components of an evaluation of pelvic disorders

Diane K. Newman, RNC, MSN, CRNP, FAAN

See also Patient Tip Sheets:

History

Assess characteristics of symptoms
- Location/site of pain/discomfort
- Duration, time, association with other activities
- Aggravating or alleviating factors
Associated urinary symptoms such as urgency, frequency, dysuria
History of recurrent UTI
Menstrual history
- cycle length
- regularity
- duration of bleeding
- cyclic pain symptoms
Changes in symptoms in relation to gastrointestinal and urinary functions
Past surgery and its relationship to onset of symptoms
Impact of symptoms on daily activities
History of bowel disorders such as constipation, IBS
History of depression or anxiety
History of low back trauma
Previous sexual abuse
Previous treatments and outcomes: e.g. surgery, acupuncture, medications (common ones are antidepressants, narcotics), physical therapy, chiropractic

Physical Examination

Abdominal
- Note any abdominal guarding (pain)
- Use gentle pressure to determine areas of tenderness, especially in lower abdominal quadrants
- Explore scars for hernias and nerve entrapment
Genitalia & Pelvic
- Assess vulva, labia, Bartholin's and Skene's glands, clitoral hood and perineal region for lesions, excoriated areas, or erythema
- Sensory assessment of vulvar mucosa and entire introitus with cotton-tipped swab to locate areas of tenderness or hypersensitivity
- Pelvic muscle assessment
- Using a single finger, palpate muscular attachments along the pubic arch and the insertion of the levator ani and coccygeus muscles
- Palpate the levators at the 4 and 8 clock position to determine if that reproduces any discomfort or tenderness
- Assess area of episiotomy scar for tenderness
- Have woman contract and relax pelvic muscle to assess muscle tone, strength and ability to isolate levators

Rectal
- Assess reflexes such as anal wink to determine an intact pudendal nerve and functional levator ani
- Assess for itching and burning

Other tests

Urinalysis
Urine culture
Urinary oxalate assay
Fungal and bacterial vaginal culture
Vaginal pH
If indicated referral for colposcopy/vulvoscopy

Adapted from Newman, DK. (2000) "Pelvic Disorders in Women: Chronic Pelvic Pain and Vulvodynia". OstomyWound Management: December 46(12): 48-54.

References

Baker, PK. (1993) Musculoskeletal Origins of Chronic Pelvic Pain. Contemporary Management of Chronic Pelvic Pain, 20(4) December:719-742.05-227.

Duleba, A.J., Keltz, M.D., Olive, D.L. (1996) Evaluation and Management of Chronic Pelvic Pain. Journal American Association Gynecologic Laparoscopists, February 1996, 3 (2), 205-227.

Glazer,H.I.,Rodke,G.,Swencionis,C., Hertz,R.,Young,A.W.(2000) "Treatment of Vulvar Vestibulitis Syndrome with Electromyographic Biofeedback of Pelvic Floor Musculature". Journal of Reproductive Medicine, 40(4),11 pp.

Metts, J.F. (1999) Vulvodynia and Vulvar Vestibulitis: Challenges in Diagnosis and Management. American Family Physician, 59(6),1547-1556.

Newman, DK. (2000) "Pelvic Disorders in Women: Chronic Pelvic Pain and Vulvodynia". OstomyWound Management: December 46(12): 48-54.

Paavonen, J. (1995) "Vulvodynia - a complex syndrome of vulvar pain". Acta Obstet Gynecol Scand. 74,243-247.

Steege,J.F. (1997) Office Assessment of Chronic Pelvic Pain. Clinical Obstetrics and Gynecology, Vol.40(3),554-563.

Steege,J.F.,Metzger,D.A.,Levy, B.S. (1998) Chronic Pelvic Pain: An Integrated Approach. W.B.Saunders,Philadelphia, PA.

Yount,J.J., Solomons, C.C.,Willems, J.J., St. Amand, R.P. (1997) "Effective Nonsurgical Treatments for Vulvar Pain". Women's Health Digest, 3(2),88-93.

Posted October 2007