Workup:
History:
- Before the office visit have the patient complete the International Pelvic Pain Society - "Pelvic Pain Assessment Form"
- https://pelvicpain.org/docs/resources/forms/History-and-Physical-Form-English.pdf
- Use patient's history to determine acute vs chronic and isolate primary components of pain: vulvar, vaginal, visceral (reproduction organs - cyclic or non-cyclic), urinary, gastrointestinal, musculoskeletal.
Physical:
- External genitalia: Lesions, abrasions, ulcerations, erythema, or edema of clitoris, urethral meatus, vulva, and/or vestibule (cotton swab exam if patient has dyspareunia and/or vulvar pain)
- Single digit vaginal exam: Tenderness or spasticity of pelvic floor muscles (pubococcygeus, obturator internus, piriformis), urethra, bladder, cervix, lower uterine segment, and vaginal fornices
- Bimanual exam: Uterine size, mobility, adnexal masses, and tenderness
- Complete bimanual with patient at rest, then with patient lifting either their head or legs to cause rectus abdominis flexion to differentiate between abdominal wall pain and visceral pain.
- Suspect abdominal wall pain if more painful with palpation during abdominal flexion.
- Rectovaginal exam: Tenderness and/or nodularity of rectovaginal septum and uterosacral ligaments
- Speculum exam: Lesions, ulcerations, or erythema of vaginal mucosa, cervix, and posterior vaginal fornix; cervical and/or vaginal cultures if purulent discharge noted