EPHect physical examination standards (EPHect-PE)

The EPHect Physical Examination tool (EPHect-PE) is a standardised physical examination assessment in endometriosis. It allows for the documentation of examination findings that provide insight into a non-surgical diagnosis of endometriosis as well as pain phenotyping.

The EPHect-PE can be combined with the other EPHect tools, whether or not surgery is performed.


Tinya Lin, Catherine Allaire, Sawsan As-Sanie, Pamela Stratton, Katy Vincent, G David Adamson, Lars Arendt-Nielsen, Deborah Bush, Femke Jansen, Jennifer Longpre, Luk Rombauts, Jay Shah, Abeesha Toussaint, Lone Hummelshoj, Stacey A Missmer, Paul J Yong; WERF EPHect Physical Examination Working Group. World Endometriosis Research Foundation Endometriosis Phenome and Biobanking Harmonization Project: V. Physical examination standards in endometriosis researchFertil Steril 2024 ONLINE AHEAD OF PRINT


Investigators using EPHect tools are asked to include the following acknowledgment in all publications and presentations that utilise data collected using the EPHect questionnaires, forms, or sample collection protocols:
"Data collection was facilitated by and conducted in compliance with the Endometriosis Phenome and Biobanking Harmonisation Project (EPHect)."

Please also cite the above paper whenever data collected utilising these protocols are published.

In addition, investigators whose data collection tools or methods included alterations to the EPHect standardised protocols are asked to describe those changes in the Methods section of manuscripts and when presenting their study results.

A guide to the assessments


Pelvic girdle pain (PGP) assessments

These are modified from: Tu F, Fitzgerald C, Senapati S, Pozolo K. Musculoskeletal Causes of Pelvic Pain. In: Vercellini P, ed. Chronic Pelvic Pain. New Jersey: Wiley, 2011:115-124.

C1-C2: Sacroiliac joint tenderness (long dorsal sacroiliac ligament)

Patient standing or sitting up, with palpation of the ligament caudomedially from the posterior iliac spine to the lateral dorsal border of the sacrum.
Positive: if painful within the borders of the ligament. 


C3-C4: Active straight leg raise pain

Patient in supine, with straight legs extended about 20cm apart. The leg is raised straight to about 30 degrees off the table one at a time.
Positive: if heaviness or difficulty, and/or improvement with posterior compression of the opposite hip. 


C5-C6: Faber test pain (Patrick)

Patient in supine, leg is flexed, abducted and externally rotated so heel is on the opposite knee.
Positive: with pain provocation in the pelvic joint. 


C7-C8: Posterior pelvic pain provocation (P4) pain

Patient in supine, femur flexed to be perpendicular to the table, with knee flexed to be parallel to the table. Gentle pressure applied to femur in the direction towards the table.
Positive: with pain provocation in the gluteal region of that leg. 


C9: Symphysis pubis tenderness

Patient in supine, with palpation of the pubic symphysis joint.`
Positive: with pain provocation of the pubic symphysis.


Abdominal wall assessments

  1. Saud Suleiman and David E Johnston. The abdominal wall: an overlooked source of pain. Am Fam Physician 2001;64(3):431-438.
  2. John Jarrell. Demonstration of cutaneous allodynia in association with chronic pelvic pain. J Vis Exp 2009(28).


D1-D5: Carnett’s

Method of differentiating between abdominal wall sources of pain versus visceral. Patient contracts the abdominal wall musculature (e.g., through a sit-up).
Positive: if abdominal tenderness remains the same or worsens with contraction1.


D1-D5: Allodynia

Q-tip is used to brush the abdominal wall, cranial to caudal, and then lateral to medial.
Positive: if sensation is noted as painful or sharp2.


Pelvic floor muscle tenderness assessments

  1. Anthony Gyang, Melissa Hartman, Georgine Lamvu. Musculoskeletal causes of chronic pelvic pain: what a gynecologist should know. Obstet Gynecol 2013;121(3):645-650
  2. Melanie R Meister, Nishkala Shivakumar, Siobhan Sutcliffe, Theresa Spitznagle, Jerry L Lowder. Physical examination techniques for the assessment of pelvic floor myofascial pain: a systematic review. Am J Obstet Gynecol 2018;219(5):497.e1-497e13.



F1-F2: Bulbocavernosus (right and left)1,2
F3-F4: Ischiocavernosus (right and left)1,2
F5: Superficial transverse perineal muscles (6 o’clock)1,2



F6-F7: Pubococcygeus: insert digit about 2.5 centimetres into the introitus, and palpate right (between 7 o’clock and 11 o’clock) and left (between 1 o’clock and 5 o’clock)1,2
F8-F9: Iliococcygeus: insert digit further into introitus, and palpate right (8 o’clock) and left (4 o’clock)1,2
F10-F11: Obturator internus: insert digit between distal and proximal interphalangeal joints, and palpate right (10 o’clock) and left (2 o’clock)1,2
F12-F13: Coccygeus: insert digit deeper into vagina, and palpate right (7 o’clock) and left (5 o’clock)1,2


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