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Evaluating Pelvic Floor Dysfunction in Chronic Pelvic Pain or Dyspareunia

Author: Jessica Sosa-Stanley, MD

Mentor: Amanda B. Murchison, MD
Editor: Brett Worly, MD

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Pelvic floor dysfunction is a broad term used to describe the abnormal activity or function of the pelvic floor musculature. Pelvic floor relaxation can lead to pelvic organ prolapse or urinary incontinence. The nonrelaxing form of pelvic floor dysfunction, involving increased activity and tone (hypertonicity) of the musculature, is attributed to symptoms of chronic pelvic pain or dyspareunia. Several other terms are used to describe this such as pelvic floor tension myalgias, levator ani syndrome, or pelvic floor spasms.

The etiology of this dysfunction is often multifactorial and difficult to assign to a single cause or inciting event. It may result from injury to the pelvic floor from surgical (including pelvic procedures involving mesh or suture placement), obstetric (associated with both cesarean and vaginal deliveries), or sexual trauma (sexual, physical, or emotional abuse). Conditions causing sexual pain, including atrophic vaginitis, vulvodynia, or vaginismus, may trigger involuntary contractions of the pelvic floor. Visceral syndromes such as endometriosis, interstitial cystitis, and irritable bowel syndrome are strongly associated with pain due to the upregulation of pain receptors, lowering of pain thresholds, and neural “cross-talk” that occurs between visceral organs and muscles, known as viscerosomatic convergence.

Symptoms related to pelvic floor dysfunction in patients with chronic pelvic pain or dyspareunia can be identified by focused history-taking. The character and chronology of the pain is important. Pain may begin following a traumatic event, surgery, menopause, or childbirth. Other common features of nonrelaxing pelvic floor dysfunction include pain that is better in the early morning (before the muscles are engaged) or following the intake of alcohol or muscle relaxants. Pain often worsens with deep penetration or after intercourse, and impaired relaxation of these muscles often leads to either pain or difficulty with urination or defecation.

While no standardized physical examination for the assessment of pelvic floor function exists, implementing a focused, systematic, and trauma-informed approach is useful. This begins with outer visual inspection of the vulva, perineum, and anus. A contracted state often leads to an upward lift or bulging perineum, which may be present without voluntary effort. A cotton swab test to detect and localize vulvodynia is often performed. Internal single digital palpation of the pelvic floor muscles (levator ani), as well as pelvic side wall muscles (obturator and piriformis), is the major component of the exam. This includes assessment of resting muscle tension, pain/tenderness localization, contraction, and relaxation. A speculum exam may be used if there is a suspicion for atrophy or inflammation, but this is often not necessary. Clinical examination is sufficient for the diagnosis of pelvic floor dysfunction and no routine laboratory or imaging tests are recommended.

Further Reading:

Chronic Pelvic Pain: ACOG Practice Bulletin, Number 218. Obstet Gynecol. 2020 Mar;135(3):e98-e109. doi: 10.1097/AOG.0000000000003716. PMID: 32080051.

Committee Opinion No 673: Persistent Vulvar Pain. Obstet Gynecol. 2016 Sep;128(3):e78-e84. doi: 10.1097/AOG.0000000000001645. PMID: 27548558.

Tu FF, As-Sanie S, Steege JF. Musculoskeletal causes of chronic pelvic pain: a systematic review of existing therapies: part II. Obstet Gynecol Surv. 2005 Jul;60(7):474-83. doi: 10.1097/01.ogx.0000162246.06900.9f. PMID: 15995564.


Final editing of initial publication performed by The Medical Pen, LLC.

Initial publication May 2023


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