C o n s e rvative Management of Female Patients With Pelvic Pain

Hollis Herm a n

he primary symptoms of Female patients with hy p e r t o nus of the pelvic musculature can ex p e- h y p e rtonus of the pelvic rience pain; burning in the cl i t o r i s , u r e t h r a , vag i n a , or anu s ; c o n s t i- m u s c u l a t u r e in female p a t i o n ; u r i n a ry frequency and urge n cy ; and dy s p a r e u n i a . P hy s i c a l patients include pain; t h e r a py techniques are effective in treating female patients with Tb u rning in the clitoris, ure t h r a , pelvic pain, and can successfully reduce the major symptoms asso- or anus; constipation; uri- ciated with it. Using a treatment plan individualized for each patient’s n a ry frequency and urgency; and s y m p t o m s , these techniques can provide considerable relief to d y s p a reu nia (DeFranca, 1996). patients with debilitating pelvic pain. T h e re are many names for hyper- tonus diagnoses involving these symptoms including: levatore s ani syndrome (Nicosia, 1985; Salvanti, 1987; Sohn, 1982), ten- alignment and instability are pre- Olive, 1998), vaginal pH alter- sion myalgia (Sinaki, 1977), sent (Lee, 1999). Patients have ation, dermatological disease, p roctalgia fugax (Swain, 1987), functional impairment with sit- c a n c e rou s vulvar disease, epi- coccygodynia (Dittrich, 1951; ting, walking, urination, and s i o t o m y, laceration, birthing trau- Thiele, 1937; 1963; Wa t e r s , defecation (DeFranca, 1996), and ma with forceps or vacuum 1992), dyspareunia (Glatt, 1990), with household and community extraction, vaginal infection, uri- vaginismus (Hall, 1952), animus, activities of daily living. A high n a ry tract infection, inflamma- vulvodynia (MacLean, 1995; resting baseline, excessive signal tion, skin irritation from chemi- M a r i n o ff & Tu rn e r, 1992; Reid, v a r i a b i l i t y, and a low net rise on cals, irritation from entrap- 1993; Secor, 1992), vulvar s u rface EMG (sEMG) is common- ment, neuro h o r monal alteration vestibulitis (deJong, 1995; Spadt, ly re c o rde d. Muscle hypert o n u s p a rticularly estrogen deficiency 1995), interstitial cystitis, puden- can be palpated on external and ( G l a z e r, Romanzi, & Polaneczky, dal neuralgia (Tu r n e r, 1991), i n t e rnal muscle 1999), psychiatric disord e r s , pelvic pain (Baker, 1993), and examination. Muscle weakness is instability of the (Lee, u rethral syndrome (Steege, m e a s u red in the levatores ani, 1999), prolapse, vasocongestion, M e t z g e r, & Levy 1998). obturator internus, gluteus and sexual trauma. Physical ther- The objective findings in medius, , adductor, and apy treatment coverage of dys- patients with hypertonus include lateral hip rotator muscles. Some p a reunia may be denied under its pain on palpation to the geni- d e g ree of dyspareunia is usually p r i m a ry ICD-9 code if viewed as talia, pain on palpation of the re p o rted. a psychiatric or sexual dysfunc- perineal region from 3 to 9 tion rather than an anatomic or o’clock, or pain in the ure t h r a , D y s p a re u n i a physiologic dysfunction. perineal body, perianal area, pos- D y s p a reunia is better defined M a r i n o ff and Tu rner (1992) terior thigh, gluteal, and abdomi- as painful penetration rather defined three levels of dyspare u- nal areas (Costello, 1998). than painful intercourse, as nia (see Table 1). Burning, sting- S a c roiliac, , symphysis many patients re p o r t painful ing, irritation, rawness, tearing, pubis, lumbosacral joint mal- gynecologic examinations using and searing pain are the most speculums or a gloved examining common complaints with pene- digit. Causes for dyspareunia can tration during and afterw a rd. If include: abscess, fissure, adhe- these symptoms are felt at the Hollis Herman, M S , P T, O c s, is a sions from prior surg e ry, adhe- i n t roi tus, superficial stru c t u re s P hysical T h e rapist in Pri vate Pra c t i c e sions causing conditions such as such as the genitalia, perineal in Cambri d g e, MA. endometriosis (Blackwell & b o d y, posterior fourchette, epi-

UROLOGIC NURSING / December 2000 / Volume 20 Number 6 393 Table 1. Pelvic Floor Muscle T h r ee Levels of Dyspare u n i a E x e rc i s e s Using sEMG with pelvic pain Level 1: Painful intercourse not severe enough to prevent the activity. patients, Glazer, Rodke, and Level 2: Painful intercourse which limits frequency of the activity. Swencionis (1995) demonstrated unstable and abnormally high Level 3: Abstinence from intercourse because of severe pain. resting baselines (tension). Unstable and weak amplitudes w e r e re c o rded during phasic, tonic, and endurance voluntary Table 2. contractions. The use of sEMG Treatment for Dyspareunia of Musculoskeletal Origin was proposed as an objective method for forming a diff e re n t i a l 1 . C o rrect any joint(s) malalignment to promote pain-free joint(s) mobility. diagnosis between functional 2 . Teach the patient self-correction joint(s) techniques (musculoskeletal) vulvovaginal (see Tables 3, 4, & 5). pain syndromes and other 3 . Stabilize the joint(s) with muscle stabilization exerc i s e s . s o u rces of vulvovaginal pain such as infections. Stabilizing 4 . Eliminate trigger points in all of the muscles. muscle variability overall and 5 . Eliminate or reduce scar adhesions and tissue restrictions (see Table 6). p r edominantly at rest was a 6 . Teach pelvic floor muscle awareness using a biofeedback device (see major factor in effective tre a t- Table 7). ment, rather than focusing on 7 . C o rrect muscle imbalances by down training (relaxation) and up train- i n c reases in the contractile ing (stre n g t h e n i n g ) . amplitude. Glazer and Mac- Conkey (1996) proposed simulta- 8 . Re-educate the pelvic floor muscles to be relaxed upon penetration. neous use of diff e rent muscle 9 . Combine down training with dilators (see Table 8). combinations to enhance the 1 0 . Educate about positions for intimacy. pelvic floor muscles contraction, 1 1 . Educate about lubricants. in order to “break” the re s t i n g tension level and reduce pain. Thus, the “Glazer protocol” (see Table 3) consists of two 20- Table 3. minute exercise sessions per day. G l a z e r ’s Pro t o c o l Each session is 60 repetitions of 10-second contractions altern a t- Patient is supine, semi-reclining, sitting, or standing. ing with 10-second re l a x a t i o n phases. Patients are asked to con- Contract the pelvic floor muscles up and in as hard as possible. tract the pelvic floor muscles maximally with all other sur- You may contract any other muscles along with the pelvic floor muscles. rounding muscles. They are re q u i r ed to use home sEMG Hold the contraction for 10 seconds. training devices with intravagi- Relax for 10 seconds. nal sensors. Over time the clinician may Repeat 60 times twice a day. o b s e rve increased contractile amplitudes, decreased variability of the contraction and re l a x a t i o n amplitude, and faster rise and re c o v e ry times with subjective siotomy site, and superf i c i a l establish that the cause is muscu- re p o rts of less pain. muscle layer may be implicated. loskeletal rather than fungal, bac- A c c o rding to Glazer, after If deeper pain occurs, adhesion terial, viral, or otherwise infec- t r eatment the sEMG demon- of the vaginal canal, adhesive tious is essential for eff e c t i v e strates a reduction in the hyper- disease, cervix and uterine dys- physical therapy treatment. Once tonicity and instability associat- function, levatores ani muscle the diagnosis is established that ed with chronic uncoord i n a t e d trigger points, or sacroiliac and pelvic pain is of musculoskeletal d i s c h a rge of fast twitch fibers symphysis pubis joint dysfunc- origin, treatment may include the seen in the resting sEMG of vul- tion may be involved. steps listed in Table 2. Following vovaginal pain patients. Va r i a t i o n s When evaluating patients o ffice treatment to correct the on “Glazer’s protocol” that have with dyspareunia, it is import a n t joint malalignment, the patient had equally significant t re a t m e n t to first rule out any medical con- can continue with self-corre c- results are two 15-minute rather ditions. Diff e rential diagnosis to tions at home. than two 20-minute sessions.

394 UROLOGIC NURSING / December 2000 / Volume 20 Number 6 Table 4. P r otocol for Using sEMG and Dilators

1 . Identify the pelvic floor muscles using biofeedback. Practice contracting and relaxing the muscles to achieve a resting baseline that is normative for that equipment. Use any biofeedback equipment available from mirrors to computerized sEMG. If using sEMG use a continuous mode for the resting baseline while inserting the dilator.

2 . Wash dilator with soap and water prior to insertion. Dilators are for single patient use only.

3 . Position the patient in supine or semi-hook lying with knees up and apart. For home use the patient can try this p ro c e d u re while in the bathtub as she is submerged in warm water; the sides of the bathtub support her knees and often it is the most private room in the house.

4 . Lubricate the end of dilator with a water-soluble lubricant.

5 . Separate the labia. Tense pelvic floor muscles then relax; while relaxing, slide lubricated dilator into the vagina or rectum a little. Tense muscles again while holding the dilator so it does not get pushed out; relax, and slide it in a little furt h e r. Try blowing out as if filling a balloon; this may relax the muscles and allow penetration. Repeat blowing out to insert dilator furt h e r. a . Maintain low resting readings once dilator is inserted for 10 minutes to allow stretching of the muscles aro u n d the canal. b . If 10 minutes of stretching is comfortable, pro g ress to inserting and removing the dilator several times for 10 minutes while maintaining a low resting sEMG baseline and maintaining relaxed muscles. c . If step b is comfortable, angle the dilator to the diff e rent quadrants of the canal to locate trigger points; keep p re s s u re on these points until they soften and recede. d . I n s e rt the dilator and practice pelvic floor muscle exercises with it in place.

6 . Never force the dilator into the canal.

7 . P ro g ress to the next size dilator and repeat steps 5a-5d.

8 . P ro g ress to having the partner participate in stretching with the dilator, with careful penetration into the patient.

9 . If the patient is not able to insert the dilator without pain, try modalities such as ultrasound, soft tissue mobiliza- tion, joint mobilization, or insertion of a digit to promote muscle re l a x a t i o n .

Therapists have tried use of pro c e d u re code 97112 (neuromuscular reeducation), 97530 (therapeutic activities), and 99070 for supplies for reimbursement.

Flexible silicone dilators are available in a set of 4 in 3 sizes (vaginal-hymeneal, rectal, or pediatric) from Milex, Chicago, IL 60631. They are packaged with a tube of Trimo-San (ph4) to re s t o re normal acidity within the canal and help prevent abnormal growth of organisms. Contraindications for use are listed as infection of any type. They are cleaned with mild soap and water. If your depart m e n t ’s infection control policy allows for intra-patient use, dilators can be sterilized in an autoclave at 250 F for 15 minutes, or boiled for 15 minutes, or submersed for 10 hours in Cidex solution.

Syracuse Medical Devices has individual dilators in XS-1/2 inch, S-7/8 inch, M-1/18 inch, L-1 3/8 inch sizes (214 H u r l b u rt Road, Syracuse, NY 13224; [315] 449-0657; Fax: [315] 449-0756).

Perianal external surface sensors muscles, poor intake of fiber and tion around the anal rim. A sec- can be used initially, pro g re s s i n g fluid, and lack of activity may ond channel for monitoring to a small intravaginal sensor the cause constipation (Whitehead, abdominal muscle use in a sitting size of a tampon for those with 1998). This condition may con- position can demonstrate the level 3 dyspareunia. There are tribute to pelvic pain. Relaxation p a t i e n t ’s ability to use the reasonably priced rental pro- of the pelvic floor muscles dur- abdominals while relaxing the grams throughout the country ing defecation is necessary to p u b o r ectalis muscle. Lack of that offer month-long home use allow the canal to open and the ability to allow relaxation is of a single channel sEMG unit, a n o rectal angle to incre a s e . t e rmed a paradoxical contraction allowing most patients the Evaluation of the activity of the and would make it necessary to o p p o rtunity to use this tre a t m e n t p u b o r ectalis muscle can be strain to try and evacuate (see Table 4). assessed using sEMG. Two chan- t h rough a closed tube. Patients nels of sEMG should be used, the can be taught proper re l a x a t i o n C o n s t i p a t i o n first with surface external sensors of the puborectalis in coord i n a- Tension in the pelvic floor placed at a 3 and 9 o’clock posi- tion with the abdominal muscles

UROLOGIC NURSING / December 2000 / Volume 20 Number 6 395 Table 5. using sEMG. Improved sitting T h i e l e ’s Massage positions with hip flexion past 90 degrees can promote muscle • Patient lies on left side. relaxation of the puborectalis for easier defecation. • Therapist is behind patient, left hand on right hip (ASIS), right hand Straining to defecate is neces- p e rf o rms massage in the rectal canal. s a r y when there is a lack of tone in • Orientation of the : the rectal walls from a re c t o c e l e . Perineal body = 12 o’clock When a significant rectocele is Left side = 1, 2, 3, 4, 5 o’clock p r esent, fecal material is pocketed Coccyx = 6 o’clock into the prolapse (into the vaginal Right side = 7, 8, 9,10,11 o’clock canal) despite eff o rts to push it out. Insertion of a gloved digit into • Orientation in the canal from deep stru c t u res to superficial: the vaginal canal, with pre s s u r e P i r i f o rmis posteriorly on the back wall will C o c c y g e u s give missing foundation to the S a c rospinous ligament rectal wall and allow for easier I l i o c o c c y g e u s P u b o c o c c y g e u s d e f e c a t i o n . S p h i n c t e r T h i e l e ’s massage (see Table 5) is a technique to directly addre s s T h i e l e ’s Massage the soft tissue hypertonus sur- • Firm sweep from 3 - 9 o’clock with index gloved finger. rounding the rectal canal by using a sweeping massage stroke while • Repeated 10 to 15 times in one session, fewer if severe spasm. inside the canal. Soft tissue fric- tion massage to an anal fissure , • Patient is asked to strain down during the massage and the muscles w h e re scar tissue is less pliable, re l a x . may free the tissue mobility and • Amount of pre s s u re is determined by patient tolerance. allow less painful stretching with defecation. • Likened to sharpening a razor on a strap in the one direction. Evaluation of the thoracolum- bar junction for vertebral Thiele recommended daily treatment for 5-6 days; then every other day malalignment may prove helpful for 7-10 days, then less often until the pain has disappeare d . to reduce irritation at the innerv a- I m p rovement should be noted in 7-10 days. tion of the rectal canal. Vi s c e r a l mobilization to free organ immo- bility may promote pain-free defe- cation. Intestinal massage clock- Table 6. wise starting from the right lower S e l f - C o rrection for Right Anterior Ilium Sacroiliac Joint abdominal quadrant, up under M a l a l i g n m e n t the ribs, across the to the left descending colon, on to Step 1 the left sigmoid colon and then Ankles together. looping out will stimulate peri- Knees 18 inches apart . stalsis action for gas elimination. Squeeze knees for 6 seconds. F i n a l l y, proper sacral joint Repeat 3 times. alignment is vital to the function of the sacral micturition center. Step 2 Right leg pulls down. When sacral joint malalignment is Left leg pushes up for 6 seconds. p resent, manual therapy tech- Repeat 3 times. niques such as sacral decompre s- sion, springing, rocking, strain Step 3 counter-strain, and myofascial Lift buttocks up for 30 to 120 seconds. release may be beneficial (see Tighten all muscles around the buttocks and hips. Table 6). Step 4 N e rve Supply Lie on the floor with bent leg up on the couch. Position the leg to turn off the The nerve supply to the tender point found on the front of the hip so it is in flexion, abduction, exter- includes branches of the nal rotation. Stay there for 90 seconds, then slowly come out of it. ilioinguinal nerve (L1), the geni- tal branch of the genitofemoral n e r ve (L1-L2), the perineal branch of the femoral cutaneous n e rve (L2-L3), and the perineal

396 UROLOGIC NURSING / December 2000 / Volume 20 Number 6 n e rve (one of the branches of the Table 7. ). The symphysis Perineal Massage pubis is innervated by branches of the iliohypogastric nerve (T12) Trim fingern a i l s . and branches of the gen- Wash hands. itofemoral nerve (L1-L2). Semi-sitting with back supported against pillows. Entrapment of may con- Knees bent up and open. tribute to pelvic pain (Baker, Hold mirror for viewing. Use water-soluble lubricant if pre f e rred: Slippery Stuff, Astroglide, KY Jelly 1 9 9 3 ) . P r o c e d u r e 1 Potential Pudendal Nerv e Practice a lifting contraction of the pelvic floor muscles, then re l a x . Entrapment Sites The lesser sciatic foramen is View in the mirror to see that the perineal body is pulled inward with the a potential hot spot for entrap- l i f t . ment of the pudendal nerve. It has firm unyielding boundaries While relaxed, slowly insert thumb fully into the vagina. with the bony on one side and the sacro t u b e r o u s / Pull down with the thumb. s a c rospinous ligaments on the o t h e r. These two ligaments fuse S t retch the bottom wall of the vagina toward the anus. as they pass one another, cre a t- Hold for 1-2 minutes. ing a tight fit for the pudendal n e rve, internal pudendal vessels, A feeling of burning in the stretched tissues usually subsides after a little and obturator internus muscle w h i l e . with its tendon passing thro u g h (Alevizon & Finan, 1996). Pull the thumb down and to the right and stretch those tissues for 1-2 min- H y p e rtonus of the obturator u t e s . i n t e rnus muscle may compre s s the pudendal nerve and vessels. Pull the thumb down and to the left and stretch those tissues for 1-2 min- A second site for entrapment u t e s . of the pudendal nerve is under Combine stretching down and stretching to the sides in a sweeping motion. the sacro t u b e r ous ligament just b e f o re it enters into Alcock’s P r o c e d u r e 2 c a n a l . I n s e rt your thumb partially into the vagina. A third site for entrapment is in Alcock’s canal as the puden- Place your index finger on the outside of the vagina over the perineal body. dal nerve makes its way toward the pubic bone, branching into Roll the posterior wall of the vagina between the thumb and index finger. the inferior rectal nerve, then the perineal nerve, and finally into Roll the tissues for 3-5 minutes. the dorsal nerve. These branches P r o c e d u r e 3 lie over the belly of the obturator Place the index and middle finger on the outside of the vagina over the per- i n t e rnus muscle. Entrapment of ineal body. the pudendal nerve and its branches can generate burn i n g , Massage the tissues sideways to free up tissue mobility and scar adhe- prickling, irritation, hypersensi- s i o n s . t i v i t y, lack of sensation, and other sensory disturbances. Massage for 3-5 minutes. Physical therapy manual techniques such as myofascial release, trigger point re l e a s e , strain counter-strain, ischemic 1998), quadratus lumboru m , lel to it. It crosses the intern a l p re s s u re, friction massage, trig- hamstrings, obturator intern u s , oblique aponeurosis in the dire c- ger point release, muscle energ y coccygeus, and gluteus medius tion of the symphysis pubis techniques, and joint mobiliza- (Lee, 1999) are essential for com- along with the round ligament. tion may reduce the pre s s u r e on plete treatment of this re g i o n The sensory distribution is the the nerve and lessen the symp- (see Tables 7, 8, & 9). inguinal area including labia toms. Addressing hypertonus in majora and inner thigh. the levatores ani, particularly the Other Nerve Entrapments Entrapment has been described pubococcygeus and iliococ- The ilioinguinal nerve arises as a complication of Pfannenstiel cygeus (DeFranca, 1996), iliop- f rom the first lumbar root and incision, appendectomy, soas (Headley, 1997; Lee, 1999), accompanies the iliohypogastric h e rn i o rrh a p h y, or needle sus- p i r i f o rmi s, adductors (Costello, n e rve , though caudal and paral- pension for stress incontinence

UROLOGIC NURSING / December 2000 / Volume 20 Number 6 397 Table 8. (Challis & Bennett, 1994; Miya- S e l f - C o rrection for a Right Inferior Pubic Bone zaki & Shook, 1992). Corre c t diagnosis after onset of symp- Lie on your back, knees bent, feet flat on the floor. toms is often as long as 20 m o n t h s . Bend your left leg up to your chest while trying to push it down with The iliohypogastric nerv e your left hand. arises from the first lumbar of the 12th thoracic nerve and passes Push your right foot down into the floor at the same time. t h rough the psoas muscle diago- Lift up your head and right shoulder and twist to the left. nally along the surface of the quadratus lumborum. It passes Hold the partial sit-up and leg lifts for a count of 6. caudally toward the crest of the ilium, laterally through the R e l a x . transversus muscle and the i n t e rnal oblique, medially to the Repeat 3 times. ASIS, then runs horizontally under the aponeurosis of the e x t e rnal oblique where its anteri- or cutaneous branch can be trapped during surg e ry. It sup- Table 9. plies the skin of the groin and S e l f - C o rrection for a Forw a rd Bent Coccyx symphysis pubis. Entrapment of the iliohypogastric nerve can To relax the coccygeus muscle that may be tight and holding the coccyx occur from the same surg i c a l f o rw a rd . p ro c e d u res listed for entrapment of the ilioinguinal nerve. Entrap- P r o c e d u re 1 ment may also result from place- Sit on a firm chair. ment in the lithotomy position Place a lipstick canister, pencil, or magic marker to one side of the tail- for vaginal deliveries, laparo- bone where the muscle meets the bone and roll your full weight onto it scopies, and vaginal hystere c- for 30 seconds to 5 minutes. tomies (Goh, 1994). The genitofemoral nerv e Imagine that your muscles are melting over the cylinder and softening arises from the first and second u p . lumbar nerves, passes thro u g h the psoas muscle, through the Repeat for the other side of the tailbone. transversalis where it splits into the g e n i t a l branch, which con- P r o c e d u re 2 Lie on your side with the painful side up. tinues along the psoas muscle to the . In the Reach around to the side of your tailbone and press firmly on the sore female it accompanies the ro u n d m u s c l e . ligament to the labia. The f e m o r a l branch lies lateral to the Hold your pre s s u re for 30 seconds to 5 minutes. genital branch in the psoas mus- cle, passing under the inguinal Repeat for the other side by rolling over. ligament with the external iliac a r t e ry, entering the femoral P r o c e d u re 3 Lie on your side. sheath. It supplies the skin of the p r oximal anterior thigh. Place your finger over your tailbone. P roblems may arise from an inci- sion that injures the nerve, or Contract your muscles around your anus and vagina and lift up and in. f rom hypertonus of the psoas muscle and malalignment of the P ress your tailbone in with your finger and hold it in for 6 seconds, then symphysis pubis joint. relax your muscles. Treatment for these nerv e entrapments may include myofas- Repeat the sequence 3 times. cial release, friction massage, strain counter-strain, trigger p o i n t release, stretching exercises, joint mobilization, and muscle energ y techniques to realign the joints and promote increased tissue m o b i l i t y.

398 UROLOGIC NURSING / December 2000 / Volume 20 Number 6 U r i n a ry Frequency and d romes. Pelvic floor exerc i s e s , Goh, J, (1994). Lithotomy position- U rg e n c y well known to nurses tre a t i n g induced femoral neuro p a t h y. Austalian/New Zealand Journal of Female patients with pelvic u r i n a ry incontinence, are a major Obstetrics and Gynaecology, 34( 5 ) , pain often re p o rt feelings of component of physical therapy 5 7 1 . u rgency and frequency with a techniques for pelvic pain Hall, S. (1952). Vaginismus as a cause of s t rong urge to void but little sig- though they are perf o rmed in a d y s p a r e u n i a. World Journal of slightly diff e rent manner. Other S u r g e ry, Obstetrics, and Gyne - nificant output. Voiding pattern s c o l o g y, 1 1 7 - 1 2 0 . can be as frequent as three times e x e rci ses assist in eliminating H e a d l e y, B. (1997). When movement per hour, causing severe lifestyle trigger points, stabilizing joints, h u r ts. B o u l d e r, CO: Innovative changes. Musculoskeletal limita- and down training (or re l a x i n g ) Systems of Rehabilitation, Inc. a ffected muscles. Using a tre a t- Kuijpers, H. (1985). The spastic pelvic tions are found in the lateral floor syndrome. Diseases of the rotators and lower- e x t re m i t y ment plan individualized for Colon and Rectum, 28, 669-672. adductors. Weakness in the each patient’s symptoms, these Lee, D. (1999). The pelvic girdle. L o n d o n : abductor and rotator muscles is techniques can provide consider- C h u rchill Livingstone. common. Trigger points from the able relief to patients with debil- MacLean, A. (1995). Benign and pre m a- itating pelvic pain. lignant dieases of the vulva. British adductors, rotators, and leva- • J o u r nal of Obstetrics and t o res ani muscles can elicit G y n a e c o l o g y, 102, 359-363. re f e rred pain elsewhere R e f e re n c e s M a r i n o ff, S., & Tu rn e r, M. (1992). Vu l v a r Alevizon, S., & Finan, M. (1996). (Costello, 1998; Travell & vestibulitis syndrome. D e rm a t o l o g i c S a c rospinous colpopexy: manage- Clinics, 10, 435-444. Simons, 1992). sEMG evaluation ment of postoperative pudendal Miyazaki, F., & Shook, G. (1992). reveals a high resting baseline n e rve entrapment. Obstetrics and Ilioinguinal nerve entrapment dur- and poor muscle awareness. A G y n e c o l o g y, 8(4), 713. ing needle suspension for stre s s possible mechanism for the con- B a k e r, P.K. (1993). Musculoskeletal ori- incontinence. Obstetrics and gins of chronic pelvic pain: G y n e c o l o g y, 80, 246. stant voiding sensation may be Diagnosis and treatment. O b s t e t r i c s Nicosia, J. (1985). Levator syndrome: A h y p e rtonic tissue connections and Gynecology Clinics of Nort h t reatment that works. Diseases of the f rom the inside of the pelvic America, 20(4), 719-742. Colon and Rectum, 28, 406-408. brim to the urethra, creating a Blackwell, R., & Olive, D. (1998). C h ro n i c Raz, S. (1996). Female uro l o g y. pelvic pain: evaluation and manage - s t retch on the canal with a sub- P h i l a d e l p h i a : W.B. Saunders Co. ment. New York: Springer- Ve r l a g . Reid, R. (1993, September). Vu l v o d y n i a : sequent feeling of the need to Challis, D., & Bennett, M., (1994). Nerv e What is it and how can we break the void (Raz, 1996). entrapment- An important compli- pain loop? P resentation to the Patients respond well to soft cation of transverse lower abdomi- Intnational Society for the Study of tissue techniques that incre a s e nal incisions. A u s t r a l i a / N e w Vulvar Disease. Quebec. Zealand Journal of Obstetrics and Salvanti, E.(1987). The levator syndro m e tissue mobility and lessen the G y n a e c o l o g y, 34(5), 594. and its variant. G a s t r o e n t e ro l o g y s t retch on the urethra. Manual Costello, K. (1998). Chronic pelvic pain: Clinics of North America, 16(1), 71. work to the adductors, levatore s An integrated approach. In J. Steege, S e c o r, M.(1992). Vulvar vestibulitis syn- ani, obturator internus, and bul- D. Metzger, & B. Levy (Eds.), d rome. Nurse Pracititioner Foru m . Myofascial syndromes (pp. 251- b o c a v e rnosus muscles re d u c e s 3(3), 161-168. 266). Philadelphia: W.B. Saunders Sinaki, M. (1977). Tension myalgia of the the re f e rred pain. The symptoms C o . pelvic floor. Mayo Clinic a re reduced by a voiding sched- DeFranca, G. (1996). Pelvic locomotor P roceedings, 52, 717-722. ule that increases the interv a l dysfunction. G a i t h e r s b u r g, MD: Sohn, N. (1982). The levator syndro m e between voids to the re c o m - Aspen Pubishers. and its treatment with high-voltage deJong, J. (1995). Focal vulvitis: A psy- e l e c t rogalvanic stimulation. A m e r - mended 2 to 4 hours, and also by chosocial problem for which surg e ry ican Journal of Surg e ry, 144, 580- submaximal pelvic floor muscle is not the answer. J o u rnal of 5 8 2 . e x e rcises, visualization, distrac- Psychosomatic Obstetrics and Spadt, S. (1995. November/December). tion, breathing, and mental exer- G y n e c o l o g y, 16, 85-91. S u ffe ring in silence: Managing vul- Dittrich, R.J. (1951). Coccygodynia as cises. var pain patients. Contemporary re f e rred pain. Journal of Bone & Nurse Practioners. A TENS unit placed over the Joint Surg e ry, 33A(3), 715. Steege, J., Metzger, D., & Levy, B. (1998). sacral micturition center at S2- Glatt, A. (1990). The prevalence of dys- C h ronic pelvic pain an integrated S4 with conventional settings p a re u n i a. Obstetrics and Gyne - a p p r o a c h . Philadelphia: W. B . may help. Down training to re l a x c o l o g y, 75, 433. Saunders Co. G l a z e r, H., Romanzi, L., & Polaneczky, M. Swain, R. (1987). Oral clonidine for pro c- the muscles is the heart of the (1999). Pelvic floor muscle surf a c e talgia fugax. Gut, 28, 1039-1040. p ro g r a m . e l e c t romyography: Reliability and Thiele, G.H. (1963). Coccygodynia: Cause clinical predictive validity. and treatment. Diseases of the Colon S u m m a ry J o u rnalof Reproductive Medicine, and Rectum, 6, 422-436. 4 4(9), 779-782. Physical therapy techniques Thiele, G.H. (1937). Coccygodynia and G l a z e r, H., Rodke, G., & Swencionis, C. pain in the superior gluteal re g i o n. a re effective in treating female (1995). Vulvar vestibulitis syndro m e J o u rna l of the American Medical patients with pelvic pain, and with electromyographic biofeedback Association, 109, 1271-1275. can successfully reduce the of pelvic floor musculature. J o u rn a l of Reproductive Medicine, 40, 2 8 3 - continued on page 417 major symptoms associated with 2 9 0 . it — dyspareunia, constipation, G l a z e r, H., & MacConkey, D. (1996). u r i n a ry frequency and urg e n c y, Functional rehabilitation of pelvic and nerve entrapment syn- floor muscles: A challenge to tradi- tion. U rologic Nursing, 16(1), 68-69.

UROLOGIC NURSING / December 2000 / Volume 20 Number 6 399 C o n s e rvative Management continued from page 399 Travell, J., & Simons, D. (1992). The lower e x t remities. In Myofascial pain and dysfunction: The trigger point manual ( Vol. 2). Baltimore: Williams & Wi l k i n s . Tu rn e r, M. (1991). Pudendal neuralgia. American Journal of Obstetrics and G y n e c o l o g y, 165, 1223-1226. Waters, E. (1992). A consideration of the types and treatment of coccygodynia. American Journal of Obstetrics and G y n a e c o l o g y, 1 6 6, 437. Whitehead, W. (1998). Gastrointestinal dis- o rders. In J. Steege, D. Metzger, & D. Levy (Eds.), C h ronic pelvic pain: An integrated approach (pp. 205-224). Philadelphia: W.B. Saunders Co.

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