Making the Diagnosis

Your physician should be asking about the location, severity, quality, and timing of your pain. This should include an obstetric history that details the patient’s menstrual cycle, pain conditions that may have occurred during a pregnancy, and complications in childbirth. A history of painful periods and painful intercourse and any problems with the bladder or bowel will also be asked. A history of diseases such as endometriosis, chronic pelvic inflammatory disease, interstitial cystitis, and irritable bowel syndrome will be asked. Questions regarding depression, anxiety, and a history of sexual or physical abuse will also be discussed.

A detailed physical examination will be performed to include an abdominal exam and a pelvic and rectal examination. Depending on the physician specialist, a neurological exam of the lower extremities and sacral area and a musculoskeletal exam of the external and internal muscular, joint, and ligamentous structures will be done. If the physician is a physiatrist or rehabilitation specialist, the examination will include assessment of the low back, hips, alignment of the external pelvis, and special tests of the pelvic joints (sacroiliac joint, hip, and pubic symphysis).

The doctor will likely examine you in several different positions. The pelvic examination may include a speculum examination by a gynecologist using stirrups but examination of the pelvic floor by a physiatrist will not involve using instruments or stirrups. The physician will be pressing on internal structures to find the most tender areas or trigger points and assessing muscular tone, relaxation, contraction, and coordination. The muscles function as a group, so isolating a specific muscle can be difficult. However, separating superficial from deep dysfunction is possible. The obturator internus which is a hip external rotator and often a source of deep myofascial pelvic pain is checked internally. Anatomic defects, scar, and evidence of pelvic organ prolapse will be evaluated as well. Manual muscle strength testing is scored using the Modified Oxford Scale similar to the assessment of incontinence. Most often in the case of chronic pelvic pain, the patient has tender muscles, trigger points, and evidence of poor relaxation of the muscles. They may not necessarily be weak.

A one digit rectal examination in the side-lying position completes the pelvic floor examination and also allows for full evaluation of the tailbone (coccyx). The coccyx is checked for tenderness, position, and range of motion. Coordination of the pelvic floor muscles where they attach to the coccyx will also be assessed. Again, typically the patient will have a non-relaxing pelvic floor which also makes passage of stool difficult and control of bowel movements tenuous.

Just because a pelvic exam has been done, this does not mean that pelvic floor pain has been ruled out.

Unfortunately, there is no perfect gold standard test to make a definitive diagnosis in pelvic pain. This is why greater attention is now paid to the physical examination as described above. Urine and blood tests to rule out a bladder infection or kidney dysfunction may be done. A pelvic ultrasound is ordered sometimes to rule out pelvic organ abnormalities or signs of cancer. Plain x-rays will mostly rule out osteoarthritis or a fracture. A CT scan of the pelvis can be done to look more closely at the internal organs or the bony pelvis whereas an MRI can visualize muscle and joints or stress reaction (that can lead to fracture) in the bone. Often these tests are only minimally helpful. It is common to have pelvic pain and normal imaging. Just because musculoskeletal structures look normal, it doesn’t mean they are not tender or abnormally functioning.

Laparoscopy is a surgical exploratory test commonly used by gynecologists to determine if the cause of the pain is related to anatomic abnormalities or adhesions caused by prior surgeries or endometriosis, a disease characterized by endometrial cells outside the uterus itself that cause scar.