Pain in the pelvic region that lasts for six months or beyond is referred to as chronic pelvic pain. It has been estimated that about 15%–20% of women aged between 18 and 50 suffer from chronic pelvic pain. Pelvic pain can have a major impact on physical activity, sleep, sexual relations, and family life.
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A form of pelvic floor dysfunction, myofascial pelvic pain syndrome is characterized by tender spastic pelvic floor muscles. However, during the evaluation process, this syndrome is usually overlooked although it can possibly affect as many as 78% of women who are diagnosed with chronic pelvic pain.
Patients suffering from chronic pelvic pain often experience a range of symptoms, such as rectal discomfort, pelvic pain, urinary urgency and frequency, and painful sex. A pelvic floor specialist usually performs a pelvic exam to make the diagnosis. Tender rigid pelvic floor muscles can be palpated during the pelvic exam. The patient’s pain is generally reproduced by deep or gentle palpation.
While the etiology of myofascial pain is not clear, repetitive or acute trauma to the pelvic floor caused by sports injuries (for example, runners), sexual trauma, traumatic obstetric delivery, or prior pelvic floor surgeries can possibly lead to hyper-intensive activation of the motor plate of the pelvic floor muscles. In order to detect the trigger agent, it is important to obtain a detailed history such as the patient’s medical and surgical history, duration of pain, allergies, sexual history, and past treatments.
Physical therapy, behavioral modifications, and topical heat/cold are first-line treatments. Drug therapy can include skeletal muscle relaxants, benzodiazepines (orally or vaginally), nonsteroidal anti-inflammatory drugs (NSAIDs), anticonvulsants, and antidepressants.
For patients who fail physical and medical therapy, pelvic floor trigger point injections are advised. However, sterile conditions are required to perform these trigger point injections. In the dorsal low lithotomy position, the vagina is prepped and this is followed by draping the surgical field. The location of the trigger points, as well as the planned injection site(s), is confirmed by performing a vaginal exam. While injections are often conducted transvaginally, a transperineal method has been particularly described for trigger points situated in the puborectalis or the perineal muscles.
Injections usually contain a steroid and a local anesthetic. A 22-gauge spinal needle and a 5.5 inch Iowa trumpet pudendal needle guide are generally used for injection. Before each injection, a 10 cc controlled syringe is used to enable aspiration. Using 2 ccs of the mixture for every injection site, multiple injections can be carried out. In an office setting, these injections are generally very well tolerated without any significant complications. Vaginal spotting and pain in the injection site are the potential side effects of these injections. Additional rare complications may include infection of the injection site, abscess formation, local anesthesia toxicity, and muscle necrosis.
Women suffering from myofascial pelvic pain can benefit from pelvic floor trigger point injections, which have demonstrated promising results in treating this pain. According to one study, 72% of patients experienced an improvement in their pain, while 33% of patients were completely pain-free. Patients usually experience an immediate relief soon after the injections are administered. Trigger point injections can be performed again at intervals of four to six weeks, depending on the recurrent pain.
Theories proposed to elucidate the mechanism of action of trigger-point injections include the release of endorphins, disruption of reflex arcs inside the skeletal muscle, and mechanical changes in abnormally spastic muscle fibers. Trigger point injections performed on the levator ani muscles is a nonsurgical, minimally invasive technique for women who have pelvic floor myofascial pain syndrome refractory to medications and physical therapy.
This article has been adapted from content authored by Dr. Mohamed Akl and Dr. Ahmed Akl at the AZ Urogynecology and Pelvic Health Center.
About AZ Urogynecology and Pelvic Health Center
The AZ Urogynecology and Pelvic Health Center is devoted exclusively to the diagnosis and treatment of all urogynecologic, pelvic floor disorders and complex gynecologic problems.
They offer a wide array of advanced diagnostic tools and specialized treatment options.
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