5/29/2023
Evaluating Pelvic Floor Dysfunction in Chronic Pelvic Pain or Dyspareunia
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Pelvic floor dysfunction (PFD) in women encompasses a wide range of clinical disorders including urinary or fecal incontinence, pelvic organ prolapse, vulvodynia, and pelvic girdle and perineal region pain syndromes. PFD etiology can result from both abnormal relaxation and nonrelaxing or hypertonicity. Abnormal pelvic floor relaxation can lead to pelvic organ prolapse or urinary incontinence. Hypertonicity of the pelvic musculature is attributed to symptoms of chronic pelvic pain and/or dyspareunia. Several other terms are also used to describe conditions of hypertonicity including pelvic floor tension myalgias, levator ani syndrome, or pelvic floor spasms.
The etiology of this PFD is often multifactorial and difficult to assign to a single cause or inciting event which can both mechanical and psychological often requiring both aspects to be evaluated and treated. Etiologies include 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 facilitation that occurs between visceral organs and muscles known as viscerosomatic reflexes.
Symptoms related to pelvic floor dysfunction in patients with chronic pelvic pain and/or dyspareunia can be identified by focused history-taking with the patient-described character and chronology of the pain remaining paramount, and will most accurately identify the nature and likely etiology of a respective patient’s pain etiology, be it of a mechanical, psychological, or mixed origin. .
Common features of PFD related to hypertonicity 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, and is again guided by the initial patient description of their pain. 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.
The principles of management includes targeted patient education, behavioral health referral for psychological support, pelvic floor physical therapy (for both mechanical and psychological etiologies), specific medical therapies depending on the condition (e.g. antispasmodics for vaginismus, tricyclic antidepressant medications for vulvodynia, etc.), and surgical interventions where appropriate (e.g. surgical management of pelvic organ prolapse.) . Adjunctive therapy often includes techniques such as biofeedback, trigger point massage, lumbopelvic joint mobilization, and myofascial release. In a systematic review of pelvic floor physical therapy for pelvic pain, 60% to 80% of women experience marked or complete relief.
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.
Dagostin Ferraz S, Rodrigues Candido AC, Rodrigues Uggioni ML, et al. Assessment of anxiety, depression and somatization in women with vulvodynia: A systematic review and META-analysis. J Affect Disord. 2024 Jan 1;344:122-131. doi: 10.1016/j.jad.2023.10.025. Epub 2023 Oct 11. PMID: 37832729.
Bonner PE, Paul HA, Mehra RS. Osteopathic Manipulative Treatment in Dysmenorrhea: A Systematic Review. Cureus. 2024 Jan 23;16(1):e52794. doi: 10.7759/cureus.52794. PMID: 38389612; PMCID: PMC10882259.
Peinado-Molina RA, Hernández-Martínez A, Martínez-Vázquez S, et al. Pelvic floor dysfunction: prevalence and associated factors. BMC Public Health. 2023 Oct 14;23(1):2005. doi: 10.1186/s12889-023-16901-3. PMID: 37838661; PMCID: PMC10576367.
Final editing of initial publication performed by The Medical Pen, LLC.
Initial Publication May 2023. Revised May 2025
Originally titled “Evaluating Pelvic Floor Dysfunction in Chronic Pelvic Pain or Dyspareunia”. Renamed May 2025.
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