1. Differential Diagnosis of Pelvic Floor pain in Pregnancy

2. Anatomy AKA Pelvic Diaphragm Coccygeus Muscle
Levator ani – pubcoccygeus, puborectalis, illeococcygeus
Pubococcygeus: can be damaged during parturition
Puborectalis: muscular sling envelops inferior rectum, vagina (uterus) & bladder (urethra)
Illeococcygeus: often underdeveloped/less significant role
Weight gain during pregnancy increased the subsequent risk of pelvic floor muscle dysfunction, and elective cesarean section did not prevent urinary incontinence (Barbosa et al, 2013).

3. Subjective Questions
Pt Hx: 1st report of sxs, aggravating/easing factors
VAS: severity
Bowel/Bladder
Sexual Function
Prolapse
ADLs
Obstetric/Gynecological
Diet
Medical Hx/Meds

4. Signs & Symptoms Muscle spasm
Muscle Pain: dull/sharp, constant/intermittent, mild/moderate/severe
Pain radiating to lower back, buttocks, thighs
Pain around connective tissue and ligaments
Pain with pelvic floor muscle contraction
Reproductive, urinary, musculoskeletal

5. Differential Diagnosis
SIJ pain
Bladder Distention-urinary urgency/incontinence
Pubic Symphysis dysfunction
LBP
Somato-visceral referred pain
Digestive, reproductive, urinary systems
Neurogenic causes (nerve irritation)
Appendicitis

6. Differential Diagnosis Continued
Colon cancer
Constipation
Crohn’s Disease
Diverticulitis
IBS
Fibromyalgia
UTI

7. Associated Impairments
Pelvic Floor Pain/Dysfunction can be caused by or lead to…
Incontinence (Stress-Urinary/Fecal)
Somatic Pain in the Lower Quadrants
Puborectalis muscle spasm
Obstructed Defecation
Myalgia
Vaginismus, Vulvodynia
Pelvic Organ Prolapse

8. Tests & Measures Pelvic Floor contraction technique
Bladder Diary/Fluid Volume
Ultrasound
Manometry
Questionnaires
Paper Towel test (urinary incontinence)
Bristol Stool Chart (Fecal incontinence)

9. Interventions Pelvic Floor muscle strengthening & relaxation
Kegels: Elevator metaphor contraction (slowly reach max contraction then slowly release the contraction, quick flick, sustained 10s contraction followed by 5s pause.
Spinal stability & strengthening exercise: LTR, lunges, squats, UE PNF
Diaphragmatic breathing: controlled expansion of abdomen on inhalation, draw in umbilicus on exhale

10. Interventions Continued
Biofeedback A biofeedback specialist uses monitoring equipment that provides feedback — visual cues, sound or verbal guidance — to the patient about body functions that usually aren't under conscious control. Biofeedback can help improve pelvic floor muscle coordination and rectal and bladder sensation.
Myofascial release (transvaginal maneuvers)
Global massage (general)

11. Alternate Treatment/Referal
Medical treatment: Various medical therapies may be helpful for pelvic floor tension myalgia, including estrogen, pain relievers, nerve pain medications, antidepressants, numbing agents or Botox injections.
Surgery: Many different surgical procedures, including minimally invasive techniques, can be used.
Acupuncture: This may relieve muscle pain, but more research is needed to determine whether it specifically helps with pelvic floor problems.

12. References
Barbosa, A., Marini, G. I., Piculo, F., Rudge, C., Calderon, I., & Rudge, M. (2013). Prevalence of urinary incontinence and pelvic floor muscle dysfunction in primiparae two years after cesarean section: cross-sectional study. Sao Paulo Medical Journal, 131(2), 95-9.
Giggins, O., Persson, U., & Caulfield, B. (2013). Biofeedback in rehabilitation. Journal of NeuroEngineering and Rehabilitation, 10(60), 1-11.
Goodman, C., & Snyder, T. (2007). Differential diagnosis for physical therapists. (4 ed., pp ). St. Louis, Missouri: Saunders Elsevier.
Kawasaki, A., & Amundsen, C. L. (2011). We need to expand the differential diagnosis for chronic pelvic pain to include pelvic myofascial pain. OBG Management, 23(10), Retrieved from
Memon, H., & Handa, V. (2013). Vaginal childbirth and pelvic floor disorders. Women's Health, 9(3),