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Chronic pelvic pain: 11 critical questions about causes and care
Fred M. Howard, MD (August 2009)
Vague symptoms. Unexpected flares. Inconsistent manifestations. These characteristics can make diagnosis and treatment of chronic pelvic pain frustrating for both patient and physician. Most patients undergo myriad tests and studies to uncover the source of their pain—but a targeted pelvic exam may be all that is necessary to identify a prevalent but commonly overlooked cause of pelvic pain. Levator myalgia, myofascial pelvic pain syndrome, and pelvic floor spasm are all terms that describe a condition that may affect as many as 78% of women who are given a diagnosis of chronic pelvic pain.1 This syndrome may be represented by an array of symptoms, including pelvic pressure, dyspareunia, rectal discomfort, and irritative urinary symptoms such as spasms, frequency, and urgency. It is characterized by the presence of tight, band-like pelvic muscles that reproduce the patient’s pain when palpated.2
Diagnosis of this syndrome often surprises the patient. Although the concept of a muscle spasm is not foreign, the location is unexpected. Patients and physicians alike may forget that there is a large complex of muscles that completely lines the pelvic girdle. To complicate matters, the patient often associates the onset of her symptoms with an acute event such as a “bad” urinary tract infection or pelvic or vaginal surgery, which may divert attention from the musculature. Although a muscle spasm may be the cause of the patient’s pain, it’s important to realize that an underlying process may have triggered the original spasm. To provide effective treatment of pain, therefore, you must identify the fundamental cause, assuming that it is reversible, rather than focus exclusively on symptoms.
Although there are many therapeutic options for levator myalgia, an appraisal of the extensive literature on these medications is beyond the scope of this article. Rather, we will review alternative treatment modalities and summarize the results of five trials that explored physical therapy, trigger-point or chemodenervation injection, and neuromodulation (TABLE).
Weighing the nonpharmaceutical options for treatment
of myofascial pelvic pain
| Treatment | Pros | Cons |
|---|---|---|
| Physical therapy | Minimally invasive Moderate long-term success | Requires highly specialized therapist |
| Trigger-point injection | Minimally invasive Performed in clinic Immediate short-term success | Optimal injectable agent is unknown Botulinum toxin A lacks FDA approval for this indication Limited information on adverse events and long-term efficacy |
| Percutaneous tibial nerve stimulation | Minimally invasive Performed in clinic | Requires numerous office visits for treatment Lacks FDA approval for this indication Limited information on long-term efficacy |
| Sacral neuromodulation | Moderately invasive Permanent implant | Requires implantation in operating room Lacks FDA approval for this indication Limited information on long-term efficacy |
Pelvic myofascial therapy offers relief—but qualified therapists may be scarce
FitzGerald MP, Anderson RU, Potts J, et al; Urological Pelvic Pain Collaborative Research Network. Randomized multicenter feasibility trial of myofascial physical therapy for the treatment of urological chronic pelvic pain syndromes. J Urology. 2009;182(2):570–580.
Physical therapy of the pelvic floor—otherwise known as pelvic myofascial therapy—requires a therapist who is highly trained and specialized in this technique. It is more invasive than other forms of rehabilitative therapy because of the need to perform transvaginal maneuvers (FIGURE 1).
This pilot study by the Urological Pelvic Pain Collaborative Research Network evaluated the ability of patients to adhere to pelvic myofascial therapy, the response of their pain to therapy, and adverse events associated with manual therapy. It found that patients were willing to undergo the therapy, despite the invasive nature of the maneuvers, because it was significantly effective.
Details of the study
Patients (both men and women) were randomized to myofascial physical therapy or global therapeutic massage. Myofascial therapy consisted of internal or vaginal manipulation of the trigger-point muscle bundles and tissues of the pelvic floor. It also focused on muscles of the hip girdle and abdomen. The comparison group underwent traditional Western full-body massage. In both groups, treatment lasted 1 hour every week, and participants agreed to 10 full treatments.
Patients were eligible for the study if they experienced pelvic pain, urinary frequency, or bladder discomfort in the previous 6 months. In addition, an examiner must have been able to elicit tenderness upon palpation of the pelvic floor during examination. Patients were excluded if they showed signs of urinary tract infection or dysmenorrhea.
A total of 47 patients were randomized—24 to global massage and 23 to myofascial physical therapy. Overall, the myofascial group experienced a significantly higher rate of improvement in the global response at 12 weeks than did patients in the global-massage group (57% vs 21%; P=.03). Patients were willing to engage in myofascial pelvic therapy, and adverse events were minor.
