A GP guide to persistent pelvic pain
Need to know:
- Persistent pelvic pain affects up to one in four women, imposing significant psychosocial, functional and physical burdens irrespective of the underlying cause/s.
- Pelvic floor myalgia is a common yet often overlooked contributor to pelvic pain. It often remains undetected and undertreated because of a lack of awareness in healthcare professionals.
- Diagnosis involves physical vaginal examination, although initial screening may be conducted through an external musculoskeletal examination.
- Management strategies encompass lifestyle modifications, relaxation exercises, women’s health physiotherapy, psychotherapy and pharmacotherapy.
- GPs are well positioned to screen for symptoms and signs, initiate early management and provide ongoing support.
Persistent pelvic pain affects up to one in four women and imposes potentially significant psychosocial, functional and physical burdens.1-3
Economic analyses report a substantial loss of productivity and subsequent economic impact associated with the condition (US$16,970 per person a year).4
Optimal patient-centered care involves communication and support to educate and help patients come to terms with the chronicity of pain and to address impacts on quality of life.5
Pelvic floor myalgia arising from the pelvic floor muscles is a frequently overlooked cause of persistent pelvic pain (PPP). This occurs, in part, because of healthcare professionals’ lack of awareness of the condition.6
The prevalence of pelvic floor myalgia in the context of PPP varies widely, ranging from 13% to 78% depending on the diagnostic methods and assessments utilised.7-9 Within this range, it is still very common, so it is important for clinicians to understand the problem and how to diagnose and initiate management.
When describing these clinical conditions, the International Continence Society recommends using the terms ‘pelvic floor myalgia’ — defined as pain arising from the pelvic floor muscles — and ‘pelvic floor tension myalgia’ — defined as pain arising from the pelvic floor muscles with associated increase in muscle tone on palpation of the muscles.10
This article outlines the potential role of pelvic floor myalgia as a contributor to PPP. It describes the aetiology, symptom profile, diagnosis and management of this clinical entity, underscoring its significance in primary care.
The published evidence base in this field focuses on women and forms the basis of this article. Bearing this in mind, clinicians are encouraged to personalise counselling and management for trans and gender-diverse individuals.
| Resources: |
| Psychological tools for pain management: — mindspot.org.au/assessment Pelvic pain resources: — Jean Hailes — Pelvic pain foundation of Australia |
Aetiology
While there are a number of proposed theories regarding the aetiology of pelvic floor myalgia (with or without tension), none have been scientifically substantiated. Pain may be primary, arising solely from the pelvic floor muscles, or secondary, coexisting with other conditions, like endometriosis or interstitial cystitis.7,8,11
The muscular pathology may arise from microscopic muscular damage, cross-sensitisation and/or central sensitisation pathways, with the pain experience influenced by social, psychological,and physical factors.11-14
Contributing factors for the development of pelvic floor myalgia (with or without tension) include surgical or obstetric trauma, improper voiding or defecation techniques, a history of sexual abuse, deviations from normal posture or gait, spinal nerve or low back injuries, interstitial cystitis, endometriosis, vulvodynia and genital cutaneous pathology.7, 11-13
Patient evaluation
Assessment includes a comprehensive history, encompassing urinary, gastrointestinal, gynaecological, sexual and psychosocial aspects.
Given the higher prevalence of trauma among patients with PPP, it is important to integrate trauma-informed care by working on the assumption that all people may have been subjected to sexual assault.15 Care must be taken to avoid retriggering during history-taking and examination. The latter can be deferred to a time when the patient is comfortable.16
The symptoms of pelvic floor myalgia (with or without tension) are variable. Consider the diagnosis in women with features outlined in box 1.
| Box 1. Potential symptoms of pelvic floor myalgia11,13,17 |
| Gynaecological — Pelvic pain, ache, heaviness (not exclusively related to menstruation) — Vaginal pain — Pain with intercourse, penetration, speculum or tampon insertion, potentially continuing for some time after the event — Pain associated with orgasm Urinary — Obstructed voiding — Incomplete emptying — Hesitancy — Urgency — Pain experienced with a full bladder — Dysuria — Symptoms of recurrent UTI with negative urine cultures Bowel — Dyschezia — Obstructed defecation and/or constipation — Rectal pain, not necessarily associated with defecation Pain features — Location: abdominal, low back, buttock, thigh, hip (often referred) — Exacerbation: specific activities, such as sitting, when assuming certain postures, exercise, wearing specific clothing (such as fitted pants) — Course: may be episodic or continuous, may wax and wane |
Diagnosis
Given the wide spectrum of symptoms and clinical presentations, differentiation from gynaecological, colorectal and urological conditions may seem daunting. In truth, the accurate diagnosis of pelvic floor myalgia may be helpful in managing a variety of symptoms across organ systems concurrently.
Physical vaginal examination of pelvic floor muscles to detect pelvic floor myalgia is as effective for diagnosis as other more invasive or complicated diagnostic tools and procedures.18 Once acute causes of pelvic pain have been ruled out, the standardised screening examination outlined in box 2 is recommended. This is estimated to take under five minutes.19,20
| Box 2. Screening examination for pelvic floor myalgia |
| 1. Initial patient positioning: sitting with both feet resting on the floor. 2. Sacroiliac joint examination: by palpation on each side, one at a time. 3. Patient repositioning: to lithotomy, with hips in neutral position. 4. Origin of iliacus muscle examination: by palpation of the medial edge of the anterior superior iliac spine. 5. Origin of rectus abdominus muscle examination: by palpation of the cephalad edge of the pubic symphysis. 6. Standardised assessment of pressure/pain: aims to familiarise the patient with the examination process and provide a scale of reference for pain reporting. It involves palpation of the inner thigh to demonstrate pressure and lack of tenderness. If tenderness is present at the inner thigh, this may indicate allodynia and pelvic pain hypersensitivity/central sensitisation. 7. Internal vaginal muscle examination: by palpation using a single finger in a counterclockwise sequence — from right obturator internus, to right puborectalis component of levator ani, to left puborectalis component of levator ani, to left obturator internus; the left hand can be used to palpate left-sided muscles (see figure 1). — Palpate over the middle of the muscle belly and along the length of the muscles, and use patient-reported numerical pain scale for each muscle. — Palpation of obturator internus muscle may require the patient to abduct the thigh against resistance while the examiner palpates over the muscle (9-12 o’clock for patient’s right obturator internus and 12-3 o’clock for patient’s left obturator internus (see figure 2). |
At the conclusion of the pelvic floor examination, other aspects of the pelvic examination can be completed (speculum, bimanual) where indicated.
When physical vaginal examination is unsuitable, an external examination alone may help since tenderness of at least one external site has been correlated with the presence of tenderness of internal vaginal muscles on palpation.20,21
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Management
Management approaches for pelvic floor myalgia should be multimodal and tailored to each patient. Current evidence to guide management is limited, and further structured and symptom-based research is needed.22,23
That said, physical therapy, psychotherapy and pharmacotherapy are all considered reasonable options, with the overarching goal of addressing and avoiding triggers, managing symptom flares and improving overall wellbeing. Reduced pain and/or improved function can be considered markers of progress.
Lifestyle modifications
Lifestyle modifications include assessment and education regarding the patient’s potential triggers for pelvic floor myalgia. Guidance on good posture and bowel and bladder care may be beneficial.
Supportive care
Encouraging open communication and offering emotional support are vital. It is useful to normalise with patients that symptoms are expected to flare from time to time.
Physical therapy
Pelvic floor physical therapy is a key component of treatment and involves pain neuroscience education to understand the condition, physical myofascial release performed with an appropriately skilled physiotherapist and guided self-release for maintenance following initiation of a treatment program.9,23-26
It is important to note there is no standardised, evidence-based approach at this time, so the patient’s response to treatment should be the arbiter of continuation of a treatment program, especially given the time and cost implications.
Self-treatment, supported by online resources, is an option for those who are unable to attend therapy immediately (see online resources).
Psychotherapy
Psychological strategies, including CBT, may be of benefit for pain management.27,28 This may be delivered by a psychologist or evidence-based online psychological treatment tools (see online resources).
Pharmacotherapy
While medications, including neuromodulators and muscle relaxants, may be trialled, there is a lack of well-controlled trials to define the specific management outcomes associated with these.22 Cautious intermittent use of medications such as benzodiazepines is recommended given the risks of tolerance and dependence associated with these drugs.
Botulinum toxin (botox) injections to the pelvic floor muscles may be considered; however, physiotherapy should be first-line therapy as quality placebo-controlled studies of botox are lacking. The exact role for botox in those who are not responsive to physiotherapy requires further study.29,30
GP role
Patients tend to be more satisfied with their care when they believe that healthcare professionals accept they are experiencing pain, acknowledge the impact on their life and address their needs in an empathetic way.31,32
GPs are well positioned to play a crucial role in providing such care while encouraging patient engagement and facilitating interdisciplinary care with other professionals with an interest in pelvic pain.
Dr Supuni Kapurubandara is an obstetrician and gynaecologist at Westmead Hospital; clinical lecturer at the University of Sydney; and a PhD candidate at UNSW Sydney, NSW.
Professor Jason Abbott is professor of obstetrics and gynaecology at UNSW Sydney and director of the Gynaecological Research and Clinical Evaluation group at the Royal Hospital for Women, Sydney, NSW.
References on request from Dr Kate Kelso.
