Dysfunction
Pelvic floor dysfunction should be classified according to 'The standardisation of terminology of pelvic floor muscle function and dysfunction'. This is an international multidisciplinary report from the International Continence Society (ICS). As in all ICS standardization documents, this is based on the triad of symptom, sign and condition. Symptoms are what the patient tells you; signs are found by physical examination. By palpation of the pelvic floor muscles, the contraction and relaxation are qualified. The voluntary contraction can be absent, weak, normal or strong. The voluntary relaxation can be absent, partly or completely. The involuntary contraction and relaxation is absent or present.
Based on these signs, pelvic floor muscles can be classified as follows:
- Non-contracting pelvic floor
- Non-relaxing pelvic floor
- Non-contracting, non-relaxing pelvic floor
Based on symptoms and signs, the following conditions are possible:
- Normal pelvic floor muscles
- Overactive pelvic floor muscles
- Underactive pelvic floor muscles
- Non-functioning pelvic floor muscles
Myofascial Trigger Points
Trigger points are defined as hyperirritable spots associated with a hypersensitive palpable nodule in a taut band. Trigger points are painful on compression and give rise to characteristic referred pain and motor dysfunction.
Pain as a result of these trigger points is aggravated by specific movements and alleviated by certain positions. Patients know what activities and postures influence the pain. Trigger points can be located within the pelvic floor muscle. In a case of pelvic floor muscle trigger points, a patient will sit down cautiously, often on one buttock. Rising after a period of sitting will cause pain. Pain will be aggravated by pressure on the trigger point (e.g., pain related to sexual intercourse). Pain will also get worse after sustained or repeated contractions (e.g., pain related to voiding or defecation). On physical examination, trigger points can be palpated and compression will give local and referred pain. In patients with chronic pelvic pain (CPP), trigger points are often found in muscles related to the pelvis like abdominal, gluteal and piriformis muscle.
Therapy
Treating pelvic floor overactivity should be considered in the management of CPP. There are a number of methods, taught by specialized physiotherapists, which can be used to improve the function and co-ordination of the pelvic floor muscles. The use of biofeedback by means of pelvic floor muscle electromyography should be considered because it might help the patient to understand the dysfunction of the pelvic floor muscles. This understanding will improve the result of the treatment.
Central trigger points are treated by stretching the muscle, which inactivates them. However, trigger points lying in the attachment of the muscle to the bone respond better to direct manual therapy. Muscle exercises are helpful, e.g., voluntary contractions followed by complete relaxation. Pressure on the trigger points and subsequent release is also effective. Stretching of the muscle will be more effective after pain relief by direct pressure on the trigger point. Injecting the trigger points with a local anaesthetic will show that the trigger points are really causing the pain; it will give an acute relief of pain and will unblock the muscle so that stretching becomes possible.
