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MyofascialPelvicPainand http://crossmark.cro
RelatedDisorders
JaclynH.Bonder, #Pages [1]
a,
MD *,MichelleChi,
b
#Pages [1]
MD ,LeiaRispoli, MD #Pages [1]
b

PALABRASCLAVE
 Pelvicpain Myofascialpain
 
Triggerpoints 
Vulvodynia 
Physicaltherapy
 Estreñimiento de Bladderpain

KEYPOINTS
 Myofascialpelvicpaincanpresentastriggerpoints,tautmusclebands,orgeneralized
musclepainandmayrefertootherregionsofthepelvis.
 Acomprehensivehistoryandphysicalexaminationprovidethemostreliablediagnostic
informationforpatientswithsuspectedmyofascialpelvicpain.
 Myofascialpelvicpainisoftenassociatedwithdisorders,suchasvulvodynia,constipa-
tion,bladderpainsyndrome,endometriosis,andanxiety.
 Treatmentsformyofascialpelvicpaincanincludephysicaltherapy,oralmedications,
cognitive-behavioraltherapy,andbotulinumtoxininjections.

DEFINITIONANDEPIDEMIOLOGY

Myofascialpelvicpain(MFPP)referstopaininthepelvicfloormuscles(PFMs),thepel-
vicfloorconnectivetissue,andthesurroundingfascia.MFPPcanbeasyndromeofits
ownandcausepelvicpainoritcanbeassociatedwithahostofotherabdominopelvic
paindisorders.Itischaracterizedbymuscularpain,tautbands,andtriggerpointsthat
referpaintospecificregionswhenpressureisapplied.TriggerpointsinthePFMscan
refertomanyareas,includingthesuprapubicregion,thelowerabdomen,theposte-
riorandinnerthighs,thebuttocks,andthelowback.Historically,ithasbeenunder-
treatedasaresultofbeingundiagnosedbyproviderswhousuallyevaluateand
treatpatientswithpelvicpainbecausedetailedPFMexaminationisnotroutinely
taughtintheirresidencytraining.Instudiesassessingtrainingofobstetrics/gynecol-
ogyresidentsondiagnosingurogynecologicdisorders,therewerenoquestions
addressingtheirknowledgeofMFPPdisorders. 1,2 #Pages [12]
Inaddition, therearenoaccepted

DisclosureStatement:Theauthorshavenothingtodisclose.
a
DepartmentofRehabilitationMedicine,NewYorkPresbyterianHospital,WeillCornellMed-
icalCollege,525East68thStreet,BakerPavilion16thFloor,NewYork,NY10065,USA; PGY3, b
DepartmentofRehabilitationMedicine,NewYorkPresbyterianHospital,525East68thStreet,
BakerPavilion16thFloor,NewYork,NY10065,USA
*Correspondingauthor.
Electrónico-mailaddress:
jab9155@med.cornell.edu

PhysMedRehabilClinNAm28(2017)501515
http://dx.doi.org/10.1016/j.pmr.2017.03.005 pmr.theclinics.com
1047-9651/17/ª 2017ElsevierInc.Allrightsreserved.
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laboratoryorimagingteststhatestablishthediagnosis.Inrecentyears,itisbeing
recognizedbypractitionersbecauseofstudiesthathaveconsistentlydemonstrated
itsexistenceaspartofotherpelvicpaindisorders.
Arecentstudythatscreenedpatientswithchronicpelvicpain(CPP)formyofascial
pelvicfloorpainorpelvicfloortriggerpointsviainterviewandphysicalexamination
#Pages [12]
3
foundthat13.2%hadpainthatwasrelatedtothePFMs.TheprevalenceofPFM
tendernessinthosewithotherCPPdisordersismuchhigherthough.Prevalenceof
levatoranipaininaCPPclinicovera7-yearperiodhasbeenfoundtobe22%.In #Pages [12
4

anotherstudyofwomeninaCPPclinic,PFMtendernesswasanisolatedfindingin
15%ofthesepatientsbutwasassociatedwithotherCPPdisordersin58.3%ofpa-
tientsversus4.2%ofhealthyvolunteers.OfthewomenintheCPPgroup,89.0%
hadtendernessofthelevatoranimuscle,50.8%hadtendernessofthepiriformismus-
cle,and31.7%hadtendernessoftheinternalobturatormuscle. #Pages [12]
5

ANATOMÍA

ThePFMsarecomposedof2majorlayers,thesuperficialPFMs,whicharepartofthe
urogenital(UG)diafragma,andthedeepPFMs(alsocalledthepelvicdiaphragm).The
superficialmusclesincludethebulbospongiosus,ischiocavernosus,andsuperficial
anddeeptransverseperinealmuscles.Inaddition,theexternalurethralsphincter
sitswithintheUGdiaphragm.TheUGdiaphragmalsocontainsfasciallayers,which
aresituatedonthemusclesandacttoformthedeepandsuperficialperinealspace.
Thesuperficialperinealfasciaisthemostinferiorlayer,sittingbetweentheskinand
thebulbospongiosus,ischiocavernosus,andsuperficialperinealmuscles.Theperi-
nealmembraneencompassesthedeeptransverseperinealmuscleonitsinferior
andsuperioraspects.Beyondthisreststheinferiorpelvicfasciabehindwhichthele-
vatoranimusclessit.Themusclesthatcomposethepelvicdiaphragmandacttosup-
porttheabdominopelviccavityandviscerabyclosingtheinferiorapertureofthepelvis
arethelevatoranimuscleandcoccygeusmuscle.Thelevatoranimuscleismadeof3
individualmuscles:thepuborectalis,pubococcygeus,andtheiliococcygeus.The
musclesareborderedsuperiorlybythesuperiorpelvicfascia.Thecoccygeusmuscle
isalsoadeepPFMlocatedposteriorly,arisingfromtheischialspineandmovingmedi-
allytothemidlinesacrococcygealjoint.Alsolocatedposteriorlyisthepiriformismus-
cle,originatingfromthesacrumandinsertingontothegreatertrochanter.Lastly,the
obturatorinternussitslaterallyabovethearcustendinous,attachingtothepelvicsur-
faceoftheobturatorforamenandexitingthepelvisaroundtheischialtuberosityto
insertonthegreatertrochanter.EachofthePFMscancontributetopelvicpain,as
aprimarysource,asareferredsource,orascomponentofamorewidespreadpelvic
paindisorder.

HISTORIA

AcomprehensivehistorymustbetakenfrompatientswithMFPP,withaparticular
focusonmedicalandsurgicalhistoryinvolvingtheabdominopelvicorgansandregion.
Patientsmustalsobescreenedforapasthistoryofphysical,sexual,andemotional
abusegiventhehighinstanceofMFPPinthispopulation.Atypicalsetofparamount
questionsregardingpainareasked,suchasalleviatingandaggravatingfactors,qual-
ity,severity,associatedsymptoms,andareasitradiatesto.Painmaybeconstantor
intermittent,atrestorwithactivity,andisusuallydescribedassore,achy,heavy,and
deep.Painattheintroituswithintercourseisoftendescribedasburningorsharp.Itis
alsocrucialtotakeanin-depthreviewofsystemsregardingurinary,bowel,andsexual
dysfunctionaspatientswithMFPPoftenhavecomorbiddisordersoftheseorgan
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systems.Patientsoftenreportdyspareunia,constipation,dyschezia,bladderpain,
andvulvarpain.Knowledgeofahistoryofanxietyand/ordepressionisalsokeyas
thesepatientsareathighriskforthesepsychiatricissues,whetherasaresultoftheir
painconditionorifitpredatestheirpain.Forwomen,anobstetrichistoryshouldbe
obtainedhighlightingthetypeofdelivery,vaginaltearing,andlengthoflabor,asthese
canpointtoinjuryofthePFMsornerves.Tohelpphysiciansdiagnosethecauseofthe
painandwhethertherearepotentiallystructuralissuescontributing,patientsshould
bescreenedforpaininthejointsofthepelvicgirdle,suchasthelumbosacraljunction,
sacroiliacjoints,hipjoints,andpubicsymphysis.Becauseofreferralpatternsof
triggerpointsinthepelvicfloor,patientswithMFPPmayhaveahistoryofbeing
treatedforanyoneofthesejointswithapoororpartialresponse.

PHYSICALEXAMINATION

PalpationofthesuperficialanddeepPFMscanassessformyofascialpain,trigger
points,andothertautbandsofmuscle.Internalpelvicfloorexaminationisprobably
themostvaluablediagnosticresourceforidentifyingpelvicfloormyofascialpain;how-
ever,ithasnotbeenextensivelystudied.OnegrouprecentlypublishedaPFMhyper-
algesiascoringsysteminwhichtheypalpatedthelevatorani,theobturatorinternus,
bulbospongiosus,ischiocavernosus,andthetransverseperinealmuscleswithmini-
malpressure.TheyratedPFMtendernessonamild,moderate,andseverescalein
bothsymptomaticandasymptomaticindividuals.Theyfoundgoodinterraterand
intraraterreliabilityandthatthiswasasimplewaytoscreenformyofascialpainbefore
andaftertreatment. 6#Pages [12]
Onthepelvicfloorexamination,iftendernessiselicitedwithpalpationofthelevator
aniandobturatorinternusmuscles,adiagnosisofMFPPcanbemade.Thepelvic
clockisoftenusedtodescribethePFMlocations,whichallowsproviderstoknowif
symptomshaveimprovedaftertreatment.Thelevatoraniispalpatedfrom3to5
oclockand7to9oclockontheleftandright,respectively.Theobturatorinternus
islocatedjustabove3and9oclockandcanoftenbefeltbyfirstpalpatingforthe
arcustendinousandthenmovingthefingerjustaboveit.Itcanthenbefurtheriden-
tifiedbyhavingpatientsexternallyrotatethehipsothatthemusclebulgesintotheex-
aminersfingertip.Itisalsopossibletoassessforpiriformispainonmusculoskeletal
vaginalpelvicfloorexamination.Rectalexaminationallowsforassessmentofthecoc-
cygeus,piriformis,andpuborectalismuscles.Tendermusclescanalsobedescribed
asdiffuselyoveractiveorunderactiveorashypotonicorhypertonic.Strengthevalua-
tionofthemusclesisalsoimportantbecauseweakness,dyssynergia,orimproper
contractioninthesettingofMFPPpointstopossiblenerveinjury.Inpatientswitha
historyofpelvicfloorsurgeryorinjury,itshouldbenotedifscartissueformationispre-
sentandrestrictingmovementofthemuscles.
ForpatientswithknownorsuspectedMFPP,acompleteneurologicandmusculo-
skeletalexaminationofthelumbarspine,pelvis,andhipisindicatedbecausethestate
ofthePFMscanbeaffectedbydisordersoftheseareasandviceversa.Testingof
theseregionsshouldincluderange-of-motionevaluation,manualmuscletesting,in-
spectionforproperalignment,andassessmentforsensorydeficits.See Box1 forpo-
tentialfindings.
#Pages [4]

DIAGNOSISANDDIAGNOSTICTESTING

DiagnosisofMFPPislargelybasedonhistoryandphysicalexamination.Therehave
beenattemptstodiagnosemyofascialtriggerpoints(MTrPs)viaultrasoundordry
needling,butnoneofthemhavebeenacceptedforroutineuseorspecificallyexplored
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Box1
Summaryofpotentialphysicalexaminationfindings

 Boneandjointpain
 Muscletightness
 Musclespasm
 Muscleweakness
 Triggerpoints
 Radicularpain
 Pelvicinstabilityorobliquity
 Neuropathicpain
 Referredpain:lumbarspine,glutealregion,hips

forthepelvicfloor.Onultrasound,MTrPshavebeenshowntoappearasfocal,hypo-
echoicregionswithreducedvibrationamplitudeonvibrationsonoelastography,indi-
7,8
catingalocalized,stiffnodule. Althoughmagneticresonanceelasticityhasalso
beenstudiedandshownthattautmusclebandshaveincreasedstiffnessas
comparedwithnormaltissue,thisisnotregularlyusedtodiagnosetriggerpoints. 9,10

MyofascialpainsyndromeinthePFMshasbeendiagnosedthroughelectromyog-
11
raphyandmeasuringtheturn-amplitudeanalysis.Itzaandcolleagues showedthatit
isareliabletesttodiagnoseMFPPwherebythesensitivitywas83%andthespecificity
was100%.Thistestisstillnotacceptedinpracticethough,andmorestudiesare
needed.

TREATMENT

MFPPcanexistindependently,butitalsofrequentlycoexistswithavarietyofother
medicalconditionsintheurologic,gynecologic,gastroenterological,musculoskeletal,
neurologic,andpsychologicaldomains.Consequently,successfultreatmentencom-
passestreatingmultiplesystemsandistailoredtotheindividual.Therefore,notonly
doesidentificationofMFPPrequirecomprehensiveclinicalhistorytakingbutaneffec-
tivetreatmentplanalsonecessitatesamultidisciplinaryteam( Box2 )approachthat
involvestreatingconcomitantmedicalpathologies.

Box2
Multidisciplinaryteamforpelvicpain

 Gastroenterology
 Gynecology
 Physicaltherapy
 Physiatry
 Psychiatry
 Psychology
 Neurology
 Urologist
 Urogynecologist/femalepelvicmedicineandreconstructivesurgery
 MyofascialPelvicPainandRelatedDisorders 505

Theseprovidersshoulddevelopatreatmentstrategycombiningphysicaltherapy
techniquesalongwithpatienteducation,painmanagement,andbehavioralmodifica-
tion.12 Severalapproacheshavebeenintroducedintheliterature,includingtheuseof
nonsteroidalantiinflammatorydrugs(NSAIDs),antidepressants,musclerelaxants,
andneuromodulators.Interventionsaretargetedtowardtreatingactivepelvicfloor
MTrPs,whichcandevelopfromseveralmechanical,physical,organsystem,andpsy-
13
chologicalstressorsandarethoughttobetheprimarypaingenerators. Inmorere-
fractorycases,variousinjectionsmayalsobeusedinconjunctionwithconservative
management.14,15 Thevarioustreatmentinterventionsareoutlinednext.

PhysicalTherapy
Pelvicfloorphysicaltherapy(PFPT)encompassesavarietyoftechniquesusedtotreat
MFPPandpelvicfloordysfunction.Together,physiciansandpelvicfloorphysicalther-
apistsdevelopanindividualizedtreatmentprogrambasedonathoroughassessment
ofthepatients’symptomsandexamination.Thisintakebyahighlytrainedpelvicfloor
physicaltherapistbeginswithtakingafulldetailedhistory,musculoskeletalexamina-
tionincludingexternalandinternalpelvicexamination,and,ifwarranted,rectalexam-
ination.MusculoskeletalexaminationofpatientswithMFPPincorporatesevaluation
16

ofpatientposture,gait,rangeofmotionofthespineandlowerextremities,aswellas
thepelvicfloorexaminationdescribedearlier.
Treatmenttoolsmayincludeeducation,behavioralmodifications,neuromuscular
reeducation,PFMstrengtheningandrelaxationtechniques,biofeedback,andpallia-
tivemethods.Manualtechniques,suchasmassage,stretching,andsofttissueand
bonymobilization,aswellaselectricalstimulationandultrasoundarealsoimportant
17
treatmentsusedbytrainedpelvicfloorphysicaltherapists. Therapistswillalso
addressstructuraldysfunctions,providehomeexerciseprogramsandself-
managementtechniques,and,ifnecessary,usecognitive-behavioraltherapyskills
tohelppatientscopewithresponsesthatmayhavedevelopedbecauseofchronic
pain.17 Educationtopatientsbypelvicfloorphysicaltherapistsisoftendonewitha
16
mirror,toassistinlearningabouttheiranatomyandvisualizetheproblemregions.
Frequencyoftreatmentmayvary;however,typicallypatientsareseen1hourper
week;durationwilldependonhowlongpatientshavebeensymptomaticaswellas
theirresponsetotherapy.
Thegoaloftherapeuticexerciseistostrengthenweakmuscles,stretchtightmus-
cles,improvemobilityandflexibility,anddecreasepain. 16Thetherapistwillworkinter-
nallytomanuallyreleasepainfultriggerpointsandrestrictionsinconnectivetissue
relatedtothevaginaand/orrectum.Softtissuemobilizationtechniques,aswellas
passiveandactiverange-of-motionexercises,areusedtolengthenshortmuscle
groupsofthepelvisandpelvicfloor.Patientsmayalsobetreatedwithscartissue
manipulation,whichinvolvespullingstrokesofskinandsubcutaneoustissueto
improvecirculationtosurroundingvisceraandtissue.Oncemusclegroupsare
releasedandlengthened,strengtheningexercisesmaybegin.Effectivenessdepends
onsynergisticcoordinationofcertainmusclegroupstorecruitaswellasrelaxappro-
priately.Exercisesmayincludepelvicfloorinhibition,withprogressiontoactivepelvic
floorlengthening,whileteachingpatientself-myofascialandconnectivetissuemanip-
ulation.Additionaltechniquesmayinvolvepelvicfloorbiofeedback,whichhasshown
about50%effectivenessinreducingpelvicpainandelectricalstimulation,whichhas
18,19
alsobeenreportedtosuccessfullyimprovepelvicpain.
InadditiontoahomeexerciseprogramtoreinforcetheeffectsofPFPT,physical
therapistsmayalsorecommendlifestyleandbehavioralchangesforpatients.These
changesmayincludecertainactivitiestomodifyoreliminate,painmanagement
506 Bonderetal

strategies,avoidanceofirritants,aswellasuseofvaginaldilators.Specifically,activ-
itiestoavoidmayincludeKegelexercises,vaginalcoitus,prolongedsitting,andwear-
17
ingelasticunderwearandtightjeans.

ConservativeTreatment
Conservativetreatmentisaimedtowardrelaxingthepelvicfloormusculatureandsur-
roundingregions.Thefollowingtreatmentsshouldbecombinedwithphysicaltherapy
whenappropriate:
 Topicalheat/cold:Itcanbeusedasanadjuncttootherconservativetherapiesto
addressmuscularspasms.Examplesincludewarmbaths,particularlyoatmeal
baths,whichcanalsopreventvaginaldryness.Therecommendedfrequency
is2timesperdayforgreaterthan15minutes.Incontrast,forwomenwithcomor-
15
bidvulvodynia,applyingacoldpackmaybepreferable.
 Behaviormodification:Itincludesbiofeedback(transvaginalortransrectal),
20
avoidanceofKegelmaneuversorexcessivestrainingwithdefecation.
 Bowel/bladdermanagement:ConstipationiscommoninbothCPPandMFPPas
aresultofincreasedpelvicfloortoneandactivity.Thus,anoptimalboweland
bladderprogramisrecommendedtopreventworseninghypertonicityandsub-
sequentdevelopmentofMTrPs. 15

Medications
Commonlyusedfirst-linetreatmentsforMFPPincludeanalgesics,suchasacetamin-
ophenandNSAIDs. 20 Opioidshavealsobeenusedwhenothertreatmentsmodalities
havefailed.Low-doseskeletalmusclerelaxants,suchasdiazepam,methocarbamol,
cyclobenzaprine,andbaclofen,havealsobeenfoundtobeeffectiveinalleviating
15,20
symptomswhencombinedwithothertherapies. Vaginaldiazepamorbaclofen
suppositoriesareanotheradjunctivetreatmentoptionthatmaybepromisingforpa-
21
tientswithMFPP.AretrospectivestudybyRogalskiandcolleagues investigated
theuseofvaginaldiazepamsuppositoriesforhigh-tonepelvicfloordysfunction
andpain.Achartreviewwasperformedonpatientswhohadreceiveddiazepam
suppositoriesinconjunctionwithpelvicphysicaltherapyandtriggerpointinjections.
Theresultsshowedsignificantimprovementinpelvicfloormusculartoneinmultiple
phases(resting,squeezing,relaxation),reducedsexualpainratedbytheFemale
SexualFunctionIndex,andreducedpainasassessedonthevisualanalogscale
(VAS)forpain.
Neuromodulators,particularlygabapentin,havealsobeenfoundtobeusefulin
treatingpelvicpain.OneprospectiverandomizedstudybySator-Katzenschlager
andcolleagues 22 comparedtheefficacyofgabapentin,amitriptyline,andthecombi-
nationofbothinwomenwithCPP.Thepatientswererandomizedtoreceivegaba-
pentin,amitriptyline,oracombinationofboth,withdosestitratedtotheirmaximum
equivalentdailydoses.Atthe6-,12-,and24-monthfollow-up,painreliefwassignif-
icantlyimprovedinthegabapentinandcombinationgroupcomparedwiththe
amitriptylinegroup. 22 However,tricyclicantidepressants,suchasamitriptyline,can
beusedfortreatingMFPPandhavealsobeenfoundtobeeffectiveinreducing
depressivesymptoms,increasingpaintolerance,andrestoringabnormalsleeping
patterns.20

Injections
Severalstudieshaveevaluatedtheuseofvarioustriggerpointinjectionsasadjuvants
topharmacotherapy,physicaltherapy,andbehavioraltherapyfortreatingMTrPs.The
 MyofascialPelvicPainandRelatedDisorders 507

PFMsthataremostcommonlyinjectedincludethelevatorani(iliococcygeus,pubo-
coccygeus,puborectalis),coccygeus,obturatorinternus,andsuperficialanddeep
transverseperineii. 15 InjectionsofextrapelvicMTrPs,suchastheiliopsoas,hipadduc-
tors,andrectusabdominis,havealsobeenshowntobeeffectiveintreatingMFPP.

Localanestheticmyofascialtriggerpointsinjection
LocalanestheticMTrPinjectionsareonemethoddescribedinliteraturefortreatingre-
fractoryMFPP.Theroleofanesthetichasbeensuggestedtoinvolvetheinactivationof
activeMTrPsandresultantreductionofpainthroughthefollowingproposedtheories:
 Mechanicaldisturbanceofmusclefibersandassociatednerves
 Disruptionofthepositivepainfeedbackloop
 Decreasedconcentrationofnociceptivesubstances
 Endorphinrelease 15
Localanestheticinjectionshavebeenreportedtobepreferabletodryneedling
becauseofitsreductioninpostinjectionsorenessaswellastheiranalgesiceffects.
Threebasicapproacheshavebeendescribed,transvaginal,paravaginal/subgluteal,
andtransperineal,usingvariousneedletrajectories.Thetransvaginalapproachallows
forcloserproximityoftheinjectionsitetothetriggerpointresultingineasieraccessto
thedeeperPFMgroups(ie,obturatorinternus).Whentheneedleisinsertedintothe
muscle,alocaltwitchresponsemayalsobeelicited,resultinginpainatthesiteor
atareferredsite.Themostcommonanestheticsusedare2.0%lidocaine,0.5%bupi-
vacaine,and0.5%ropivacaine. 15 Itisimportanttonotethatanestheticscontaining
epinephrineshouldbeavoidedbecauseoftheincreasedriskforlocalischemiaand
productionofMTrPs.SteroidinjectionsintoMTrPsshouldalsobeavoidedbecause
oftheincreasedmusclewastingwithsubsequentinjectionsaswellasincreased
riskformuscledimpling.
Wheninjectinganesthetic,roughlynomorethan0.25to0.5mLpertriggerpoint
shouldbeinjected.Typically,nomorethan3.5mLto5.0mLofsolutionisinjected
oneachsideofthepelvicfloor.Itmaytakeupto3injectionsbeforeachievingafavor-
ableeffect.Adverseeffectsmayincludeintravascularinjection,infection,andhema-
toma.Contraindicationstoinjectionsincludelocalorsystemicinfection,anticoagulant
15
therapy,bleedingdisorder,allergytoanestheticagents,andacutemuscletrauma.

Botulinumtoxin-A
ForMFPPthatisunresponsivetomoreconservativetreatments,suchasphysical
therapyandmedications,botulinumtoxin-A(BTX-A)injectionsmaybesoughtasan
alternativetreatmentoption.SeveralstudieshaveexaminedtheutilityofBTX-Afor
15,23
treatingMTrPsinMFPPandothersimilarconditionswithpromisingresults. The
theorybehindtheuseofBTX-AfortreatingpelvicfloorMTrPsissuchthatBTX-A
blocksacetylcholinereleaseattheneuromuscularjunction,leadingtodecreased
15
restingtoneandcontractionstrength. WithregardtoBTX-Adosingandinjection
technique,thereiscurrentlynostandardizedguideline;however,severalapproaches
havebeendescribedintheliteraturewithvaryingeffects.Injectionlocationisalso
oftenindividualizedbasedonclinicalexamination.
BTX-Awasshowntobeeffectiveinthetreatmentofpainassociatedwithlevatorani
24
spasminastudyconductedbyJarvisandcolleagues. Inthispilotstudy,12women
withagreaterthana2-yearhistoryofCPPwererecruited.Thebilateralpuborectalis
andpubococcygeusmuscleswereselectedforinjectionandlocatedbydigitalmuscle
palpation.Atotalof10unitsofBTX-Awereinjectedateachsite,totaling40units.
Threedifferentdilutionswereused:10IU/mL,20IU/mL,and100IU/mL.Theresults
508 Bonderetal

showedsignificantdecreaseinpainfordyspareuniaanddysmenorrheaasassessed
bytheVAS.PFMmanometryalsoshowedasignificantreductioninrestingpressures.
Alaterrandomized-controlledstudyevaluatedtheeffectsofBTX-Ainjectionsinto
PFMscomparedwithsaline.Participantswererandomizedtoreceiveeither80units
ofBTX-Aat20units/mLorsalineinjections.Undersedation,thestudydrugwas
injectedinto2sitesbilaterallyinthepuborectalisandpubococcygeusmusclesin1-
mLaliquots.Similartothepilotstudy,theBTX-Agroupreportedsignificantly
decreasednonmenstrualpelvicpain,dyspareunia,andpelvicfloorpressures
comparedwithsalinecontrols. 25
WhenadministeringBTX-A,itisimportanttonotethatinjectionsshouldnotbegiven
soonerthanevery3months.BTX-Ashouldalsobeusedmorejudiciouslyinthosewith
neuromuscularjunctiondisorders,suchasmyastheniagravis,andthosetakinganti-
cholinergicagentsormusclerelaxants.Someofthesideeffectsthatmaybereported
includepainattheinjectionsite,malaise,flulikesymptoms,bladderandbowelincon-
tinence,andrarebutseriouslife-threateningtoxiceffectswhenthereisdistant
spread.15
Dryneedling
DryneedlingisanalternativemethodofMTrPtherapy.Itstherapeuticeffectsare
basedonthepremisethatwhenapainful,tenderlocalizedareaispenetratedrepet-
itivelywithafineneedle,ananalgesiceffectisproduced.Studieshaveshownthat
dryneedlingmayexerttherapeuticeffectsbyactingatsitesdistantfromtheactive
MTrP.15 Therearealsoseveralassociatedadverseeffectsthatareimportantto
note,includingpostneedlingsoreness,hematomaformation,hemorrhageatthe
needlingsite,andsyncopalepisodes. 15
NeuromodulationTherapy
Sacralneuromodulationisanothertreatmentoptionthathasbeenstudiedtoshow
20,26
promisingresultsinpatientswithpelvicfloorpainbyalteringPFMactivity. Apro-
26
spectivestudybySiegelandcolleagues exploredtheutilityofsacralnervestimula-
tionin10patientswithCPPrefractorytoconservativetreatment.Followingapositive
responsetopercutaneousteststimulation,aneuro-prostheticsacralnervestimulation
devicewasimplantedwithelectrodestimulationoftheS3andS4sacralnerveroots.
Painwasassessedatbaselineandat1-,3-,6-,and19-monthfollow-upintervals.The
resultsshowedthatatleast80%ofpatientsexperiencedadecreaseinthenumberof
hoursofpainandseverityofpainatlong-termfollow-up.Thus,sacralneuromodula-
tionmaybeconsideredasanalternativetreatmentoptionforpatientswithMFPPre-
fractorytomoreconservativemeasures.

ASSOCIATEDDISORDERS

PatientswithMFPPfrequentlypresentwithadditionalurologic,gynecologic,gastroin-
testinal,musculoskeletal,and/orpsychologicalcomplaints.Thesesymptomsshould
berecognized,addressed,andtreated.Cliniciansshouldbeawareofthecommonly
associateddisorderswithMFPP,andtheyshouldbeconsideredwhencollectinga
detailedhistory. 12
Gynecologic
GynecologicdisordersthatareoftenlinkedtoMFPPincludevulvodynia,dyspareunia,
andendometriosis.Vulvodyniaisvulvarpainofgreaterthan3months’duration,
generallywithoutanyvisualizedabnormality.Itcanbedividedintoprovokedorunpro-
vokedandalsodescribedaslocalizedorgeneralized.Localized,provokedvulvodynia
 MyofascialPelvicPainandRelatedDisorders 509

presentspreciselyasdescribed.Patientsexperiencepaininonespecificareaofthe
vulva(ie,vaginalvestibuleorclitoris)withvariousformsofcontact,tampon,speculum,
and/orsexualrelations. 27 Generalizedvulvodynia,ontheotherhand,isusuallyunpro-
vokedvulvarpain.Thispainmayormaynotbeexacerbatedbysexualactivityor
reproducedonphysicalexamination.Treatmentsincludetopicalanesthetics,tricyclic
antidepressants,pelvicfloortherapy,pudendalnerveblockwhenwarranted,or,inse-
vereprotractedcases,vestibulectomy.
Itiscommonforpatientswithvulvodyniatohaveaccompanyingsexualdysfunc-
tionandPFMdysfunction. 28 Hypertonicmuscledysfunctionwithtendernessofthe
PFMs,highrestingtension,muscleirritability,andweaknessisusuallypresent
withvulvodynia. 29 Inwomenwithprovokedvestibulodynia,acombinationofthe
followingpelvicfloormuscularfindingsexist:elevatedrestingtone,tautbands
and/oractivetriggerpoints,elevatedtoneofbothobturatorinternusmuscles,
increasedtensioninoneorbothtendinousarchesofthepelvicfasciaand/orthele-
vatorani,andincreasedtoneorvisceralspasmintheurethra,bladder,uterus,or
rectum.30 In2015,theEvidence-BasedVulvodyniaAssessmentProjectshowed
31
that90%ofwomenwithvulvodyniahadmuscularabnormalitiesinthepelvicfloor.
VulvodyniaandMFPPhavebeenlinkedtogetherunderthebroadcategoryof CPP
syndromes inthemedicalliterature 32 andmaypresentsimilarly,withoverlapping
symptoms.However,recognizingthepresenceofbothconditionsmaybroaden
theoptionsfortreatmentapproaches.ThecorrelationofMFPPwithvulvodyniais
bestprovedbytheimprovementinpainthatthesepatientshaveafterPFPT.Several
studieshavehighlightedtheeffectsofPFPTforwomenwithvulvodynia.In2002,
Bergeronandcolleagues 27 performedaretrospectivestudy,evaluatingpatients
withprovokedvestibulodyniaafter6to8sessionsofPFPTprograms.Approximately
71%ofwomenwithprovokedvulvodynia(PVD)reportedmoderatetocomplete
33
improvementinpainwhenfollowedup.In2008,Dionisiandcolleagues cited
110of145patientswithimprovementinpainafter10weeklysessionsofPFPT.
Andfinally,in2016the JournalofSexualMedicine publishedupdatedevidence-
basedrecommendationsforthetreatmentofvulvodyniaandconcludedPFPTisrec-
34
ommendedforthemanagementofvulvodynia(gradeB).
Dyspareunia,definedaspainfulvaginalpenetration,isoftenobservedinwomen
withMFPP.PaincandevelopduetoUGatrophy,perinealscarringfrompriorsurgery
orchildbirth,vulvodynia,hypertonicpelvicfloormusculature,orothermoreserious
medicalconditions,suchasendometriosis. 28 Vaginismus,themostcommoncause
ofentrydyspareunia,affectsmorethan1%ofallwomen.Vaginismuspresentsas
35 35
persistentinvoluntarycontractionofthepelvicfloormusculature. Butrick de-
scribesaperpetualcycleinvolvingapatient’sconditionedresponse.Dyspareuniais
frequentlyinitiatedbyanunpleasantexperience,causingthefearoranxietyofpain
withthenextattempt.Thisfear,inturn,leadstoinvoluntaryhypertonicpelvicfloor
musculature,orvaginismus,resultinginentrydyspareunia,withapersistentcycle
tofollow.
Endometriosisaffectsroughly10%ofwomenofreproductiveage.Itisdefinedasa
chronicinflammatoryconditionthatoccurswhenendometrialtissueimplantsoutside
oftheuterinelining. 36 Endometriosisalsoaffects50%ofwomenwithpelvicpain. 37
Endometriosiscancausearangeofsymptoms,includingdysmenorrhea,dyspareu-
nia,lowerabdominalpain,andinfertility. 38 However,thedirectassociationwithendo-
metriosisandMFPPhasyettobesupportedinliterature.Arecentstudyperformedby
Strattonandcolleagues 39 in2015concludedthatsensitizationandMTrPswerecom-
moninwomenwithpainregardlessofwhetherornottheyhadendometriosisatsur-
gery.Butthosewithanyhistoryofendometriosisweremostlikelytohave
510 Bonderetal

sensitization.Strattonandcolleagues 39 alsospeaktotheimportanceofnongyneco-
logicfactorscontributingtopelvicpain,especiallyintheCPPpopulation.

Urologic
ThemostcommonurinarytractdysfunctionfoundinpatientswithMFPPisinterstitial
cystitis(IC)orpainfulbladdersyndrome.PatientswithICtypicallypresentwithbladder
35
pain,urgency,frequency,dysuria,nocturia,and/orpelvicpain. Inoneprospective
trial,itwasfoundthat84%ofpatientswithCPPhadsymptomsconsistentwith
IC.40 Anotherstudyestimated50%to87%ofpatientswithICalsopresentwithpelvic
floorhypertonicdysfunction. 41 Urinaryfrequency,urgency,andpainmayalsobe
referredsensationswithaskeletalratherthansmoothmusclecause.Spasmofthein-
termediatelayermusclesofthepelvicfloor,sphincterurethrae,andcompressorure-
thraemaycreatethesensationofurgency,whereasMTrPsinthelevatormuscles,
obturatorinternus,andevenrectusabdominismayalsocreateurgencyasareferred
sensation.42 TreatmentsforICincludestressreduction,dietmodification,pelvicfloor
therapy,andmedications,suchasamitriptyline,histamineblockersandpentosanpol-
ysulfate,orbladderinstillationtherapy. 28
Chronicprostatitis,alsoknownasCPPsyndromeinmen,isclassifiedasinfectious
ornoninfectious,symptomsthatareacuteorchronic,andwithorwithoutthepres-
enceofCPP.About90%to95%ofthesepatientsarewithoutevidenceofinfection
andwithCPP. 43 Patientstypicallypresentwithassociatedurinarysymptomsorsexual
dysfunction;however,thepathophysiologyexplainingthesourceofchronicpainisnot
wellunderstood. 43 Varioustreatmentshavebeenproposed,yetnotwidelyaccepted;
theseincludealphablocker,antiinflammatory,PFPTaimedatmyofascialrelease,and
urologyreferralifanyabnormalfindings.

Gastrointestinal
Chronicconstipationiscommonlyexperiencedproblem,especiallyamongwomen
withpelvicfloordisorders. 44 Minimalliteratureexistsevaluatingconstipationand
managementwithwomenwithpelvicfloordysfunction.Onecross-sectionalstudy
describedchronicconstipationsymptomsinthepelvicfloordysfunctionpopulation
asincludingmultipledistressinganduncomfortablesymptoms.Thesepatients
respondedwelltoself-managementstrategies,suchaslaxatives,manualfacilitation,
andenema;however,amorethoroughassessmentwithinthispopulationwaswar-
ranted.44 Irritablebowelsyndrome(IBS)affectsabout10%ofthepopulationand
45–47
aboutone-thirdofwomenwithpelvicpain. IBSisdefinedasfunctionalgastroin-
testinaldisordercharacterizedbyabdominalpain,cramping,bloating,constipation,
45
anddiarrhea,frequentlyexacerbatedbymenstruation. Mostpatientseitherhave
IBSwithconstipationorIBSwithdiarrhea.Theliteratureondiagnosisandtreatment
ofIBSisvast;however,currenttreatmentsavailableincludecognitive-behavioralther-
apy,hypnotherapy,antispasmodics,antidepressants,dietarymanipulation,fiber,and
5-hydroxytryptamine3receptorantagonists. 28 InbothchronicconstipationandIBS
withconstipation,itisimportanttoalsorecognizeandaddressthepotentialroleof
pelvicfloormusculardysfunction.Hypertonicorpainfullevatoranimusclesmayrefer
paintotheabdomenandcontributetoabdominalpainsthatmayinitiallybesugges-
tiveofagastrointestinaldiseaseprocess. 43 WomenwithMFPPmaycomplainofcon-
stipation;painbefore,during,orafterdefecation;aswellassensationsofincomplete
evacuationofbowelorbladder.Thesecomplaintsmaybeduetoashortenedpubor-
ectalismuscle,whichslingsaroundtherectum,andmaycreateananorectalangle
12
thatistooacutemakingbowelevacuationdifficultorpainful. Constipationmay
alsobeduetotheinabilityofthepuborectalismuscletorelaxduringdefecation.
 MyofascialPelvicPainandRelatedDisorders 511

MusculoskeletalDisorders
PelvicfloorMTrPscandevelopasaresultofaprimarydysfunctionintrinsictothepel-
vicfloororasafunctionaladaptationtoothermusculoskeletalimbalancesanddisor-
48
dersassociatedwiththehip,spine,orpelvis. MTrPsbecomeactivatedfrom
underlyingchronicmusclefatigue,overuseinjuries,impairedposture,oraltered
bodymechanics,whichmayresultfromaprimarymusculoskeletalpathologyoroccur
secondarilyfromorganpathology. 15 Therefore,itisimportanttotreattheotherunder-
lyingmusculoskeletalcausesthatplayaroleinthedevelopmentofMFPPand
MTrPs.15
SkeletalcausesofMFPPincludehipandsacroiliacjointdysfunction,lumbarspine
pathology,pubicsymphysisdisorders,andcoccydynia.Conditionssuchasosteoar-
thritis,acetabularlabraltears,femoralacetabularimpingement,lumbarspondylosis,
49
andcoccyxmisalignmenthavebeenimplicatedinthedevelopmentofMFPP.
Muscularcausesincludelevatoraniandpiriformissyndromes,whichmayresultin
thesettingoftrauma,suchaschildbirth.Morecommonly,paininthePFMsiswidely
attributedtothefunctionaldemandsofthesemusclesandoccursthroughoverusein-
13,14,48
juries,repetitivestrains/sprains,andposturaldysfunction. Whentheseprob-
lemsarenotaddressed,CPPcanresultintheformationofMTrPsasaresultof
abnormalmuscleactivationpatternsofthePFMs.Anotherstudiedtheoryisthatan
underlyingmusculoskeletaldisorderorimpairmentcancausemusclepainandinjury,
resultinginmuscularstrains.Musclestrainsthenleadtoreducedcirculationandlocal-
12
izedhypoxia/ischemia,whichcansubsequentlyresultinthedevelopmentofMTrPs.
Thelocationofpaininsomepatientsmaynotbelocalizedtothepelvicfloor.Pa-
tientswithMFPPmaycommonlydescribesymptomsoflowbackpain;gluteal,groin,
andlegpain;aswellasradiationtothesacrum.Radiationtothehipandposteriorthigh
isalsocharacteristicofaneuropathyorradiculopathy,whichshouldbeevaluatedand
treatedappropriately.Patientswithunderlyingmusculoskeletalconditionscontrib-
utingtoMFPPmayalsodescribepainwithprolongedsitting,standing,and/orphys-
icalactivity. 48
TheassociationoffibromyalgiaandMFPPhasalsobeenexaminedinliterature.One
studyevaluatedthedifferencesinbody-widemusculoskeletaltenderpointsinwomen
withdifferenttypesofCPP,specificallybladderpainsyndrome(BPS)andMFPP.The
followingtenderpointswerepalpated:pelvicfloor,abdomen,groin,innerthigh,andall
18fibromyalgiatenderpointsasdescribedbytheAmericanCollegeofRheuma-
tology.49 Pelvicfloortenderpointsincludedbilaterallevatoraniandobturatorinternus
musclesandasinglemidlineperinealassessment.Thefindingsshowedthatpatients
withMFPPwerefoundtohavehigherpelvicfloorandfibromyalgiatenderpoints
comparedwiththosewithBPSalone.Therefore,thisstudydemonstratedastrong
positivecorrelationbetweenpelvicfloorandfibromyalgiatenderpointsforpatients
withMFPP. 50

PsychosocialDisorders
WhenobtainingaclinicalhistoryforwomenexperiencingMFPP,athoroughhistoryof
pasttrauma,suchaspelvictraumaorhistoryofphysicalabuseorsexualabuse,is
alsowarranted.Literaturehasalsofoundthatpsychologicalstressorsareclosely
correlatedwithMFPP.Bothmentalandemotionalstresshavebeendemonstrated
toactivateunderlyingMTrPs. 12 Inaddition,anxietyanddepressionhavebeenlinked
toMFPPandCPPonnumerousoccasions.Across-sectionalstudyconductedby
Coelhoandcolleagues 50 evaluatedconditionsfrequentlyassociatedwithCPP.The
studyexamined284womenwithCPP,andtheresultsshowedasignificant
512 Bonderetal

associationbetweenCPPanddepressionasmeasuredbythePatientHealthQues-
tionnairewithanoddsratioof2.33.Similarly,asystematicreviewbyLattheandcol-
leagues51
alsoevaluatedfactorspredisposingwomentoCPPandfoundthatanxiety
anddepressionwerepositivelyassociatedwithdyspareuniawithanoddsratioof3.23
and7.77,respectively. 52 In2010,astudyinBrazilexaminedtheprevalenceofpelvic
muscletendernessinwomenwithCPP.TheyfoundthatamongthosewithCPP,
womenwhoalsohadpelvicmuscletendernesshadhigherBeckDepressionIndex
scoresaswellashigherratesofdyspareuniaandconstipationthanthosewithoutpel-
vicmuscletenderness.Giventhesupportofliterature,itisreasonabletoconclude
5

thatthetreatmentofMFPPassociatedwithotherpsychosocialconditionswarrants
psychologicalservicesforcognitive-behavioralinterventions,whichmayinclude
relaxationtechniques. 14

SUMMARY/DISCUSSION

MFPPofthePFMsisafrequentcauseCPPinwomenandmen.Itoftencoexistswith
otherdisordersoftheabdomenandpelvisaswellasproblemsofthejoints,muscles,
andligamentsofthepelvicgirdle.Treatmentneedstobemultidisciplinarysothateach
syndrome,dysfunction,andrelatedinjuryisaddressed.Physicaltherapy,oralpain
medications,behavioralchanges,andcognitive-behavioraltherapyarethemainstays
ofmanagementforthesepatients.Researchinthisfieldisstillevolving.Morestudies
areneededtohelpprovidersdiagnoseMFPPanddeterminethebestcourseof
treatment.

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