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Herman & Wallace Blog

An Updated Look at Endometriosis

Recent data suggests that there are about 4 million American women diagnosed with endometriosis, but that 6/10 are not diagnosed. Currently, using the gold standard for diagnosis there are potentially 6 million American woman that may experience the sequelae of endometriosis without having appropriate management or understanding the cause of their symptoms.

The gold standard for endometriosis is laparoscopy either with or without histologic verification of endometrial tissue outside of the uterus. However, there is a poor correlation between disease severity and symptoms. The Agarwal et al study suggests a shift to focus on the patient rather than the lesion and that endometriosis may better be defined as “menstrual cycle dependent, chronic, inflammatory, systemic disease that commonly presents as pelvic pain”. There is often a long delay in symptom appreciation and diagnosis that can range from 4-11 years. The side effects of this delay are to the detriment of the patient; persistent symptoms and effect of quality of life, development of central sensitization, negative effects on patient-physician relationship. If this disease continues to go untreated it may affect fertility and contribute to persistent pelvic pain.

The authors suggest a clinical diagnosis with transvaginal ultrasound for patients presenting with persistent or cyclic pelvic pain, patient history, have symptoms consistent with endometriosis, or other findings suggestive of endometriosis. The intention of using transvaginal ultrasound is to make diagnosis more accessible and limit under diagnosis. It is not intended to minimize laparoscopy as a diagnostic tool or treatment option.

The algorithm for a clinical diagnosis evaluates patient presentation of the following:

  • Symptoms including persistent or cyclic pelvic pain, dysmenorrhea or painful menstruation cramps, deep dyspareunia or pain with deep vaginal penetration, cyclic dyschezia or straining for soft stools, cyclic dysuria or pain with urination, cyclic catamenial symptoms located in other systems such as acne or vomiting.
  • Assessment of patient history including infertility, current chronic pelvic pain, or painful periods as an adolescent, previous laparoscopy with diagnosis, painful periods that are not responsive to NSAIDS, and a family history.
  • Physical exam physicians assess for nodules in cul de sac, retroverted uterus, mass consistent with endometriosis, visible or obvious external endometrioma. Imaging should be ordered or performed.
  • Clinical signs would consist of endometrioma with US, presence of soft markers (sliding sign) this is where the fundus of the uterus is compared to its neighboring structures and can indicate the immobility of those structures, and nodules or masses.

Of course, there are differential diagnosis for endometriosis, and those are symptoms of non-cyclical patterns of pain and bladder/bowel dysfunction that would indicate IBS, UTI, IC/PBS. A history of post-operative nerve entrapment of adhesions. Examination positive for pelvic floor spasm, severe allodynia in vulva and pelvic floor, masses such as fibroids. It is important to note that these other diagnoses can coexist with endometriosis and do not rule out possible endometriosis diagnosis.

Hopefully, diagnosing individuals earlier and possibly at a younger age would limit the disease severity and symptoms. This would allow this population to limit the possibility of central sensitization and pain persistence that can affect so much of daily life. Earlier diagnosis may affect infertility and allow this population to make informed decisions about family and career from a place of empowerment.


Agarwal SK, Chapron C, Giudice LC, Laufer MR, Leyland N, Missmer SA,Singh SS, Taylor HS, "Clinical diagnosis of endometriosis: a call to action", American Journal of Obstetrics and Gynecology (2019), doi: https://doi.org/10.1016/j.ajog.2018.12.039.

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Myofascial Pelvic Pain: Symptoms and Assessment

The following is a guest submission from Alysson Striner, PT, DPT, PRPC. Dr. Striner became a Certified Pelvic Rehabilitation Practitioner (PRPC) in May of 2018. She specializes in pelvic rehabilitation, general outpatient orthopedics, and aquatics. She sees patients at Carondelet St Joesph’s Hospital in the Speciality Rehab Clinic located in Tucson, Arizona.

Myofascial pain from levator ani (LA) and obturator internus (OI) and connective tissues are a frequent driver of pelvic pain. As pelvic therapists, it can often be challenging to decipher whether pain is related to muscular and/or fascial restrictions. A quick review from Pelvic Floor Level 2B; overactive muscles can become functionally short (actively held in a shortened position). These pelvic floor muscles do not fully relax or contract. An analogy for this is when one lifts a grocery bag that is too heavy. One cannot lift the bag all the way or extend the arm all the way down, instead the person often uses other muscles to elevate or lower the bag. Over time both the muscle and fascial restrictions can occur when the muscle becomes structurally short (like a contracture). Structurally short muscles will appear flat or quiet on surface electromyography (SEMG). An analogy for this is when you keep your arm bent for too long, it becomes much harder to straighten out again. Signs and symptoms for muscle and fascial pain are pain to palpation, trigger points, and local or referred pain, a positive Q tip test to the lower quadrants, and common symptoms such as urinary frequency, urgency, pain, and/or dyspareunia.Levator Ani Internal View

For years in the pelvic floor industry there has been notable focus on vocabulary. Encouraging all providers (researchers, MDs, and PTs) to use the same words to describe pelvic floor dysfunction allowing more efficient communication. Now that we are (hopefully) using the same words, the focus is shifting to physical assessment of pelvic floor and myofascial pain. If patients can experience the same assessment in different settings then they will likely have less fear, and the medical professionals will be able to communicate more easily.

A recent article did a systematic review of physical exam techniques for myofascial pain of pelvic floor musculature. This study completed a systematic review for the examination techniques on women for diagnosis of LA and OI myofascial pain. In the end, 55 studies with 9460 participants; 99.8% were female, that met the inclusion and exclusion criteria were assessed. The authors suggest the following as good foundation to begin; but more studies will be needed to validate and to further investigate associations between chronic pelvic pain and lower urinary tract symptoms with myofascial pain.

The recommended sequence for examining pelvic myofascial pain is:

  1. Educate patient on examination process. Try to ease any anxiety they may have. Obtain consent for an examination
  2. Ask the patient to sit in lithotomy position
  3. Insert a single, gloved, lubricated index finger into the vaginal introitus
  4. Orient to pelvic floor muscles using clock face orientation with pubic symphysis at 12 o'clock and anus at 6 o'clock
  5. Palpate superficial and then deep pelvic floor muscles
  6. Palpate the obturator internus
  7. Palpate each specific pelvic floor muscle and obturator internus; consider pressure algometer to standardize amount of pressure

Authors recommend bilateral palpation and documentation of trigger point location and severity with VAS. They recommend visual inspection and observation of functional movement of pelvic floor muscles.

The good news is that this is exactly how pelvic therapists are taught to assess the pelvic floor in Pelvic Floor Level 1. This is reviewed in Pelvic Floor Level 2B and changed slightly for Pelvic Floor Level 2A when the pelvic floor muscles are assessed rectally. Ramona Horton also teaches a series on fascial palpation, beginning with Mobilization of the Myofascial Layer: Pelvis and Lower Extremity. I agree that palpation should be completed bilaterally by switching hands to make assessment easier for the practitioner who may be on the side of the patient/client depending on the set up. This is an important conversation between medical providers to allow for easy communication between disciplines.


Meister, Melanie & Shivakumar, Nishkala & Sutcliffe, Siobhan & Spitznagle, Theresa & L Lowder, Jerry. (2018). Physical examination techniques for the assessment of pelvic floor myofascial pain: a systematic review. American Journal of Obstetrics and Gynecology. 219. 10.1016/j.ajog.2018.06.014

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