Assessment
History
- Urination: frequency, urgency, nocturia, pain
- Incontinence: triggers, severity (pads per day)
- GU hx: stones, UTI, hematuria
- Fluid intake: include timing, caffeine, alcohol
- OBGYN hx: # pregnancies, vaginal vs C-section, pregnancy complications, menopause status
- Sexual hx: prior STIs, pain with intercourse (dyspareunia), pain with erection/ejaculation
- GI hx: bowel habits, constipation, pain
- MSK hx: hip/back pain
- Prior pelvic floor PT experience (and exercises)
- Prior GU/GI/GYN surgeries
- GU/GI medications
Physical exam findings
- Lumbar lordosis: indicates imbalances in lumbopelvic/hip complex
- Difficulty sitting or sitting to one side: pudendal neuralgia, compression from obturator internus or piriformis
- Painful abdominal scars or nodules: myofascial trigger points
- SI joint pain (with palpation): SI joint instability
- Hip manipulation pain (Fitzgerald test): hip labral tear, may radiate to vaginal wall
- Anterior vaginal wall tenderness (exacerbated with hip abduction): obturator internus spasm
- Posterior vaginal wall tenderness: levator ani spasm
- Pale mucosa, urethral caruncle: vaginal atrophy, lack of estrogen
- Rectal exam tenderness: mistaken for prostatitis
Treatments
Pelvic floor dysfunction
Trigger point injections
- Combination of bupivicaine and steroid injection for pain and inflammation
- Inject at 1 and 11 (obturator internus), 3 and 9 (levator ani), and 5 and 7 (iliococcygeus)
- Can consider botox injections, small study evidence
Other options
- Suppositories (vaginal/rectal): baclofen, ketamine, diazepam, cyclobenzaprine, may be helpful prior to therapy sessions
- Neuromodulation: can consider, discuss surgical risks