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Myofascial Pelvic Pain Syndrome

Myofascial Pelvic Pain Syndrome refers to pain in the muscles of the pelvic floor that is attributed to PFD. Sometimes it is called proctalgia fugax, coccygodynia, levator ani syndrome, pain in the muscles, or myalgia, can develop in three ways.

It may be caused by a direct injury to a muscle, a viscera-muscular reflex, or primary dysfunction in which muscles do not act in a coordinated manner. Direct injury may result from trauma, childbirth, or surgery.

Painful spasms of the muscles of the pelvic floor can occur because of musculoskeletal changes that occur with posture changes or low back pain.

Conversely, tension and pain in the pelvic floor can be the cause of mobility problems in the bony pelvis and sacroiliac joint.

PFD is often associated with other conditions that cause chronic pelvic pain. Conditions like interstitial cystitis (IC), irritable bowel syndrome (IBS) and endometriosis, for example, stimulate the nervous system which sends signals to the pelvic floor to contract. Chronic stimulation of the nervous system can cause the muscles to contract continuously. Muscle spasm and painful trigger points that occur in response to other organ problems are a type of problem caused by a viscera-muscular reflex.

Almost 90 percent of women with IC have pain in the muscles of the pelvic floor in conjunction with PFD, and at least half of women diagnosed with IC have IBS. About 85 percent of women with chronic pelvic pain have muscular spasm of the pelvic floor or postural changes.

Symptoms

  • Aching, heaviness, or burning
  • Cyclic or continuous  pain
  • Worsening symptoms around the time of menses
  • Pain with vaginal penetration 
  • Pain with orgasm   
  • Deep pelvic pain with intercourse
  • Prior surgery for prolapse
  • Difficulty starting or stopping stream of urine
  • Urine leaking with cough, sneeze, or straining
  • Pain attributed to uterine cramping or ovarian cysts
  • Pain with bowel movements
  • Chronic constipation or difficulty evacuating
  • Pain with sitting for any length of time
  • Feeling of sitting on a golf ball

Associated conditions in women

Gynecologic

  • Dysmenorrhea
  • Ovarian cysts
  • Endometriosis
  • Pelvic congestion syndrome
  • Pelvic inflammatory disease
  • Vulvodynia
  • Provoked vestibulodynia or vulvar vestibulitis syndrome

Urologic

  • Interstitial cystitis
  • Recurrent urinary tract or bladder infections
  • Kidney stones 

Gastrointestinal

  • Inflammatory bowel disease
  • Irritable bowel syndrome
  • Chronic constipation
  • Diverticulitis
  • Colon cancer
  • Hemorrhoids

Psychological

  • Depression
  • Anxiety
  • Personality disorder
  • History of physical or sexual abuse

Musculoskeletal or neurologic

  • Fibromyalgia
  • Myofascial abdominal wall pain
  • Piriformis syndrome
  • Poor posture
     

Work-up

The diagnoses of pelvic floor dysfunction and pelvic floor tension myalgia are often overlooked. Complete evaluation of pelvic organs and the pelvic floor should be undertaken with a complete medical, surgical, and personal history, a thorough physical exam, and appropriate diagnostic testing depending on specific symptoms. Part of the evaluation includes a comprehensive exam of the pelvic floor musculature.

Treatment options

Treat all associated conditions

Medications

  • Analgesics
  • Anti-inflammatory medication
  • Muscle relaxants
  • Anti-depressants or anti-seizure medications

Physical therapy

  • Exercises
  • Biofeedback
  • Direct massage

Behavioral and psychosocial therapy

 

Trigger point injections

  • Anesthetics with or without steroids
  • Botulinum toxin
  • Neurostimulation
  • TENS unit
  • Implanted neuromodulation

Adjunct treatment options

  • Acupuncture
  • Massage therapy 

Resources

International Pelvic Pain Society

Sources

Howard FM: Introduction. Pelvic pain—Diagnosis and Treatment.Edited by Howard FM, Perry CP, Carter JE, El-Minawi AM. Philadelphia: Lippincott Williams &Wilkins; 2000:477-492.

Karlovsky ME and Moldwin RM Pelvic Floor Dysfunction a treatment update. New treatment modalitis take advantage of the maturing relationship between pelvic floor dysfunction and chronic pelvic pain. accessed 2/5/2012

Montenegro MLLS, Vasconcelos ECLM, Candido dos Reis FJ, Nogueira AA, Poli-Neto OB. Physical therapy in the management of women with chronic pelvic pain. Medscape. Accessed 2/4/2012.

Peters KM, Carrico DJ, Kalinowski SE, Ibrahim IA, DioknoAC. Prevalence of pelvic floor dysfunction in patients with interstitial cystitis. Urology. 2007 Jul:70(1):16-8. Accessed 2/5/2012.

Srinivasan AK, Kaye JD, Moldwin R. Myofascial dysfunction associated with chronic pelvic floor pain: management strategies. Current Pain and Headache Reports. 2007. 11:359-364. Accessed 2/4/2012.

Uptodate.com/contents/clinical-manifestations-abd-diagnosis-of-myofascial-pain-syndrome-in-women. Accessed 2/4/2012. Elkadry e and Myonihan NK. Last update 6/2/2009.

Won HR and Abbott J. Optimal management of chronic cyclical pelvic pain: an evidence-based and pragmatic approach. Int J Women’s Health. 2010 Aug(2):263-277.