"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).
|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|
- 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
- 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
- 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
- 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.
- 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
- External Trunk and Abdominal Palpation:
- 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
- Sensation: Lower extremity and perineal sensation should be assessed for any alterations or deficits.
- External Pelvic Floor Palpation:
- Internal Palpation/Exam (vaginal):
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
- 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