Urologic Manifestations of Nonrelaxing Pelvic Floor Dysfunction: Insights on Clinical Workup and Management.

Long-Term Outcome and Surgical Interventions After Sacral Neuromodulation Implant for Lower Urinary Tract Symptoms: 14-Year Experience at 1 Center

Pelvic floor disorders can present with lower urinary tract symptoms, bowel, sexual dysfunction, and/or pain. Symptoms of pelvic muscle spasm (nonrelaxing pelvic floor or hypertonicity) vary and can be difficult to recognize. This makes diagnosis and management of these disorders challenging. In this article, we review the current evidence on pelvic floor spasm and its association with voiding dysfunction. To distinguish between the different causes of voiding dysfunction, a video urodynamics study and/or electromyography is often required. Conservative measures include patient education, behavioral modifications, lifestyle changes, and pelvic floor rehabilitation/physical therapy. Disease-specific pelvic pain and pain from pelvic floor spasm needs to be differentiated and treated specifically. Trigger point massage and injections relieves pain in some patients. Botulinum toxin A, sacral neuromodulation, and acupuncture has been reported in the management of patients with refractory symptoms. Pelvic floor spasm and associated voiding problems are heterogeneous in their pathogenesis and are therefore often underrecognized and undertreated; it is therefore essential that a therapeutic strategy needs to be personalized to the individual patient's requirements. Therefore, careful evaluation and assessment of individuals using a multidisciplinary team approach including a trained physical therapist/nurse clinician is essential in the management of these patients.

Cost-Effectiveness of Sacral Neuromodulation Versus Intravesical Botulinum A Toxin for Treatment of Refractory Urge Incontinence

To develop evidence- and consensus-based clinical practice guidelines for management of high-tone pelvic floor dysfunction (HTPFD). High-tone pelvic floor dysfunction is a neuromuscular disorder of the pelvic floor characterized by non-relaxing pelvic floor muscles, resulting in lower urinary tract and defecatory symptoms, sexual dysfunction, and pelvic pain. Despite affecting 80% of women with chronic pelvic pain, there are no uniformly accepted guidelines to direct the management of these patients. A Delphi method of consensus development was used, comprising three survey rounds administered anonymously via web-based platform (Qualtrics XM) to national experts in the field of HTPFD recruited through targeted invitation between September and December 2021. Eleven experts participated with backgrounds in urology, urogynecology, minimally invasive gynecology, and pelvic floor physical therapy (PFPT) participated. Panelists were asked to rate their agreement with rated evidence-based statements regarding HTPFD treatment. Statements reaching consensus were used to generate a consensus treatment algorithm. A total of 31 statements were reviewed by group members at the first Delphi round with 10 statements reaching consensus. 28 statements were reposed in the second round with 17 reaching consensus. The putative algorithm met clinical consensus in the third round. There was universal agreement for PFPT as first-line treatment for HTPFD. If satisfactory symptom improvement is reached with PFPT, the patient can be discharged with a home exercise program. If no improvement after PFPT, second-line options include trigger or tender point injections, vaginal muscle relaxants, and cognitive behavioral therapy, all of which can also be used in conjunction with PFPT. Onabotulinumtoxin A injections should be used as third line with symptom assessment after 2-4 weeks. There was universal agreement that sacral neuromodulation is fourth-line intervention. The largest identified barrier to care for these patients is access to PFPT. For patients who cannot access PFPT, experts recommend at-home, guided pelvic floor relaxation, self-massage with vaginal wands, and virtual PFPT visits. A stepwise approach to the treatment of HTPFD is recommended, with patients often necessitating multiple lines of treatment either sequentially or in conjunction. However, PFPT should be offered first line.

Consensus Definitions and Interpretation Templates for Fluoroscopic Imaging of Defecatory Pelvic Floor Disorders: Proceedings of the Consensus Meeting of the Pelvic Floor Consortium of the American Society of Colon and Rectal Surgeons, the Society of Abdominal Radiology, the International Continence Society, the American Urogynecologic Society, the International Urogynecological Association, and the Society of Gynecologic Surgeons.

INTRODUCTION: Nonrelaxing pelvic floor dysfunction (PFD) is a condition characterized by tension of the pelvic floor musculature, often resulting in pelvic pain. The objective of this study was to review patient-reported pain outcomes following treatment of nonrelaxing pelvic floor dysfunction to identify gaps in current evidence. METHODS: A systematic review of the following databases from inception to July 2020 was performed: Ovid MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus. Two authors reviewed titles and abstracts for relevance, and full articles were obtained and evaluated for inclusion. Studies were included if they assess interventions for nonrelaxing PFD characterized by pelvic pain. The third author was consulted in instances of disagreement. RESULTS: Of the 1,184 abstracts identified and reviewed, 36 full text articles were reviewed. Treatments for nonrelaxing PFD included biofeedback, botulinum toxin injections, electrical stimulation, intravaginal diazepam, massage, osteopathy, psychiatric interview, physical therapy, sacral nerve stimulation, trigger point injection, and combined therapies. Nineteen studies assessed the effectiveness of treatment based on patient reported pain outcomes. All studies demonstrated an improvement in pelvic pain. Several limitations were identified including varied pre-treatment diagnostic evaluation, small sample size, retrospective and single arm design, heterogeneity in treatment administration within and between studies, lack of standardized pain assessments, and limited long term outcome data. CONCLUSION: Nonrelaxing PFD is a debilitating condition. There is a paucity of high-quality clinical trials evaluating the effectiveness of pelvic floor muscle dysfunction treatments. Although preliminary studies support multi-modal treatment options, robust trials assessing patient-centered outcomes are necessary.

Sacral Neuromodulation in Patients with Idiopathic Overactive Bladder after Initial Botulinum Toxin Therapy

Management of Bladder Pain Syndrome: Green-top Guideline No. 70.

This study aims to evaluate the efficacy, safety, and socioeconomic impact of botulinum toxin type A trigger point injection therapy and ten-point injection therapy for chronic pelvic pain syndrome (CPPS) caused by muscle spasm, while also exploring the efficacy and clinical significance of botulinum toxin type A ten-point injection therapy in the treatment of chronic pelvic pain. This study conducted a retrospective analysis of patients hospitalized at a tertiary hospital from January 2024 to December 2024 who were diagnosed with chronic pelvic pain syndrome (CPPS) caused by pelvic floor muscle spasm. On the basis of the treatment protocol, these patients were divided into the trigger point pelvic floor muscle injection group and the ten-point injection therapy group, with data collected through follow-up visits or telephone interviews. The baseline characteristics of the two groups were compared, including age, body mass index (BMI), pain intensity (assessed using the Facial Pain Scale-Revised [FPS-R]), Short Form 12 Health Survey (SF-12), Hamilton Anxiety Rating Scale (HARS), and Overactive Bladder Symptom Score (OABSS). Propensity score matching (PSM) was used to balance significant differences in general characteristics between the two groups at a 1:1 ratio. Among the 91 patients, 44 received trigger point pelvic floor muscle injection therapy, and 47 received ten-point injection therapy. PSM successfully matched 64 patients, with 32 in each group. Among the 91 patients, 64 were successfully matched using the PSM method, divided into two groups of 32 patients each. The baseline characteristics of the patients in each group were well matched, with all showing (P > 0.05). Postoperative follow-up data indicated that both groups of patients showed a synchronous improvement trend in pain relief, anxiety improvement, and quality of life enhancement, with no statistically significant differences at any time point. This suggests that both injection methods have similar efficacy in improving clinical symptoms and quality of life in patients with chronic pelvic pain caused by muscle spasm. Both the ten-point injection method and trigger point injection method using type A botulinum toxin demonstrate comparable safety and efficacy in treating chronic pelvic pain caused by pelvic floor muscle spasm. However, the ten-point injection method has significant advantages in terms of not relying on trigger point localization, having a relatively fixed operational process, a shorter learning curve, less time-consuming procedures, and causing less discomfort to patients, which supports its broader clinical application.

AimsSacral neuromodulation (SNM) and Botulinum toxin A (BoNT‐A) injections are well‐known third‐line treatment options in patients with refractory overactive bladder (OAB). Our aim is to evaluate the success rate of SNM in patients who received prior therapy with BoNT‐A injections.MethodsAll patients with OAB symptoms referred for SNM between 2006 and 2019 were included. History taking and 3‐day voiding diaries assessed the complaints and suitability for SNM. The success rate of SNM in patients who received prior BoNT‐A was compared with BoNT‐A naive patients. Success was defined as an improvement of 50% or greater in voiding diary parameters. Satisfaction was registered at their most recent visit.ResultsA total of 263 patients underwent SNM test stimulation, of which 75 (16 male/57 female) received prior BoNT‐A and 188 (46 male/142 female) were BoNT‐A naive. Success rate for SNM in BoNT‐A naive patients was 72.9% and in BoNT‐A patients 66.7% (p = 0.316). Success rate after ≤2 BoNT‐A injections was 68.5%, compared to 61.1% after ≥3 injections (p > 0.05). Success rate in patients perceiving lack of efficacy of BoNT‐A was 67.4% (p > 0.05), subjected to temporary CISC was 73.7% (p > 0.05) and with temporary effect of BoNT‐A was 50% (p > 0.05). In 86% of BoNT‐A patients the system was still activated and used to their satisfaction at their last follow‐up visit (mean FU, 40.70 months).ConclusionSNM in patients with refractory OAB who failed prior BoNT‐A is an excellent approach. The number of injections nor reason of BoNT‐A discontinuation have predictive value for success with SNM.

Trigger Point Injections Followed by Immediate Myofascial Release in the Treatment of Pelvic Floor Tension Myalgia

Introduction Vestibulodynia, vulvar pain localized to the vestibule without an identifiable cause, has a multifactorial etiology including neurologic, hormonal, inflammatory, psychologic, and musculoskeletal factors. Key pathophysiologic drivers likely vary from patient to patient. Published studies demonstrate that compared to controls, patients with provoked vestibulodynia are more likely to have pelvic floor hypertonicity and decreased pelvic floor strength, as measured by dynamometric speculum and ultrasound. Further, observational studies describe improvement of vestibulodynia symptoms with pelvic floor physical therapy, suggesting a causal relationship between pelvic floor hypertonicity and vestibulodynia. Objective To describe the pathophysiologic mechanism by which pelvic floor dysfunction and myofascial trigger point development could cause vestibuoldynia, with a focus on pelvic floor anatomy. Methods Literature about vestibulodynia, pelvic floor dysfunction, and pelvic floor anatomy was reviewed and synthesized in conjunction with expert clinical experience of pelvic floor physical therapists and gynecologists. Results The pelvic floor consists of the levator ani muscles (iliococcygeus, pubococcygeus, and puborectalis) and ischiococcygeus, which form a basket to support the pelvic organs. The puborectalis inserts in the posterior vestibule, and hypertonicity can cause allodynia in this region. The levator ani are innervated by the levator ani nerve, which originates from S3-S5 and traverses the visceral surface of the muscles. Some cadaveric studies suggest dual innervation of the levator ani by the pudendal nerve, which originates from S2-S4 and courses over the inferior surface of the muscles. Pelvic floor hypertonicity, increased resting tone of the pelvic floor muscles, can result from many factors including stress, bladder and rectum voiding habits, and painful pelvic processes (i.e. interstitial cystitis, endometriosis). Increased muscle tone can promote sensitization of muscle afferent fibers and neuropathic upregulation. This may be perceived as vestibulodynia because the vestibule contains visceral and somatic sensory nerve fibers, whose signals are integrated at the same spinal levels as those from the levator ani. This anatomy allows for somatovisceral convergence of afferent signals, and thus perception of vestibular pain. Hypertonicity of the pelvic floor muscles decreases circulation creating localized hypoxia that can promote development of myofascial trigger points (tender nodules) in the pelvic floor. These trigger points can cause allodynia, perceived in the vestibule. In some cases, vestibulodynia may develop first and promote pelvic floor hypertonicity. Conclusions As pelvic floor hypertonicity can contribute to the pathogenesis of vestibulodynia, it is imperative for clinicians to include pelvic floor tone evaluation in their assessment of vestibulodynia. If pelvic floor hypertonicity is present, it should be treated concurrently with vestibular pain through a combination of pelvic floor physical therapy, trigger point injections, and botulinum toxin injections as pelvic floor hypertonicity and vestibulodynia may each perpetuate the other. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Johnson & Johnson.

Overactive bladder (OAB) syndrome is a combination of complex urinary symptoms, and is defined as urinary urgency with or without urgency incontinence, usually accompanied by frequency and nocturia, in absence of urinary tract infection or other obvious pathology. Treatment of patients with OAB is complex and international guidelines suggest life style interventions, pelvic floor re-education, bladder retraining and antimuscarinic drugs as first-line treatment option. Sacral neuromodulation (SNM) has been approved by Food and Drug Administration (FDA) in 1997 and more than 150,000 patients have already received this treatment worldwide. SNM is currently recommended by expert panels for the treatment of intractable OAB syndrome. Seven randomized trials have reported results in publications and are consistently in favour of SNM. In more than the 40 case series studies, about 39 % of patients with urgency urinary incontinence were cured following implantation, and 67% of patients achieved 50 % or greater improvement in incontinence symptoms. Studies comparing the effectiveness of the SNM versus botulinum toxin (BTX) injection have produced conflicting results, but studies comparing the cost-effectiveness of SNM suggested that SNM treatment strategy was more expensive but also more effective than BTX injections in the first 2 years. However, a recent study showed that SNM treatment was cost-effective after 5 years compared to BTX injection. Currently SNM stands as the single licensed second-line treatment for OAB, but more research is needed to improve the selection of patients and the identification of more prognostic factors and clarify the reduction in effectiveness over time.

Sacral neuromodulation (SNM) is an effective method for the treatment of refractory urge-frequency syndrome, urge urinary incontinence, non-obstructive urinary retention, and defecation dysfunction, and it is more commonly used in adults. In recent years, reports on SNM in children have gradually increased. However, there are many controversies regarding the indications and evaluation of treatment effects of SNM in children and adolescents, which need to be standardized. In order to better guide the clinical practice, the Pediatric Urodynamics and Pelvic Floor Group of Chinese Medical Association Pediatric Surgery Branch organized the experts of pediatric urodynamics, pelvic floor, and urology developed this "Expert Consensus on Clinical Application of Sarcal Neuromodulation in Children and Adolescents (2025 Edition)" according to the current available evidence-based medicine. The consensus was prepared using the consensus conference method. Its main contents include clinical indications and contraindications, preoperative assessment, treatment protocols, postoperative programming and follow-up, efficacy evaluation, complications, and management principles for pediatric SNM. The aim of this consensus is to further standardize the indications, techniques, efficacy evaluation, and prevention of complications of SNM in children and adolescents.

Satisfaction and Patient Experience With Sacral Neuromodulation: Results of a Single Center Sample Survey