Pelvic Floor Spasm Research Articles

Botulinum toxin type A injection combined with biofeedback in the treatment of spastic pelvic floor syndrome.

Spastic pelvic floor syndrome (SPFS) is a refractory pelvic floor disease characterized by abnormal (uncoordinated) contractions of the external anal sphincter and puborectalis muscle during defecation, resulting in rectal emptation and obstructive constipation. The clinical manifestations of SPFS are mainly characterized by difficult defecation, often accompanied by a sense of anal blockage and drooping. Manual defecation is usually needed during defecation. From physical examination, it is commonly observed that the patient's anal muscle tension is high, and it is difficult or even impossible to enter with his fingers. To investigate the characteristics of anorectal pressure and botulinum toxin A injection combined with biofeedback in treating pelvic floor muscle spasm syndrome. Retrospective analysis of 50 patients diagnosed with pelvic floor spasm syndrome. All patients underwent pelvic floor surface electromyography assessment, anorectal dynamics examination, botulinum toxin type A injection 100 U intramuscular injection, and two cycles of biofeedback therapy. After the botulinum toxin A injection combined with two cycles of biofeedback therapy, the patient's postoperative resting and systolic blood pressure were significantly lower than before surgery (P < 0.05). Moreover, the electromyography index of the patients in the resting stage and post-resting stages was significantly lower than before surgery (P < 0.05). Botulinum toxin A injection combined with biofeedback can significantly reduce pelvic floor muscle tension in treating pelvic floor muscle spasm syndrome. Anorectal manometry is an effective method to evaluate the efficacy of treatment objectively. However, randomized controlled trials are needed.

Research Progress of Traditional Chinese Medicine in the Treatment of Pelvic Floor Spasm Constipation

Research Progress of Traditional Chinese Medicine in the Treatment of Pelvic Floor Spasm Constipation

O-156 Role of botulinum toxin for the treatment of sexual and pelvic pain in endometriosis

Abstract Pelvic pain persists despite standard care in about 30% of women with a history of endometriosis and pain. Pelvic pain may be accompanied by spasm in pelvic floor muscles that results in sexual pain, impairs intimacy, and might contribute to maintenance of chronic pelvic pain. These women also often have pain sensitization, within and beyond the pelvis. Botulinum toxin is commonly used for conditions with muscle overactivity and pain. We therefore evaluated its potential to decrease pelvic floor spasm and ameliorate chronic pelvic pain in such women. In a randomized, double-masked, placebo-controlled trial, women aged 18-50 years with surgically diagnosed endometriosis and chronic pelvic pain despite optimized hormonal treatment received 100U onabotulinumtoxinA or placebo into pelvic floor muscles with palpable spasm (NCT01553201). At least one month after the masked injection and any time over the next year, participants could request a 2nd injection, which was always botulinum toxin, again injected into muscles with spasm. Pain and spasm were assessed before the first (masked) study injection and one month later (before a second open injection of botulinum toxin) as the primary outcome measure and then at regular intervals over the next year, including after the optional 2nd injection. The women were able to continue their regular pain medications while in the study but were asked not to change any hormonal treatments they were using. Pain medication usage and other aspects of response, including side effects, were tracked. This National Institutes of Health study included 29 women who were premenopausal and who had persistent pain for over 10 years on average despite having optimized standard treatment, such as surgery and hormones, for their endometriosis. All had pelvic floor muscle spasm and described the pelvic floor as a major focus of pain. Twenty-two of 23 reporting current hormone use had menses suppression. Nineteen of 29 characterized pelvic tenderness as focal, not diffuse. All showed widespread myofascial dysfunction with myofascial trigger-points in &amp;gt;two-thirds of assessed regions. Widespread sensitization was present in 16/29; regional sensitization (thoracic: 20/29; pelvic 17/29) was common. The primary outcome, participants’ self-report of benefit and pain relief, showed that botulinum toxin was more likely than placebo to provide benefit. On exam, the women receiving toxin had a corresponding decrease in spasm in the muscles of the pelvic floor compared to before injection. Twenty-seven women requested a 2nd injection, 16 at the one-month time point and 11 later in the year. The 2 patients who did not ask for a 2nd injection had received botulinum toxin and experienced persistent benefit; one subsequently became pregnant. Over the entire year-long study, only 4 patients, two from the group who initially received botulinum toxin and two from the placebo group, did not have durable benefit even after the 2nd injection. Sixteen women had continued benefit at the end of the study. While there was local pain and discomfort with the intravaginal injections, there were no serious side effects attributable to the botulinum toxin itself at the 100U dose used in the study. Baseline and current disability predicted improvement in pain, sexual intercourse, functioning, fatigue and mental health scores. We demonstrate pelvic floor muscle spasm as part of endometriosis-associated chronic pelvic pain and relief of pain/spasm from onabotulinumtoxinA compared to placebo that persisted over time. OnabotulinumtoxinA was well-tolerated. The findings illustrate a viscero-somatic reflex relationship between endometriosis lesions and muscle spasm and suggest that pelvic floor spasm may initiate or maintain sensitization. Although additional research is needed, this study supports that onabotulinumtoxinA can safely and effectively treat chronic pelvic pain in women with a history of endometriosis and ongoing spasm in the pelvic floor muscles.

Widespread myofascial dysfunction and sensitisation in women with endometriosis-associated chronic pelvic pain: A cross-sectional study.

Chronic pelvic pain persists in some women with endometriosis even after lesion removal and optimized hormonal treatment. Characterize the presence and distribution of pain, myofascial dysfunction and sensitisation beyond the pelvis in women with endometriosis-associated chronic pelvic pain. Cross-sectional study of 30 women prior to participation in a clinical trial. Evaluation included pain-focused abdominopelvic gynaecologic examination with the identification of pelvic floor muscle spasm. Neuro-musculoskeletal examination assessed paraspinal allodynia and hyperalgesia bilaterally and myofascial trigger points in 13 paired muscles. Pressure-pain thresholds were measured over interspinous ligaments and trigger points. Women completed the body territories element of the Body Pain Index. All women had a pelvic floor muscle spasm that they self-identified as a major focus of pain. Twenty of 30 women described their pelvic pain as focal. However, all demonstrated widespread myofascial dysfunction with low pressure-pain thresholds and trigger points in over two-thirds of 26 assessed regions. Widespread spinal segmental sensitisation was present in 17/30, thoracic in 21/30 and lumbosacral/pelvic in 18/30. Cervical sensitisation manifested as low pressure-pain thresholds with 23/30 also reporting recurrent, severe headaches and 21/30 experiencing orofacial pain. Those reporting diffuse pelvic pain were more likely to have widespread (p=.024) and lumbosacral/pelvic (p=.036) sensitisation and report over 10 painful body areas (p=.009). Women with endometriosis-associated chronic pelvic pain often have myofascial dysfunction and sensitisation beyond the pelvic region that may be initiated or maintained by on-going pelvic floor spasm. These myofascial and nervous system manifestations warrant consideration when managing pain in this population. Clinicaltrials.gov identifier: NCT01553201. Women with endometriosis often have pelvic pain persisting after surgery despite hormonal therapies and these women have regional pelvic sensitisation and myofascial dysfunction. Pelvic floor muscle spasm is a major pain focus in this population. Sensitisation and myofascial dysfunction are widespread, beyond the pelvic region. On-going pelvic floor spasm may initiate or maintain sensitisation. Myofascial/sensitisation manifestations warrant consideration when managing pain in this population.

Botulinum toxin for chronic pelvic pain in women with endometriosis: a cohort study of a pain-focused treatment

Background and objectivesMany women with endometriosis continue to have pelvic pain despite optimal surgical and hormonal treatment; some also have palpable pelvic floor muscle spasm. We describe changes in pain,...

Widespread myofascial dysfunction and spinal sensitization in women with endometriosis-associated chronic pelvic pain

Despite optimal surgical/hormonal treatment, some women with endometriosis continue to have chronic pelvic pain (endo-CPP). Comorbid non-pelvic pain, myofascial dysfunction, and sensitization have rarely been reported in this population. We systematically assessed the presence and distribution of pain, myofascial dysfunction, and spinal sensitization in women with endo-CPP. Women (18–50 years) with endo-CPP after optimized surgical/hormonal treatment were evaluated. Participants underwent gynecologic examination of pelvic floor muscles to identify tenderness/spasm. Neuromusculoskeletal examination included assessment of paraspinal tactile allodynia (Von Frey monofilament) and hyperalgesia (Wartenburg pinwheel). Myofascial trigger points (MTrPs) were identified in 13 regions bilaterally. Pressure-pain thresholds (PPTs) were measured over interspinous ligaments and MTrPs. Twenty-eight women with endo-CPP for a median of 12 years (range 1–20) were evaluated. All had pelvic floor muscle spasm on gyn examination. All endorsed the pelvic floor as a major focus of pain, which was described as focal in 19/28. All women had widespread myofascial dysfunction with MTrPs in more than two-thirds of assessed regions. Low PPTs (< 9 b/in 2 ) were found over interspinous ligaments in 24(86%) women. Widespread spinal segmental sensitization (allodynia and hyperalgesia) was present in 15(53%) subjects. Thoracic sensitization was present in 19(68%) women and lumbosacral sensitization related to the pelvic region in 17(61%). While cervical sensitization was detected in only 2(7%), 22(79%) reported recurrent, severe headaches and 14(50%) experienced orofacial pain. Women with endo-CPP can have myofascial dysfunction beyond the pelvic focus of pain, demonstrated by widespread diffuse and regional allodynia, hyperalgesia, MTrPs, and lowered PPTs, likely reflecting central sensitization. Sensitization may be initiated and maintained by pelvic floor spasm and may account for pain persisting after resection of endometriosis lesions and despite continued use of hormonal treatment. These diffuse and focal myofascial and central nervous system manifestations warrant consideration in management of pain in this population.

PD62-03 CASE SERIES OF LOW INTENSITY SHOCK WAVE THERAPY FOR MEN WITH CHRONIC PROSTATITIS/CHRONIC PELVIC PAIN SYNDROME

You have accessJournal of UrologyInfections/Inflammation/Cystic Disease of the Genitourinary Tract: Prostate & Genitalia II1 Apr 2018PD62-03 CASE SERIES OF LOW INTENSITY SHOCK WAVE THERAPY FOR MEN WITH CHRONIC PROSTATITIS/CHRONIC PELVIC PAIN SYNDROME Daniel Shoskes and Brandon Mooney Daniel ShoskesDaniel Shoskes More articles by this author and Brandon MooneyBrandon Mooney More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.2839AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS) is a heterogeneous syndrome that is often challenging to treat. Low Intensity Shock Wave (LiSW) has emerged as a potential therapy and several sham controlled studies have shown efficacy. We wished to study the efficacy and safety of LiSW in CP/CPPS patients with clinical phenotyping to better understand who may best respond. METHODS Men were enrolled in this IRB approved study provided they had a diagnosis of CP/CPPS for at least 6 months and were able to return for weekly treatments. Those on multi-modal therapy continued other therapies as long as the dose was stable. LiSW was delivered with the Urogold 100 machine (Tissue Regeneration Technologies, Woodstock, GA) using the standard probe. There were 4 treatment sites, 2 on each side of the perineum at 500 shocks each for a total of 2000 shocks. Symptom severity was measured with the National Institute of Health Chronic Prostatitis Symptom Index (CPSI) at baseline and 1 month following the last treatment. Patients also self reported a General Response Assessment (GRA) ranging from 1 (significantly improved) to 5 (significantly worse). Patients were clinically phenotyped by the UPOINT system. Pre and post values were compared with the paired t test with significance set at p<0.05. RESULTS 14 men enrolled with a mean age of 45.1 years (range 22-67) and median duration of 36 months (range 9-240). Men had a mean of 2.6 positive UPOINT domains (range 1-5) and all but 2 had pelvic floor tenderness (domain ″T″). Total CPSI improved from 27.7 +/- 5.4 to 19.4 +/- 7.5 (p=0.003). While the pain and quality of life scores improved significantly, there was no change in the urinary subscore. 9 patients (64.3%) had a >6 point drop in CPSI. By GRA, 7 patients said they were significantly improved, 2 was somewhat improved and 5 were unchanged. There were no significant differences in responders to non-responders for phenotype or symptom duration although responders had a higher starting pain score (14.0 vs 9.4, p=0.005) and both patients without pelvic floor spasm failed to improve. CONCLUSIONS LiSW with the Urogold 100 improved symptoms of CP/CPPS in the majority of patients. All responders had pelvic floor spasm, and shock wave therapy is well established in the treatment of pain from trigger points. While small numbers preclude meaningful subgroup analysis, there was no impact on urinary symptoms. In conclusion, once weekly low intensity shock wave lithotripsy improved the symptoms of CP/CPPS in the majority of patients without side effects. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e1157-e1158 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Daniel Shoskes More articles by this author Brandon Mooney More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Utility of trigger point injection as an adjunct to physical therapy in men with chronic prostatitis/chronic pelvic pain syndrome.

BackgroundChronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is often associated with pelvic floor muscle spasm. While pelvic floor physical therapy (PFPT) is effective, some men are unable to resolve their symptoms and have residual trigger points (TPs). TP injection has been used for treatment in several neuromuscular pain syndromes. The objective of this study was to examine the efficacy and side effects of TP injection in men with CP/CPPS and pelvic floor spasm refractory to PT.MethodsUsing an IRB approved Men’s Health Registry we reviewed the records of all men with a diagnosis of CP/CPPS who received at least 1 TP injection. Patients were phenotyped with UPOINT (all had the “T” domain for tenderness of muscle) and symptoms measured with the NIH Chronic Prostatitis Symptom Index (CPSI). Response was measured by a 5-point Global Response Assessment (GRA) and change in CPSI (paired t-test). For pelvic TPs, a pudendal block was done in lithotomy position and then each TP was identified transrectally by palpation. A nerve block needle was passed through the perineum into the TP confirmed by palpation. Between 0.5–1 cc was injected into each TP of a local anesthetic mixture (30:70 of 2% lidocaine and 0.25% bupivacaine). For anterior TPs, an ultrasound guided ilioinguinal block was done first and then each TP injected by direct palpation through the abdominal skin. Men were offered up to three sets of injections separated by 6 weeks each.ResultsWe identified 37 patients who had a total of 68 procedures. Three men had no follow-up after their first injection and were included for side effects but not included for outcome. The indication was failure to progress on PT in 33, recurrent symptoms in 1 and refusal to do PT in 3. Mean age was 43.7 years (range 21–70 years) and median UPOINT domains was 3 (range 1–5). Initial CPSI was pain 13.7±3.4, urinary 5.3±2.2, quality of life 9.8±2.1 and total 28.8±6.0. 16 men had 1 injection, 11 had 2 and 10 had 3. All had pelvic TPs injected and 9 also had anterior TPs. By GRA, 12 had significant improvement (35.3%), 10 had some improvement (29.4%), 11 had no change (32.3%) and 1 was worse (2.9%). Mean CPSI dropped from 28.8±6.0 to 21.8±7.2 (P<0.0001). 18 men had a drop of 6 or more points in CPSI (53%). Of note, none of 3 men who were noncompliant with PT had benefit. 3 men had temporary numbness in the lateral thigh after the injection (4.4%) and 1 had difficulty weight bearing on 1 leg for about 30 minutes.ConclusionsTP injection in CP/CPPS patients as an adjunct to PT is well tolerated and leads to symptom improvement in about half. Durability and long term results are yet to be determined.

Pelvic floor spasm as a cause of voiding dysfunction.

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.

Patients with Pelvic Floor Muscle Spasm Have a Superior Response to Pelvic Floor Physical Therapy at Specialized Centers

Chronic prostatitis/chronic pelvic pain syndrome is a common condition that often requires multimodal therapy. Patients with chronic pelvic pain syndrome have a high incidence of pelvic floor spasm, which can be treated with pelvic floor physical therapy. However, this is a specialized skill. We compared outcomes of pelvic floor physical therapy as part of multimodal therapy in patients with chronic pelvic pain syndrome between those treated at our institution and elsewhere. We identified patients from our chronic pelvic pain syndrome registry with pelvic floor spasm who were seen between 2010 and 2014 for more than 1 visit. Patient phenotype was assessed with the UPOINT system and symptom severity was determined by the National Institutes of Health CPSI. A 6-point decrease in CPSI was used to define patient improvement. A total of 82 patients fit the study criteria. Mean age was 41.6 years (range 19 to 75) and median symptom duration was 24 months (range 3 to 240). Mean CPSI was 26.8 (range 10 to 41), the median number of positive UPOINT domains was 3 (range 1 to 6) and 27 patients (32.9%) were treated locally. At followup 9 patients had refused pelvic floor physical therapy, and 24 and 48 had undergone pelvic floor physical therapy elsewhere and at CCF, respectively. The mean change in CPSI was 1.11 ± 4.1 in patients who refused, -3.46 ± 6.7 in those treated elsewhere and -11.3 ± 7.0 in those treated at CCF (p <0.0001). Individual improvement was seen in 1 patient (11%) who refused, 10 (42%) treated elsewhere and 38 (79.2%) treated at CCF (p <0.0001). On multivariable analysis only physical therapy at CCF (OR 4.23, p = 0.002) and symptom duration (OR 0.52, p = 0.03) predicted improvement. Pelvic floor physical therapy can be effective for chronic pelvic pain syndrome in patients with pelvic floor spasm. However, the outcome depends on specialty training and experience of therapists.

MP25-13 MICROSURGICAL DENERVATION OF THE SPERMATIC CORD FOR ORCHIALGIA: RESULTS AND PHENOTYPIC ANALYSIS OF TREATMENT FAILURES

INTRODUCTION AND OBJECTIVES: Microsurgical denervation of the spermatic cord is an established technique for chronic orchialgia with variable outcomes. We present our initial results, with an emphasis on the clinical phenotype of patients who did not improve METHODS: Data was extracted from our Men’s Health registry for men with orchialgia who had MDSC between Sept 2010 and Aug 2014. All patients reported temporary resolution of their pain following a cord block with 0.25% bupivacaine. RESULTS: There were 22 procedures in 20 patients (2 staged bilateral). Age ranged from 22 to 62 years (mean 38.5). Symptom duration ranged from 6 to 240 months (median 24). Five patients had prior vasectomy. Other prior surgeries included 3 epididymectomies, 3 orchidopexies and 1 inguinal hernia repair. Four patients had pelvic floor spasm and either declined pelvic floor physical therapy (2) or didn’t improve with therapy (2). At last follow up (range 6-38 months) 15 procedures led to complete pain resolution (68.1%). Of the 7 procedures that did not resolve the pain, 1 patient admitted that the cord block did not work, 2 patients had pelvic floor spasm and refused pelvic floor physical therapy, 1 was resolved following ablation of the genitofemoral nerve and 1 patient was diagnosed with fibromyalgia. There was no significant difference in age or symptom duration by surgical outcome. Surgical complications were minor including 1 patient with scrotal bruising and 1 with prolonged incisional pain CONCLUSIONS: MDSC can provide durable pain relief in a subset of patients with orchialgia with minimal morbidity. Patients with a systemic pain syndrome are unlikely to have resolution by simply removing the initial pain generator and therefore prior to MDSC it is important to demonstrate pain resolution with cord block and to identify and treat any systemic conditions, especially pelvic floor spasm.

1173 ETIOLOGIC EVALUATION OF ERECTILE DYSFUNCTION IN MEN WITH CHRONIC PROSTATITIS/CHRONIC PELVIC PAIN SYNDROME

You have accessJournal of UrologyInfections/Inflammation of the Genitourinary Tract: Prostate & Genitalia1 Apr 20131173 ETIOLOGIC EVALUATION OF ERECTILE DYSFUNCTION IN MEN WITH CHRONIC PROSTATITIS/CHRONIC PELVIC PAIN SYNDROME Gregory Lieser and Daniel Shoskes Gregory LieserGregory Lieser Cleveland, OH More articles by this author and Daniel ShoskesDaniel Shoskes Cleveland, OH More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.810AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES A high proportion of men with Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS), also known as NIH category III prostatitis, complain of erectile dysfunction (ED). The etiology of ED in these patients is not known. We present a cohort of patients with ED and CP/CPPS evaluated with hormonal, endothelial and vascular hemodynamic tests and correlated these findings with their symptom severity and disease phenotype. METHODS A cohort of patients with both ED and CP/CPPS who completed full ED evaluation was identified from our MenÆs Health Registry. None had ED prior to developing CP/CPPS. The CP/CPPS phenotype was determined clinically using the UPOINT system. International Index of Erectile Function (IIEF) and NIH Chronic Prostatitis Symptom Index (CPSI) scores assessed symptom severity. Patients had color penile Doppler with pharmacologic erection, Endopat measurement of peripheral arterial tone (PAT) plus free and total serum testosterone. RESULTS A total of 10 patients met all criteria, with a mean age of 32.9 (range 19-43). There was no correlation between severity of ED or CPPS symptoms by IIEF (mean 32 +/− 8.7) and CPSI (mean 20.9 +/− 4.2) scores. One patient had a marginally low total testosterone (260 ng/dl, mean of group 478). Three patients had abnormal PAT (suggesting early systemic arterial disease). Four patients had abnormal penile hemodynamics: 3 with decreased arterial flow (peak systolic velocity < 30 cm/s), 1 with veno-occlusive disease (end diastolic velocity > 5 cm/s) and 1 patient with both arterial and venous disease. In this young cohort, age did not correlate with vascular findings. Interestingly, both patients with veno-occlusive disease were positive for the pelvic floor Tenderness domain in their UPOINT phenotype and all 3 patients with decreased arterial penile blood flow were positive for both Tenderness and Psychosocial (depression or catastrophizing) domains (p=0.03 by Fisher Exact test). CONCLUSIONS Most young men who develop ED as a complication of CP/CPPS have normal hormonal and hemodynamic testing, suggesting a psychogenic cause related to pain and/or stress. There is however a smaller but potentially significant group with abnormal hemodynamics that may point to increased cardiac risk. This association between abnormal hemodynamics and pelvic floor spasm may suggest an etiologic link and could support the benefit of pelvic floor physical therapy for ED in those CP/CPPS patients positive for the “Tö” domain in their UPOINT phenotype. © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e479 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Gregory Lieser Cleveland, OH More articles by this author Daniel Shoskes Cleveland, OH More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Botulinum neurotoxin type A injection of the pelvic floor muscle in pain due to spasticity: a review of the current literature

The role of muscle spasm is not a new concept in the genesis of pain. Botulinum neurotoxin type A (BoNTA) has been successfully employed in a variety of muscular and inflammatory conditions. The aim of our study was to review the published literature on the role of BoNTA injection of the pelvic floor muscle in the management of women with chronic pelvic pain (CPP). A systematic search of the literature published up to June 2012 on the use of BoNTA in the treatment of female pelvic floor muscle spasm was carried out using relevant search terms in MEDLINE and EMBASE databases. The results were limited to full-text English language articles. Relevant trials as well as relevant reviews were selected and analyzed by two independent reviewers. Five studies (2 case reports, 1 prospective pilot study, 1 retrospective study and 1 randomised double-blind placebo controlled study) were included in this systematic review. Overall, BoNTA has shown to be beneficial in relieving CPP related to pelvic floor spasm. The role of BoNTA as a treatment of CPP has been recognized for more than 10 years. Although data are still scarce preliminary results are encouraging. BoNTA is an attractive option for refractory CPP related to pelvic floor muscle spasm, but further studies using validated and reproducible outcome measures are needed, to establish its effectiveness, safeness, technique, optimal dosage, and duration of symptom relief.

Chronic Prostatitis/Chronic Pelvic Pain Syndrome and Pelvic Floor Spasm: Can We Diagnose and Treat?

National Institutes of Health category III prostatitis, also known as chronic prostatitis/chronic pelvic pain syndrome, is a common condition with significant impact on quality of life. This clinically defined syndrome has a multifactorial etiology and seems to respond best to multimodal therapy. At least half of these patients have pelvic floor spasm. There are several approaches to therapy including biofeedback, acupuncture, and myofascial release physical therapy. However, the only multicenter study of pelvic floor physical therapy for pelvic floor spasm in men failed to show an advantage over conventional Western massage. We have proposed a clinical phenotyping system called UPOINT to classify patients with urologic chronic pelvic pain and subsequently direct appropriate therapy. Here, we review the current approach to category III prostatitis and describe how clinical phenotyping with UPOINT may improve therapy outcomes.

Using botulinum toxin for pelvic indications in women

Botulinum toxin (BoNT) is a potent neurotoxin. Its ability to cause muscle paralysis is increasingly being utilised for the management of a number of conditions of interest to the gynaecologist. This review aims to give the reader an overview of the use of BoNT for conditions presenting a management challenge for the gynaecologist, such as chronic pelvic pain and idiopathic detrusor overactivity. The literature was reviewed regarding the use, side-effects and complications of BoNT in the pelvis, focussing on chronic pelvic pain, provoked vestibulodynia, conditions involving the lower gastrointestinal tract and detrusor overactivity. In terms of pain caused by pelvic floor spasm, daily pelvic pain and dyspareunia are the symptoms most likely to be improved by BoNT. Limited data regarding use for provoked vestibulodynia indicate an improvement in pain scores. In the lower gastrointestinal tract, injection into puborectalis has been showed to objectively improve intravaginal pressures, though there are no randomised controlled trials (class I studies) validating its use in this setting. Class I studies demonstrate a role for BoNT in the management of idiopathic detrusor overactivity, though long-term follow-up data are lacking. Potential problems with BoNT injection include toxin reactions, urinary and faecal incontinence, urinary retention and secondary treatment failure due to antibody production. A single class I study supports the use of BoNT for refractory pelvic floor spasm; however, further adequately powered class I studies for this indication and for provoked vestibulodynia are warranted.

Pregnancy Following Botulinum Toxin Type A Injections to the Levator Muscles for Chronic Pelvic Pain and Pelvic Floor Spasm

Study Objective: To report the outcome of pregnancies occurring within six months of injection of 80 to 100IU of Botulinum Toxin Type A (BOTOX®) into pelvic floor muscles in women suffering from chronic pelvic pain and associated pelvic floor muscle spasm.

Botulinum Toxin Treatment of Pelvic Floor Disorders and Genital Pain in Women

Background and Objective: Botulinum neurotoxin (BoNT), now commonly used for reducing muscular spasms in other neuromuscular disorders, is now increasingly proposed also for treating pelvic floor disorders, including chronic pelvic pain syndromes, vaginismus, vulvodynia and vulvar vestibulitis syndrome. To provide up-to-date information on these advances we reviewed the literature about BoNT injections for pain and spasms related to pelvic floor disorders. Methods: We conducted a Medline search using the terms botulinum neurotoxin, pelvic floor disorders, levator ani myalgia, vaginismus, vulvar vestibulitis, vulvodynia, dyspareunia, interstitial cystitis, recurrent cystitis, and postcoital cystitis. We sought information on the indications and techniques used for BoNT treatment for pelvic floor dysfunctions, and related pain syndromes in women. Results: Our search identified 12 studies for review (including a randomized controlled trial) showing that BoNT effectively reduces pain in chronic genital pain syndromes associated with pelvic floor spasm. Before BoNT trials, patients with idiopathic lifelong vaginismus and dyspareunia, associated with hyperactive pelvic floor muscles, had no effective treatment options. BoNT injected under electromyographic (EMG) guidance in pelvic floor muscles improves vaginismus, helping to restore a normal sexual life. BoNT injections also seem to improve vulvodynia and vulvar vestibulitis. Though some patients need periodic injections, in about 65% of affected women BoNT achieves permanent benefit. Conclusions: These encouraging evidence-based results suggest that BoNT injected intramuscularly should extend treatment options for women with lifelong or acquired pelvic floor disorders and genital pain. Keywords: Pelvic floor disorders, urinary dysfunctions, chronic pelvic pain, vaginismus, vulvar vestibulitis syndrome, EMG, botulinum toxin type A

Incidence and Significance of Prostatic Stones in Men with Chronic Prostatitis/Chronic Pelvic Pain Syndrome

Prostatic calcification is common in asymptomatic elderly men. However, young men with chronic pelvic pain syndrome (CPPS) often have significantly calcified prostates. We studied the incidence and significance of prostatic calcification in men with CPPS. From July 2005 to August 2006, 130 new patients with CPPS were seen at our clinic. Of these 130 patients, 47 underwent transrectal ultrasonography. Prostatic calcification correlated with symptoms (National Institutes of Health chronic prostatitis symptom index score), examination findings, and culture results. The variables were compared using the Student t test, Wilcoxon unpaired test, or chi-square test. The 47 men who had undergone transrectal ultrasonography had symptoms identical to those who had not but were older (range 46.1 to 41.6 years, P = 0.02) and had had symptoms longer (median 60 versus 12 months, P = 0.0001). Of the 47 patients, 22 (47%) had significant calcification. The symptoms with or without calcification were identical (chronic prostatitis symptom score 23.7 versus 23.9). Men with calcification had had symptoms longer (median 84 versus 27 months, P = 0.05) but were similar in age (49 versus 45 years, P = 0.21) and had a similar prostate size (21.7 cm3 for both groups). Men with calcification were less likely to have pelvic floor tenderness (50% versus 85%, P = 0.03) but were more likely to have bacteria in the prostatic fluid (P = 0.05) and had a higher median white blood cell count (3.5 versus 0 white blood cells per high power field, P = 0.058). Prostatic calcification is common in patients with CPPS and is associated with greater inflammation, bacterial colonization, and symptom duration. Pelvic floor spasm is more common in patients without calcification. This might be an important parameter with which to stratify clinical trials.

Botulinum Toxin Type A for Chronic Pain and Pelvic Floor Spasm in Women

To estimate whether botulinum toxin type A is more effective than placebo at reducing pain and pelvic floor pressure in women with chronic pelvic pain and pelvic floor muscle spasm. This study was a double-blinded, randomized, placebo-controlled trial. All participants presented with chronic pelvic pain of more than 2 years duration and evidence of pelvic floor muscle spasm. Thirty women had 80 units of botulinum toxin type A injected into the pelvic floor muscles, and 30 women received saline. Dysmenorrhea, dyspareunia, dyschezia, and nonmenstrual pelvic pain were assessed by visual analog scale (VAS) at baseline and then monthly for 6 months. Pelvic floor pressures were measured by vaginal manometry. There was significant change from baseline in the botulinum toxin type A group for dyspareunia (VAS score 66 versus 12; chi2 = 25.78, P < .001) and nonmenstrual pelvic pain (VAS score 51 versus 22; chi2 = 16.98, P = .009). In the placebo group only dyspareunia was significantly reduced from baseline (64 versus 27; chi2 = 2.98, P = .043). There was a significant reduction in pelvic floor pressure (centimeters of H2O) in the botulinum toxin type A group from baseline (49 versus 32; chi2 = 39.53, P < .001), with the placebo group also having lower pelvic floor muscle pressures (44 versus 39; chi2 = 19.85, P = .003). Objective reduction of pelvic floor spasm reduces some types of pelvic pain. Botulinum toxin type A reduces pressure in the pelvic floor muscles more than placebo. Botulinum toxin type A may be a useful agent in women with pelvic floor muscle spasm and chronic pelvic pain who do not respond to conservative physical therapy. Australian Clinical Trials Registry, http://www.actr.org.au/, ACTRN012605000515695 LEVEL OF EVIDENCE: I.

A PROSPECTIVE, RANDOMIZED, PLACEBO CONTROLLED, DOUBLE-BLIND STUDY OF PELVIC ELECTROMAGNETIC THERAPY FOR THE TREATMENT OF CHRONIC PELVIC PAIN SYNDROME WITH 1 YEAR OF FOLLOWUP

Male chronic pelvic pain syndrome is a condition of uncertain etiology and treatment is often unsatisfactory. There is evidence that the symptom complex may result from pelvic floor muscular dysfunction and/or neural hypersensitivity/inflammation. We hypothesized that the application of electromagnetic therapy may have a neuromodulating effect on pelvic floor spasm and neural hypersensitivity. Following full Stamey localization men with National Institute of Diabetes and Digestive and Kidney Diseases category III prostatitis were prospectively randomized to receive active electromagnetic or placebo therapy. Active therapy consisted of 15 minutes of pelvic floor stimulation at a frequency of 10 Hz, followed by a further 15 minutes at 50 Hz, twice weekly for 4 weeks. Patients were evaluated at baseline, 3 months and 1 year after treatment using validated visual analog scores. A total of 21 men with a mean age of 47.8 years (range 25 to 67) were analyzed. Mean symptom scores decreased significantly in the actively treated group at 3 months and 1 year (p <0.05), unlike the placebo group, which showed no significant change (p >0.05). Subanalysis of those receiving active treatment showed that the greatest improvement was in pain related symptoms. The novel use of pelvic floor electromagnetic therapy may be a promising new noninvasive option for chronic pelvic pain syndrome in men.