INTRODUCTION — Myofascial pelvic pain syndrome (MPPS) is a source of chronic pelvic pain that is defined by short, tight, tender pelvic floor muscles that cause referred pain. The pain can be continuous or episodic. MPPS can impact urinary, bowel, and sexual function. As pelvic pain is a common reason for patients to seek health care and many individuals with chronic pelvic pain have some degree of MPPS, clinicians need to include this syndrome in the differential when evaluating patients with pelvic pain.
Clinical manifestations and diagnosis of MPPS in females are reviewed here. Treatment of this condition and other causes of female pelvic pain are reviewed separately.
●(See "Myofascial pelvic pain syndrome in females: Treatment".)
●(See "Myofascial pelvic pain syndrome in females: Pelvic floor physical therapy for management".)
●(See "Chronic pelvic pain in adult females: Evaluation".)
●(See "Chronic pelvic pain in nonpregnant adult females: Causes".)
In this topic, when discussing study results, we will use the terms "woman/en" or "patient(s)" as they are used in the studies presented. However, we encourage the reader to consider the specific counseling and treatment needs of transgender and gender-expansive individuals.
DEFINITIONS
Myofascial pelvic pain syndrome — MPPS is a chronic pain disorder characterized by tenderness elicited by palpation of the muscles and connective tissue in the pelvic floor and/or pelvic girdle; pain can also occur in referred areas such as the vulva, perineum, rectum, and bladder, and to more distant areas such as the thighs, buttocks, or lower abdomen [1-3]. The pain and tenderness can be localized or present in a combination of muscles, potentially including the levator ani complex (comprised of the iliococcygeus, pubococcygeus, and puborectalis), obturator muscles, pyriformis, and/or iliopsoas. At sites outside the pelvic floor, irritative symptoms, including urinary urgency, frequency, dysuria, vulvar or vaginal burning, itching, or pain (alone or in combination), can be more prominent than the pelvic pain components.
Trigger points — Trigger points are a hallmark of myofascial pain and are diagnosed based upon finding at least two of the following: a taut band, hyperirritable spot, and referred pain [4-7]. MPPS is thought to originate at the trigger point [8] and is usually accompanied by a high-tone pelvic floor [9] or other hypertonic muscle groups. Trigger points can be active (ie, spontaneously painful) or latent (ie, painful only with stimulation such as stretching) [10]. Latent trigger points can be asymptomatic for years and may be activated by physical trauma (musculoskeletal injury), painful event (UTI or procedure), or emotional stress [11].
EPIDEMIOLOGY — The estimates of prevalence of MPPS in the general population vary widely, from 14 to 78 percent. Among patients with gynecologic, urologic, and colorectal pain syndromes, as many as 85 percent have myofascial trigger points [9]. (See "Chronic pelvic pain in nonpregnant adult females: Causes".)
PATHOGENESIS
Myofascial pain — The pathogenesis of MPPS is unclear [8,12,13]. Theories for the etiology of myofascial pain include neuromuscular microtrauma [14-16], metabolic imbalance in the peripheral tissue [12,17], and centralization of pain [18,19]. These processes likely work in combination. Acute trauma or repetitive microtraumas can cause high-intensity stimulation of the motor end plates of the pelvic floor muscles, which in turn may result in chronic muscle contraction (hypertonus) and formation of trigger points. Metabolic imbalance, consisting of elevated levels of pain-producing compounds and therefore neuroinflammation, has been demonstrated in the vicinity of active trigger points [12,17]. Centralization of pain occurs when the sensory pain information is abnormally processed in the central nervous system (ie, central pain sensitization) and appears to result in pain that is then perpetuated by the central nervous system, also known as a dysfunctional pain syndrome [18,20,21].
The pelvic floor is believed to be at risk of developing hypertonus, myofascial trigger points, and pain because pelvic floor muscles (1) are involved in several different kinds of activities, including musculoskeletal support of the upper body and lower extremities, and control of bladder, bowel, and sexual function; (2) must elongate and contract eccentrically; and (3) are affected by physiologic and psychologic stress [22-24]. Over time, muscles with trigger points become weak, tender, and shortened [25]. Dysfunction of one muscle can then cause surrounding muscle groups, including muscles of the buttocks, thighs, and abdomen, to contract and develop trigger points, thereby worsening myofascial pain and related symptoms [22]. Pain can also be referred to other areas.
Relation to other pelvic pain syndromes — Pelvic floor muscle hypertonus and MPPS have been associated with other pain processes including painful bladder syndrome/interstitial cystitis, vulvodynia, endometriosis, dysmenorrhea, and dyspareunia [7,9,20]. Central sensitization of pain has been demonstrated in all these syndromes and therefore provides one possible explanation for the coexistence of multiple pain syndromes in the same patients [20,26,27].
Additionally, there is a correlation between visceral inflammation and myofascial abnormalities in tissues that share the same innervation [1]. Because of the proximity in the spinal cord between the afferent nerve endings of deep muscles of the pelvic floor and the parasympathetic nerves of the bladder, the bladder can be negatively impacted by pelvic floor contraction and trigger points [23]. This nerve proximity could explain why patients with painful bladder syndrome often have a high tone, or contracted, pelvic floor [28,29]. (See "Interstitial cystitis/bladder pain syndrome: Clinical features and diagnosis".)
CLINICAL PRESENTATION — Patients with MPPS generally present with pain in the pelvis, vagina, vulva, rectum, or bladder, or in more distant referral areas such as the thighs, buttocks, hips, or lower abdomen. Commonly associated symptoms include a sense of aching, heaviness, or burning in these areas and/or symptoms of overactive bladder (including bladder pain, dysuria, and urinary urgency), constipation, dyspareunia, or dyschezia [30]. Symptoms can be continuous or episodic and acute or chronic. The pain is often worsened with specific positions/activities and improved by others [7]. Stress can trigger or worsen symptoms.
In our experience, the clinical course is unpredictable as dysfunction typically waxes and wanes, or may even be latent for a prolonged period of time.
DIAGNOSTIC EVALUATION
History — The evaluation of patients with MPPS starts by taking a complete history that includes urinary, gastrointestinal, gynecologic, sexual, and psychosocial symptoms [7]. One purpose of the history is to identify other possible pain etiologies, such as endometriosis. Deep muscular pain and visceral pain can be difficult, if not impossible, for most patients to differentiate [2]. The International Pelvic Pain Society has developed a detailed history and physical examination form for evaluation of patients with chronic pelvic pain of any etiology. The general approach to evaluation of patients with pelvic pain is described in detail in a separate topic review. (See "Chronic pelvic pain in adult females: Evaluation".)
As part of the history, we specifically inquire about the following:
●Symptoms suggestive of MPPS [1,25]:
•Pelvic/abdominal pain (location, duration, and referral patterns)
•Urinary tract symptoms (eg, frequency, urgency, incontinence, nocturia, dysuria, sensation of incomplete emptying, bladder pain)
•Vulvovaginal discomfort, including dyspareunia or recurrent symptoms suggestive of infection
•A feeling of abdominal fullness or bloating
•Rectal fullness or constipation, dyschezia
•Rectal, vaginal, or bladder spasms
•Low back, low abdominal, and/or hip pain
●Impact of position on pain – Pain that results from MPPS and trigger points can be aggravated by specific movements and alleviated by certain positions [7]. We ask patients which positions and/or activities (including prolonged sitting, intercourse, and exercise) worsen or improve their symptoms.
●History of genitourinary infection – We ask whether the patient has had laboratory-proven urinary tract, vaginal, or pelvic infections. MPPS can be a sequelae of infection and inflammation [20]. Additionally, patients may report the sensation of a urinary tract infection or vaginitis after MPPS flares, but tests are consistently negative. Because these symptoms can be erroneously diagnosed as an infectious etiology, we ask patients if they have previously been diagnosed with recurring pelvic infections (urine, vagina, or cervix) that were negative for infection upon testing.
●Impact of menstrual cycle – MPPS symptoms can vary in intensity during menses or other times in the menstrual cycle, although the impact is unpredictable. Menses can both exacerbate or improve the pain due to monthly hormonal fluctuations that impact sensory pain perception.
●Referred pain – MPPS often mimics visceral pain in that it can be poorly localized and referred to a distant cutaneous site, which can also be tender. Conversely, the patient may note that skin compression, such as by clothing or position, causes deep visceral discomfort [2].
●History of pain at other locations – Individuals with MPPS frequently have pain in other muscles of the pelvic girdle, including back and hips (figure 1). In our experience, when directly asked about pain in other locations, many patients acknowledge pain that they previously had not thought pertinent. Additionally, MPPS is associated with other pelvic pain syndromes, including painful bladder syndrome/interstitial cystitis and vulvodynia [20]. (See 'Relation to other pelvic pain syndromes' above.)
●History of interventions for pain – Myofascial pelvic pain that begins as a local process can become widespread or more severe, sometimes as a result of diagnostic interventions or surgical attempts to resolve pain [22,31]. As an example, a patient who undergoes laparoscopic evaluation for chronic pelvic pain can have postoperative worsening of her myofascial symptoms. The cause is unknown, but the pain of the procedure may potentially act as another trigger [7]. At times, however, we have seen symptoms improve after laparoscopy. A potential reason may be that the stretching of the abdominal wall nerves and muscles temporarily alleviates pain.
●History of pelvic trauma – MPPS can result from pelvic trauma such as pelvic surgery, injuries or surgery to the back or hip, or childbirth. We specifically inquire about recent falls or injuries as patients often do not equate musculoskeletal issues with their pelvic floor symptoms.
●History of psychological trauma – Patients with chronic pelvic pain have higher rates of past emotional or sexual abuse [7,32]. Patients should be asked about any history of sexual or emotional trauma without implying causation as they may be unaware of the connection between trauma and pain syndromes [7].
Physical examination — Physical examination for MPPS includes an external examination of the trunk muscles and connective tissue, a pelvic examination with assessment of the pelvic floor musculature, and assessment of the patient's gait and motor strength. There is little correlation between any single presenting symptom and physical findings in patients with MPPS [33]. Having the patient indicate the site of pain helps to direct the examination; this area is examined last to minimize the effects of voluntary guarding.
Palpation is the main method for clinical assessment of pelvic floor hypertonus and trigger points [34]. Skeletal muscles are palpated for a tight band of tissue (hypertonus) or nodule (trigger point) that produces local pain, a twitch response, and/or referred pain to the pelvic organs or surrounding tissues [35]. Studies support that palpation is reliable when performed by a skilled examiner [36-38]. Most patients with MPPS have pelvic floor trigger points that are exquisitely tender [39]. In a series of 49 women with MPPS, 92 percent had trigger points in the levator ani muscles. Other commonly affected muscle groups included the rectus (65 percent), iliopsoas (43 percent), obturator internus (45 percent), and piriformis (8 percent) [1]. The variation in trigger point location may account for the diversity of presenting symptoms among patients with MPPS.
Our approach to physical examination is based on a standardized, reproducible examination for diagnosing MPPS [40]:
External — We begin with the patient lying supine. We perform an external examination that includes visual inspection and palpation of the abdomen, hips, low back, buttocks, and thighs. We also examine any other areas of concern to the patient. We assess for areas of tenderness, referred pain, and trigger points. (See 'Trigger points' above.)
●Examine the rectus abdominis at its insertion points superior to the pubic symphysis for tenderness, trigger points, referred pain, and diastasis recti. Patients with MPPS often have diffuse tenderness in the abdomen, particularly over the rectus abdominis and external oblique muscle groups. We also assess pyriformis muscle involvement as well as iliopsoas, especially if the patient has lower abdominal quadrant symptoms.
●Palpate the insertion of the iliacus muscle, located medially to the anterior superior iliac spine for tenderness; pressing deeper, if indicated, can help assess the iliopsoas muscle as well.
●Assess the connective tissues by rolling the skin lightly between two fingers (not pinching); tender areas often feel thickened or tight and will elicit sharp pain or a deep "bruise-like" pain [1].
●Apply pressure over the suprapubic area to see if pain is elicited, especially as the bladder is compressed.
●Manipulate any surgical scars. Scars should move easily and without restrictions; scars that are puckered, have limited movement, or are tender could be a source of MPPS or exacerbate symptoms.
Pelvic — We perform a standard pelvic examination that also includes assessment of pelvic floor motion. (See "The gynecologic history and pelvic examination", section on 'Pelvic examination'.)
●Assess muscle contraction – Observe the external genitalia both as the patient bears down and contracts the pelvic floor. Patients with MPPS often have muscles with limited mobility, that move paradoxically, or with limited or inability to relax.
•Visual inspection – Visually, the muscles may not move with contraction or attempted relaxation.
•Muscle weakness or limited contraction – Due to limited range of motion, pelvic floor muscles may seem weak. If the patient has difficulty contracting the pelvic floor, we ask the patient to squeeze the vaginal muscles around the examiner's single digit or to imagine trying to "pick up a marble" with the vaginal muscles. As the pelvic floor contracts and relaxes, we assess for asymmetry of contraction and strength, incomplete contraction or relaxation, limited mobility, and paradoxical contraction.
•Teaching points – We point out any use of accessory muscles and try to help the patient isolate the pelvic muscles. If the patient is able, we encourage focus on "dropping" or relaxing the pelvic floor. If this can be practiced daily, then at times of stress or pain, a patient may be able to relax the pelvic floor and achieve some relief. We perform this assessment and teaching at the time of the initial exam.
●Anal wink – Provoke an anal wink reflex by gently stroking the skin immediately surrounding the anus; this results in a reflexive contraction of the external anal sphincter. For patients with MPPS, the reflex can be absent because the pelvic floor muscles are already contracted. However, the absence of this reflex can also be due to nerve damage and interruption of the spinal arc. Thus, an absent anal wink contributes to the clinical impression but is not definitive. In addition, many asymptomatic patients have an absent anal wink.
●Speculum examination – Perform a speculum examination and assess for signs of hypoestrogenism or infection. Both hypoestrogenism and vaginal infections can cause pain as well as trigger or exacerbate MPPS. Pain from MPPS will not resolve after treatment for vaginal atrophy or infection. (See "Genitourinary syndrome of menopause (vulvovaginal atrophy): Clinical manifestations and diagnosis" and "Genitourinary syndrome of menopause (vulvovaginal atrophy): Treatment" and "Vaginitis in adults: Initial evaluation".)
●Bimanual examination – Perform a bimanual examination. The uterus, bladder, and adnexa are palpated to determine if other pathology, such as fibroids or ovarian cysts, are present. MPPS and other pelvic pathology may coexist. However, identifying another possible cause for the pelvic symptoms does not exclude MPPS. (See "The gynecologic history and pelvic examination", section on 'Bimanual examination'.)
Pelvic floor musculature — We perform a detailed assessment of the pelvic floor musculature with focus on identifying areas of hypertonic muscle bands and/or trigger points. Trigger points can often be localized in areas of tight or bandy muscles, which can feel like violin strings; these areas can be exquisitely tender with even light palpation. Pain is usually associated with involuntary spasm of the pelvic floor muscles (eg, bulbospongiosus, ischiocavernosus, transversus perineum, sphincter ani, piriformis, levator ani, or obturator internus, alone or in any combination) (figure 2 and figure 3 and figure 4) [25]. Prior to examination, we inform patients that pain may be worsened following the muscle examination. Persistent or worsened pain confirms their diagnosis, can last for several hours, and typically resolves with time.
In the examination, we do the following:
●Apply pressure to the patient's thigh as a baseline reference of how much pressure to expect during the examination (enough pressure to blanch the examiner's fingernail). For the rest of the examination, proceed slowly and gently and ask the patient to indicate if she has discomfort at any point. We ask her to rate her pain on a scale of zero (feels pressure, but no pain) to 10 (worst pain imaginable).
●Perform a single digit vaginal examination, moving counterclockwise. First, apply pressure to the right obturator internus, located laterally and deep to the vaginal opening. Asking the patient to abduct the knee against resistance while the hip is flexed will make this area easier to palpate. Next, sweep the fingers medially to the right then left levator ani to locate the iliococcygeus, noting any areas of tenderness, tension, or banding.
●Assess the deep pelvic muscles on vaginal examination. In particular, the levator ani muscle group can develop hypertonus, myalgia, overuse, and fatigue (figure 3 and figure 4). We do not examine all deep pelvic muscles but instead assess one or two groups on each side. If there is severe pain elicited on palpation of one muscle group, we do not continue the examination on the painful side. Instead, we examine the same muscle group on the other side of the pelvis, to assess symmetry of pain.
●Assess the urethral sphincter and pubococcygeus in the vagina by gently compressing these areas between your finger and the pubic symphysis (figure 3 and figure 4). If this area is involved, the patient will often note a feeling of urinary urgency or tenderness.
●Assess the puborectalis (medial portion of pubococcygeus) with either the vaginal or rectal examination (figure 4). A rectal examination is necessary to assess the anal sphincter and coccyx.
Posture, gait, and range of motion — Evaluation of posture, gait, and range of motion is important because patients with MPPS can develop muscle asymmetry and resultant weakness. Muscles with trigger points are in a state of contraction and/or spasm and do not have full range of motion. Trigger points prevent normal muscle contraction/lengthening and restrict range of movement, which further compromises muscle strength [7].
This evaluation is best done as part of a complete evaluation by a physical therapist specialized in the treatment of pelvic floor disorders. Full evaluation includes assessment of posture, gait, range of motion of the trunk and hips, pelvic instability, and lower extremity strength, mobility, and length as well as assessing the pelvic muscles [24]. Some therapists also assess breathing patterns and the impact of thoracic or dysfunctional breathing patterns. (See "Myofascial pelvic pain syndrome in females: Treatment", section on 'Pelvic floor physical therapy'.)
Confounding issues such as scoliosis, leg-length discrepancy, or other spinal abnormalities can contribute to MPPS and usually require a longer course of treatment. (See "Myofascial pelvic pain syndrome in females: Pelvic floor physical therapy for management".)
Laboratory tests — MPPS does not cause laboratory abnormalities. Laboratory evaluation is done to exclude other causes for the patient's symptoms. Tests that are commonly performed to exclude infection as a cause of pelvic pain include urine culture, tests of vaginal discharge for yeast, and cervical tests for the sexually transmitted infections gonorrhea, chlamydia, and trichomonas (if indicated).
Imaging — Imaging techniques are not used to diagnose myofascial pain syndromes but can be useful to identify anatomic causes of pain, such as uterine fibroids or ovarian cysts. Thus, most patients with pelvic pain undergo transvaginal ultrasound to assess for visceral pathology. However, presence of an abnormal imaging finding does not exclude MPPS as they can coexist. More data are needed on the role of modalities such as ultrasound and magnetic resonance imaging in the diagnosis of MPPS [41-44].
DIAGNOSIS — MPPS is a clinical diagnosis based on physical examination demonstrating significant muscle and connective tissue tenderness in the region of pain as well as trigger points that evoke referred pain [13,45]. The diagnosis of MPPS is supported by a history of prior trauma or infection-like symptoms despite negative laboratory tests.
A clinician does not need to feel the actual trigger point or muscle quivering to make a diagnosis of MPPS. The finding of tender muscles and hypersensitive tissues confirms this diagnosis. The presence of other pelvic abnormalities (eg, fibroids or ovarian cyst) at the time of physical examination does not exclude the diagnosis of MPPS.
DIFFERENTIAL DIAGNOSIS — The differential diagnosis of MPPS includes many potential causes of acute and chronic pelvic pain (table 1 and table 2). The pelvic organs, bladder, and bowel should be evaluated for underlying pathology. Additionally, MPPS is included in the differential diagnosis for any patient presenting for the evaluation of pelvic pain, particularly when no other cause has been identified.
For patients with suspected or surgically confirmed endometriosis, it can be difficult to ascertain whether the pain relates to endometriosis or to pelvic floor hypertonicity, which often coexist. We advise addressing any pelvic floor findings either concurrently or sequentially, as MPPS can be a significant contributing factor to patient symptoms. Endometriosis is addressed below.
●(See "Acute pelvic pain in nonpregnant adult females: Evaluation".)
●(See "Evaluation of acute pelvic pain in female children and adolescents".)
●(See "Chronic pelvic pain in adult females: Evaluation".)
For patients suspected of having MPPS, we specifically exclude:
●Endometriosis – Endometriosis is a common cause of pelvic pain and often co-occurs with MPPS. One study of 30 women with endometriosis-associated chronic pain found that all participants had pelvic floor muscle spasm and myofascial pain [40]. Endometriotic lesions can develop their own nerve supply, creating a direct relationship with the central nervous system; this biology is believed to allow patients with endometriosis to develop pain that is independent of their disease [46]. Separately, some patients develop persistent pain after surgery for endometriosis. In our practice, we have found the presence of hypertonic pelvic floor and MFPS in many women with endometriosis. Addressing these findings can help alleviate pelvic pain and lessen the intensity of cyclic pain.
Content discussing the presentation and diagnosis of endometriosis is available separately. (See "Endometriosis in adults: Pathogenesis, epidemiology, and clinical impact".)
●Abdominal myofascial pain – Trigger points in the rectus abdominis muscles can cause cutaneous allodynia, an unpleasant sensation from a stimulus that does not usually cause pain [47]. Cutaneous allodynia of the abdomen can present with pain, burning, or a sense of bloating or fullness. Cutaneous allodynia is relatively common among patients with chronic pelvic pain [48].
Abdominal wall myofascial pain is easily confused with pain of a visceral origin. Abdominal myofascial pain can usually be identified by having the patient Valsalva (by performing a half sit-up from the supine position), which tightens the rectus muscles. If tenderness is worsened with palpation of the abdominal wall during Valsalva, the patient's pain is likely originating from the abdominal musculature. If the abdominal wall contraction lessens the pain, the pain is more likely visceral in origin. (See "Anterior cutaneous nerve entrapment syndrome", section on 'Diagnostic approach'.)
●Other myofascial pain syndromes – Other muscle groups can refer pain to the pelvis and are likely intertwined with MPPS [25]. Coccydynia, piriformis syndrome, and proctalgia fugax share hypertonicity of regions of the pelvic musculature as an underlying problem, and may represent various manifestations of the same disease state. These syndromes are differentiated from MPPS by their specific anatomic location. However, it is impossible to attribute specific symptoms to distinct muscle groups. Typically, the same muscle groups are involved in differing degrees in patients presenting with other myofascial pelvic pain syndromes. (See "Proctalgia fugax" and "Coccydynia (coccygodynia)".)
●Fibromyalgia – Fibromyalgia is a collection of symptoms including widespread pain (figure 5), accompanied by allodynia, fatigue, sleep disturbance, and psychological distress [49]. Fibromyalgia differs from MPPS in that patients with fibromyalgia have pain throughout their bodies, have other somatic symptoms, and generally do not have trigger points. (See "Clinical manifestations and diagnosis of fibromyalgia in adults".)
●Pudendal neuralgia – Pudendal neuralgia is a rare condition that causes neuropathic pain along the distribution of the pudendal nerve. It is thought to develop as a result of mechanical injury (compression, stretching, tearing) or non-mechanical injury (due to diseases like multiple sclerosis, diabetes). Symptoms include unilateral intense sharp, burning pain, and sometimes numbness that is worse with sitting [50]. This syndrome can coexist or develop along with MFPS and can improve by decreasing surrounding muscle hypertonicity. (See "Female sexual pain: Differential diagnosis", section on 'Other conditions contributing to increased pain'.)
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Female pelvic pain".)
SUMMARY AND RECOMMENDATIONS
●Description – Myofascial pelvic pain syndrome (MPPS) describes a disorder in which pelvic pain is attributed to short, tight, tender pelvic floor muscles that usually contain hypersensitive trigger points. (See 'Myofascial pelvic pain syndrome' above.)
●Trigger points – Trigger points are hyperirritable, palpable nodules within muscles that are painful to compression. Trigger points can be active (ie, spontaneously painful) or latent (ie, painful only with stimulation). Pelvic trigger points often refer pain to the vagina, vulva, perineum, rectum, and bladder, as well as to more distant areas such as the thighs, buttocks, or lower abdomen. (See 'Trigger points' above.)
●Clinical presentation – Patients with MPPS generally present with pain in the pelvis, vagina, vulva, rectum, or bladder, or in more distant referral areas such as the thighs, buttocks, hips, or lower abdomen. Commonly associated symptoms include a sense of aching, heaviness, or burning in these areas and/or symptoms of overactive bladder, constipation, or dyspareunia. Symptoms can be continuous or episodic. The clinical course is unpredictable as dysfunction typically waxes and wanes, or may even be latent for a prolonged period of time. (See 'Clinical presentation' above.)
●Diagnostic evaluation – A complete diagnostic evaluation assesses urinary, gastrointestinal, gynecologic, sexual, and psychosocial symptoms. One purpose of the evaluation is to exclude other possible causes of pelvic pain (table 1 and table 2). The International Pelvic Pain Society has developed a detailed history and physical examination form for evaluation of patients with chronic pelvic pain of any etiology. (See 'Diagnostic evaluation' above.)
•Symptoms suggestive of MPPS include (see 'History' above):
-Pelvic and/or abdominal pain
-Urinary tract symptoms (eg, frequency, urgency, incontinence, nocturia, dysuria, sensation of incomplete emptying, bladder pain) in the setting of negative urine cultures
-Vulvovaginal discomfort, including dyspareunia
-A feeling of abdominal fullness or bloating
-Rectal fullness or constipation, dyschezia
-Rectal, vaginal, or bladder spasms
•Manual palpation identifies pelvic muscle hypertonus and pain as well as trigger points. Skeletal muscles are examined for a tight band of tissue or painful nodule (trigger point) that produces a twitch response, as well as local and/or referred pain to the pelvic organs or surrounding tissues. Studies support that palpation is reliable when performed by a skilled examiner. The examination includes the abdomen, back, and hips in addition to detailed internal and external pelvic evaluations (figure 1 and figure 3 and figure 4). (See 'Physical examination' above.)
•Laboratory and imaging studies are not helpful in making the diagnosis of MPPS, but can be useful in excluding other etiologies of pelvic pain. (See 'Laboratory tests' above and 'Imaging' above.)
●Diagnosis – The diagnosis of MPPS is based on a physical examination demonstrating significant muscle and connective tissue tenderness in the region of pain as well as trigger points that evoke referred pain. A clinician does not need to feel the actual trigger point or muscle quivering to make a diagnosis of MPPS. Supporting information comes from the history, which can include information on prior pelvic trauma or infection. The symptoms can be acute or chronic.
●Differential diagnosis – The differential diagnosis of MPPS includes many potential causes of acute and chronic pelvic pain (table 1 and table 2). Infections or other pathology must be excluded before beginning of treatment. For patients suspected of having MPPS, we also assess for abdominal myofascial pain syndromes, other myofascial pain syndromes, fibromyalgia, cutaneous allodynia, and endometriosis and address these simultaneously in a multidisciplinary manner. (See 'Differential diagnosis' above.)
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