Evaluation of the Levator Ani And Pelvic Wall Muscles in Levator Ani Syndro m e

M a rg a ret Hull Marlene M. Cort o n

h ronic pelvic pain is a C h ronic pelvic pain is a difficult pro blem to evaluate and treat. debilitating condition K n ow l e d ge of the pelvic floor and pelvic wall mu s cles may enable the that affects many wo- p rovider to identify levator ani spasm syndro m e, a possible cause of men. The location of ch ronic pelvic pain. Cpain may be vague and diff i c u l t for patients to define, or it may © 2009 Society of Urologic Nurses and Associates include specific symptoms of U rologic Nurs i n g, p p . 2 2 5 - 2 3 2 . d y s p a r eunia, irritative voiding symptoms, low back and buttock Key Wo rd s : Levator ani, pelvic wall muscles, chronic pelvic pain, pain, constipation, vaginal and levator ani spasm syndrome. vulvar pain, and low abdominal pain (Lilius & Valtonen, 1973). C h ronic pelvic pain is defined as O b j e c t i v e s the complaint of pain in the lower abdomen and pelvic floor 1 . Explain chronic pelvic pain. muscles for greater than 6 months 2 . Discuss the examination process for properly diagnosing chron- and affects approximately 15% to ic pelvic pain. 20% of women 18 to 50 years of age (Jamieson & Steege, 1996; 3. Identify treatment modalities for chronic pelvic pain. Mathias, Kuppermann, Liberm a n , Lipschutz, & Steege, 1996). Patients may present for evalua- multiple times with many pro- Background tion and treatment of these com- viders before the patient re c e i v e s To d a y ’s re s e a rche rs and clini- plaints, only to be told there is a re f e rra l for a definitive diagno- cians refer to this condition as nothing physically wrong with sis. levator ani spasm/syndro m e them. This scenario may occur T h e re can be many causes of (LAS) (Hoffman, 2008; Smith, c h ronic pelvic pain, including 1959). It was first described by gynecologic sources (such as Simpson in 1859 and later by endometriosis), gastro e n t e ro l o g i c Thiele (1963), although these M a rgaret Hull, M S N , W H N P - B C , is a s o u rces (irritable bowel syn- re s e a rchers called it, somewhat Urogynecology Nurse Pra c t i t i o n e r, the d rome), urologic sources (intersti- i n a c c u r a t e l y, coccygodynia (Grant Center for Pelvic Health, St. Thomas Health tial cystitis), and musculoskeletal & Salvati, 1975). Thiele (1963) S e r v i c e s, Franklin, T N . s o u rces (sacroiliac joint dysfunc- made significant contributions to tion). This discussion will Marlene M. C o rt o n , M D, is an Associate f u rther understanding the syn- P r o fe s s o r, University of Texas Southwe s t e rn a d d r ess the specific cause of d r ome by noting that patients Medical Center, Dallas, T X . c h ronic pelvic pain attributed to who had levator spasm often dysfunction of the levator ani and complained of low back and but- N o t e : The authors reported no actual or other pelvic wall muscles. potential conflict of interest in relation to this tock pain, which are common c o n t i nuing nursing education art i c l e. Dysfunction occurring fro m complaints of people who have spasm of these muscles may N o t e : O b j e c t i ves and CNE Evaluation Fo rm coccygodynia. appear on page 232. result in significant chronic pain Even though similarities exist for the patient. between LAS and coccygodynia,

UROLOGIC NURSING / July-August 2009 / Volume 29 Number 4 225 i m p o rtant diff e rences exist to Figure 1. separate them. For example, L evator Ani and Pelvic Wall Muscl e s early re s e a rch ers noticed that patients with levator ani spasm could not describe any traumatic or triggering event; unlike coccy- godynia, the symptoms of levator spasm may worsen during peri- ods of stress that led observers in the past to question a re l a t i o n s h i p between the syndrome and psy- chiatric disorders (Grant & Salvati, 1975). Furthermore, patients with spasm may experi- ence rectal pain when the levator ani muscles are palpated, but the pain may not be re p ro d u c i b l e when applying pre s s u r e or mov- ing the coccyx, as is seen in those with coccygodynia (Smith, 1959; Wright, 1969). As seen in early discussions, S o u rc e : R e p rinted with permission from Marie Sena, University of Tex a s this debate over what constitutes S o u t h we s t e r n Medical Center. LAS and coccygodynia is some- what nebulous, with much con- t roversy surrounding the defini- A n a t o m y evacuation (voiding, defecation, tion. Much of the confusion con- One of the muscle layers in and during parturition) (Cort o n , tinues to this day with disagre e- the pelvic floor is collectively 2 0 0 8 ) . ment over the evaluation and known as the pelvic diaphragm. The most commonly re c o g- diagnosis of LAS. There f o re, the This diaphragm consists of the nized components of the levator objectives of this discussion are levator ani and coccygeus mus- ani muscles are the pubococ- to provide a detailed description cles along with their superior cygeus, puborectalis, and iliococ- of the levator ani muscles and to and inferior layers of fasciae (see cygeus muscles. The pubococ- p res ent a thorough system of F i g u re 1). cygeus muscle arises from the examination of these muscles. The levator ani is a very pubic bone and inserts at the Discussion will also include a i m p o rtant muscle complex in the anococcygeal body forming a description and examination of pelvic floor and re p resents a crit- sling around the urethra, vagina, the pelvic wall muscles, which ical component of pelvic org a n and rectum. According to include the piriformis and obtu- s u p p o r t. The normal levators Delancey and Ashton-Miller rator internus muscles. While maintain a constant state of re s t- (2007), this muscle elevates the these muscles do not comprise ing contraction, maintained by vagina, perineal body, and anus. the levator ani complex, and the action of Type I (slow twitch) Spasm from this muscle can cre- t h e r e f o re, are not included as fibers that predominate in this ate low abdominal pain, back p a rt of the diagnosis of LAS, dys- muscle. This baseline activity of pain, and insertional dyspare u- function of them may impact the the levators keeps the uro g e n i t a l nia, as well as pain with re p e t i t i v e levator ani muscles, which may hiatus narrowed and draws the penile movement and thru s t i n g g r eatly affect patients with distal parts of the urethra, vagina, (see Table 1). The pubore c t a l i s c h r onic pelvic pain. Finally, and rectum toward the pubic also arises on either side f rom the some basic therapeutic measure s bones. Type II (fast twitch) mus- pubic bone and forms a U-shaped will be described. While not cle fibers allow for involuntary sling behind the anorectal junc- meant to be a complete listing of reflex muscle contraction elicited tion. The action of the pubore c- techniques and treatments for by sudden increases in abdomi- talis draws the anorectal junction LAS, this information will fur- nal pre s s u re. The levators can t o w a rd the pubis contributing to ther aide the provider in under- also be voluntarily contracted, as the anorectal angle (Cort o n , standing how some techniques with Kegel exercises and sudden 2008). Spasm of this muscle may may help relax the muscles and i n c reases in abdominal pre s s u re . result in chronic constipation as alleviate the patient’s pain. Relaxation of these muscles the anorectal canal re m a i n s occurs only briefly and interm i t- angulated, prohibiting the re l a x- tently during the processes of ation needed for proper evacua-

226 UROLOGIC NURSING / July-August 2009 / Volume 29 Number 4 Ta ble 1. al surface of the sacrum and par- such as from an episiotomy. Symptoms of LAS and Pe l v i c tially fills the postero l a t e r a l F u rt h e rm o re, the examiner assess- Wall Muscle Spasm pelvic walls. It exits the pelvis es skin integrity by looking for t h rough the greater sciatic fora- any atrophic or dermatologic Pubococcygeus: Dyspareunia, men, attaches to the gre a t e r changes that may contribute to the lower abdominal pain, low back pain t r ochanter of the femur, and p a t i e n t ’s discomfort. While the Iliococcygeus: Dyspareunia, low functions as an external or lateral patient may have LAS, if such back pain, low abdominal pain hip ro t a t o r. Spasm of this muscle lesions or conditions are pre s e n t , can cause pain that is re f e rre d to f u rther evaluation is necessary. Puborectalis: Painful defecation, multiple regions of the pelvis Next, the clinician should constipation and low back (Simons & Tr a v e l l , evaluate the patient’s perineal Coccygeus: Dyspareunia, low back 1999), and may contribute to dys- sensation and bulbocavern o s u s pain, low abdominal pain p a r eunia and painful defecation and anal reflexes. When evaluat- Piriformis: Hip and back pain, ( B row n, 2000). ing sensation, the clinician can referred pain to lower abdomen, The obturator internus mus- use the soft and sharp sides of a dyspareunia cle partially fills the sidewalls of cotton swab and apply light touch the pelvis. This muscle arises to firm touch to all parts of the Obturator Internus: Urinary f rom the pelvic surfaces of the perineum and inner thighs symptoms, dyspareunia, hip pain ilium and ischium, and from the attempting to discern the patient’s obturator membrane. It exits the ability to diff e rentiate between the pelvis through the lesser sciatic two types of stimulation. This tion of stool (El-Minawi, 2000; foramen, attaches to the gre a t e r evaluation is also useful to deter- Grant & Salvati, 1975). Finally, t rochanter of the femur, and as mine if the pain has a neuro p a t h- the iliococcygeus muscle, which the piriformis muscle, it func- ic cause (Hoffman, 2008). The per- is the most posterior part of the tions as an external hip ro t a t o r ineum and lower extremities are levators, arises laterally from the ( H o w a r d, 2003; Simons & i n n e rvated by S2 to S4, and an a rcus tendineus levator ani and Travell, 1983). Patients with understanding of the nerve path- the ischial spines, and muscle spasm of this muscle may com- ways can help the clinician deter- fibers from one side join those plain of severe urinary fre q u e n c y, mine the source of the patient’s f rom the opposite side at the ilio- u rg e n c y, and dysuria, as well as pain (see Figure 2). coccygeal raphe and the coccyx d y s p a reunia (Oyama et al., 2004). Looking for involuntary ( C o rton, 2008). Spasm from this movement, reflex evaluation is muscle may result in low abdom- completed by using the soft part Examination inal pain, low back pain, and of a cotton swab while gently d y s p a reunia as well. Conducting a compre h e n s i v e striking the right and left labia The coccygeus muscle lies physical examination is an majora and either side of the anal posterior and adjacent to the ilio- essential part of a proper diagno- meatus, re s p e c t i v e l y. Frawley coccygeus. It attaches to the sis of chronic pelvic pain. The and Bower (2007) write that an ischial spine laterally, to the coc- first step is observation of the absent reflex may be seen in a cyx, and the lowest aspect of the p a t i e n t ’s gait and sitting habits. patient who has spasm in the s a c rum medially (Corton, 2008; Patients may be observed walk- muscles. An excursion test can Simons & Travell, 1999). While ing slowly and stiff l y, attempting be perf o rmed to evaluate coord i- spasm of the pubococcygeus and to guard the abdominal are a . nation and relaxation of the leva- iliococcygeus portion of the leva- When seated, the patient may tor ani muscles. While continu- tors may cause dyspareunia with lean somewhat lopsidedly, ing to observe the perineum, the penile insertion, spasm of the avoiding the side that causes examiner asks the patient to con- coccygeus muscle may result in g reater discomfort, or may fre- tract her levator ani muscles, d y s p a reunia with deep penetra- quently shift positions while relax them, then valsalva and tion. No data support this pro b - seated in an attempt to re d u c e relax again (Castello, 1998). lem, and observation is support- the pain (Simons & Tr a v e l l , P e rf o r mance of this test may ed by anecdotal experience alone. 1 9 9 9 ) . p rove useful to the clinician While not part of the levator A systematic pelvic examina- because the patient with spasm ani complex, the pelvic wall tion is necessary to thoro u g h l y may not have the ability to thor- muscles can contribute to chro n- evaluate the cause of one’s pain. oughly relax the pelvic floor, may ic pelvic pain. Discussion of With the patient in the lithotomy re c rui t additional muscles in an these muscles will include the position, a thorough inspection of attempt to contract the levator p i r i f o r mis and the obturator the pelvic floor should be com- ani, and may not have the ability i n t e rnus. The piriformis muscle pleted. This includes both obser- to properly valsalva (Frawley & arises from the anterior and later- vation and palpation of any scars, B o w e r, 2007).

UROLOGIC NURSING / July-August 2009 / Volume 29 Number 4 227 Figure 2. The focus of the intern a l S2-S4 Dermatomes examination is the evaluation of the levator ani and pelvic wall muscles for spasm. There f o re , the examiner evaluates for any taut muscle bands; any small, pea-sized nodules within the muscle that may or may not be painful; and any tenderness with palpation. Pre s s u re applied to the levator ani during the exami- nation should be firm but gentle, with the examiner paying close attention to the patient’s experi- ence of pain. Internal examina- tion can be achieved by picturing the vagina on the face of a clock. I n t roducing the gloved index fin- ger approximately one inch, or to the first knuckle, into the distal vagina, the examiner will palpate the pubococcygeus muscle fro m 7 to 11 o’clock on the left and f rom 1 to 5 o’clock on the right. Palpation of the puborectalis can also be achieved vaginally and may be felt more laterally in the S o u rc e : Schorge et al., 2008. R e p rinted with permission from The McGraw - H i l l distal vagina. C o m p a n i e s. I n s e rtion of the examining finger further into the vagina Figure 3. allows for palpation of the ilio- Obturator Internus Eva l u a t i o n coccygeus. This muscle can be felt from the 4 to 8 o’clock posi- tions. With the examining finger still positioned in the vagina at a p p roximately the second and t h i rd knuckles, evaluation of the obturator internus muscle can be p e rf o rmed by directing the index finger superiorly and laterally palpating it at the 10 and 2 o’clock positions (see Figure 3). I n s e rtin g the finger very deeply into the vagina and d i recting it to the 5 and 7 o’clock positions enables the examiner to evaluate the coccygeus muscle. With the vaginal muscle assessment completed, the exam- iner evaluates coccygeal mobility with a two-handed technique (Smith, 1959). Demonstration of this technique is perf o rmed with the examiner inserting the finger of the dominant hand into the rectum. While using this hand to palpate the coccyx intern a l l y, the S o u rc e : R e p rinted with permission from Marie Sena, University of Tex a s examiner then uses the other S o u t h we s t e rn Medical Center. hand to palpate the coccyx exter-

228 UROLOGIC NURSING / July-August 2009 / Volume 29 Number 4 n a l l y. With the coccyx anchore d marks at the greater tro c h a n t e r but should not feel severe pain. between the two fingers, the and sacrum, and perf o rming light P e rf o rmance is completed with examiner can assess its mobility and deep palpation, evaluating the examiner using deep palpa- by rocking the fingers in an ante- for any tightness in the muscle tion to the affected muscle and rior and posterior fashion. The while directing the fingers acro s s maintaining a constant pre s s u r e coccyx should be freely mobile the imaginary line created fro m for 90 seconds to 2 minutes until and non-tender when palpated the lateral border of the sacrum to the muscle relaxes. Likewise, if with a 30-degree range of motion. the proximal end of the gre a t e r the patient has palpable trigger The examiner then com- t r ochanter (Simons & Tr a v e l l , points within the muscle, the pletes the rectal examination by 1 9 9 9 ) . p rovider may perf o rm trigger i n s e rting the gloved index finger point massage by applying con- into the rectum to palpate the stant, direct pre s s u re to the spe- Treatment p u b o rectalis muscle, which is cific point to reduce the pain. beyond the external anal sphinc- Several therapeutic tech- This technique is slightly diff e r- ter (Delancey & Ashton-Miller, niques have been described and ent from ischemic compre s s i o n , 2007). Evaluation of the muscle may prove useful in re l i e v i n g w h e re the provider applies pre s- is achieved by using a down- symptoms of LAS. The following s u re to the spastic muscle. Wi t h w a rd, U-shaped, or sweeping a re only some of the described trigger point massage, pre s s u r e is motion on the muscle from 1 to t reatments that may prove eff e c- d i rected to the specific trigger 11 o’clock. tive for the patient. point within the muscle. Tr i g g e r While palpating the pubore c- points, as defined by Simons and talis muscle, the examiner T h i e l e ’s Massage Travell (1999), are tender, hyper should direct the patient to push P e r f o rmance of Thiele’s mas- i rritable nodules within the mus- the examining finger out of the sage rectally or through a vaginal cle. When palpated in the vagina, anus. Similar to the excursion a p p r oach has been shown to they can cause re f e rred pain test, this pro c e d u re can be used relieve pain from muscle spasm t h roughout the pelvis. Patients to evaluate non-relaxation and (Oyama et al., 2004; Thiele, with LAS may or may not have i n c o o rdination of the pubore c t a l- 1963). With the patient in the palpable trigger points. Likewise, is muscle. Does the patient con- S i m ’s position, the index finger is patients without LAS may still tract around the examiner’s fin- i n s e r ted into the re c t u m . have trigger points within the ger while attempting to valsalva? Palpating the levator ani, the muscle causing pain and re q u i r- Does she have the ability to re l a x examiner then provides firm , ing therapy. Identification of the muscles when dire c t e d ? steady pre s s u re while perf o rm- these nodules appears to be com- These examination techniques ing a sweeping, U-shaped mas- mon. In 1984, Slocumb evaluated can provide the clinician with sage to the muscle. Massage 177 patients and found 133 of f u rther clues to determine the should be perf o rme d 10 to 15 them had identifiable trigger cause of the patient’s chro n i c times using firm but gentle pre s- points that contributed to their pelvic pain. s u re. Ideally, massage is pro v i d e d c h ronic pelvic pain. During per- Palpation of the medial por- e v e ry other day and gradually f o rman ce of this therapy, the tion of the piriformis may be spaced out as the patient’s pain patient may describe a decre a s e achieved during the rectal exami- resolves (Thiele, 1963). Modi- in pain as the trigger point disin- nation as well (Simons & Tr a v e l l , fying this technique through the tegrates, aff i rming that massage 1999). With the index finger fully vaginal approach still allows the has been beneficial. i n s e rted into the rectum, the piri- examiner to reach the levator ani f o rmis muscle can be felt at the 4 but also aides in the massage of P h a rmacologic Therapy or 5 o’clock and 7 or 8 o’clock the obturator internus muscle. Several medications can be positions. In addition to the inter- This modified technique is per- used to help relax the muscles. nal examination, an extern a l f o rmed most effectively while Analgesics (acetaminophen, anti- examination should be complet- the patient is in the lithotomy i n f l a m m a t o ry medications, and ed to fully evaluate the piriform i s position, a diff e rent method fro m aspirin) are considered first-line muscle for spasm. External palpa- the traditional side-lying re c t a l p h a rmacologic therapy choices tion of the piriformis muscle is a p p r oach (Oyama et al., 2004). when managing pain. However, completed with the patient first the focus of this discussion will lying in the right and then the left Ischemic Compression and be on the use of other potentially lateral Sim’s position, and with Trigger Point Massage therapeutic options, such as low the dependent thigh flexed to 90 Ischemic compression may doses of antidepressants, skeletal d e g rees and the independent leg also provide relief for the patient. muscle relaxants, and anticon- fully extended. Examination is With this technique, the patient vulsants (see Table 2). Other completed by locating the land- may experience some discomfort analgesic agents, such as opioids,

UROLOGIC NURSING / July-August 2009 / Volume 29 Number 4 229 Ta ble 2. tive effect. Care must also be exer- clinician to be knowledgeable of Pharmacologic Modalities cised, specifically with Valium, as all treatment modalities for leva- it can be habit forming. tor ani spasm, since this may sig- I . Tr i cy clic Antidepressants F i n a l l y, gabapentin (Neuro n- nificantly benefit the patient by ® a . E l av i l : 10 to 100mg Q HS to tin ), an anticonvulsant, may reducing her experience of pain. escalate weekly PRN prove beneficial by acting on This article focuses on levator b. To f ra n i l : 10 to 75mg Q HS h y p e r-stimulated nerve endings to ani massage; however, it is d e c rease a patient’s perception of i m p o rtant to note that massage I I . M u s cle Relaxants pain (ACOG Committee on can be made more effective when a . F l exe ri l : 5 to 10 mg T I D Practice Bulletins–Gynecology, working with the patient on her b. Va l i u m : 2 to 10 mg TID to QID 2004). While often used to tre a t p o s t u re, exercise, and joint align- I I I . A n t i c o nv u l s a n t s n e u ropathic pain, with some evi- ment, as well as re - e d u c a t i o n dence showing its usefulness in with electromyogram and other a . N e u r o n t i n : 300 mg Q HS to the treatment of pain associated types of feedback. While the cli- escalate weekly PRN with interstitial cystitis (Gunter, nician (nurse, nurse practitioner, 2003), it may also prove beneficial physician assistant) may not be for the treatment of LAS. the primary provider of these may be used, but only when All medications reviewed t reatments, a complete under- other pharmacologic tre a t m e n t s h e r e have been used for the tre a t- standing of the potential benefits have failed. The use of these ment of LAS with varying re s u l t s . will help facilitate proper re f e r- medicines for the management of Extensive re s e a rch is needed to rals to alleviate the patient’s pain c h ronic pain is very contro v e r- f u r ther characterize and under- caused by LAS. There f o re, tre a t- sial (Howard, 2003). stand the beneficial effects of ment for LAS should involve a T h e re is some evidence to these dru g s . m u l t i d i s c i p l i n a ry approach of s u p p o rt the use of tricyclic anti- physicians, nurse practitioners, d e p ressants, such as amitripty- physician assistants, and physi- C o n c l u s i o n line (Elavil®) or imipramine cal therapists. ( To f r a n i l ®). These drugs work by Dysfunction of the pelvic As a final note, one must not s u p p r essing histamine re l e a s e floor and pelvic wall muscles f o rget other health care pro f e s- and decreasing the reuptake of may lead to chronic pelvic pain. sionals who may prove support- n o rep inephrine and sero t o n i n . A thorough understanding of the ive in alleviating the many emo- This chemical process can poten- pelvic wall and pelvic floor tional and psychological issues tially decrease a patient’s pain anatomy is essential to the sys- that are often a part of one’s expe- levels and improve one’s overall tematic examination of patients rience of LAS. These expert s tolerance to the pain (American s u f fering from chronic pelvic include sex therapists and psy- College of Obstetricians and pain. Only a few therapeutic chologists; the inclusion of these Gynecologists [ACOG] Committee techniques have been briefly p roviders can be tre m e n d o u s on Practice Bulletins–Gynecology, described in this article, and a when navigating the complicated 2004). While re s e a rch has shown t h o r ough knowledge of these issues that occur from the inter- these medications to be eff e c t i v e modalities is important to pro p- ruptions of patients’ interperson- in alleviating neuropathic causes erly treat the patient. There is al relationships. There f o re, when of pain (Bryson, 1996), use of some evidence to support the t reating the patient with LAS, it these medications for pain stem- positive benefits of these listed is important to have a thoro u g h ming from LAS is not as well t reatments; however, there is still re f e rra l system in place to pro p- understood, and it is important to a lack of randomized trials to erly assist the patient. An associ- note that use of them in the tre a t - s u p p o rt the improvements noted ation of skilled multidisciplinary ment of chronic pelvic pain is with them. With few objective p roviders is essential in the eval- strictly an off-label practice. p ro c e d u res to measure the re d u c- uation and treatment of LAS, in Another option to consider for tion of pain, the clinician must an eff o rt to significantly impro v e the treatment of LAS includes use often rely on anecdotal experi- quality of life. of skeletal muscle relaxants, such ence to gauge whether or not the as cyclobenzaprine (Flexeril®) o r t reatments are effective. R e f e re n c e s diazepam (Va l i u m ®). These dru g s Other treatments not men- American College of Obstetricians and Gynecologists [ACOG] Committee may help control pain thro u g h tioned in this article may also on Practice Bulletins – Gynecology. relaxation of the levator ani p rove helpful; they include elec- (2004). ACOG practice bulletin no. (McGivney & Cleveland, 1965). trical stimulation, biofeedback 51: Chronic pelvic pain. O b s t e t r i c H o w e v e r, the patient may find with electro m y o g r a p h y, trigger and Gynecology, 103(1), 589-605. these medications less tolerable B rown, J.S. (2000). Faulty posture and point injections, and re l a x a t i o n c h ronic pelvic pain. In F.M. Howard because they can produce a seda- t h e r a p y. It is important for the (Ed.), Pelvic pain diagnosis and man -

230 UROLOGIC NURSING / July-August 2009 / Volume 29 Number 4 agement (pp. 363-380). Philadelphia: the pelvic floor (pp. 19-33). New Mathias, S.D., Kuppermann, M., Lippincott, Williams & Wi l k i n s . York: Livingstone Elsivier. L i b e rman, R.F., Lipschutz, R.C., & B ryson, H.M. (1996). Amitriptyline. A Grant, S.R.. & Salvati, E.P. (1975). Levator Steege, J.F. (1996). Chronic pelvic review of its pharmacological pro p- s y n d r ome: An analysis of 316 cases. pain: Prevalence, health-related qual- e rties and therapeutic use in chro n i c Diseases of the Colon and Rectum, ity of life, and economic corre l a t e s . pain states. D rugs and Aging, 8( 6 ) , 1 8(2), 161-163. Obstetrics and Gynecology, 87( 3 ) , 4 5 9 - 4 7 6 . G u n t e r, J. (2003). Chronic pelvic pain: An 3 2 1 - 3 2 7 . Castello, K. (1998). Myofascial syndro m e s . integrated approach to diagnosis Oyama, I.A., Rejba, A., Lukban, E.F. , In J.F. Steege, D.A. Metzgear, & B.S. and treatment. Obstetrics and Dellogg-Spadt, S., Holzberg, A.S., & Levy (Eds.), C h ronic pelvic pain: An Gynecology Surv e y, 58, 615-623. W h i t m o re, K.E. (2004). Modified integrated approach (pp. 251-266). H o ffm an, B.L. (2008). Pelvic pain. In J.O. Thiele massage as therapeutic inter- Philadelphia: W.B. Saunders. S c h o r ge, J.I. Schaff e r, L.M. vention for female patients with C o rton, M.M. (2008). Anatomy. In J.O. Halvorson, B.L. Hoffman, K.D. interstitial cystitis and high-tone S c h o rge, J.I. Schaff e r, L.M. Halvorson, B r a d s h a w, F., & G. Cunningham pelvic floor dysfunction. U ro l o g y, B.L. Hoffman, K.D. Bradshaw, F., & G. (Eds.), Williams gynecology (pp 244- 6 4, 862-865. Cunningham (Eds.), Williams gyne - 268). New York: McGraw-Hill. S c h o rge, J., Schaff e r, J., Halvorson, L., cology (pp. 773-802). New York: H o w a r d, F.M. (2003). Chronic pelvic H o ffman, B., Bradshaw, K., M c G r a w - H i l l . pain. Obstetrics and Gynecology, Cunningham, F. (2008). Wi l l i a m s D e l a n c e y, J.O. & Ashton-Miller, J.A. 1 0 1(3 ), 594-611. g y n e c o l o g y. Columbus, OH: McGraw- (2007). Functional anatomy of the Jamieson, D.J., & Steege, J.F. (1996). The Hill Co. female pelvic floor. In K. Bo, B. p revalence of dysmenorrheal, dys- Simons, D.G., & Travell, J.G. (1983). B e rghmans, S. Morkved, & M. Va n p a reunia, pelvic pain, and irr i t a b l e Myofascial origins of low back pain. Kampen (Eds.), E v i d e n c e - b a s e d bowel syndrome in primary care Postgraduate Medicine, 73(2), 99- physical therapy for the pelvic floor practices. Obstetrics and Gynecology, 1 0 8 . (pp. 19-33). New York: Churc h i l l 8 7(1), 55-58. Simons, D.G., & Travell, J.G. (1999). Livingstone Elsevier. Lilius, H.G. & Valtonen, E.J. (1973). The Pelvic floor muscles. In J.P. Butler El-Minawi, A.M. (2000). Constipation. In levator ani spasm syndrome: A clini- (Ed.), Myofascial pain and dysfunc - F.M. Howard (Ed.), Pelvic pain diag - cal analysis of 31 cases. A n n a l e s tion: The trigger point manual ( 1 s t nosis and management (pp. 220-228). C h i ru rgiae et Gynaecologiae Fenniae, ed.) (pp. 110-131). Philadelphia: Philadelphia: Lippincott, Williams, & 6 2 , 9 3 - 9 7 . Lippincott Williams & Wi l k i n s . Wi l k i n s . M c G i v n e y, J.Q., & Cleveland, B.R. (1965). Simpson, J.Y. (1859). Coccygodynia and F r a w l e y, H. & Bower, W. (2007). Pelvic The levator syndrome and its tre a t- diseases and deformities of the coc- pain. In K. Bo, B. Berghmans, S. ment. S o u t h e rn Medical Journal, 58, cyx. M Times Goz, 40, 1 0 0 9 - 1 0 1 0 . Morkved, & M. Van Kampen (Eds.), 5 0 5 - 5 1 0 . Slocumb, J.C. (1984). Neurological factors Evidence-based physical therapy for in chronic pelvic pain: Tr i g g e r s points and the abdominal pelvic U rologic Nursing Editorial Board Statements of Discl o s u r e pain syndrome. American Journal of Obstetrics and Gynecology, 149( 5 ) , In accordance with ANCC-COA gove rning rules Urologic Nursing E d i t o rial Board state- 5 3 6 - 5 4 3 . ments of disclosure are published with each CNE offe ri n g . The statements of disclosure fo r Smith, W. T. (1959). Levator spasm syn- this offe ring are published below. d rome. Minnesota Medicine, 42( 8 ) , K aye K. G a i n e s , M S , A R N P, C U N P, disclosed that she is on the Speake r s ’ Bureau fo r 1 0 7 6 - 1 0 7 9 . P f i ze r, Inc., and Nova r tis Oncology. Thiele, G.H. (1963). Coccygodynia: Cause and treatment. Diseases of the Colon Susanne A. Q u a l l i ch , A N P - B C , N P - C , C U N P, disclosed that she is on the Consultants’ and Rectum, 6, 422-436. Bureau for Coloplast. Wright, R.R. (1969). The levator ani spasm All other U rologic Nurs i n g E d i t o r ial Board members reported no actual or potential con- s y n d rome. The American Journal of flict of interest in relation to this continuing nursing education art i c l e. P ro c t o l o g y, 20(6), 447-451.

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