Dr. Colleen Dy Disclosures: Member of an advisory board for Bio Synth and speaker for Pfizer. Mitigating Potential Bias: Recommendations are consistent with current practice patterns. Treatments or recommendations in this article are unrelated to treatments and recommendations involved in the disclosure statement.
What we have noticed
Individuals with Chronic Pelvic Pain (CPP) often experience disruptions in multiple aspects of their reproductive health care. Routine pelvic examinations often become extremely challenging due to pain. This presents challenges to family physicians and obstetricians in particular as pelvic inspection, and indeed, routine pap tests become almost impossible.
What changed our practice
With recognition of the multitude of experiences that can trigger an individual’s pain experience, the role of the physiotherapist, in particular, has been highlighted as an important aspect of a patient’s healthcare team in the pelvic rehabilitation process. To reduce the trauma that individuals experiencing CPP often go through and the negative effects on their sexual health, it is important to remember that negative experiences with pelvic exams can further contribute to the worsening of CPP. Thus, we, as physicians, must remain aware of this factor as we modify our practice to reduce this trauma.
What does the literature say about chronic pelvic pain?
Chronic pelvic pain (CPP) is a term that encompasses the persistence of pain beyond the period expected for normal tissue healing, occurring for longer than 3 months. CPP is often a difficult condition to treat due to the multifactorial reasons that pain persists. The persistence of CPP can be explained by the Neuromatrix theory which describes the persistence of pain as a safety mechanism from the brain to prevent a perceived or actual threat (1). Within the neuromatrix, there are different body maps, including sensory and motor maps that allow for distinctive localization of pain (2). As shown with other chronic pain syndromes such as complex regional pain syndrome, with CPP there is a “smudging” of body maps in that patients with pelvic pain might experience the sensation that they have altered or missing pelvic anatomy or localize their pain to another body part (2). In CPP, this smudging of body maps is often demonstrated by lack of 2-point discrimination on Q-tip examination (2).
In addition, the literature well documents that the experience of CPP is influenced by biopsychosocial factors in that an individual’s experience with pain is heavily influenced not only by biological effects, such as the firing of nociceptive receptors, but also by psychological factors such as anxiety, and social factors such as previous adverse or painful experiences (3). It can therefore be extrapolated that treatment of CPP must be one that encompasses a biopsychosocial approach with the therapeutic goal of reducing the expression of pain, while also avoiding triggering the protective pain response on assessment and treatment.
What we do now (practice tips)
(a) Patient History:
As with other conditions, when taking a history for pelvic pain disorders, it is important to get a detailed understanding of the onset and characteristics of pain, as well as alleviating and aggravating factors. Pain diaries in particular can be quite effective for this aspect of history taking. Pain that often worsens as the day progresses or is heightened by negative self-image and body exposure during sexual activities are evidence for the effect of cognitive-behavioural factors on CPP (4). For those a heightened response to pain secondary to psychosocial factors questionnaires, including the Pain Catastrophizing Scale (PCS) and the Tampa Kinesiophobia Scale (TSK) can be administered by trained physiotherapists to identify individuals with a high central sensitization component of pain (1, 3).
A detailed medical and gynecological history is essential in evaluating pelvic pain and should include a detailed sexual history and potential exploration of a history of sexual assault or genital trauma (5). Of note, adults with a history of elimination disorders in childhood may have an increased risk of pelvic pain disorders such as vulvodynia (4). Similarly, those with a history of anxiety or of previous pain or trauma to their pelvic organs or genitalia often have a propensity towards pelvic floor overactivity and pelvic pain syndromes (4). Therefore, throughout the history-taking process it is essential that the practitioner uses a trauma-informed care approach and maintain a supportive relationship with the patient, especially when discussing sensitive topics such as a history of sexual assault or trauma.
(b) Physical examination:
Physical examination is an essential aspect of assessing pelvic pain. It is important to note that individuals reporting a more diffuse pattern of pain or those reporting more distress during pelvic examination, suggest a more anxiety-driven or cognitive component of their pain experience rather than a purely biomedical response (4). We suggest a gradual, stepwise approach to the pelvic exam starting with visual inspection and ending with the speculum exam, which tends to be the most traumatic aspect of the pelvic examination. If the patient is willing, they can also participate in their own examination by spreading their labia or placing the speculum against the vaginal introitus. It is also important, to ask the patient for permission to proceed with each of the different steps of physical examination, ensuring that the patient knows that they have the option to withdraw consent and stop the examination at any point. Our general approach to the pelvic examination for those with pelvic pain is as follows:
- Visual inspection: Assess for the quality of skin mucosa. Ask the patient to contract and relax their pelvic floor muscles, you should be able to observe the range of motion.
- Q-tip examination: Start at the periphery and move inwards to test perineal sensation and tenderness, as well as to assess for any anticipatory or reactive responses from the patient. Lack of two-point discrimination, hypersensitivity, hyposensitivity, allodynia, and poor localization of touch of the perineum and external genitalia are objective findings that point towards the smudging of body maps as previously discussed (2).
- Internal pelvic examination: Gently insert a finger into the vaginal canal and assess the level of resting tension and hiatal dimensions. Ask the patient to contract and relax to further grade the resting tension, and to identify if the patient remains contracted or can relax either fully or partially. Ask the patient to cough or bear down to assess for tone/distensibility of the perineum and prolapse. Palpate each pelvic structure independently to assess for pain. For example, gently palpate the left and right pelvic floor, the left and right obturators, the bladder base, cul-de-sac, left and right adnexa, and uterus. Simultaneously assess for uterine position, masses, and pelvic organ prolapse. When palpating the pelvic floor muscles, assess for any changes in tissue quality, bulk, sensation, or tenderness. Palpate with graded pressure to attempt reproduction of the symptoms experienced, being mindful to only reproduce pain at a minimal, tolerable level. Digital exam also allows the practitioner to assess pelvic muscle strength and whether or not other muscles such as the gluteal or adductor muscles are activated in compensation for pelvic floor weakness. This part of the examination can replace the bimanual examination as palpating each individual pelvic structure often causes less discomfort. For practitioners wishing to learn more about pelvic floor anatomy, 3D pelvic floor models (such as those from totalpelvichealth.ca) may be helpful (6).
- Speculum examination: A speculum examination may be indicated for patients requiring a pap or STI testing, or for those experiencing abnormal uterine bleeding. If the patient is able to tolerate all of the above steps and genital hiatus will accommodate a speculum, the practitioner can proceed. If, however, the patient is unable to tolerate speculum examination, it is important to stop the examination to prevent further trauma.
(c) A Biopsychosocial Approach to Pelvic Floor Rehabilitation:
Even when pelvic floor anatomy might appear normal on investigation, the individual’s experience with pain is real, and may be due to Central Sensitization, or a heightened response to pain secondary to psychosocial factors (4). Therefore, a biopsychosocial approach to pelvic floor rehabilitation must be incorporated.
We should also be mindful of the psychological and social factors that contribute to the pain response. Strategies that target the psychological aspect of hyperalgesia that practitioners can counsel patients on may include Cognitive Behavioural Therapy (CBT), pain education, mindfulness-based exercises, and yoga (3). CBT in particular can be useful in treating the aftereffects of Adverse Childhood Events (ACE) such as sexual trauma, that can often predispose patients to CPP, and should warrant further referral to psychiatric professionals. Furthermore, if partners are willing, couples’ therapy and engagement of the partner in cognitive behavioural therapy can be helpful in improving interpersonal dynamics and the impact of CPP on the sexual response cycle (5).
Patient empowerment is also important in pelvic health rehabilitation. Patients can actively engage in pelvic floor rehabilitation exercises while at home to target the biological aspect of CPP, as pelvic floor musculature in these patients is often short, tender, and weak (7). These may include stretching exercises for the abdominal wall, pelvic floor lengthening exercises such as knee pushes and pelvic drops, manual massaging of tissues, and timed voiding for those with urinary frequency (8). Engagement with a physiotherapist who practices pelvic-floor rehabilitation would be ideal for patients with CPP. It is important to note, however, that not all pelvic health physiotherapists are trained and experienced with CPP; therefore, as practitioners, it is important to communicate with pelvic health physiotherapists in the community to determine who is experienced in both trauma-informed care and practices using a biopsychosocial model specifically for CPP. Physiotherapy approaches that have been proven to be helpful include pelvic floor muscle exercises with biofeedback, manual therapy, electrotherapy, and the progressive use of dilators (5).
CPP is a complex, multidimensional condition where biopsychosocial factors greatly influence the individual’s pain experience. Central sensitization, as a learned response, often complicates treatment and requires addressing in the pelvic rehabilitation process through practices such as mindfulness and CBT. When performing a pelvic examination, it is important to be aware that the speculum examination does not have to precede the bimanual examination and should not especially in cases of CPP. Instead, we suggest leaving speculum insertion until the end to gauge a patient’s tolerance to examination and to reduce the chances of a traumatic experience. Clinics that are publicly funded and multidisciplinary in nature in treating pelvic pain syndromes, include British Columbia’s Women’s Hospital (BCWH) also has a Centre for Pelvic Pain and Endometriosis. To identify pelvic physiotherapists in your area, you can use the directory on the Physiotherapists of BC website, but being cognizant that not all physiotherapists have training in trauma-informed care or pelvic-floor rehabilitation specific to CPP.
- Hilton S, Vandyken C. The puzzle of pelvic pain: a rehabilitation framework for balancing tissue dysfunction and central sensitization I: pain physiology and evaluation for the physical therapist. J Womens Health Phys Therap. 2011;35(3):103-113. DOI: 10.1097/JWH.0b013e31823b0750. (Request with CPSBC or view with UBC)
- Vandyken C, Hilton, S. The puzzle of pelvic pain: a rehabilitation framework for balancing tissue dysfunction and central sensitization II: a review of treatment considerations. J Womens Health Phys Therap. 2012;36(1):44-54. DOI: 10.1097/JWH.0b013e31824e0ab4. (Request with CPSBC or view with UBC)
- Vandyken C, Hilton S. Physical therapy in the treatment of central pain mechanisms for female sexual pain. Sex Med Rev. 2017;5(1):20-30. DOI: 10.1016/j.sxmr.2016.06.004. (Request with CPSBC or view with UBC)
- Padoa A, McLean L, Morin M, Vandyken C. The overactive pelvic floor (ORF) and sexual dysfunction, part 1: pathophysiology of OPF and its impact on the sexual response. Sex Med Rev. 2020;9(1):64-75. DOI: 10.1016/j.sxmr.2020.02.002. (Request with CPSBC or view with UBC)
- Padoa A, McLean L, Morin M, Vandyken C. The overactive pelvic floor (ORF) and sexual dysfunction, part 2: evaluation and treatment of sexual dysfunction in OPF patients. Sex Med Rev. 2020;9(1):76-92. DOI: 10.1016/j.sxmr.2020.04.002. (Request with CPSBC or view with UBC)
- Forget MJ. 2020. Total pelvic health. https://totalpelvichealth.ca. Updated 2021. Accessed October 7, 2020. (View)
- FitzGerald MP, Kotarinos R. Rehabilitation of the short pelvic floor I: Background and patient evaluation. Int Urogynecol J. 2003;14(4):261-268. DOI: 10.1007/s00192-003-1049-0. (View)
- FitzGerald MP, Kotarinos R. Rehabilitation of the short pelvic floor II: treatment of the patient with the short pelvic floor. Int Urogynecol J. 2003;14(4):269-275. DOI: 1007/s00192-003-1050-7. (View)
- Ahangari A. Prevalence of chronic pelvic pain among women: an updated review. Pain Physician. 2014;17(2):E141-7. (View)