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Recognizing Myofascial Pelvic Pain in the Female Patient with Chronic Pelvic Pain
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3492521/

Myofascial pelvic pain is a major component of CPP in women that is often not properly identified by health care providers. Attempting to reproduce symptoms in the woman who is experiencing CPP by performing a brief musculoskeletal screen and pelvic floor muscle assessment during the medical examination can help establish if a myofascial pain component exists. Chronic pelvic pain affects women of all ages and every socioeconomic class, and occurs amidst a myriad of physical and psychological conditions making a cure challenging. However, successfully treating the MFPP component of CPP is feasible with a comprehensive approach. In addition to addressing the medical, psychological, and sexual concerns, the women’s health practitioner should refer women to a pelvic floor physical therapist who can provide effective treatments, such as skillful manual therapy, biofeedback, and training in self-care strategies to reduce MFPP and improve associated complaints. An interdisciplinary team in which nurses play a critical role is essential for identifying and successfully treating MFPP in women with CPP.

Internal Pelvic Muscle Assessment

To proceed with the intra-vaginal exam, change gloves to avoid any contamination from the external exam. Palpating the right hand side of a woman’s pelvic floor is easiest using the right hand and visa versa to palpate the left side by using the left hand. Initial entry into the vaginal vault may itself be painful or anxiety provoking. Prepare the woman with what to expect and maintain eye contact throughout the exam. Proceed slowly and use plenty of lubricant to ease a woman’s discomfort. Techniques such as gently depressing the tissues lateral to the clitoris using a pincer grasp with thumb and index finger to widen the introitus, or asking the woman to bulge or bear down gently during finger insertion, as if “blowing bubbles with the vagina” helps to slacken the superficial muscles and prevent muscle gripping during the intra-vaginal exam. The practitioner may ask the woman to “let go” to ensure she is not guarding during the exam, and imagery such as “let your muscles be heavy” or “let your muscles relax like you would let your shoulders drop,” may also be helpful.

First, specific muscle layers are identified by landmarks corresponding to the index or middle finger used during the examination. Using the hymenal ring as the reference point, layer 1 corresponds to depth of the nail bed or first knuckle of the finger that is associated with the location of the bulbocavernosus, ischiocavernosus, superficial transverse perineal, and external anal sphincter muscles. Middle knuckle depth corresponds to layer 2 that is associated with the location of the urethra muscles superiorly and deep transverse perineal muscles inferiorly. Beyond the middle knuckle and up to the length of the examining finger is the deepest layer 3 musculature that is associated with the location of the levator ani, coccygeous, pirifomis and laterally the obturator internus muscles (Wallace & Herman, 2009).

Next, pelvic floor muscle tone, trigger points and pain are assessed. Although surface electromyography is the gold standard for objectively measuring pelvic floor muscle activity, digital examination can be very useful in detecting increased muscle tone. In women with moderate to severe hypertonicity, the examiner immediately notices introital tightness around the examining finger and tension or resistance in the muscles. The same “around-the-clock” methodthat was used for the external palpation is used for the internal exam, and the flat palpation is employed. Palpate superficial, intermediate, and deep layer muscles according to depth of finger in relation to the hymenal ring. Gauge the force used so it is acceptable to the woman. Tender or trigger points may be found anywhere in the muscle bellies but may especially be present laterally along the insertion points at the arcus tendineus levator ani (Butrick, 2009). Often the examiner will reproduce the woman’s referred symptoms, such as suprapubic pain, urinary urgency, or even her rectal or clitoral pain.