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assessment of pelvic pain: history and physical exam

by Diane K. Newman, DNP, FAAN, BCB-PMD

A pelvic pain diagnosis can be difficult to make and a caring health care provider will conduct a complete assessment including a sexual history and physical exam before offering a diagnosis.

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Sexual History as Part of a Chronic Pelvic Pain Assessment

A complete history of women with chronic pelvic disorders includes a careful listing of symptoms and their onset. Questions about sexual history are important, as women with these disorders report dyspareunia and decreased sexual activity. Risk-taking sexual behavior is rare and few women have a history of sexually transmitted diseases (STDs). A standard pain scale, as well as visual analog and graphic scales will help with quantifying the severity of the pain and its effect on the woman's daily life.

Physical Examination for Chronic Pelvic Pain

For women with chronic pelvic pain and vulvodynia, the initial visit should include a comprehensive physical examination to rule out systemic disease. The Components of an evaluation for Pelvic Disorders are an aid for performing a complete history and physical examination. At the beginning of the exam and while the woman is lying flat, ask her to point out the site of the pain or tenderness.

Large masses, which are sometimes missed on pelvic examination, may be felt during the abdominal examination. Also, the abdominal wall should be palpated while the woman's abdominal muscles are stretched (legs hyperextended) and while relaxed (knees bent) so that trigger points typical of myofascial syndrome may be detected. Evidence of palpable lymph nodes in the inguinal canal may indicate syphilis.

In women with chronic pelvic pain, palpation should start at the umbilicus and move downward. It is important to distinguish abdominal wall pain from intraabdominal pathology, which can be accomplished by having the woman raise her head off the exam table while tensing the rectus muscles. The tense rectus muscle protects the peritoneum from stretch. If tenderness and discomfort are diminished with the head raised, the origin of the pain is likely to be internal. Discomfort that is not relieved with this maneuver originates either in the abdominal wall and superficial structures or in the neural pathways.

Pelvic Examination for Chronic Pelvic Pain

The clinician should also perform a thorough pelvic examination beginning with an inspection of the external genitalia for signs (e.g., draining fistulas) of sexually transmitted disease, including herpes. Leiomyomas (benign tumors) and other common uterine abnormalities should be sought on bimanual examination. The adnexa (specifically, the ovaries and fallopian tubes) should be palpated for cysts or enlarged masses. Palpable lesions with reproducible trigger points may be found in women with endometriosis. The urethra should be palpated (felt) from within the vagina to clarify if a urethral syndrome (usually suggestive of chlamydial infection) is present. Extreme scarring is found with chronic bartholinitis.

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During the speculum examination, the vagina should be inspected for old obstetric lesions. Culture samples for gonorrhea and chlamydial infection should be obtained during the cervical examination. Biopsy specimens of any gross legions of the cervix should be obtained. A digital pelvic muscle assessment should also be performed. Vaginismus, the most common muscular problem that may contribute to chronic pelvic pain, is the involuntary contractions of the pelvic (levator ani) and perineal muscles. Often referred to as pelvic muscle spasms or pelvic floor tension myalgia, vaginismus may cause dyspareunia due to painful and difficult vaginal penetration. Treatments for vaginismus may include pelvic muscle relaxation exercises and, in severe cases, vaginal dilatation. Vulvodynia, coccygodynia, levator ani syndrome, piriformis syndrome, urethral syndrome, and lumbar or pelvic joint dysfunction may all produce hyperactivity and trigger points in the levator ani and associated muscles of the pelvic diaphragm. Trigger Points provides and defines the concept of pelvic pain trigger points and includes examples.

A rectal-vaginal examination should be performed to rule out rectal disease and the uterosacral ligaments should be palpated. A frozen pelvis, which is characteristic of advanced endometriosis or pelvic inflammatory disease, may be noted.

Other Diagnostic Examinations for Chronic Pelvic Pain

Beginning with assessment of the woman's body posture and tension level, a neurologic examination may provide insights into the problem. For example, a woman who guards or positions herself in a certain manner may be experiencing a pelvic muscle spasm and will sit forward in the chair or put weight on one buttock. Pained women often adopt a typical faulty posture in response to organ pain, which gives rise to muscle shortening and joint strain. Musculoskeletal pain, in response to the original source, is frequently involved in chronic pelvic pain syndromes as either the primary or the secondary cause of pain. Affected muscles may become hyperactive and develop 'holding patterns' in response to pain. Shortened or hyperactive muscles develop trigger points, which have a specific pain referral pattern.

An important part of the examination, then, is an assessment of the hip, gluteal and trunk muscles to determine their length, strength, coordination and imbalance. Muscles frequently involved in chronic pelvic pain syndromes include the hip adductors, abdominals and levator ani. A piriformis muscle spasm can also cause chronic pelvic pain. The piriformis muscle, which is responsible for external rotation of the leg, originates at the lateral margin of the perineum, encompasses the greater sciatic nerve and attaches to the greater trochanter of the femur. A spasm of the piriformis muscle may cause secondary pain and can occur when climbing stairs or driving a car. One way to assess for spasm, is to elicit pelvic pain by having the woman in the supine position externally rotate the entire leg while keeping the leg straight.

References

Baker, PK. (1993) Musculoskeletal Origins of Chronic Pelvic Pain. Contemporary Management of Chronic Pelvic Pain, 20(4) December:719-742.05-227.

Duleba, A.J., Keltz, M.D., Olive, D.L. (1996) Evaluation and Management of Chronic Pelvic Pain. Journal American Association Gynecologic Laparoscopists, February 1996, 3 (2), 205-227.

Glazer,H.I.,Rodke,G.,Swencionis,C., Hertz,R.,Young,A.W.(2000) "Treatment of Vulvar Vestibulitis Syndrome with Electromyographic Biofeedback of Pelvic Floor Musculature". Journal of Reproductive Medicine, 40(4),11 pp.

Metts, J.F. (1999) Vulvodynia and Vulvar Vestibulitis: Challenges in Diagnosis and Management. American Family Physician, 59(6),1547-1556.

Newman, DK. (2000) "Pelvic Disorders in Women: Chronic Pelvic Pain and Vulvodynia". OstomyWound Management: December 46(12): 48-54.

Paavonen, J. (1995) "Vulvodynia - a complex syndrome of vulvar pain". Acta Obstet Gynecol Scand. 74,243-247.

Steege,J.F. (1997) Office Assessment of Chronic Pelvic Pain. Clinical Obstetrics and Gynecology, Vol.40(3),554-563.

Steege,J.F.,Metzger,D.A.,Levy, B.S. (1998) Chronic Pelvic Pain: An Integrated Approach. W.B.Saunders,Philadelphia, PA.

Yount,J.J., Solomons, C.C.,Willems, J.J., St. Amand, R.P. (1997) "Effective Nonsurgical Treatments for Vulvar Pain". Women's Health Digest, 3(2),88-93.

Posted October 2007
Updated July 2009

See Also: Vulvar/vaginal Disease, Women's Sexuality 

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