1. Pelvic Pain Rehab By Anelyn Delmonte-Purifoy, PT
Civilian Supervisor of Physical Therapy
Fort Belvoir Community Hospital in Virginia

2. Pelvic Pain Definition
Pelvic pain according to the Mayo Clinic Staff is pain in the lowest part of your abdomen and pelvis.
Pelvic pain may be dull or sharp, constant or intermittent, vary in intensity from mild, moderate, or severe.
Pain with bladder, bowel, or sexual function.

3. Causes of Pelvic Pain
After surgeries-pelvic reconstruction (bladder slings, mesh), hysterectomies, C-sections, prostate surgeries, multiple abdominal surgeries
Women’s Health disorders-Interstitial cystitis, endometriosis, irritable bowel syndrome, pelvic organ prolapse, diastasis recti

4. What are we treating in Physical Therapy?
Musculoskeletal with MFTP, spasms, neuromas, nerve irritations and impingements
Postural alignment, improved body awareness, soft tissue normalization
Function with voiding/eliminating when you want and the ability to control till you can void/eliminate
Pain with vaginal coitus, erection/ejaculation, voiding/difficulty voiding, constipation, chronic incontinence

5. Pelvic Floor Anatomy

6. Pelvic Floor Anatomy

7. Pelvic Pain ICD-9 Commonly used diagnoses codes 564.6 Proctalgia Fugax
Spasms, anus/ani sphincter
Interstitial cystitis
Dyspareunia
Vulvodynia
Vaginismus
Pelvic pain (female), unspecified symptoms
Coccygodynia/coccydynia
Pelvic floor muscle spasms

8. Pelvic Pain Evaluation
History of current condition and symptoms
Onset
Mechanism of injury
Aggravating/alleviating factors

9. Pelvic Pain Evaluation
Incontinence affected?
How frequent
Amount (drops, soaking undergarments/clothing, streaming down the leg/full bladder leakage)
Use of any protection (panty liners, pads, diapers)

10. Pelvic Pain Evaluation
Past Medical/Surgical History
Any abdominal surgeries/GI disorders
Pregnancy Complictions (lacerations, prolonged pushing)
Pasted Cancer RX Radiation? Chemotherapy?

11. Pelvic Pain Evaluation
Current Functional Status/Prior
Job/Daily Routine
Recreational Physical Activities
Sexual Active, Ability to have Clitorial and/or Vaginal Orgasms

12. Pelvic Pain Evaluation
Objective Measurements
Screen the Spine, Pelvis, and the Hips (ROM, Pain, Functional Movement Patterns)
Abdominal muscle efficiency

13. Pelvic Pain Evaluation
TALK to your patients on the process of the pelvic assessment before and during.
Pelvic Assessment
Introitus (Clock method-assess pain and sensation)
Palpation of pelvic floor anatomy (Muscle tone, spasms, atrophy, integrity of soft tissue/scar tissue/neuromas, MFTP and reproduction of symptoms)

14. Pelvic Pain Evaluation
Pelvic Assessment
Pelvic floor strength (sustained contractions)
Pelvic floor coordination (quick flick contractions)
Diaphramatic Breathing

15. Pelvic Pain Rehab Goals
Normalize pelvic floor musculature
Increase pelvic floor contractions to 3+/5 with 10 sec hold/10X
Increase pelvic floor quick flicks to 10X in 10 sec
Ability to manage bowel and bladder function
Ability to engage in vaginal coitus managing pain

16. Pelvic Pain Rehab Goals
Other Goals
Engage in regular low impact cardio routine and low resistance weight training
Postural and Dynamic spinal stabilization training

17. Pelvic Floor Physical Therapy RX
Normalization of soft tissue using Manual techniques, MFTP releases, contract relax, vaginal dilators
Neuro-muscular re-education of the pelvic floor using manual cueing, biofeedback, assistance for significant other
Functional training in the clinic for dynamic stretching and stabilization
Return to vaginal coitus

18. Tools of Practice

19. Pelvic Pain Rehab
Take home message is You have to include the significant others. It will be hard to reach success with function without active participation specifically of the spouse. As a physical therapist you can return patients to normalized and improved recruitment with efficiency of the pelvic floor musculature, but functionality rarely takes place unless a gentle nudge of reassurance and confidence is added to the rehab component.

20. Pelvic Pain Rehab
Questions?