Physical Examination Techniques for the Assessment of Pelvic Floor Myofascial Pain: A Systematic Review

Myofascial pain is common in both women and men with chronic pelvic pain (CPP) and pelvic floor disorder symptoms. It is characterized by the presence of trigger points, tenderness to palpation, and local or referred pain and can result in debilitating CPP. Pelvic floor myofascial pain has also been observed in the absence of local or referred pain in patients with lower urinary tract symptoms (LUTSs). Preliminary data support a correlation between the presence of myofascial pain in the levator ani and internal obturator internus muscles and the degree of LUTSs. A growing body of evidence has shown a correlation between myofascial pain and CPP syndromes and emerging data suggesting a link between subclinical myofascial pain and LUTSs. Many patients report an improvement in LUTSs after receiving myofascial-targeted pelvic floor physical therapy. Although pelvic floor myofascial pain is prevalent in patients with CPP, there is no standardized and reproducible protocol for the physical examination of myofascial pelvic pain and for assessing levator ani and internal obturator internus myofascial pain. Few clinicians evaluate for pelvic floor myofascial pain even in patients presenting with CPP. The aim of this systematic review to summarize and synthesize published examination strategies for the assessment of pelvic floor myofascial pain in women. Some components of the pelvic floor myofascial examination may be similar in males and females, but because the approach to access these muscles is different, this review focused on examination strategies in women. The authors were interested in further understanding the relationship between pelvic floor myofascial pain and LUTSs in patients seen by general or subspecialist gynecologists. A systematic review of the literature was performed using strategies for the concepts of pelvic floor disorders, myofascial pain, and assessment. Databases examined included Ovid MEDLINE 1946, EMBASE 1947, Scopus 1960, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effects, and Cochrane Database of Systematic Reviews. Searches were completed in June 2017. Three authors screened the articles, and those included contained a description of a pelvic myofascial physical examination. The initial search identified 404 full-text articles; 55 of these met the criteria for inclusion. Examination components varied significantly among the 55 studies and were frequently undefined. Objectives of the included studies varied widely as did the level of detail for included examination components. Most (49/55 [89.0%]) did not document counseling or consent prior to beginning the pelvic examination. Based on the available data, a consensus examination guideline was developed. The guideline includes use of a single digit (62% [34/55]) to perform transvaginal palpation (75%[41/55]) of the levator ani (87% [48/55]) and obturator internus (45% [25/55]) muscles using a patient-reported scale to assess the level of pain to palpation (51% [28/55]). Findings from this systematic review show that techniques for pelvic myofascial examination vary significantly and frequently are not well defined. The overall level of evidence to guide standardization of a pelvicmyofascial examination is poor. The known role of pelvic floor myofascial pain in CPP and link between pelvic floor myofascial pain and LUTSs suggest that physicians should be trained to evaluate for pelvic floor myofascial pain as part of the physical examination in patients presenting with LUTSs. The common elements of these consensus-based guidelines provide a good foundation for building an evidence-based protocol for the assessment of pelvic myofascial pain. Development of a standardized reproducible pelvic floor myofascial examination is needed to identify those patients with pelvic floor myofascial pain (as a contributing factor in their CPP and LUTSs), who may benefit from myofascial-targeted therapies.