Data-driven diagnosis and clinical presentation of high-tone pelvic floor dysfunction

Despite widespread agreement that high-tone pelvic floor dysfunction is highly prevalent among women with pelvic pain, there is no consensus regarding standardized assessment strategy or diagnostic criteria. Furthermore, there are scant primary data regarding clinical presentation of high-tone pelvic floor dysfunction and most existing literature related to symptoms is based on expert opinion rather than patient-reported data. The lack of consensus in diagnostic assessment and data regarding clinical presentation associated with this condition creates substantial barriers to improving clinical identification and evaluating efficacy of treatment strategies.

To identify a pelvic myofascial tenderness score that corresponded to patient-reported reproduction of pain and to compare clinical presentation of patients with and without high-tone pelvic floor dysfunction.

Cross-sectional study of 612 patients presenting to a chronic pelvic pain referral center from July 2019 to January 2023. Patients complete comprehensive questionnaires prior to first visit and undergo standardized physical examination, including palpation of 6 pelvic muscle sites (bilateral pubococcygeus, iliococcygeus, and obturator internus) at first visit. Receiver operating characteristic curve analyses were performed to identify a pelvic myofascial tenderness score that corresponded to patient-reported pain reproduction on palpation of pelvic floor muscles. Comparative analyses were performed to explore differences in clinical presentation associated with high-tone pelvic floor dysfunction.

Summative score of ≥12/60 on palpation of pelvic floor muscles demonstrated good accuracy by receiver operating characteristic analyses (sensitivity 82.3%; specificity 79.1%) for patient-reported pain reproduction and compared favorably to previously used methods for classifying high-tone pelvic floor dysfunction. Using ≥12/60 tenderness score as diagnostic threshold for high-tone pelvic floor dysfunction, 389 (63.6%) patients were categorized as having high-tone pelvic floor dysfunction and 223 (36.4%) as no high-tone pelvic floor dysfunction. Compared to patients without high-tone pelvic floor dysfunction, those with high-tone pelvic floor dysfunction were more likely to experience persistent pain with at least 14 pain days per month (odds ratio, 2.32; 95% confidence interval, 1.60, 3.35; P<.001). They were more likely to report pain exacerbation with physical activity, including exercise (odds ratio, 1.69; 95% confidence interval, 1.21, 2.32; P=.002) and walking (odds ratio, 1.85; 95% confidence interval, 1.32, 2.60; P<.001). Patients with high-tone pelvic floor dysfunction were more likely to describe pain as "heavy feeling in the pelvis" and report that pain radiated to other body regions and was associated with nausea and vomiting (all P<.001). Patients with high-tone pelvic floor dysfunction reported significant worse sexual function with more severe and consistent dyspareunia, pain occurring during and continuing 24 hours following intercourse, and were more likely to interrupt or avoid intercourse due to pain (all P<.001).

High-tone pelvic floor dysfunction should be considered when patients report summative tenderness of ≥12/60 on palpation of 6 pelvic floor muscles. High-tone pelvic floor dysfunction is associated with more persistent pain that may radiate to other body regions and is exacerbated by physical activity. Dyspareunia and impaired sexual function appear to be hallmark symptoms of high-tone pelvic floor dysfunction.