Pelvic Pain of Myofascial Origin in Women: Correlation with Lower Urinary Tract Symptoms.

The association between pelvic pain and pelvic floor muscle (PFM) tone in women with persistent noncancer pelvic pain (PNCPP) is unclear. To synthesize the evidence of the association between pelvic pain and PFM tone in women with PNCPP. A systematic review was conducted via MEDLINE, Emcare, Embase, CINAHL, PsycINFO, and Scopus to identify relevant studies. Studies were eligible if pelvic pain and PFM tone outcome measures were reported among women aged >18years. The National Heart, Lung, and Blood Institute's Quality Assessment Tool for Observational Cohort and Cross-sectional Studies was used to assess study quality. Studies were pooled by assessment of PFM tone via a random effects model. Associations between the presence of pelvic pain and PFM tone were assessed with odds ratio (OR), while linear associations were assessed with Pearson or Spearman correlation. Pelvic pain measures (intensity, threshold, and frequency) and resting PFM tone in women with PNCPP, as evaluated by any clinical assessment method or tool. Twenty-four studies were included in this review. The presence of pelvic pain was significantly associated with increased PFM tone as assessed by digital palpation (OR,2.85; 95% CI, 1.66-4.89). Pelvic pain intensity was inversely but weakly associated with PFM flexibility when evaluated through dynamometry (r = -0.29; 95% CI, -0.42 to -0.17). However, no significant associations were found between pelvic pain and PFM tone when measured with other objective assessment methods. Pelvic pain and increased PFM tone may not be directly associated; alternatively, a nonlinear association may exist. A range of biopsychosocial factors may mediate or moderate the association, and clinicians may need to consider these factors when assessing women with PNCPP. This review was reported according to the PRISMA guidelines. All possible findings from relevant theses and conference abstracts were considered in our search. However, nonlinear associations between pelvic pain and increased PFM tone were not assessed as part of this review. Pelvic pain may be linearly associated with increased PFM tone and decreased PFM flexibility when measured with digital palpation or dynamometry; however, this association was not observed when other aspects of PFM tone were assessed through objective methods. Future studies are required using robust assessment methods to measure PFM tone and analyses that account for other biopsychosocial factors that may influence the association.

The ability to express one's sexuality and engage in sexual activity requires multisystemic coordination involving many psychological functions as well as the integrity of the nervous, hormonal, vascular, immune, and neuromuscular body structures and functions. The purpose of this study was to investigate the associations among pelvic floor function, sexual function, and demographic and clinical characteristics in a population of women initiating physical therapy evaluation and treatment for pelvic floor-related dysfunctions (urinary incontinence, pelvic organ prolapse, vulvodynia, vaginismus, and constipation). We consented and collected completed demographic data and data related to symptoms and clinical condition on 85 consecutive patients in an outpatient physical therapy clinic. Clinical and anthropometric characteristics were analyzed descriptively. Analysis of variance and linear regression analyses were used to analyze Female Sexual Function Index (FSFI) scale ratings, whereas zero-inflated beta-binomial regression was applied to the pain subscale. Main outcome measure was FSFI score, whereas the secondary outcome measure was the FSFI subscale score related to pain. Women in our sample were 38 years old on average, 33% of whom had given birth and 82% of whom had high tone pelvic floor. Being in the middle-tercile age group and exhibiting low pelvic floor tone (Beta = 6.8; 95% confidence interval [CI] = [1.4; 12.0]) were significantly associated with lower levels of sexual dysfunction. Women with low tone pelvic floor also reported lower pain (odds ratio = 4.0; 95% CI = [1.6; 9.6]), whereas younger aged and physically unsatisfied subjects were more likely not to have sexual activity in the month prior to scale measurement. In female patients with pelvic floor muscle dysfunction undergoing physical therapy and rehabilitation, sexual dysfunction appears to be significantly correlated with age and high pelvic floor muscle tone.

6-Day Intensive Treatment Protocol for Refractory Chronic Prostatitis/Chronic Pelvic Pain Syndrome Using Myofascial Release and Paradoxical Relaxation Training

Background:Patients presenting with lower urinary tract symptoms (LUTS) are historically classified to several symptom clusters, primarily overactive bladder (OAB) and interstitial cystitis/bladder pain syndrome (IC/BPS). Accurate diagnosis, however, is challenging due to overlapping symptomatic features, and many patients do not readily fit into these categories. To enhance diagnostic accuracy, we previously described an algorithm differentiating OAB from IC/BPS. Herein, we sought to validate the utility of this algorithm for identifying and classifying a real-world population of individuals presenting with OAB and IC/BPS and characterize patient subgroups outside the traditional LUTS diagnostic paradigm.Methods:An Exploratory cohort of 551 consecutive female subjects with LUTS evaluated in 2017 were administered 5 validated genitourinary symptom questionnaires. Application of the LUTS diagnostic algorithm classified subjects into controls, IC/BPS, and OAB, with identification of a novel group of highly bothered subjects lacking pain or incontinence. Symptomatic features of this group were characterized by statistically significant differences from the OAB, IC/BPS and control groups on questionnaires, comprehensive review of discriminate pelvic exam, and thematic analysis of patient histories. In a Reassessment cohort of 215 subjects with known etiologies of their symptoms (OAB, IC/BPS, asymptomatic microscopic hematuria, or myofascial dysfunction confirmed with electromyography), significant associations with myofascial dysfunction were identified in a multivariable regression model. Pre-referral and specialist diagnoses for subjects with myofascial dysfunction were catalogued.Findings:Application of a diagnostic algorithm to an unselected group of 551subjects presenting for urologic care identified OAB and IC/BPS in 137 and 96 subjects, respectively. An additional 110 patients (20%) with bothersome urinary symptoms lacked either bladder pain or urgency characteristic of IC/BPS and OAB, respectively. In addition to urinary frequency, this population exhibited a distinctive symptom constellation suggestive of myofascial dysfunction characterized as “persistency”: bothersome urinary frequency resulting from bladder discomfort/pelvic pressure conveying a sensation of bladder fullness and a desire to urinate. On examination, 97% of persistency patients demonstrated pelvic floor hypertonicity with either global tenderness or myofascial trigger points, and 92% displayed evidence of impaired muscular relaxation, hallmarks of myofascial dysfunction. We therefore classified this symptom complex “myofascial frequency syndrome”. To confirm this symptom pattern was attributable to the pelvic floor, we confirmed the presence of “persistency” in 68 patients established to have pelvic floor myofascial dysfunction through comprehensive evaluation corroborated by symptom improvement with pelvic floor myofascial release. These symptoms distinguish subjects with myofascial dysfunction from subjects with OAB, IC/BPS, and asymptomatic controls, confirming that myofascial frequency syndrome is a distinct LUTS symptom complex.Interpretation:This study describes a novel, distinct phenotype of LUTS we classified as myofascial frequency syndrome in approximately one-third of individuals with urinary frequency. Common symptomatic features encompass elements in other urinary syndromes, such as bladder discomfort, urinary frequency and urge, pelvic pressure, and a sensation of incomplete emptying, causing significant diagnostic confusion for providers. Inadequate recognition of myofascial frequency syndrome may partially explain suboptimal overall treatment outcomes for women with LUTS. Recognition of the distinct symptom features of MFS (persistency) should prompt referral to pelvic floor physical therapy. To improve our understanding and management of this as-yet understudied condition, future studies will need to develop consensus diagnostic criteria and objective tools to assess pelvic floor muscle fitness, ultimately leading to corresponding diagnostic codes.Funding:This work was supported by the AUGS/Duke UrogynCREST Program (R25HD094667 (NICHD)) and by NIDDK K08 DK118176 and Department of Defense PRMRP PR200027, and NIA R03 AG067993.

To evaluate and compare the sexual function and pelvic floor muscles (PFM) function of women with endometriosis and chronic pelvic pain (CPP) with and without Myofascial Pelvic Pain Syndrome (MPPS). Cross-sectional study conducted between January 2018 and December 2020. Women with deep endometriosis underwent assessments for trigger points (TP) and PFM function using the PERFECT scale. Electromyographic activity (EMG) and sexual function through Female Sexual Function Index (FSFI) were assessed. Statistical analyses included chi-square and Mann-Whitney tests. There were 46 women. 47% had increased muscle tone and 67% related TP in levator ani muscle (LAM). Weakness in PFM, with P≤2 was noted in 82% and P≥3 in only 17%. Incomplete relaxation of PFM presented in 30%. EMG results were resting 6.0, maximal voluntary isometric contraction (MVIC) 61.9 and Endurance 14.2; FSFI mean total score 24.7. We observed an association between increased muscle tone (P<.001), difficulty in relaxation (P=.019), and lower Endurance on EMG (P=.04) in women with TP in LAM. Participants with TP presented lower total FSFI score (P=.02). TP in the right OIM presented increased muscle tone (P=.01). TP in the left OIM presented lower values to function of PFM by PERFECT (P=.005), and in MVIC (P=.03) on EMG. Trigger points (TP) in pelvic floor muscles (PFM) and obturator internus muscle (OIM) correlates with poorer PFM and sexual function, particularly in left OIM TP cases. Endometriosis and chronic pelvic pain raise muscle tone, weaken muscles, hinder relaxation, elevate resting electrical activity, lower maximum voluntary isometric contraction, and reduce PFM endurance.

Relationships Between 3-Dimensional Transperineal Ultrasound Imaging and Digital Intravaginal Palpation Assessments of the Pelvic Floor Muscles in Women With and Without Provoked Vestibulodynia

Pelvic floor myofascial pain severity and pelvic floor disorder symptom bother: is there a correlation?

Painful Myofascial Trigger Points and Pain Sites in Men With Chronic Prostatitis/Chronic Pelvic Pain Syndrome

Association of coccygodynia with pelvic floor symptoms in women with pelvic pain.

Alterations in pelvic floor muscle (PFM) function have been observed in women with persistent noncancer pelvic pain (PNCPP) as compared with women without PNCPP; however, the literature presents conflicting findings regarding differences in PFM tone between women with and without PNCPP. To systematically review the literature comparing PFM tone in women with and without PNCPP. MEDLINE, Embase, Emcare, CINAHL, PsycINFO, and Scopus were searched from inception to June 2021 for relevant studies. Studies were included that reported PFM tone data in women aged ≥18years with and without PNCPP. The risk of bias was assessed with the National Heart, Lung, and Blood Institute Quality Assessment Tool. Standardized mean differences (SMDs) for PFM tone measures were calculated via random effects models. Resting PFM tone parameters, including myoelectrical activity, resistance, morphometry, stiffness, flexibility, relaxation, and intravaginal pressure, measured by any clinical examination method or tool. Twenty-one studies met the inclusion criteria. Seven PFM tone parameters were measured. Meta-analyses were conducted for myoelectrical activity, resistance, and anterior-posterior diameter of the levator hiatus. Myoelectrical activity and resistance were higher in women with PNCPP than in women without (SMD = 1.32 [95% CI, 0.36-2.29] and SMD = 2.05 [95% CI, 1.03-3.06], respectively). Women with PNCPP also had a smaller anterior-posterior diameter of the levator hiatus as compared with women without (SMD = -0.34 [95% CI, -0.51 to -0.16]). Meta-analyses were not performed for the remaining PFM tone parameters due to an insufficient number of studies; however, results of these studies suggested greater PFM stiffness and reduced PFM flexibility in women with PNCPP than in women without. Available evidence suggests that women with PNCPP have increased PFM tone, which could be targeted by treatments. A comprehensive search strategy was used with no restriction on language or date to review studies evaluating PFM tone parameters between women with and without PNCPP. However, meta-analyses were not undertaken for all parameters because few included studies measured the same PFM tone properties. There was variability in the methods used to assess PFM tone, all of which have some limitations. Women with PNCPP have higher PFM tone than women without PNCPP; therefore, future research is required to understand the strength of the relationship between pelvic pain and PFM tone and to investigate the effect of treatment modalities to reduce PFM tone on pelvic pain in this population.

Dear Editor, We have read with interest the report by El-Khawand and colleagues on use of botulinum toxin for conditions of the female pelvis [1]. The authors describe with a systematic approach the mechanism of action of botulinum toxin and its use in different urogynaecological conditions and pelvic floor disorders. It was of particular interest for us to read about the use of botulinum toxin in high-tone pelvic floor dysfunction (pelvic floor muscles spasm), myalgia or vestibulodynia, as we have used it in selected patients for the same conditions in our unit. There are several studies confirming that the muscle spasm could be relieved by the injection of botulinum toxin type A directly into myofascial trigger points [2], leading to a significant reduction in pelvic floor pain. The disadvantages of this treatment are the need for general anaesthesia and the temporary nature of the effect of botulinum toxin on the muscle, necessitating repeated injections. The authors mention that the aetiology of the condition is uncertain and that diagnosis is made only by history and physical examination. There is some evidence in the literature that pelvic floor dysfunction, spasms and associated pelvic floor pain could be attributed to traumatic childbirth and be the result of pelvic floor muscle damage or denervation [3]. Usually, pelvic floor trauma comprises perineal and anal sphincter damage, but recently levator muscle damage (LAM) has been included in this group [4]. It is well known that LAM trauma, and as a consequence chronic pelvic floor pain, is commonly seen in multiparous women with a history of forceps delivery. With regard to diagnosis, several clinical and imaging techniques are currently used in diagnosing levator muscle injury, such as ultrasound and MRI. We would also like to share our experience of injecting botulinum toxin into myofascial trigger points in the outpatient setting, which makes this method more accessible and especially successful, as patients could directly comment on the painful trigger points, assuming that the procedure is tolerated well. It also reduces the risk by avoiding anaesthetic, and in these times of austerity, improving costeffectiveness. To our knowledge this method has not been described before in the scientific literature in women with pelvic floor disorders.

Introduction and hypothesisPelvic floor muscle weakness is a common cause of pelvic organ prolapse and urinary incontinence. Surgical repair of prolapse is commonly undertaken; however, the impact on pelvic floor muscle tone is unknown. The aim of this study was to compare the effect of anterior and posterior colporrhaphy on pelvic floor activation.MethodsPatients aged under 70 undergoing primary anterior or posterior colporrhaphy were recruited. Intra-vaginal pressure was measured at rest and during pelvic floor contraction using the Femfit® device (an intra-vaginal pressure sensor device [IVPSD]). Peak pressure and mean pressure over 3 s were measured in millimetres of mercury. The pre- and post-operative measurements were compared. The difference between the means was assessed using Cohen’s D test, with significance set at p<0.05ResultsA total of 37 patients completed pre- and post-operative analysis, 25 in the anterior colporrhaphy group and 12 in the posterior colporrhaphy group. Anterior colporrhaphy showed no significant change in pelvic floor tone. Change in peak pressure was −1.71mmHg (−5.75 to 2.33; p=0.16) and change in mean pressure was −0.86 mmHg (−4.38 to 2.66; p=0.31). Posterior colporrhaphy showed a significant increase in peak pelvic floor muscle tone of 7.2 mmHg (0.82 to 13.58; p=0.005) and mean pressure of 4.19 mmHg (−0.09 to 8.47; p=0.016).ConclusionsPosterior colporrhaphy significantly improves pelvic floor muscle tone, whereas anterior colporrhaphy does not. Improved understanding of the impact of pelvic floor surgery may guide future management options for other pelvic floor disorders. Further work is needed to confirm the association of this improvement in pelvic floor disorders.

Osteopathic Manipulative Treatment of Chronic Pelvic Pain due to High-Tone Pelvic Floor Dysfunction

Objective To investigate the relationship between pelvic floor pain and pelvic floor injury in female patients with lower urinary tract disease. Methods Transvaginal and rectal pelvic floor acupressure was used to perform pelvic floor pain point examination in women with lower urinary tract disease. The number of tender points and the pain point of tenderness were recorded. Results The positive rate of pelvic pain points was 61.5% (3 507 checkpoints, 2 156 checkpoints had tenderness); there was a difference in the degree of pain caused by pain points in different regions (H=159.144, P<0.01). There was no difference in pain level between the P3 area, P4 and P5 areas and P2 (adjust P=1), and the pain points of the other areas were statistically different from the pain level (adjust P<0.01). Conclusions The density of tender points and degree of pain in pain points in female pelvic floor are related to the pelvic floor injury. It is of clinical significance to evaluate the degree of pelvic floor injury by taking the pelvic floor pain point. Key words: Lower urinary tract symptoms; Female urogenital diseases; Pelvic floor; Pain; Wounds and injuries

INTRODUCTION: Lower urinary tract symptoms (LUTS) are prevalent in women with uterine fibroids. Research suggests that increased fibroid volume and uterine bulk is associated with more severe LUTS and pelvic floor symptoms, however the correlation between fibroid size/location, adenomyosis, and symptoms has been under-studied. We sought to investigate this correlation using MRI which provides detailed information on fibroid characteristics. METHODS: A retrospective chart review was conducted for patients seen at the Stanford Fibroid Clinic. Patient demographics, medical history and pelvic MRI data were collected on 60 patients with completed Uterine Fibroid Symptom (UFS) and Pelvic Floor Distress Inventory (PFDI) validated symptom surveys. Primary outcome was scaled symptom scores and sub-scores including the Urogenital Distress Inventory (UDI-6). RESULTS: Dominant fibroid volume correlated negatively with urinary frequency (r=-0.307, P=.030), urgency (r=−0.287, P=.043), and pelvic pain or discomfort (r=-0.281, P=.049). Longest fibroid dimension also negatively correlated with UDI-6 (r=-0.304, P=.028). Number of fibroids and uterine volume were not significantly associated with LUTS. However, higher PFDI score was significantly associated with presence of adenomyosis on MRI (mean 82.9 vs 159.6, P=.018) and serosal fibroid location (mean 139.3 vs 69.0, P=.011). Patient BMI correlated positively with UDI-6 (r=0.415, P=.002) and PFDI (r=0.371, P=.005). CONCLUSION: Contrary to common belief, dominant fibroid size was inversely associated with LUTS, suggesting that fibroid dimensions may not predict bulk-related symptom severity. Adenomyosis should be considered in the evaluation of LUTS in women with uterine fibroids. In accordance with current literature, BMI is associated with LUTS including incontinence, urgency, and frequency.