History

As discussed in the prior article, “ Pelvic Pain and Pelvic Floor Disorders in Women: A Physiatrist’s Approach to Epidemiology and Examination ”, it is important to obtain obstetric and gynecologic history including labor complications, lacerations, instrumentation, and menstrual history. It is also important to take note of comorbid pain conditions or comorbid mood disorders. Key descriptors that may suggest MFPP include descriptors such as “deep” or “internal” pain worse with sitting or associated with dyspareunia, dyschezia, or dysuria.

Examination

As described in the previous article, “ Pelvic Pain and Pelvic Floor Disorders in Women: A Physiatrist’s Approach to Epidemiology and Examination ”, a detailed musculoskeletal physical examination of the lumbar spine, hips, pelvic girdle, lower limbs, and PFMs should be performed. The characteristic examination findings of MFPP are found on the internal examination. Internally, the examiner will likely find referring trigger points, taut bands and tenderness, often in the levator ani or obturator internus, although these findings can be in any of the PFMs. During the examination, patients may experience muscle spasms, referred pain to the lumbar spine, gluteal region or hips, or neuropathic pain.

Patients with MFPP may have pain with the active straight leg raise test, which is typically associated with pelvic girdle pain (PGP), because the test also causes a contraction of the PFMs. Additionally, patients may have weakness, poor ability to relax, or poor coordination. Findings of improper contraction or weakness may suggest a possible nerve injury, especially in patients with a history of childbirth or pelvic floor surgery.

Diagnostic testing

MFPP is a clinical diagnosis that can be made with adequate history taking and the examination findings of painful trigger points and taut bands as described earlier. However, PFM physical examination is subjective and may change among providers. A recent 2024 systematic review, demonstrated electromyography, ultrasonography, and manometry are the most common, objective measures of pelvic floor dysfunction and may provide objective data to aid in the diagnosis of MFPP. Imaging, such as pelvic, hip, or lumbar radiographs, may be useful to help rule out other musculoskeletal causes of lumbopelvic pain. If there is concern for more serious causes of pelvic pain such as fracture, malignancy, lumbosacral disc herniation or infection, magnetic resonance imaging (MRI) of the spine, pelvis, or hip may be indicated.

Myofascial trigger points have been evaluated with ultrasound and magnetic resonance elasticity, by some groups, but none have been specifically studied in PFMs. On ultrasound, myofascial trigger points appear as focal, hypoechoic regions with reduced vibration amplitude. On MRI, the taut muscle bands have increased stiffness compared to normal tissue. ^, A recent systematic review highlights the lack of diagnostic tests currently available in myofascial pain assessment.

Treatment

MFPP is treated conservatively through several different approaches with the goal being to return the pelvic floor musculature back to normal function and coordination through pelvic floor therapy, behavioral modifications, and bowel and bladder management. Pain management medications such as nonsteroidal anti-inflammatory drugs (NSAIDs), antidepressants, muscle relaxants, and neuromodulators can also be considered after obtaining adequate history, though there is little evidence to support their use. Given the knowledge that MFPP can occur both independently and secondary to other medical conditions, it is important to address multiple systems and tailor treatment to each patient.

Pelvic floor physical therapy (PFPT) is the mainstay treatment of most pelvic floor disorders, including MFPP. A highly trained, specialized pelvic floor therapist will complete a history and examination including external and internal pelvic examination and rectal examination if indicated. PFPT may include neuromuscular re-education, PFM strengthening, soft tissue mobilization, relaxation techniques, biofeedback, behavioral modifications, education, bowel and bladder training, and creation of a home exercise program. ^, As the muscle groups release and stretch, pelvic floor strengthening techniques can be incorporated. Home exercise programs may include the use of a mirror so the patient may visualize the lifting and relaxation of the pelvic floor with contractions. Pelvic floor therapists may also recommend the use of vaginal dilators or pelvic wands. Typically, patients are advised to avoid activities such as Kegel exercises, prolonged sitting, or wearing tight clothing.

Vaginal baclofen or diazepam suppositories can be prescribed for use before PFPT, prior to intercourse, or before sleep in an effort to reduce pelvic floor muscular tone and pain. Vaginal diazepam has, in the past, shown to be effective in women with high-tone pelvic floor dysfunction, ^, but in more recent studies it has demonstrated no benefit in terms of vaginal muscle tone or pain. ^, Given there is systemic uptake of vaginal valium, there can be a sedating effect similar to oral dosing, as well as risk for tolerance and dependence.

Myofascial trigger point injections with anesthetic agents or botulinum toxin can be considered if therapy and medication treatment does not provide adequate pain relief. ^, A recent 2021 systematic review evaluating 9 studies demonstrated significant improvement in pain scores among patients with chronic pelvic pain (CPP) at 6 and 12 weeks after botulin toxin injections. It is important to note that injections should not be used alone, but rather as a part of rehabilitation plan to improve progress in therapy and overall function. An ultrasound-guided trigger point injection to the piriformis or obturator internus may also be considered if the patient has posterior pelvic myofascial pain.

Medications commonly used as first-line treatments for MFPP include acetaminophen and for acute pain, NSAIDs. NSAIDs should not be taken long term due to the risk of bleeding as well as gastrointestinal, renal, and cardiovascular side effects. Opioids are not recommended in the treatment of CPP. Oral muscle relaxants can be effective when combined with therapies, though to date there is little supportive evidence. Neuromodulating medication such as gabapentin, pregabalin, antiepileptics, or serotonin norepinephrine reuptake inhibitors (SNRIs) may be useful particularly for patients with overlapping neurologic diagnoses such as radiculopathy, peripheral neuropathy, central sensitization, or fibromyalgia. A recent randomized control trial showed no benefit of gabapentin compared to placebo in the treatment of women aged between 18 and 50 years with CPP. Given the side effects and potential harm of these medications, it may be helpful to explore other treatment options prior to initiation of off-label neuromodulating medications such as gabapentin.

History

It is critical to understand the patient’s description of pain to adequately characterize vulvodynia. Vulvodynia can be provoked or unprovoked, referring to pain exacerbated by contact or pain that is spontaneous. Provoked vulvodynia is initiated or provoked by contact, such as inserting a tampon or sexual activity. Unprovoked vulvodynia is spontaneous pain and is present regardless of contact. This distinction is important as it can help guide treatment. Vulvodynia is also characterized by location, for example, if pain is localized to one part of the vulva such as the vestibule versus generalized or mixed. Onset and temporal pattern can also help further describe vulvodynia. ^,

Examination

Although not always positive, the characteristic physical examination finding in vulvodynia is the Q-tip test. The test involves applying mild pressure with a cotton swab to various areas of the vulva and asking the patient to rate their pain levels on a Likert scale of 0 to 10. The tested positions typically move laterally to medially and include the labia majora and minora and vulvar vestibule. During the Q-tip test, the examiner may also visually inspect the vulva, which is typically normal in patients with vulvodynia.

Patients with vulvodynia often have accompanying sexual and pelvic floor dysfunction. Specifically, it is common to see high tone in the PFMs, weakness with voluntary and involuntary contractions, and muscle tenderness on examination. In 2015, the Evidence-Based Vulvodynia Assessment Project demonstrated that 90% of women with vulvodynia had muscular abnormalities in the pelvic floor. Therefore, it is important to do a complete external and internal pelvic floor examination in patients presenting with vulvodynia.

Treatment

PFPT is recommended as the first-line treatment of vulvodynia ^, in conjunction with multidisciplinary approaches including psychotherapy, sex therapy, and pharmacotherapy. Physical therapy modalities often used include manual techniques, desensitization, PFMs exercises, stretching, and insertional techniques using dilators or pelvic wands. ^, A recent large, randomized control trial demonstrated that physical therapy is effective and superior in reducing vulvodynia symptoms when compared to overnight topical lidocaine.

Although there is currently a lack of literature to support pharmacotherapy, in practice, often oral or topical neuromodulators are used in the treatment of vulvodynia. Oral neuromodulators such as gabapentin or pregabalin are often used in the management of unprovoked or generalized vulvodynia while topical compound creams are used for provoked vulvodynia. In women with vulvovaginal atrophy, commonly seen in postmenopausal women, topical estrogen therapy should be the first-line therapy. In some cases, symptoms may be refractory to multidisciplinary management, and it may be beneficial to consider the use of baclofen suppositories or botulinum toxin injections, which may help relax the PFMs and relieve pain. Often, patients with vulvodynia have associated high tone and shortening of the PFMs that may inhibit progress in PFPT, and the clinician may consider pharmacotherapy to aid in relaxation of the PFMs. Although botulinum toxin remains off label for use in the pelvic floor, a recent 2019 study demonstrated localized botulinum toxin injections were helpful in reducing dyspareunia and improving quality of life in treatment refractory, localized, provoked vulvodynia. Therefore, injections may be considered for specific, refractory cases of vulvodynia.

History

Obtaining a thorough history, paying close attention to pain descriptions and location of pain can be most helpful in making a diagnosis, especially because motor, sensory, and reflex examination may often be normal. Pain described as burning or numbness should raise suspicion for neuropathic pain. Patients may describe a foreign body sensation in the perineum or rectum. Patients with neuropathic pain may also have associated pelvic floor dysfunction, and it can be difficult to determine whether the muscle or nerve is the primary source of the pain as hypertonic PFMs may be the cause or the consequence of a pudendal neuroalgia.

Examination

Neuropathic pelvic pain can be difficult to assess on physical examination due to overlapping borders of the pelvic nerves. The Nantes criteria are a validated set of clinical conditions that are sensitive, but not specific for pudendal neuralgia. The criteria involve pain in the anatomic territory of the pudendal nerve, worse with sitting, not awakened from sleep by pain, no sensory loss on examination, and positive anesthetic nerve block. The criteria may be helpful in characterizing pain; however, several components of the criteria are often present with overactive pelvic floor dysfunction and, therefore, are not specific for pudendal neuralgia.

Diagnostic testing

To confirm a diagnosis of neuropathic pelvic pain, diagnostic nerve blocks are performed. Nerve blocks are considered reliable for the iliohypogastric, ilioinguinal, and genitofemoral nerves, but are less clear for the pudendal nerve. It has been proposed that patients with primary pelvic floor dysfunction may also respond well to a pudendal nerve block because the pudendal nerve innervates the sphincters and PFMs. Therefore, the block may not be helpful in determining if the pudendal nerve is the primary source of pain, despite possible improvements in symptoms following the block. ^, Magnetic resonance (MR) neurography technology has recently began to be recognized as one of the most effective tools for diagnosing nerve injury as it is thought to be superior to MRI for nerve visualization. The lumbosacral plexus, specifically, is demonstrated well on MR neurography and can be useful in visualizing injury to the iliohypogastric, ilioinguinal, genitofemoral, and pudendal nerves.

Treatment

PFPT, often in conjunction with medications, is the first-line treatment of neuropathic pelvic pain. Neuromodulating medications typically used include gabapentin, pregabalin, SNRIs, or tricyclic antidepressants (TCAs). These medications may also be compounded into creams or vaginal/rectal suppositories ; data are minimal to support their effectiveness. Image-guided corticosteroid injections mixed with local anesthetic have also been reported as helpful for neuropathies of the pelvic floor. ^{, ,} In some severe cases, surgery, typically a neurectomy or nerve resection, may be recommended for the iliohypogastric, ilioinguinal, and genitofemoral nerves. For severe groin pain, a triple neurectomy where all 3 nerves are resected or transected may be performed. ^, Pain relief after neurectomy of the iliohypogastric, ilioinguinal, and genitofemoral nerves has been reported in 66% to 100% of patients. ^, However, surgical outcomes for pudendal neuralgia have not been consistent. ^,

History

Patients often experience pain in the SIJ or pubic symphysis described as pain in their low back, buttock, or hip. Pain often worsens with transitional movements and impact ability to stand, sit, and walk. Patients may describe a feeling of giveaway weakness on the effected side, pain in the groin with legs crossed, or pain with increases in speed when walking or stair climbing. Patients may describe difficulty finding comfortable positions to sleep or pain when rolling in bed. Pain may radiate down the posterior thigh, sometimes with associated numbness and tingling, and therefore, etiologies such as lumbosacral plexopathy, herniated disc, and radiculopathy should be ruled out before a diagnosis of PGP is given. Other etiologies that should be included in the differential diagnosis include inflammatory disorders, hip disorders, collagen abnormalities, infections, sacral fractures, and tumors.

Examination

The examination should include evaluation of gait, posture, strength, sensation, and reflexes. Evaluation of the lumbar spine and hips should also be performed. Pain provocation tests for PGP include Patrick’s/FABER, posterior pelvic pain provocation test (P4), Gaenslen’s test, Modified Trendelenburg, and assisted straight leg raise test (for detail, see the previous article, “ Pelvic Pain and Pelvic Floor Disorders in Women: A Physiatrist’s Approach to Epidemiology and Examination ”). Examination maneuvers specific to PGP include a positive Patrick’s/FABER, active straight leg raise, and P4. FABER and P4 are the most sensitive tests for pregnancy-related PGP. Pain originating from the pubic symphysis should be suspected when there is tenderness to palpation of the pubic symphysis that lasts more than 5 seconds after the examiner removes their finger. Modified Trendelenburg may also be present with pubic symphysis pain.

Treatment

First-line treatment of PGP is physical therapy, which may focus on posture, stabilizing exercises, motor control, and strengthening. Strengthening of the entire spine is recommended in addition to pelvic stabilization due to conflicting evidence with the use of pelvic stabilization techniques alone. Pelvic stabilizing belts may also be used to provide passive force closure of the pelvis and relieve pain. A recent study demonstrated significant pain reduction and function improvement with the use of stabilizing belts in pregnancy-related PGP. There is also evidence to support the use of stabilizing belts in non–pregnancy-related PGP. ^, The addition of PFPT may be helpful if patients have PFM pain or dysfunction on physical examination.

Medications such as NSAIDs or acetaminophen can be taken for pain relief. However, NSAIDs should be avoided in the pregnant population. Recent studies have found benefit in osteopathic manipulations and acupuncture in this population, when other medications or injections may be less desirable. ^, Other medications that may be used in the pregnant or nonpregnant population include topical lidocaine patches, antispasmodic, or muscle relaxant medication (pregnancy category B). Oral steroids can also be considered. Steroid injections into the SIJ or pubic symphysis can be helpful for severe pain refractory to conservative management. Steroid injections should only be considered in the pregnant population on a case-by-case basis as steroids are pregnancy category C medications.

History

Patients with coccydynia typically report worsened pain when sitting or standing up from a seated position. They may report frequent urge to defecate or pain with defecation. They may also have pain with intercourse. History should be taken with note of recent trauma and onset of pain.

Examination

Examination will reveal tenderness to palpation over the coccyx. Rectal examination will allow the examiner to palpate the coccyx internally. The coccyx is grasped between the forefinger and thumb to allow for manipulation and evaluation of pain and hypermobility or hypomobility of the sacrococcygeal joint. Normal range of motion is 13°. The muscles of the pelvic floor may also be tender on palpation with the internal or external examination as the PFMs often tighten and shorten in response to coccyx pain, which can further contribute to pelvic pain.

Diagnostic testing

Coccydynia itself can be diagnosed through history and physical examination. However, radiographic images can help further evaluate for anterior angulation, subluxation/dislocation, fractures, degenerative changes, or masses that may be causing or contributing to coccyx pain. Dynamic radiographs, taken when standing and sitting, and MRI can help evaluate for sacrococcygeal joint mobility.

Treatment

Conservative treatment is successful in 90% of cases, and many cases resolve without any medical management. ^, Early participation in physical therapy can be helpful as reports have shown benefit of physical therapy over placebo, with further benefit demonstrated when therapy was started within 1 year of onset of symptoms. Activity modification such as adopting proper sitting posture and using circular-shaped or wedge-shaped pillows can help relieve pressure on the coccyx. Often NSAIDs may be recommended, especially in acute injury, but opioids should be avoided.

Patients who are not improving with conservative measures may be evaluated for fluoroscopy-guided injections around the coccyx, sacrococcygeal joint, or sacrococcygeal ligaments. Studies have shown that injection alone has a 60% success rate, while the combination of injection with coccygeal manipulation, as done in physical therapy, has an 85% success rate over a 3 month period. Epidural steroid injections have been used to treat coccyx pain secondary to Tarlov cysts causing lower radicular pain. Ganglion impar blocks can also be performed in treatment refractory cases. Surgical treatment involving coccygectomy is not recommended as the procedure has high major complication rates. ^, Additionally, coccygectomy can negatively impact the PFMs as several muscles insert onto the coccyx.