and to desensitize the tissue in this area should be utilized. Such
techniques would include: scar mobilization, myofascial release, trigger point
release, muscle energy techniques, strain-counterstrain, and joint mobilization.19,
22 Passive and resistive stretching techniques
are designed to improve blood flow and mobility to the pelvic and vulvar
region, and normalize postural imbalances.22 In
either cases of over- or under-active PFM dysfunction, correction of spinal,
hip, pelvic, sacroiliac joints, and coccyx dysfunction will help to balance the
system and may improve some of the function and pain level experienced by the patient. Correcting dysfunctional movement patterns,
resolving neural tension, resolving pelvic visceral adhesions, and increasing
abdominal strength are all important in this population.2
External
Perineal Treatments: Skin
rolling, external trigger point/myofascial release techniques, and scar
mobilization to the affected regions around the pelvic and vulvar region can be
useful.
Internal Treatments
(intra-vaginal): Transvaginal
manual techniques of the pelvic floor muscles have been used for the treatment
of high-tome dysfunction of pelvic floor patients with CPP and IC, with
symptoms remaining significantly improved after four and one half months.5 Trigger
point release, myofascial release, stretching, manual scar mobilization, strength
and coordination training of the pelvic floor musculature using digital tactile
cueing, is also warranted in this population.5 Manual therapy techniques directed at the
vaginal introitus can be useful for increasing vaginal entry space and
desensitizing areas that are painful to touch.22
Surface Electromyography (sEMG) Biofeedback:
Biofeedback with use
of sEMG can be beneficial to facilitate a patient’s awareness of the activity
in their pelvic floor muscles and facilitate pelvic floor muscle coordination
and relaxation or downtraining as appropriate.3,19 Biofeedback
is a conditioning treatment whereby typically unknown information about a
bodily function (pelvic floor muscle activity) is converted into simple auditory
or visual cues so they can be voluntarily altered to become more efficient.23
·
In
the case of a patient with overactive PFM contributing to their pain, sEMG can
be used to facilitate a reduction in the patient’s resting level of activity of
the PFM. When the PFM improve in their resting level as demonstrated by
decreased activity at rest, then PFM weakness may become more apparent.2
This should then be addressed with pelvic floor muscle uptraining as described
below. Home biofeedback can also be issued to the patient if needed for further
training.
Rehabilitative
Ultrasonic Imaging (RUSI):
Incoordination
of the PFM, abdominal muscles or both may be observed with RUSI. Therefore,
RUSI can be used to facilitate increased patient awareness of the inappropriate
muscle activity to promote proper PFM and/or abdominal contraction and synergy.2
Therapeutic Exercise:
If
there is imbalance of the muscles of the pelvic floor, trunk, and hips, the
following therapeutic exercise strategies can be used: stretching of shortened musculature in and around the pelvis after
pelvic obliquity correction and specific trunk stabilization exercises
including transverse abdominis, multifidus, and pelvic floor musculature and
breathing diaphragm.2, 22
Modalities:
Additional intervention options include modalities such as
internal or external electrical stimulation, ultrasound, moist heat, and
cryotherapy.2 Heat applied
to the lower pelvis and pelvic floor musculature can be facilitory of pelvic
floor muscle relaxation.3 Heat and cold modalities can be helpful to promote pain management and
relaxation of muscles.19
Transvaginal
electrostimulation has been associated with a success rate of 50%,
approximately with pain intensity being improved after 4 weeks post-treatment
and remained after 30 weeks post-treatment in patients with CPP and
interstitial cystitis symptoms.5 Furthermore, the use of pelvic floor electrical stimulation in patients
with pelvic pain and pelvic floor muscle over activity has been reported to
both reduce pain and increase muscle strength in patients with vulvar
vestibulodynia.25
Behavioral Retraining:
Retraining of proper
bladder and bowel habits and techniques, as well as proper postural awareness
is essential for long term management of pain in this population.3 Proper breathing strategies are also
important in patients with pelvic pain. There is a normal synergy between the
respiratory diaphragm and the pelvic floor muscles, in that during inhalation,
the pelvic floor muscles descend and relax, while during exhalation the pelvic
floor muscles return to their resting baseline. Patients should be taught that
during rest, the pelvic floor muscles should be relaxed and the patient
educated on ways to monitor pelvic floor muscle activity during the day so that
the muscle tone in this area is not inadvertently raised at the end of the day.19
Frequency & Duration:
Typically, a patient with pelvic or vulvar pain is seen by
the physical therapist for one visit per week for at least 8 to 12 weeks.12
Patient’s Discharge Instructions:
Patient’s instructions at discharge should include: continuation
of and independence with home exercise program to promote independent symptom
management, as well as independence with activity modification and postures to
minimize pain as appropriate. Patients should follow up with their physician if
symptoms progress or re-occur."
www.brighamandwomens.org/.../Pelvis%...
