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Case Report  |   November 2019
Myofascial Release for Vulvar Pain and Pubic Shear After a Straddle Injury in a 3-Year-Old Girl
Author Notes
  • From Ohio University Heritage College of Osteopathic Medicine (Student Doctor Dade) Department of Obstetrics and Gynecology (Dr Broecker) and Ohio Health O'Bleness Memorial Hospital (Dr Broecker) in Athens. 
  • Financial Disclosures: None reported. 
  • Support: None reported. 
  •  *Address correspondence to Maggie Dade, OMS IV, 1787 State Rte 850 Unit D, Bidwell, OH 45614. Email: md334415@ohio.edu
     
Article Information
Emergency Medicine / Neuromusculoskeletal Disorders / Obstetrics and Gynecology / Osteopathic Manipulative Treatment
Case Report   |   November 2019
Myofascial Release for Vulvar Pain and Pubic Shear After a Straddle Injury in a 3-Year-Old Girl
The Journal of the American Osteopathic Association, November 2019, Vol. 119, 768-771. doi:https://doi.org/10.7556/jaoa.2019.127
The Journal of the American Osteopathic Association, November 2019, Vol. 119, 768-771. doi:https://doi.org/10.7556/jaoa.2019.127
Abstract

Pelvic malalignment is a somatic dysfunction that can lead to pelvic discomfort, despite normal genital examination findings. A 3-year-old girl presented with vulvar discomfort after a straddle injury sustained while riding a tricycle. The symptoms persisted despite standard medical treatment for vulvovaginitis and chronic vulvar irritation. An osteopathic structural examination revealed distortions of the bony pelvis, often associated with genitourinary complaints. After 5 osteopathic manipulative treatment sessions, the patient experienced significant relief. With persistent vulvar pain, somatic dysfunction should be considered in the differential diagnosis. A brief musculoskeletal examination of the pubic tubercles, iliac crest, and iliac spines can help to identify somatic dysfunction in a gynecologic patient with symptoms that are unresponsive to standard treatments.

The complaint of genital pain in a prepubescent girl can be a diagnostic dilemma. The differential diagnosis can be broad, and young girls may have limited verbal ability to describe their discomfort. Vulvovaginitis is perhaps the most common diagnosis,1,2 but other causes of pain include genital trauma, genital masses, dermatologic conditions, and musculoskeletal dysfunction.3,4 
Straddle injuries, in which a patient falls directly onto the perineum while straddling an object, are a common form of genital trauma among pediatric patients2 and are often considered in patients with vulvodynia.5 Although this injury often affects the superficial vaginal mucosa,2,3,5,6 it may also cause trauma to the underlying bony pelvis.7 
The pelvis is defined as 2 innominates that connect posteriorly to the sacrum and anteriorly by the pubic tubercles,8 all of which can become distorted after traumatic impact. Superior pubic shear is a pelvic dysfunction that may be suspected in a patient who expresses perineal discomfort1,5,9 after a straddle injury. This somatic dysfunction can be appreciated when one pubic bone is more cephalad and posterior when compared with its counterpart.8,10 It is caused by movement past the physiologic barrier, which prevents proper motion of the pelvis, lumbar spine, and sacrum.8 The shear of the pubic bones can lead to tension between pelvic and urogenital diaphragms, leading to lumbar and pelvic floor discomfort, dyschezia, and dysuria, often mimicking other pathologic disorders.8,10 Constipation after pelvic diaphragmatic strain is common in pediatric patients as a result of increased angulation of the anorectal junction.10 This change in angulation can lead to abnormal external sphincter mechanics and, in turn, decreased fecal elimination.10 
The present case report describes a pediatric patient who presented with persistent vulvar pain. After being evaluated by her family physician and a pediatric gynecologist, a referral was made for osteopathic manipulative treatment (OMT). The OMT specialist identified multiple somatic dysfunctions, and, after 5 treatment sessions, the pain resolved. All examinations were completed and all treatments applied in the presence of the patient's mother. 
Report of Case
Initial History and Evaluation
A 3-year-old girl presented with her mother to her primary care physician with a chief complaint of vulvar discomfort and dysuria. The child's parent denied increased frequency of urination, fever, and vaginal discharge. On review of systems, the parent reported that several days ago, the patient had a jarring straddle injury that occurred while she was riding her plastic big-wheeled tricycle. Because the girl did not report any vaginal bleeding or pain after the accident, the mother had not brought her in for evaluation at the time of the straddle injury. 
In the days following the injury, the patient began to complain of persistent dysuria. She was brought in to see her primary care physician. At that time, the patient's urinalysis results were positive for Staphylococcus urinary tract infection. After antibiotic treatment and a negative finding on repeated urine culture, the patient still had vulvar discomfort, which caused pain while sitting. Because of persistent symptoms, the child was referred to a pediatric gynecologist for further assessment. 
On initial gynecologic examination, only gentiourinary abnormalities were identified, including a small amount of vulvar irritation, mild erythema, and a slightly injected hymen. Due to the physical findings, mild vulvovaginitis and chronic irritation were suspected as possible causes of the pain. The patient's vulvovaginitis and irritation were treated topically with 10 days of premarin cream and 1% hydrocortisone ointment. The mother was also given a handout describing routine hygiene measures, and the patient and mother were educated on appropriate hygiene practices. 
At her scheduled follow-up 4 weeks later, the patient continued to report the same vulvar discomfort and pain while sitting. During the physical examination, a Q-tip was used to palpate different areas of the patient's vulva. The patient expressed discomfort when the Q-tip touched the superior aspect of her left labia and above her clitoris. The patient denied significant discomfort when the Q-tip touched her hymen. There were no other abnormal findings during the genital examination, and the mild vulvovaginitis had resolved. 
Due to the persistence of the vulvar discomfort despite normal physical examination findings, somatic dysfunction was then considered. The patient was referred for OMT. 
Osteopathic Examination
At the first OMT visit, which occurred 8 weeks after the straddle injury, the patient continued to express ongoing vulvar discomfort. Additionally, new-onset constipation and dyschezia were noted. 
During the osteopathic structural examination, multiple somatic dysfunctions were identified through palpation of vertebral landmarks and mobilization of the respiratory diaphragms. Mobilization of the respiratory diaphragms included but was not limited to the assessment for symmetry bilaterally both with and without respiration, compression, traction, and rotation. The dysfunctions included malalignment of the occipitoatlantal joint and the third and fourth thoracic vertebrae, right quadratus lumborum hypertonicity, increased tension of the right sacrotuberous ligament, a right anterior innominate, an externally rotated left femur, right-sided pelvic diaphragmatic restriction, and significant bilateral thoracoabdominal diaphragmatic restriction. The patient was treated with myofascial release in the supine position for each somatic dysfunction. A laxative was prescribed to be taken daily for 1 week to resolve the gastrointestinal symptoms. 
At the 4-week follow-up, the mother reported some improvement in her daughter's pain and return of normal bowel patterns. Because of the residual pelvic pain, an osteopathic structural examination was performed and revealed improved motion throughout the sacrum and pelvis as well as a new somatic dysfunction of the left superior pubic shear (Figure). The pubic shear and other somatic dysfunctions were treated with myofascial release with the patient in the supine position. The patient's mother was advised to stop laxative treatment and to monitor the patient for signs of constipation. The patient was scheduled for follow-up in 4 weeks. The parent was reassured that incomplete resolution after initial treatment was common and that multiple OMT sessions are often necessary for complete recovery. 
Figure.
Illustration of left superior pubic shear.
Figure.
Illustration of left superior pubic shear.
At the following visit, substantial improvement was reported. Upon examination, the patient had minor residual somatic dysfunctions in the cervical, thoracic, and lumbar regions; in the lower extremities bilaterally; and in the abdomen. In addition, 2 new somatic dysfunctions were identified: a left-on-left sacral torsion and a right pelvic anterior innominate dysfunction causing pelvic malalignment. All somatic dysfunctions were treated with myofascial release in the supine position. 
The patient presented for 2 more visits, each 4 weeks apart, and reported continuous improvements. At the fifth visit (24 weeks after the saddle injury and 16 weeks after the first OMT session), the patient's pain had resolved, and her mother was advised to schedule follow-up appointments as needed. 
Discussion
In this case, we present a pediatric patient with persistent vulvar discomfort who was ultimately found to have several somatic dysfunctions underlying her pelvic pain. In cases of persistent vulvar discomfort, a thorough osteopathic structural examination should be sought. To palpate the pubic tubercles, it is best for the examiner, with his or her palm down, to start palpating at the umbilicus and move the palm of the hand inferiorly until the first midline bony prominence (the pubic tubercles bilaterally) is detected.8,9 
In the present case, the patient's initial injury was likely the pubic shear, but that malalignment led to other areas of hypertonicity and dysfunction, which required treatment to restore normal anatomic relationships and function. Constipation likely resulted from the various pubic, sacral, and innominate dysfunctions, all of which distorted alignment of the pelvic floor and, consequently, the anal canal. 
Because of the young age and the complexity of somatic dysfunctions in this patient, indirect and direct myofascial release were the main treatment modalities used. The focus of myofascial release is to identify areas of fascial and visceral tension and, with varying degrees of tension and pressure, to move the tissue into a more relaxed state.8 The combination of the laxative and myofascial release of the pelvic diaphragm likely restored the oblique angle of the anal canal and normalized the patient's bowel patterns. 
Conclusion
Pelvic pain is a concern that does not discriminate among age groups or specialties. Keeping musculoskeletal dysfunction in the differential diagnosis can help expedite resolution of pain. Furthermore, a firm understanding of the underlying visceral structures and predisposing symptoms can prevent additional discomfort. Prompt referral to a physician who practices OMT can often help resolve pain that exists despite seemingly normal physical examination findings. 
Acknowledgments
We thank David Eland, DO, for reviewing the osteopathic examination portion of this report to ensure clear articulation among providers. 
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Figure.
Illustration of left superior pubic shear.
Figure.
Illustration of left superior pubic shear.