Pelvic Pain: Physiatric Evaluation and Management

Pelvic Anatomy, Function, and Physical examination

Jaclyn H. Bonder, MD

Assistant Professor, Department of Rehabilitation Medicine

Medical Director, Women’s Health Rehabilitation

ANATOMY

The Boney Pelvis (Pelvic Girdle)

http://www.musclereleasetherapy.com/postural-balancing-2.html

ARS: What are the bony landmarks of the urogenital triangle?

• Pubic symphysis

• Bilateral Ischial tuberosities

• Bilateral ischial spines

• Coccyx

• Bilateral ischiopubic rami

Answers are in red

Poll: What are the bony landmarks of the urogenital triangle?

Bony Landmarks

• Urogential Triangle

– Pubic symphsis/arch

– Ischiopubic ramus

– Ischial tuberosity

• Anal triangle

– Ischial tuberosity

– Sacrotuberous

Ligament

– Coccyx

– Ischial spine

Joints and Ligaments

7

•Anterior & Posterior (LDL)

SI Ligament

•Sacrotuberous ligament

•Sacrospinous ligament

•Pubic symphysis

•Sacroiliac Joint

•Sacrococcygeal joint

Pelvic Floor Muscles: Superficial

8

A. Superficial & Deep transverse perineal

B. Bulbcavernosus/spongiosus

C. Ischiocavernosus

D. External Anal Sphincter (EAS)

E. Perineal body

9

Pelvic Floor Muscles: Levator Ani

Levator Ani

Puborectalis

Pubococcygeus

Iliococcygeus

PR

PR

PC

PC

IC

IC

IC

IC

Pelvic Floor Muscles: Deeper Layer

10

Piriformis

Obturator internus

More Anatomy – It never ends!

Nerves of the Pelvis

•Lumbosacral trunk

•Pudendal nerve

•Nerve to Levator Ani and Coccygeus

12

Pudendal Nerve: Anatomy

Nerve Anatomy continued: Abdominopelvic nerves

ARS:What are the nerves that provide sensory/cutaneous

innervation to this region?

1 (correct answer) 2 3 4

A = Pudendal Pudendal Pudendal Pudendal

B = Inferior cluneal Posterior femoral cutanueousnerve

Inferior cluneal Posterior femoral cutaneous n.

C = Obturator Obturator Medial cutaneousn. of thigh

Medial Cutaneous n. of thigh

D = Ilioinguinal + Genitofemoral

Iliohypogastric & Ilioinguinal

Iliohypogastric only Ilioinguinal + Genitofemoral

Physical Exam for Pelvic Pain

Physical Exam

•Gait/Posture

•Neurologic

•MSK

•Pelvic asymmetries

•Pelvic floor: Vaginal & Rectal

•SIJ testing

•Pubic Symphysis

•Hip

•L-S spine

17

Photo: Pelvic Floor Physical Therapy, 2006

MSK Pelvic Floor Examination: External Vaginal

•Essentially the same components as other body parts

•Extension of MSK exam

•External Assessment:

• Inspection: labia, perineum, and introitus

•Palpation: superficial genital muscles

•Muscle evaluation: PFM contraction and relaxation

–Lift/descent of perineal body during voluntary contraction/relaxation

–Involuntary relaxation – valsalva

–Involuntary contraction - cough

•Assess for prolapse

•Reflexes: Check anal wink

•Sensory testing w/ LT and PP

•Q-tip test for vulvodynia

–Inner thigh, 1,4,6,7,11o’clock

•Palpate the muscles

–Superficial Genital muscles – DIP

–LAM – PIP @ 3-5 & 7-9 o’clock

–Compare L vs R

•Pain

•Quality of tone

•Muscle bulk

–Oburator Internus• Above arcus tendinous @ 3 & 9 o’clock

• ER hip into examiner’s hand

–Piriformis• Deep

• Bring knee to opposite shoulder

MSK Pelvic Floor Examination: Internal Vaginal

MSK Pelvic Floor Examination: Internal Vaginal

•Perform manual muscle testing

• Quality of contraction in 4 quadrants

–Left, right, anterior, posterior

• Strong hold

• Assess 5-10 quick flicks

• Compare right and left sides

• Modified Oxford Scale

–Poor inter-rater reliability

•Palpate ischial spine

–Tinel’s sign: pudendal n paresthesia

Grading of Strength (Modified from Laycock 2001)

• 0/5 - No contraction of muscles

• 1/5 - Flicker or pulsation is felt, no discernible lifting or

tightening

• 2/5 - Weak contraction, no discernible lifting or

tightening

• 3/5 - Moderate, some lifting of the posterior wall and

some tightening around the examiner's finger,

contraction is visible

• 4/5 - Good, elevation of the vaginal wall is felt against

resistance, drawing in of the perineum is felt, able to

hold for 5 or more seconds

• 5/5 - Strong resistance is felt, if 2 fingers are inserted,

fingers will be approximated, able to hold for with 10-

second hold

External

• Inspection:

–hemorrhoids, lesions

•Sensory testing

•Anal wink reflex

•Palpate the coccyx externally

Internal

•Sphincter exam–EAS

–IAS

–Resting tone and contraction

•Coccyx–Tenderness

–Position

–Mobility

•Ligaments - sacrococcygeal junction

•Muscle exam:–Coccygeus, OI and LAM

–Compare R and L

MSK Pelvic Floor Examination: Rectal

Function of Pelvic Floor Musculature

• Kegel 1950's –

– Support

– Sphincteric closure

– Sexual appreciation

• Herman & Wallace

– Above +

• Stabilization

• Sump Pump