Pelvic Floor and Other Pelvic Disorders

Original Editor - Laura Ritchie

Top Contributors - Laura Ritchie, Evan Thomas and Nicole Hills

Vulvodynia

Pelvic Floor Muscles.jpg

Definition

Vulvar discomfort occurring in the absence of relevant visible findings or a specific, clinically-identifiable, neurological disorder.

Symptoms

  • Burning
  • Stabbing
  • Stinging
  • Itching
  • Allodynia (light touch perceived as pain)
  • Hyperalgesia (mildly noxious stimulus perceived as severely noxious)
  • Functional limitation (e.g. pain during intercourse, using tampons, sitting)

Diagnosis

Symptoms should be present for 3-6 months before this diagnosis is considered.

Other conditions that should be ruled out include:

  • Vulvovaginal candidiasis
  • Bacterial vaginosis
  • Trichomoniasis
  • Genital herpes
  • Neuropathic viruses (e.g. Herpes zoster)
  • HPV
  • Lichens simples chronicus
  • Lichens simples sclerosus
  • Lichens planus
  • Contact dermatitis
  • Atrophic vaginitis
  • Squamous cell carcinoma
  • Pudendal nerve injury
  • Referred pain from sacral nerve roots after disc injury
  • Neurologic disease (e.g. MS)

Classifications

Generalized vulvodynia:

  • Almost constant, typically burning pain
  • Affects the entire vulva
  • Provoked (sexual, non-sexual or both)
  • Unprovoked
  • Mixed (provoked and unprovoked)

Localized vulvodynia / vestibulodynia:

  • Localized to vulvar vestibule
  • Burning / cutting pain at entrance of vagina
  • Provoked (sexual, non-sexual or both)
  • Unprovoked
  • Mixed (provoked and unprovoked)

Co-Morbidities

Dyspareunia / Vaginismus

Definition

Dyspareunia: Painful vaginal penetration in the absence of disease

Vaginismus: Inability to penetrate due to spasm of the muscles

Causes

  • Painful scar / episotomy
  • Vulvodynia - Interstitital cystitis
  • Protective response to infection, inflammation, injury or decreased estrogen or fear

Lichens Simplex

  • Chronic irritation of the vulva
  • Leads to itching, scratching and thickening of the skin
  • Vulva can be weepy, causing moisture

Lichens Sclerosis

  • Auto-immune disorder
  • Itching or burning
  • Skin with white patches
  • Scars and adhesions of the vulva
  • Easily bruised and torn

Lichens Planus

  • Chronic mucocutaneous disease
  • Itching or burning
  • Scar adhesions
  • On the vulva and in the vagina
  • Affects other mucosal membranes e.g. oral, genital, esophageal - oral rash typically occurs first
  • Significant pain

Desquamative Inflammatory Vaginitis

Definition

  • Profuse discharge with irritation of the vulva and vagina
  • Inflammation causes the vaginal wall to peel or shed (desquamation)
  • No cancerous, contagious or bacterial origin known

Signs and Symptoms

  • Pus-like yellow/green discharge
  • May be vulvar burning and itching
  • Usually no odour
  • PAP smear may be abnormal
  • No improvement with antibiotics or antifungals

Atrophic Vaginitis

  • Decreased estrogen causes thinning of the vaginal epithelium leading to inflammation
  • Can cause vaginal soreness, itching, and dyspareunia
  • Sores and cracks can occur spontaneously
  • Can have an odourous discharge

Interstitial Cystitis / Painful Bladder Syndrome

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Dysmenorrhea

Definition

Painful menstrual periods

Classification

Primary: Menstrual pain without pelvic pathology, onset shortly after menarche

Secondary: Pain associated with secondary pathology, onset may be years after menarche

Risk Factors

  • Low BMI and low consumption of fruit, eggs and fish (for primary dysmenorrhea)
  • Poor mental health
  • Primary co-morbidities: irritable bowel syndrome, interstitial cystitis, vulvodynia, dyspareunia, TMJ and migraines
  • Secondary co-morbidities: endometrioses, presence of intra-uterine device, pelvic inflammatory disease, uterine myomas and adhesions
  • Smoking

Endometriosis

Definition

The abnormal presence of endometrial tissue outside of the uterus. This tissue implants and can behave in a similar manner to the uterus, shedding tissue and inflammatory molecules into the abdominal/pelvic cavity.

Symptoms

  • Subfertility
  • Pelvic pain including dysmenorrhea

Co-morbidities

Anal Fissures

Definition

Tears in the mucosal membrane of the anal canal, usually extending from anal opening. Can become chronic and deep.

Signs and Symptoms

  • Pain after bowel movement
  • May notice bright red bleeding on toilet paper

Causes

  • Stretching of anal mucosa beyond its capacity
  • Constipation or prolonged diarrhea
  • Trauma during childbirth
  • Crohn's disease
  • Anal sex
  • Poor toileting in young children

Prostatitis

Category 1: Acute Bacterial Prostatitis

  • Diagnosed through expressed prostatic excretions
  • Symptoms may include fever/chills, prostate pain, dysuria, perineal pain, difficulty urinating (hesitancy), urinary retention, low back pain

Category 2: Chronic Bacterial Prostatitis

  • Recurrent bacterial infection
  • Diagnosed through expressed prostatic excretions
  • Symptoms may include fever/chills, prostate pain, dysuria, perineal pain, difficulty urinating (hesitancy), urinary retention, low back pain
  • Constant or intermittent symptoms that tend to be associated with the same bacteria

Category 3: Chronic Non-Bacterial Prostatitis

Category 3A: With inflammation

Category 3B: Without inflammation

  • Also called Chronic Pelvic Pain Syndrome or Prostatodynia
  • Symptoms may include pain (perineal, rectal, suprapubic, penile, coccygeal, groin, low back), pain radiating into testicles/scrotum/central perineal tendon/anus, burning, itchiness, muscle tension, pain during and after ejaculation, feeling as if sitting on a golf ball
  • Urinary symptoms may include hesitancy, dysuria, nocturia, frequency and urgency, decreased stream, feeling of poor emptying

Category 4: Asymptomatic Inflammatory Prostatitis

  • Inflammation found in the semen

Pelvic Floor Dysfunction in Women - Videos

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[2]
[3]

Presentations

http://www.youtube.com/watch?v=w08iCzxnQBUKegel or not.png
Pelvic Physiotherapy - to Kegel or Not?

This presentation was created by Carolyn Vandyken, a physiotherapist who specializes in the treatment of male and female pelvic dysfunction. She also provides education and mentorship to physiotherapists who are similarly interested in treating these dysfunctions. In the presentation, Carolyn reviews pelvic anatomy, the history of Kegel exercises and what the evidence tells us about when Kegels are and aren't appropriate for our patients.

View the presentation

References

  1. Health Alert USA. Pelvic Floor Dysfunction in Women part 1 of 3. Available from: http://www.youtube.com/watch?v=La54dC-0KH8 [last accessed 30/04/14]
  2. Health Alert USA. Pelvic Floor Dysfunction in Women part 2 of 3. Available from: http://www.youtube.com/watch?v=61teXduzmx4 [last accessed 30/04/14]
  3. Health Alert USA. Pelvic Floor Dysfunction in Women part 3 of 3. Available from: http://www.youtube.com/watch?v=k1E6s9St7v0 [last accessed 30/04/14]