Evaluation

An initial evaluation should include a thorough musculoskeletal assessment. Consider referring to a physical therapist who treats chronic pelvic pain. Musculoskeletal evaluation includes posture assessment, gait and transfer analysis, active range of motion, and strength tests of the extremities and trunk (American Physical Therapy Association, 1997). Patients are also examined for scar tissue on the abdominal wall and flexibility. A pelvic muscle examination should include grading muscle strength and coordination of slow-twitch and fast-twitch fibers, overall muscle tone, tissue sensation and color, location of tender and trigger points, organ descent, perineal movement, and scarring. Surface electromyographic evaluation of the PFM documents baseline resting and contraction ability.

During the musculoskeletal assessment particular attention should concentrate on the hip rotators, hip flexors, hip adductors, hip extensors, sacroiliac joint function, lumbosacral joint function, leg lengths, upper body position, and general movement patterns. A therapeutic exercise program targeting dysfunctions found in these musculoskeletal groups is very helpful. First, consider a stretching program for tight and painful muscles. As the patient progresses add strengthening exercises for all muscle groups especially the pelvic girdle and trunk muscles. Pelvic stability and abdominal strengthening are significant as well. Pelvic floor muscle instruction is important to regain control and coordination of these muscles.

Treatment Options

Biofeedback is useful for monitoring the pelvic floor muscles and accessory muscles for patients with CPP. Biofeedback uses computerized (and other) instruments to relay information to patients about a physiologic activity. Interpreting information about pelvic muscle use through visual displays (such as computer monitors) is very helpful. Biofeedback can be used to strengthen the pelvic floor; facilitate relaxation and reduce resting tone of the pelvic floor; enhance coordination of pelvic muscles; inhibit accessory muscles, which substitute for PFM, to reduce voiding and defecating dysfunctions; and to train for general relaxation techniques (American Physical Therapy Association, 1997; Pauls, 1995). Often, patients with CPP have high resting tone of the pelvic floor muscles and poor ability to properly contract and relax the PFM and accessory muscles. To assist the patient with relaxation techniques, try working with breathing techniques, visualization, massage, and progressive relaxation exercises.

Transcutaneous electrical nerve stimulation (TENS) may be effective for treating patients with chronic pelvic pain. TENS has been used with patients with interstitial cystitis (Kotarinos, 1994). Interferential electrical stimulation is effective in pelvic floor strengthening but may require frequent visits to the clinic. Neuromuscular electrical stimulation (NMES) is used for pelvic floor strengthening and reflex inhibition with patients with pelvic muscle dysfunction (Laycock, Schussler, Norton, & Stanton, 1994). Try to use a vaginal or anal sensor with NMES and have patients use it before bedtime for assistance with sleeping and relaxation.

Manual therapy is another essential component of the treatment plan for patients with chronic pelvic pain. Manual therapy may include visceral mobilization of the pelvic organs and supporting structures, soft tissue massage or myofascial techniques to pelvic girdle musculature, scar tissue massage, internal vaginal and/or anal work to muscles and tissues, and joint mobilization to spine and extremities. Proper training is required to perform these techniques and referral to a skilled physical therapist may be best for your patient. Contact the American Physical Therapy Association Section on Women's Health at (800) 999-APTA, ext. 3237 to locate a regional representative who can refer you to a practitioner in your area.

Written educational materials are beneficial resources to have available for your patients. Maintain a list of professionals who specialize in counseling patients with chronic pain. Many areas have support groups for people with chronic pain that your patient may join. There are several national organizations whose brochures are available to distribute to your patients (see Table 1).

The Internet is a valuable resource for you and your patients to use for education and networking. Several chat rooms are available to patients and families to discuss their problems (see Table 2). Working with patients with chronic pelvic pain can be challenging and rewarding. Be creative and be sincere with your care and treatment plan. Many patients are willing to work with you to improve their conditions and are motivated much more than other patients because of their chronic pain. Document the treatments you perform and monitor for functional outcomes. Most of all, enjoy your work and good luck.

References

American Physical Therapy Association. (1997). The gynecological manual. Alexandria, VA: APTA

Jamieson, D., & Steege, J. (1996). The prevalence of dysmenorrhea, dyspareunia, pelvic pain, and irritable bowel syndrome in primary care practices. Obstetrics and Gynecology, 1, 55-58.

Kendall, F., McCreary, E., & Proveance P. (1993). Muscle testing and function (4th ed.). Baltimore: Williams & Wilkins.

King Baker, P. (1998). Musculoskeletal problems. In J. Steege, D. Metzger, & D. Levy (Eds.) Chronic pelvic pain: An integrated approach (pp. 205-224). Philadelphia: WB Saunders Co.

Kotarinos, R. (1994). Interstitial cystitis. Journal of OB/GYN Physical Therapy, 18(4).

Laycock, J., Schussler, B., Norton, P., & Stanton, S. (Eds.). (1994). Pelvic floor re-education: Principles and practice. London: Springer-Verlag.

Mathias, S., Kupperman, M., Liberman, R., Lipschutz, R., & Steege, J. (1996). Chronic pelvic pain: Prevalence, health-related quality of life, and economic correlates. Obstetrics and Gynecology, 1(3), 321-327.

Pauls, J. (1995). Therapeutic approaches to women's health. Rockville, MD: Aspen Publishers.

Whitehead, W. (1998). Gastrointestinal disorders. In J. Steege, D. Metzger, & D. Levy (Eds.) Chronic pelvic pain: An integrated approach (pp. 205-224). Philadelphia: WB Saunders Co.