Medical Providers

A quick, easy, reproducible, MSK exam can be incorporated into an internal exam by simply rotating your hand 180 degrees following the bimanual exam. This will enable medical providers and specialists to palpate the MSK features of the pelvic floor.

1. Describe the steps of the manual exam and get consent.
2. Begin the unidigital transvaginal examination by inserting a gloved, lubricated index finger into the vaginal introitus
3. Utilize clock face orientation with the pubic symphysis at 12 o clock and the anus at 6 o clock to localize pelvic floor muscles
4. Start with unidigital palpation of superficial pelvic floor musculature and then proceed to deep pelvic floor musculature.
5. Use the following clock face positions to palpate the superficial and then deep PFM.
   
   • Superficial Layer: Bulbospongiosus (2 and 10 o clock), Ischiocavernosus (1 and 11 o clock)
   • Superficial transverse perineal muscles (3 and 9 o clock)
   • Deep Layer: Pubococcygeus (7 and 11 o clock for left side; 1 and 5 o clock for right side)
   • Iliococcygeus (4 and 8 o clock)
   • Coccygeus (5 and 7 o clock; requires deeper digital insertion)
6. Then palpate obturator internus at 2 and 10 o clock
7. Examine the piriformis with the finger pressed posterolaterally and superior to the ischial spine at 11 and 1 o’clock
8. During palpation, apply pressure to specific sites predefined on each of the pelvic floor muscles and obturator internus.
9. Use a graded scale (either NRS or VAS) to assess patient reported pain after palpation of each site and notate any trigger points palpated
   • Spasm of a portion of the levator ani is often detected as a palpable band resembling a guitar string within the muscle or focal trigger points. In the patient with normal pelvic floor musculature, palpation of the levator ani and piriformis typically elicits a sensation of pressure, whereas a patient with pelvic floor myalgia will report significant pain.
   • Another typical finding during examination is a distinct asymmetry between the right and left elements of the pelvic diaphragm.
10. Assess for general strength of pelvic floor musculature. Ask the patient to squeeze their pelvic floor muscles as if they were trying to stop urinating and hold for 3 seconds. Is the patient able to do a contraction against the pressure of your finger and sustain it for 3 seconds in the different regions of the pelvic floor. Notate general areas that the contraction feels weaker to initiate or that weaken before 3 seconds. During this musculoskeletal assessment, muscles can easily be identified as flaccid and unresponsive; instead of a taut guitar-string like band, the global musculature will be soft, without fiber distinction with an absence of pain.