Table 3:

Recommended Structure for Physical Examination of Pelvic Myofascial Pain

Examination Method	Supporting References
1) Provide counseling to patient about the pelvic examination process. Explain thoroughly the steps that are a part of the examination and pay particular attention in trying to ease the fear and hesitancy that the patient may have. Finally obtain consent to begin physical examination.	6/55 studies documented counseling and/or consent of patient prior to start of physical examination
2) Ask patient to sit in the lithotomy position for examination	14/55 studies used the lithotomy position for examination of pelvic musculature
3) Begin the unidigital transvaginal examination by inserting a gloved, lubricated index finger into the vaginal introitus	34/55 studies palpated muscles with single digit Of these, 19/34 studies palpated muscles with palmar side of the index finger
	42/55 studies performed a transvaginal exam for the pelvic musculature
	17/55 studies explicitly mentioned gloving and/or lubrication of examining digit
4) Utilize clock face orientation with the pubic symphysis at 12 o clock and the anus at 6 o clock to localize pelvic floor muscles	16/55 studies utilized clock face orientation to locate pelvic floor muscles
5) Start with unidigital palpation of superficial pelvic floor musculature and then proceed to deep pelvic floor musculature.	17/55 studies specified order for pelvic muscle palpation Of these, 6/17 studies started with superficial PFM and then moved to deep PFM palpation
6) 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)	Number of studies that assessed superficial muscles: bulbospongiosus (12/55), ischiocavernosus (9/55), superficial transverse perineal muscles (13/55)
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)	Number of studies that assessed deep muscles: pubococcygeus (22/55), iliococcygeus (24/55), coccygeus (18/55), unspecified levator ani (25/55)
7) Then palpate obturator internus at 2 and 10 o clock	25/55 studies palpated obturator internus for tenderness Of these, 5/25 studies specified palpating obturator internus after palpating pelvic floor muscles
8) During palpation, apply pressure to specific sites predefined on each of the pelvic floor muscles and obturator internus. Consider vaginal pressure algometer to standardize amount of pressure being applied to each site.	21/55 studies used site specific palpation and did not palpate along length of muscle
	6/55 studies used a vaginal pressure algometer
9) Use a graded scale (either NRS or VAS) to assess patient reported pain after palpation of each site	28/55 studies used patient reported scores to assess muscle tenderness
	25/55 studies used graded scale to assess muscle tenderness
	9/55 studies used visual analogue scale and 15/55 studies use numerical rating scale
10) Additional items that can be included in examination:
external genitalia, vestibule, urethra, bladder, anus, abdomen, vaginal wall	31/55 studies that assessed additional non-muscular sites for tenderness
strength of pelvic floor musculature	23/55 studies evaluated the strength of the pelvic floor musculature