Differential
Diagnosis of
Pelvic Floor pain
in Pregnancy
Anatomy
AKA Pelvic Diaphragm
 Coccygeus Muscle
 Levator ani – pubcoccygeus, puborectalis,
illeococcygeus
 Pubococcygeus: can be damaged during
parturition
 Puborectalis: muscular sling envelops inferior rectum,
vagina (uterus) & bladder (urethra)
 Illeococcygeus: often underdeveloped/less
significant role
 Weight gain during pregnancy increased the
subsequent risk of pelvic floor muscle dysfunction,
and elective cesarean section did not prevent
urinary incontinence (Barbosa et al, 2013).
Subjective Questions
 Pt
Hx: 1st report of sxs, aggravating/easing factors
 VAS: severity
 Bowel/Bladder
 Sexual Function
 Prolapse
 ADLs
 Obstetric/Gynecological
 Diet
 Medical Hx/Meds
Signs & Symptoms
 Muscle
spasm
 Muscle Pain: dull/sharp,
constant/intermittent,
mild/moderate/severe
 Pain radiating to lower back, buttocks,
thighs
 Pain around connective tissue and
ligaments
 Pain with pelvic floor muscle contraction
 Reproductive, urinary, musculoskeletal
Differential Diagnosis
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SIJ pain
Bladder Distention-urinary
urgency/incontinence
Pubic Symphysis dysfunction
LBP
Somato-visceral referred pain
Digestive, reproductive, urinary systems
Neurogenic causes (nerve irritation)
Appendicitis
Differential Diagnosis Continued
 Colon
cancer
 Constipation
 Crohn’s Disease
 Diverticulitis
 IBS
 Fibromyalgia
 UTI
Associated Impairments
Pelvic Floor Pain/Dysfunction can be caused by or
lead to…
 Incontinence (Stress-Urinary/Fecal)
 Somatic Pain in the Lower Quadrants
 Puborectalis muscle spasm
 Obstructed Defecation
 Myalgia
 Vaginismus, Vulvodynia
 Pelvic Organ Prolapse
Tests & Measures
 Pelvic
Floor contraction technique
 Bladder Diary/Fluid Volume
 Ultrasound
 Manometry
 Questionnaires
 Paper Towel test (urinary incontinence)
 Bristol Stool Chart (Fecal incontinence)
Interventions
Pelvic Floor muscle strengthening & relaxation
 Kegels: Elevator metaphor contraction (slowly
reach max contraction then slowly release
the contraction, quick flick, sustained 10s
contraction followed by 5s pause.
 Spinal stability & strengthening exercise: LTR,
lunges, squats, UE PNF
 Diaphragmatic breathing: controlled
expansion of abdomen on inhalation, draw in
umbilicus on exhale
Interventions Continued
 Biofeedback A biofeedback
specialist uses
monitoring equipment that provides feedback —
visual cues, sound or verbal guidance — to the
patient about body functions that usually aren't
under conscious control. Biofeedback can help
improve pelvic floor muscle coordination and
rectal and bladder sensation.
 Myofascial release (transvaginal maneuvers)
 Global massage (general)
Alternate Treatment/Referal
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Medical treatment: Various medical therapies may be helpful
for pelvic floor tension myalgia, including estrogen, pain
relievers, nerve pain medications, antidepressants, numbing
agents or Botox injections.
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Surgery: Many different surgical procedures, including
minimally invasive techniques, can be used.
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Acupuncture: This may relieve muscle pain, but more research
is needed to determine whether it specifically helps with pelvic
floor problems.
References
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Barbosa, A., Marini, G. I., Piculo, F., Rudge, C., Calderon, I., & Rudge, M.
(2013). Prevalence of urinary incontinence and pelvic floor muscle dysfunction in
primiparae two years after cesarean section: cross-sectional study. Sao Paulo
Medical Journal, 131(2), 95-9.
Giggins, O., Persson, U., & Caulfield, B. (2013). Biofeedback in rehabilitation.
Journal of NeuroEngineering and Rehabilitation, 10(60), 1-11.
Goodman, C., & Snyder, T. (2007). Differential diagnosis for physical therapists.
(4 ed., pp. 3-912). St. Louis, Missouri: Saunders Elsevier.
Kawasaki, A., & Amundsen, C. L. (2011). We need to expand the differential
diagnosis for chronic pelvic pain to include pelvic myofascial pain. OBG
Management, 23(10), 17-28. Retrieved from
http://www.obgmanagement.com/pdf/2310/2310OBG_Update.pdf
Memon, H., & Handa, V. (2013). Vaginal childbirth and pelvic floor disorders.
Women's Health, 9(3), 265-277.