Australian Doctor 13th Sept Issue | Page 38

38 CLINICAL FOCUS

38 CLINICAL FOCUS

13 SEPTEMBER 2024 ausdoc . com . au
| THE | WOMEN ’ S AND MEN ’ S HEALTH SPECIAL
Therapy Update

Persistent pelvic pain

Gynaecology
Dr Supuni Kapurubandara ( left ) 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 ( right ) 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 .
A common contributor to pelvic pain , pelvic floor myalgia is often overlooked , but GPs can play a crucial role in diagnosis and management .
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 .

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 .
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 .
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
GPs are well positioned to screen for symptoms and signs , initiate early management and provide ongoing support .
outlined in box 2 is recommended . This is
19 , 20 estimated to take under five minutes .
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
20 , 21 muscles on palpation .
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
22 , 23 needed .
11 , 13 , 17
Box 1 . Potential symptoms of pelvic floor myalgia
• 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
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 ).