AUGS executive summary: Assessment of the pelvic floor and associated musculoskeletal system

Abstract

Objectives:

This study aimed to assist practitioners in performing an accurate assessment of the external and internal pelvic musculoskeletal (MSK) systems to improve appropriate diagnosis and referral of patients with pelvic floor disorders or pelvic pain and to improve understanding of physical therapy (PT) treatment principles, thereby improving communication between practitioners and encouraging a multidisciplinary approach.

Methods:

A referenced review of the anatomy of the pelvic floor muscles, pelvis, and surrounding structures, followed by a detailed assessment of anatomy, posture, and gait, is presented. A thorough description of PT assessment and treatment is included with clinical relevance.

Results:

When proper assessments are routinely performed, MSK conditions can be recognized, allowing for prompt and appropriate referrals to PT. Assessment and treatment by qualified physical therapists are integral to pelvic health care. After efficient medical assessment, MSK dysfunction can be addressed expeditiously, thereby avoiding further decline. Left unaddressed, pelvic dysfunction may become chronic.

Conclusions:

We propose a guide for MSK assessment of the pelvis and associated structures that can be used for both clinical and research purposes. This guide is designed for health care providers caring for women with pelvic floor disorders, including physicians, advanced practice providers, and nurses. This guide serves to improve communication among multidisciplinary practitioners to refine MSK assessment and treatment approaches and thereby advance clinical care and research. Key Words: musculoskeletal system, pelvic floor, pelvic floor

Pelvic floor disorders (PFDs), including pelvic organ prolapse (POP), urinary and fecal incontinence, defecatory disorders (constipation), and pelvic pain, are difficult to completely and accurately diagnose without a comprehensive understanding of the musculoskeletal (MSK) components of the pelvis and the surrounding structures. Accurate assessment of the pelvic floor and associated conditions is further complicated by the interaction of multiple body systems within the pelvis; these include gynecologic, urologic, gastrointestinal, neurologic, rheumatologic, and endocrine systems.¹ Assessment of pelvic floor muscle (PFM) function, however, is not routinely performed.² Few medical health care providers perform a basic, let alone a comprehensive, intravaginal palpatory examination.³ Myofascial dysfunction is typically overlooked as a result of the lack of knowledge and adequate training.⁴ Because MSK dysfunction is rarely recognized or addressed, women suffer for extended periods without proper treatment.³ In a cross-sectional study, Sedighimehr et al⁵ found a higher frequency of pelvic MSK dysfunction in women with chronic pelvic pain (CPP) (also known as persistent pelvic pain); the authors concluded that routine MSK examination should be included in an assessment of the pelvis. A recent literature review suggests that MSK examination by knowledgeable health care providers is essential for identifying MSK-associated dysfunction and ensuring appropriate referral to physical therapy (PT). Stein et al⁶ also recommend PT intervention for patients with CPP and sexual dysfunction as a noninvasive treatment option. It is equally important to properly assess the entire pelvic complex. Pelvic, hip, and back dysfunction can contribute to or mimic other disorders. The lack of knowledge of the MSK system in the pelvic region, coupled with methodological inconsistencies in assessment techniques, contributes to delayed or underused care. Appropriate management of patients presenting with PFD and CPP requires a comprehensive evaluation and treatment to ensure that patients receive proper care.⁷ Lack of consensus terminology and consistent research protocols lead to confusion and difficulty comparing outcomes. A narrative review performed by Harris-Hayes et al⁸ found that the lack of consistent and valid terms in the reviewed studies limited meaningful conclusions regarding the relationships of MSK dysfunction and CPP. This illustrates that there is a great need for standardization in both clinical and research environments to provide guidance in comprehensive, accurate, and comfortable MSK assessment.^4,9,10

Table 1.

Evidence that supports implementation of safe and comfortable pelvic MSK assessments by multidisciplinary medical practitioners is evolving.^10,12 When proper assessments are routinely performed, MSK issues can be recognized, allowing for prompt and appropriate referrals for PT.^2,9,10 Assessments and interventions delivered by qualified physical therapists are integral components of overall pelvic health care. With more efficient and proper medical assessment, MSK dysfunction(s) can be addressed expeditiously, stopping the progression of decline. Left unaddressed, pelvic dysfunction has a much greater risk of becoming chronic. Improved recognition of pelvic and pelvic floor dysfunction by health care providers will reduce impairment and disability that often leads to pelvic floor pain.¹¹ When practitioners use standardized assessments and terminology, communication will improve. This in turn will strengthen the interdisciplinary model and will continue to improve patient care, optimizing treatment outcomes.^3,4 This publication serves as a guide for comprehensive pelvic floor assessment and provides a detailed description of evidence based PT treatment. Our goal is to encourage practitioners to perform comfortable, safe, and effective pelvic floor and associated system MSK examinations. This document describes baseline MSK assessment of the pelvis that can be used in clinical practice and research alike. This guide serves to open and improve communication among multidisciplinary practitioners. Evolving clinical care and research will help refine how the pelvic floor and pelvic region will be assessed and treated.

REFERENCES

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2. Lamvu G, Carrillo J, Witzeman K, et al. Musculoskeletal considerations in female patients with chronic pelvic pain. Semin Reprod Med 2018;36(2): 107–115. doi:10.1055/s-0038-1676085.

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8. Harris-Hayes M, Spitznagle T, Probst D, et al. A narrative review of musculoskeletal impairments associated with nonspecific chronic pelvic Pain. PM R 2019;Suppl 1(Suppl 1):S73–S82. doi:10>1002/pmrj.12209.

9. Sanses TVD, Chelimsky G, McCabe NP, et al. The pelvis and beyond: musculoskeletal tender points in women with chronic pelvic pain. Clin J Pain 2016;32(8):659–665. doi:10.1097/AJP.0000000000000307.

10. Meister MR, Shivakumar N, Sutcliffe S, et al. Physical examination techniques for the assessment of pelvic floor myofascial pain: a systematic review. Am J Obstet Gynecol 2018;219(5):497.e1–497.e13. doi:10.1016/ j.ajog.2018.06.014.

11. Prather H, Dugan S, Fitzgerald C, et al. Review of anatomy, evaluation, and treatment of musculoskeletal pelvic floor pain in women. PM R 2009; 1(4):346–358. doi:10.1016/j.pmrj.2009.01.003.

(Female Pelvic Med Reconstr Surg 2021;27: 711–718)

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