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Ultrasound BethShellycommentsonly BethShellycommentsonly 1 80 Dec 19, 2014 by BethShellycommentsonly BethShellycommentsonly
Editor Beth Shelly

Perineal pain is felt: in the female, between the posterior fourchette (posterior lip of the introitus) and the anus, and in the male, between the scrotum and the anus.
Taxonomy: 1. Lower Urinary Tract Symptoms (LUTS), 1.6 Genital and Lower Urinary Tract Pain

Perineal pain syndrome is the occurrence of persistent or recurrent episodic perineal pain, which is either related to the micturition cycle or associated with symptoms suggestive of urinary tract or sexual dysfunction. There is no proven infection or other obvious pathology.
EXPLANATORY NOTE 11: The ICS suggests that in men, the term prostatodynia (prostate-pain) should not be used as it leads to confusion between a single symptom and a syndrome.
Taxonomy: 1. Lower Urinary Tract Symptoms (LUTS), 1.7 Genito-Urinary Pain Syndromes and Symptom Syndromes Suggestive of LUTD.

These definitions are derived from the Standardisation of Terminology of Lower Urinary Tract Function: Report from the Standardisation Sub-committee of the International Continence Society. Abrams P, Cardozo L, Fall M, Griffiths D, Rosier P, Ulmsten U, Van Kerrebroeck P, Victor A, Wein A. Neurourol Urodyn 2002;21:167-78. (see Abrams et al. 2002).

Terminology for chronic pelvic pain syndromes is currently being updated by the ICS working group and will be linked here when available.

The perineum includes the perineal body a fibromuscular mass which serves as the attachment to several key structures including the bulbocavernosus, superficial transfers perineal, puboperinealis portion of the pubococcygeus, deep transverse perineal, and the external anal sphincter. (Ashton-Miller, Wei, Kerney) Text and figures can be found at
Other structures of the perineum include skin, fascia, adipose tissue, nerves, and blood vessels. Nerve innervations in the area includes S2, S3, and S4 although some texts place only S4 over the perineal body.
Male Perineum

The terms perineal pain and perineal pain syndrome do not specify the mechanism of pain. Multiple mechanisms are possible. Although it is not specified it appears the major mechanism implied is a myofascial dysfunction (including trigger points) broadly described as decreased mobility and pain in muscle and facial tissues. This would include pain related to scar adhesion subsequent to any number of wounds such as surgical incisions (including episiotomy), fistulas, or skin lesions. Endometrial lesions can imbed in the tissue of the perineum leading to adhesion related pain. Pain may be referred from nearby structures including hemorrhoids, perineal descent, vulvodynia, anismus, and others.
These terms would not include diagnosable skin lesions such as dermatitis, yeast infection, lichen sclerosus, cancer, and sexually transmitted disease. Careful examination and evaluation is needed to identify cause of pain and develop an appropriate treatment plan.

Treatment for perineal pain would be related to the mechanism of pain. In the case of referred pain; treatment would be directed at the origin of pain. The treatment of myofascial pain could include or diagnosable condition
  • Ensure there is no current infection, wound or other skin lesions
  • Place the gloved index finger on the scar and attempt to slide the tissue to the right and left
  • Note restriction and reproduction of pain
  • In some cases the scar is so painful that testing is not possible to examine
Treatment technique
  • Therapeutic ultrasound before scar massage may help soften tissue
  • Possible location of treatment
    • Slide external perineal body to the right or left
    • Press inward (toward head) on external perineal body
    • Press downward on internal perineal body (6:00 at introitus) toward table/rectum
    • Press into muscle/scar perpendicular to vaginal mucosa
    • Inside rectum, press anterior toward perineal body
    • One finger inside rectum, one finger inside vagina, pill rolling
  • Direct pressure (Edgar 2004)
    • Apply slow, steady pressure into the restricted area with gloved index finger
    • Hold steady 90 seconds or longer until the tissue softens
  • Slow friction massage
    • After tissue softens, move the finger a small distance side to side attempting to slide the skin along the second layer of tissue
    • A tolerable burning sensation can be expected
  • Skin rolling (for scaring or other CT restrictions)
    • At the posterior vaginal opening
    • Over the labia majora and around the clitoris
    • Over the lower gluteal and adductor muscles
    • Be aware of vestibulodynia / localized vulvodynia: vestibular skin that is extremely painful with no scarring present
Evidence of benefit of episiotomy scar massage
  • Patient noted decreased occurrence of fecal incontinence with increase PFM strength and resolution of episiotomy scar pain following MFR techniques by PT and patient. (Weiss Coffey)

The term "perineal region" is used in some texts to refer to the tissue of the pelvic outlet distal to the pelvic diaphragm and is often divided into the anterior urogenital triangle and the posterior anal triangle. (O'Rahilly) This area includes the urethral meatus, vaginal and anal openings, skin, muscle, nerve, blood vessel, and fascia. This broad area can be confused with the localized perineum and authors should be careful to distinguish the terms "perineal region" and "perineum". The later referring to the specific area between the vagina or scrotum and anal opening as described above.

Ashton-Miller JA, Howard D, DeLancey JO. The functional anatomy of the female pelvic floor and stress continence control system. //Scand J Urol Nephrol Suppl//. 2001;207:1–125.

Kerney R, Sawhney R, DeLancey J. Levator ani muscle anatomy evaluated by origin-insertion pairs. //Obstet Gynecol//. 2004;104:168–173.

Wei JT, DeLancey JO. Functional anatomy of the pelvic floor and lower urinary tract. Clin Obstet Gynecol. 2004;47:3–17.

O'Rahilly, Muller, Carpenter, Swenson. Basic Human Anatomy. online by Dartmouth Medical School. Chapter 38

Edgar D, Brereton M. Rehabilitation after burn injury. BMJ 2004;329:343-345.

Weiss Coffey S, Wilder E, Majsak MJ, Stolove R, Quinn L. The effect of a progressive exercise program with surface electromyographic biofeedback on an adult with fecal incontinence. //Phys Ther//. 2002;82:798-811.