Jillian Rau, CUSOM MSIV
H Paul Singh MD
Pelvic floor dysfunction is a broad diagnosis encompassing pelvic organ prolapse, dysfunctional bowel, dysfunctional bladder evacuation and chronic pain1. It has been estimated that up to 24% of the female population in the United States experience some form of pelvic floor disorder1. Risk factors shared broadly across all forms of pelvic floor dysfunction include increasing age, obesity, and childbirth.
One of the most difficult disorders of pelvic floor dysfunction to diagnose and treat is pelvic pain. Chronic pelvic pain (CPP) is defined as sub-umbilical pain that persists for at least six months and impairs normal function2. CPP is an extremely common indication for referral to gynecologists and other subspecialists, often leading to surgical exploration for definitive management. CPP must be evaluated from the lens of various physiological systems including: gynecologic, genitourinary, gastrointestinal, musculoskeletal, and psychological3.
Myofascial pelvic pain syndrome (MPPS) falls within the subset of CPP etiologies. Although MPPS occurs in both men and women, this review will focus on MPPS presentation and treatment in women. MPPS is defined as musculoskeletal pain related to shortened, tender pelvic floor muscles and the presence of trigger points4. Trigger points are palpable nodules within muscle bands which induce referred pain. Women may experience trigger points constantly (active trigger points), or only with stimulation (latent trigger points). Referred pain is a classic feature of trigger points. When found within the pelvic floor musculature the pain may refer to the vagina, vulva, perineum, rectum or bladder and even further into the thighs and lower abdomen4. Trigger points are shown to be causative of symptoms aside from pain such as urinary urgency and frequency, vaginal pruritus or burning, dysuria, overactive bladder, constipation, dyspareunia5.
The specific cause of MPPS has not yet been determined. However, current theories best support the pain is multifactorial in origin resulting from microtrauma, metabolic imbalances as
well as pain centralization4. Microtrauma leads to motor end plate stimulation causing hypertonic musculature and the eventual formation of trigger points. The pelvic floor is at increased risk for such microtrauma as the musculature is involved in activities related to upper and lower extremity movement, bladder control, bowel function, as well as sexual function. It is also well known that these muscles are heavily impacted by psychologic stress. Additionally, symptoms are often exacerbated by dysfunction of surrounding musculature in the buttocks, thighs and abdomen.
When evaluating all forms of chronic pelvic pain, especially MPSS, it is essential to take a complete detailed medical history with specific review of systems focused on abdominal pain, urinary complaints, vulvovaginal discomfort, and gastrointestinal issues. As the pain of MPPS is musculoskeletal in origin, patients often report alleviation with certain movements or positions. However, the pain is typically unchanged during menstrual cycles. It is essential that clinicians document any history of trauma, pelvic or abdominal surgeries, and childbirth.
A detailed and thorough physical exam is the most essential step in accurate diagnosis of MPSS. The physical exam consists of multiple quintessential components; an external examination, a pelvic examination, a pelvic floor examination, in addition to assessment of posture and gait. The external examination must inspect the patient’s core musculature as well the hips, back, buttocks and thigh. These areas are assessed for the presence of trigger points, areas of muscle weakness, and identification scar tissue or tissue density. A pelvic examination must be performed in order to rule out infectious processes or signs of decreased estrogen levels. The bimanual exam serves to assess the presence or absence of additional gynecological pathology that may be contributing to pain severity, such as the presence of fibroids or ovarian masses. The strength of the pelvic floor can be examined as a woman contracts her pelvic floor. Signs of weakness include the presence of organ prolapse, decreased motility, inability to relax, or paradoxical movements4. An even more specific examination of the pelvic floor involves identifying hypertonic muscles and the presence of trigger points via palpation. Pain may be elicited upon palpation of the following musculature: bulbospongiosus, ischiocavernosus, transversus perineum, sphincter ani, piriformis, levator ani, or obturator internus5.
Aside from history and physical exam, other components of patient examination have limited utility in the diagnosis of MPSS. Basic labs may be performed in order to rule out
infection or hormonal imbalances, however patients experiencing MPSS alone will have normal results. Additionally, imaging will not demonstrate abnormalities specific to MPSS. If suspicion of other gynecologic etiologies exists, such as fibroids or masses, imaging may help in further evaluation and treatment guidance.
Ultimately, the diagnosis of MPSS is purely clinical and relies on identifying the presence of pelvic muscle tenderness and trigger points while simultaneously ruling out the many etiologies that may contribute to the presence of pelvic pain and pelvic floor dysfunction.
A variety of treatment modalities are in current use for the resolution of MPSS symptoms, however each patient requires a tailored approach specific to her. Ideally, treatments utilize a combination of modalities including physical therapy, pharmacotherapy, and cognitive therapy/ behavioral counseling. Once the patient becomes aware of specific pain triggers, the goal is to implement lifestyle changes to avoid painful reoccurrences6. Despite the treatment modality utilized, the earlier therapy is initiated, the less likely the patient is to develop chronic reoccurrences6.
One of the first steps in initiating therapy is to identify associated patterns or triggers that predispose women to flares. For some women this involves stress management or changing of physical activity to avoid repetitive motions. Physical therapy should also be included as an initial treatment for women with MPSS7. Focused pelvic therapy allows women to strengthen the affected pelvic floor muscle while stretching affected tissues and releasing fascial restrictions to prevent the formation of trigger points. Ideally, women should be treated by a therapist with specialized training in manipulation of the pelvis7. Therapists may also implement specific techniques to post-surgical scar tissue in the pelvic region to reduce adhesions and fascia restrictions. Dry-needling has become a unique method applied to such areas of pathology. Patients should undergo physical therapy weekly for a minimum of 8-12 weeks. This timeframe is extended for patients who have experienced chronic symptomology as it requires more extensive therapy for equivalent pain reduction7.
Injections may be offered to provide relief during acute, debilitating flares. Injections are typically performed by specialists of Female Pelvic Medicine and Reconstructive Surgery (FPMRS) although gynecologists may be able to provide a similar service depending on their personal practice procedures. Injections of bupivacaine alone 1-3 mL of 0.25% is sufficient for rapid relief6. This method may provide patients with instantaneous resolution of pain for a period of hours to days, thus it should only be used in combination with other treatment modalities.
Other pharmacologic methods for pain include the use oral medications, including gabapentin, tricyclic antidepressants and and baclofen. These prescriptions are considered first line approaches of pharmacotherapy. Vaginal estrogen may be prescribed in the cases of co-existing atrophic vaginitis. Although NSAIDs are commonly used to relieve pelvic pain especially that associated with cramping and endometriosis, experts state that this may only provide relief to those with mild complaints, and women with chronic pain require further treatments6.
Overall, the chief complaint of pelvic pain and diagnosis of pelvic floor dysfunction encompasses a broad differential diagnosis across various medical specialties. Although myofascial pelvic pain syndrome does not require an emergent or surgical treatment, it may be an under-recognized source of chronic pain and dysfunction. The key elements of diagnosis include extensive evaluation of patient history and a complete physical exam. Once a diagnosis has been reached, patients and providers can begin to formulate a specific treatment approach to achieve reduction of symptoms and ultimately an improved quality of life.
References
1. Yeo C. Shackelford’s Surgery of the Alimentary Tract. Philadelphia, PA: Elsevier/Saunders; 2013.
2. Relter R. A Profile of Women with Chronic Pelvic Pain. Clin Obstet Gynecol. 1990;33(1):130-136.
3. Tu, MD. MPH F, As-Sanie, MD, MPH S. Evaluation of Chronic Pelvic Pain in Women. UpToDate. 2018.
4. Elkadry, MD, FACOG E, Moynihan, RNC, MSN L. Clinical manifestations and diagnosis of myofascial pelvic pain syndrome in women. UpToDate. 2017.
5. Itza F, Zarza D, Salinas J, Teba F, Ximenez C. Turn-Amplitude Analysis as a Diagnostic Test for Myofascial Syndrome in Patients with Chronic Pelvic Pain. Pain Research and Management. 2015
6. Moynihan, RNC, MSN L, Elkadry, MD, FACOG E. Treatment of myofascial pelvic pain syndrome in women. UpToDate. 2017.
7. Kotarinos, DPT, MS R. Pelvic floor physical therapy for management of myofascial pelvic pain syndrome in women. UpToDate. 2017.
