Examination of a Patient with Chronic Pelvic Pain
Examination of a Patient with Chronic Pelvic Pain
The aims of examination are to assess the relative importance of each component of the patient’s pain and exclude
infection. A sequence of examination may include:
- Gait: slow, awkward rising from a chair, slow walk from the waiting room or sudden sharp pains are suggestive of pelvic muscle pain
- Palpation of the lower back and gluteal muscles: tenderness of gluteus medius, coccyx and sacroiliac joints posteriorly; tenderness is common in conjunction with intra-pelvic muscle dysfunction
- Palpation of Abdomen: signs of extensive heat pack use, for masses or tender points in rectus abdominus
- Assessment of cold sensation (optional): reduced cold sensation in the area of maximal pain may be present (Figure 2) and is suggestive of nerve pathway involvement
Vulva and Vaginal Examination with or without speculum
- Vulva skin irritation, atrophic vaginal skin, vaginal discharge , exclusion of sexually transmitted infections
- Cotton tip swab assessment; vaginal introital sensitivity between 4 and 8 o’clock near Bartholins Glands suggests provoked vulvar vestibulodynia
- One-finger vaginal examination of the pelvic floor and obturator internus: the pelvic floor muscles are palpated
(stroked) laterally just inside the vagina; the obturator internus is palpated slightly deeper at the level of the mid vagina by pressing laterally toward the hip. The right obturator internus will become tight and easier to palpate with your right forefinger when the patient’s flexed right knee is abducted laterally against your externally placed left hand;
the left obturator internus is easier to palpate with your left forefinger vaginally and her left leg abducted laterally against your externally placed right hand. Where pelvic floor muscles are already tight, further contraction and then relaxation of the pelvic muscles around the examiners fingers on request may not be possible. - vaginal examination: uterus and adnexae, then bladder and urethra through anterior vaginal wall
Penile and Prostate examination
- Penile irritation, penile discharge, exclusion of sexually transmitted infections
- Feel for inguinal hernias
- Palpation of perineum for muscle tenderness
- Digital rectal examination
Investigations
There is a limited role of laboratory testing and imaging in diagnosing patients with CPP, history and physical examination are the most important components. Although these diagnostic tests may be required for referrals to Gynaecology and/or Urology.
A complete blood count, C-reactive Protein, urinalysis, chamydia and gonorrhoea testing, prostate specific antigen test, and pregnancy test may be done to screen for chronic infectious or inflammatory processes and to exclude prostate cancer and pregnancy.
Pelvic ultrasonography is helpful to identify pelvic masses, adenomyosis, hydrosalpinx, and ovarian cysts. Ectopic endoemtrial glands such as ovarian endometriomas, peritoneal implants and deep pelvic endometriosis may be visible on ultrasonography Magnetic resonance imaging may be useful to define an abnormality found on ultrasonography.
Unfortunately, all these investigations may return normal and sometimes even laparoscopy, leaving many patients without a diagnosis for the cause of the chronic pelvic pain.
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