A detailed understanding of the anatomic structures that comprise the pelvis is essential in determining the musculoskeletal components of dyspareunia. The bony pelvis is comprised of three bones on each side—the ilium, is-chium andpubis bones, which together form the ox coxae. Also referred to as the innominate bone, they are joined anteriorly at the symphysis pubis and posteriorly to the sacrum and coccyx. The endopelvic portion of the pelvis surrounds the pelvic organs, which include the bladder, urethra, uterus, and rectum, as well as the perineum, which supports the viscera and gives structure to the urethra, vagina, and anus. The abdominal peritoneum extends inferiorly, covering the uterus, bladder, and rectum. Dynamically, the pelvis allows transfer of weight bearing forces between the trunk and lower limbs, provides protection of the pelvic organs, attachments for muscle, fascia, and ligaments in and around the midsection, and directs propulsive forces during parturition. Mobility and function are influenced by the muscles and soft tissues that attach to the pelvis, hips, and spine. In addition, the pelvic viscera and their fascial attachments within the pelvis (broad ligament, uracus, pubovesical ligament, vesicov-aginal fascia) provide support to the bladder and urethra. The uterosacral, broad, and round ligaments support the uterus.

The pelvic floor is divided into layers. The deepest layer comprises the pelvic viscera and its supportive endopelvic fascia. These fascial structures are composed of loose connective tissue, smooth muscle, elastic fibers, blood vessels, and nerves, more closely resembling a mesentery than skeletal ligaments. The endopelvic fascia serves to suspend the pelvic viscera to the pelvic side walls. The middle layer comprises the levator ani muscles, which include the pubococcygeous and iliococcygeus which support the viscera and allows for the urethral, vaginal, and anal opening. The puborectalis muscles act together with the external anal and urethral sphincters to contract the sphincters and prevent urinary or fecal leakage. Superficial to this layer is the urogenital diaphragm which crosses the anterior pelvic outlet, connecting the perineal body to the ischiopubic rami and securing the distal urethra. Most superficial are the bulbocavernosus, ischiocavernosus, and superficial transverse perineal muscles of the anterior urogenital triangle and the anal sphincter of the posterior anal triangle. As a whole, the pelvic floor muscles function to support the pelvic organs, to assist in both fecal and urinary continence, to provide support for the rectum and inhibition to the bladder, and to assist in pelvic-spinal stability. In addition, the pelvic floor is involved in enhancing sexual pleasure for both partners [4].

Pelvic floor muscle dysfunction generally refers to disorders of laxity (hypotonus) or overactivity (hypertonus). Hypotonus disorders, due to hormonal factors, mechanical damage, or weakness are generally associated with urinary and fecal incontinence, as well as pelvic organ prolapse. They have also been implicated in contributing to pelvic pain and dyspareunia. However, it is generally believed that pelvic floor hypertonus is the primary pelvic floor dysfunction causing sexual pain disorders.

As this book demonstrates, there are many pain disorders in which a physical therapist may be involved in treatment including pudendal neuralgia, fibromyalgia, low back pain, endometriosis, bowel disorders, interstitial cystitis, generalized or localized vulvodynia, postpartum dyspareunia, postmenopausal dyspareunia, and vaginismus. Therefore, a physical therapy evaluation must begin with a detailed medical, gynecological, and sexual history (described in depth in Chapter 4). A thorough history focuses on the location, timing, and nature of the pain. Additionally, the PT should ask about urinary symptoms (frequency, urgency, stress or urge incontinence, hesitancy) and changes in bowel function (frequency, consistency of stool, urgency, constipation, bloating, flatulence, or fecal incontinence). A PT should inquire about prior musculoskeletal problems or injuries including back pain, hip pain, scoliosis, and ruptured or herniated vertebral discs. Lastly, obstetrical, surgical, and accident/trauma history should be discussed.

In some cases, patients may present for treatment of a primary pain condition such as generalized vulvodynia, chronic pelvic pain, fibromyalgia, or interstitial cystitis, in which dyspareunia is just one component of a constellation of symptoms affecting overall quality of life. In other cases, the presenting complaint may refer directly to sexual function, such as the inability to have sexual intercourse. For example, a patient may have always had localized vestibulodynia which prevented her from using tampons, but her inability to have intercourse is the current trigger for seeking treatment. Understanding the context of the patient’s presentation and her current sexual relationship is important in the assessment, as one of the major aims of obtaining an accurate history is to determine the goals for both the patient and her partner and consider suggesting concurrent relationship counseling or sex therapy.

General Observation and Posture

The physical evaluation of a patient actually begins when she initially walks through the door. Relevant data that can be gained from this first observation includes an assessment of body language, posture, and gait. For example, a PT should look for evidence of anxiety which is associated with upper respiratory breathing patterns, which in turn can lead to decreased pelvic joint mobility and shortening of the muscles of the hips and pelvis [5].