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MELANIE MEISTER: Myofascial pain is a chronic musculoskeletal pain disorder characterized by the presence of contracted bands of skeletal muscle. Within these bands are discrete, painful nodules called trigger points. Trigger points are the hallmark of myofascial pain, and these can be active, meaning spontaneously tender, or latent. Latent trigger points may be activated as a result of physical or emotional stress. Because trigger points may remain dormant for many years, seemingly insignificant stressors can lead to trigger point reactivation and pain.
In the pelvis, myofascial pain most often arises in the muscles and connective tissue of the internal hip, primarily the obturator internus and the levator ani, which is composed of the pubococcygeus, iliococcygeus, and puborectalis muscles. Characteristic trigger points have also been described in the piriformis and coccygeus muscles.
Unfortunately, physical examination methods to assess the internal hip and pelvic floor muscles for the presence of trigger points or tenderness characteristic of myofascial pain are poorly defined. As a result, few physicians are trained to examine these muscles in the evaluation of patients with pelvic floor complaints or to consider pelvic floor myofascial pain among the differential diagnoses for patients with pelvic floor symptoms.
We developed a simple, reproducible examination based on our clinical expertise at our center and previously published examination strategies to screen for the presence of pelvic floor myofascial pain.
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The examination begins with a patient seated on the examination table with both feet resting on the floor. The patient is counseled on the examination, and the steps of the examination are explained. Verbal consent is obtained to begin the examination.
JERRY LOWDER: I'm going to be checking for tender points in any muscles in your lower back, lower abdomen, and in the pelvic exam. With the pelvic exam specifically, I'll be checking for tender points in the internal hip and pelvic floor muscles. May we proceed with the examination?
PATIENT: Yes.
MELANIE MEISTER: The patient's bilateral sacroiliac joints are palpated, and the patient is asked whether this elicits tenderness.
JERRY LOWDER: So the first thing I'm going to do is check for tenderness at the sacroiliac joint. So I'm just going to raise your shirt up a little bit. And any tenderness here?
PATIENT: No.
JERRY LOWDER: And what about here?
PATIENT: No.
MELANIE MEISTER: In some patients, the SI joint can be easily identified by dimples in the skin overlying the SI joint and/or by palpating the indentation where the sacrum and iliac bones join.
JERRY LOWDER: What about here?
PATIENT: No.
JERRY LOWDER: OK.
MELANIE MEISTER: The patient is then repositioned in lithotomy with her feet in stirrups. Care is taken to ensure the hips are neutral without excessive flexion, abduction, or external rotation. Next, the cephalad edge of the pubic symphysis is palpated, followed by the abdominal wall medial to the anterior superior iliac spine, which is palpated bilaterally. These sites correspond to the insertion of the rectus abdominis muscle and the origin of the iliacus muscles, respectively.
JERRY LOWDER: Next, I'm going to examine three spots on your lower abdomen. OK? First, I'm going to press right here in the midline. Any tenderness?
PATIENT: No.
JERRY LOWDER: And then what about here?
PATIENT: No.
JERRY LOWDER: OK. And here?
PATIENT: No.
MELANIE MEISTER: The patient is then oriented to the internal examination.
JERRY LOWDER: Next, I'm going to do an internal examination where I'm going to be assessing for any tender points in the internal hip and pelvic floor muscles. OK?
PATIENT: OK.
JERRY LOWDER: Before we do that examination, I'm going to press on your mid thigh to give you a reference point for the amount of pressure that I'll be applying to those internal pelvic floor muscles.
PATIENT: OK.
JERRY LOWDER: So do you feel me pressing on your thigh?
PATIENT: Yes.
JERRY LOWDER: Does that hurt?
PATIENT: No.
JERRY LOWDER: Is this pressure and no pain?
PATIENT: Right.
JERRY LOWDER: So if this is pressure, no pain, we'll rate this as 0 on a scale of 0 to 10. When I'm doing the internal exam, if any of those spots hurt more than this, I want you to give me a number between 1 to 10 where anything in the 1 to 3 range will be mild, 4 to 6 will be moderate, and 7 to 10 would be severe.
MELANIE MEISTER: The pelvic floor muscles are palpated once in the center of the muscle belly, then in a sweeping motion along the length of the muscle, in the orientation of the muscle fibers, using the index finger of the dominant hand. The examination proceeds counterclockwise, beginning with the right obturator internus, then the right levator ani, left levator ani, and finishing with the left obturator internus. The patient indicates a score with each palpation.
After completion of the pelvic floor myofascial examination, the remainder of the pelvic examination, including a speculum examination, bimanual exam, assessment for pelvic organ prolapse, and urethral catheterization, is performed if indicated. In order to test the reproducibility of this examination, an agreement between examiners, we performed a cross-sectional analysis.
35 patients were enrolled and underwent pelvic floor myofascial examination by two providers. According to this protocol, one third to one half of patients had tenderness to palpation at each external site. Reported pain scores on internal examination span, the entire range of possible scores at each site. For each internal site, the median pain score with palpation along the length of the muscle was equivalent to or slightly higher than the median pain score on palpation of the muscle belly.
Agreement was high between examiners at each external and internal site examined. This simple examination reliably and reproducibly screens for the presence of pelvic floor myofascial pain in women presenting with pelvic floor symptoms. Given the ease with which this examination can be incorporated into a typical examination and the consistency among providers that we demonstrated in this study, we advocate for its use by providers who routinely evaluate patients with chronic pelvic pain. And we would encourage consideration of this myofascial pain screening examination for all patients, presenting with new pelvic floor complaints.
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