Pelvic floor muscle dysfunctions are prevalent in female chronic pelvic pain: a cross-sectional population-based study

Advancing women's pelvic floor muscle function diagnosis: the EFSMAP examination and its reliability evaluation

BACKGROUND

The accurate diagnosis of pelvic floor muscle impairments is essential. The plethora of terms and the lack of evidence to support widely used pelvic floor muscle function (PFMF) measurements hinder diagnostic labels.

OBJECTIVE

To structure an examination of PFMF using visual observation and digital palpation and terms consistent with the ICF terminology, and to test its intra and interrater reliability/agreement.

METHODS

A panel of 9 physical therapists applied Delphi method to structure the PFMF exam under ICF terminology and to verify its measurements reproducibility. For reliability and agreement, a convenience sample of women aged 51.2 ± 14.7 years had the sensitivity to pressure, pain, muscle tone, involuntary movement reaction, control of voluntary movement (contraction/relaxation), coordination, strength, and endurance examined by two raters, in the same day for interrater (n = 40), and one week apart, for intrarater reliability (n = 25). Percent agreement, linear weighted kappa, intraclass correlation coefficient, and Bland-Altman's limits of agreement were calculated (alpha = 0.05).

RESULTS

Four round Delphi discussion structured the PFMF exam, named EFSMAP (Exame das Funções Sensoriais e Motoras do Assoalho Pélvico/Examination of Pelvic Floor Sensory and Motor Functions), set a list of concepts and instructions targeted at reproducibility and established PFMF diagnostic labels. Reliability, except for pain and tone, were moderate to excellent (Kw= 0.67-1.0 and ICC=0.48-0.82). Agreement was substantial for most PFMF features (0.64-1.00), except pain.

CONCLUSIONS

The EFSMAP was successfully developed as a valid and reliable exam to be used in research and clinical practice; it provides labels for the diagnosis of pelvic floor muscle impairments. It might be easily adopted worldwide as it uses ICF terminology.

Botulinum Toxin for the Management of Pelvic Floor Tension Myalgia and Persistent Pelvic Pain: A Systematic Review and Meta-analysis

OBJECTIVE

To systematically review the literature on use of botulinum toxin to treat pelvic floor tension myalgia and persistent pelvic pain.

DATA SOURCES

The ClinicalTrials.gov , PubMed, EMBASE, and Scopus databases were searched from inception to November 2022 by two independent assessors (B.L.K. and F.G.L.). Identified studies were screened by title and abstract and included after full-text review. Data extraction was subsequently performed and recorded in Microsoft Excel.

METHODS

This study was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines after registration in PROSPERO (CRD42022289132). All randomized studies, prospective studies with more than five participants, and retrospective studies with more than 10 participants published in English or French and assessing the use of botulinum toxin for the treatment of pelvic floor tension myalgia and persistent pelvic pain in women were included. Meta-analyses were performed on randomized data.

TABULATION, INTEGRATION, AND RESULTS

Of 4,722 articles identified, 24 satisfied inclusion criteria. A meta-analysis of five randomized controlled trials totaling 329 participants demonstrated no differences in patient- and clinician-reported outcome measures, including pain, dyspareunia, sexual function, and vaginal manometry. Mean duration of follow-up was 6 months. A qualitative analysis of 14 prospective and four retrospective studies including 804 participants is supportive of botulinum toxin; however, the quality of data is low, and there is marked heterogeneity between studies.

CONCLUSION

Meta-analyses of randomized data do not support the use of botulinum toxin to treat pelvic floor tension myalgia and persistent pelvic pain. Failure of these data to confirm the findings of nonrandomized prospective studies that suggest a treatment benefit may be attributable to the absence of placebo control and confounding outcomes obtained from an active comparator group. Further randomized controlled trials with true placebo are strongly recommended.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42022289132.

Guideline No. 445: Management of Chronic Pelvic Pain

OBJECTIVE

To provide evidence-based recommendations for the management of chronic pelvic pain in females.

TARGET POPULATION

This guideline is specific to pelvic pain in adolescent and adult females and excluded literature that looked at pelvic pain in males. It also did not address genital pain.

BENEFITS, HARMS, AND COSTS

The intent is to benefit patients with chronic pelvic pain by providing an evidence-based approach to management. Access to certain interventions such as physiotherapy and psychological treatments, and to interdisciplinary care overall, may be limited by costs and service availability.

EVIDENCE

Medline and the Cochrane Database from 1990 to 2020 were searched for articles in English on subjects related to chronic pelvic pain, including diagnosis, overlapping pain conditions, central sensitization, management, medications, surgery, physiotherapy, psychological therapies, alternative and complementary therapies, and multidisciplinary and interdisciplinary care. The committee reviewed the literature and available data and used a consensus approach to develop recommendations. Only articles in English and pertaining to female subjects were included.

VALIDATION METHODS

The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations).

INTENDED AUDIENCE

Family physicians, gynaecologists, urologists, pain specialists, physiotherapists, and mental health professionals.

TWEETABLE ABSTRACT

Management of chronic pelvic pain should consider multifactorial contributors, including underlying central sensitization/nociplastic pain, and employ an interdisciplinary biopsychosocial approach that includes pain education, physiotherapy, and psychological & medical treatments.

SUMMARY STATEMENTS

RECOMMENDATIONS.

Pelvic floor hypertension: possible factors for pelvic floor tenderness in endometriosis patients-a pilot study

PURPOSE

Chronic pelvic pain (CPP) is one of the main problems of endometriosis, leading to a significant impairment of quality of life. Understanding the pain mechanisms and the pelvic floor muscles (PFM) changes in these patients is essential to integrate additional therapeutic strategies. We hypothesize that endometriosis patients have changes in PFM and that targeted vaginal electrostimulation can be a treatment option for CPP in this disease.

METHODS

Fifteen patients with endometriosis and chronic acyclical pelvic pain were included. PFM electromyography with the Multiple Array Probe Leiden (MAPLe) was performed. Mapping of PFM was utilized and targeted electrostimulation of the hypertensive muscles was conducted. Control electromyography was performed afterward to evaluate the electrostimulation therapeutic effect.

RESULTS

In 12/15 (80%) patients, the myofascial trigger point could be localized by digital examination. The most frequently affected muscle was the puborectalis (10/15-66.7%). Most of the patients showed serious changes in the average resting tone (aRT) of PFM. aRT was significantly increased in all patients and decreased after stimulation, whereby the difference prior to and after stimulation was not significant (p = 0.064). The detailed separated analysis of the hypertensive muscles showed a significant (p = 0.026) reduction in their resting tone (hRT), after targeted stimulation.

CONCLUSION

Vaginal electrostimulation is a promising and feasible complementary treatment option for CPP in endometriosis patients. Targeted treatment of pelvic floor dysfunction should be included in clinical trials.

Botulinum toxin injection in vulva and vagina. Evidence from a literature systematic review

INTRODUCTION

Botulinum toxin (BoNT) administration has been proposed in the gynecologic field for pelvic, vulvar and vaginal disorders. On this regard, we aimed assessing the therapeutic effectiveness and safety of BoNT usage in the treatment of vaginal, vulvar and pelvic pain disorders.

METHODS

We searched for all the original articles without date restriction until 31.12.2021. We included all the original articles which administered botulinum toxin in the vulva or vagina of women suffering from vaginismus, dyspareunia, and chronic pelvic pain. Only English language studies and those performed in humans were eligible. We excluded all case reports and pilot study from the qualitative analysis, although we accurately evaluated them. 22 original studies were finally included in the systematic review.

RESULTS

Botulinum toxin injection was found to be effective in improving vulvar and vaginal dyspareunia, vaginismus, and chronic pelvic pain. No irreversible side effects were detected. Major side effects reported were transient urinary or fecal incontinence, constipation and rectal pain. The risk of bias assessment proved original articles to be of medium quality. No metanalysis could have been performed since lack of congruency in the definition of pathology and methods of botulinum toxin administration.

CONCLUSION

Data extraction pointed out different endpoints and different methods of analysis. Studies focus on different types of participants and use various techniques and timing. According to the best evidence available, different techniques provide evidence about positive outcomes, with the need for a standardized protocol.

Evaluation of a scoring system for the detection of central sensitization among women with chronic pelvic pain

BACKGROUND

Central sensitization is frequently associated with chronic pelvic pain and requires specific management. The pain is described as hypersensitivity to an innocuous stimulus that is both widespread and persistent. However, no study has evaluated if central sensitization can be measured objectively with neurophysiological tests in the pelvic and perineal area to prove this concept in women with chronic pelvic pain.

OBJECTIVE

This study aimed to evaluate nociceptive thresholds (primary objective) and spatial and temporal diffusion of pain among women with chronic pelvic pain and high or low scores of central sensitization.

STUDY DESIGN

This prospective, assessor-blinded, comparative study compared a cohort of women with chronic pelvic pain and a high (>5/10; n=29) vs low (<5/10; n=24) score of sensitization according to the Convergences PP criteria. Participants underwent a noninvasive bladder sensory test, a rectal barostat test, and a muscular (algometer) and a vulvar (vulvagesiometer) sensory test. Poststimulation pain (minutes), quality of life (Medical Outcomes Study 36-Item Short Form Survey), and psychological state, comprising anxiety (State-Trait Anxiety Inventory), depression (Beck Depression Inventory Short Form), and catastrophizing (Pain Catastrophizing Scale), were assessed.

RESULTS

The participants mostly suffered from endometriosis (35.8%), irritable bowel syndrome (35.8%), bladder pain syndrome (32.1%), and vestibulodynia (28.3%). Baseline characteristics were similar. Women with a high sensitization score had more painful diseases diagnosed (2.7±1.3 vs 1.6±0.8; P=.002) and suffered for longer (11±8 vs 6±5 years; P=.028) than participants with a low score. The bladder maximum capacity was equivalent between participants (399±168 vs 465±164 mL; P=.18). However, the pain felt at each cystometric threshold was significantly increased in women with a high sensitization score. No difference was identified for the rectal pain pressure step (29.3±5.5 vs 30.7±6.5 mm Hg; P=.38). Rectal compliance was decreased in women with a high sensitization score with a considerable increase in pain felt. The average of pain pressure thresholds at the 5 vulvar sites tested was decreased in these participants (162.5±90.5 vs 358.7±196.5 g; P=.0003). Similar results were found for the average of the pain pressure thresholds at 6 muscles tested (1.34±0.41 vs 2.63±1.52 kg/m2; P=.0002). A longer period was needed for patients with high sensitization score to obtain a VAS <3 out of 10 after the stimulation of the bladder (4.52±5.26 vs 1.27±2.96 minutes; P=.01), the rectum (3.75±3.81 vs 1.19±1.23 minutes; P=.009), and the muscles (1.46±1.69 vs 0.64±0.40 minutes; P=.002). The psychological state was equivalent between groups. No association was found between the sensory thresholds and the psychological state results. The physical component of the quality of life score was reduced in women with high sensitization score (P=.0005), with no difference in the mental component.

CONCLUSION

Using neurophysiological tests, this study showed that there are objective elements to assess for the presence of central sensitization, independently of psychological factors.

Are pelvic pain and increased pelvic floor muscle tone associated in women with persistent noncancer pelvic pain? A systematic review and meta-analysis

BACKGROUND

The association between pelvic pain and pelvic floor muscle (PFM) tone in women with persistent noncancer pelvic pain (PNCPP) is unclear.

AIM

To synthesize the evidence of the association between pelvic pain and PFM tone in women with PNCPP.

METHODS

A systematic review was conducted via MEDLINE, Emcare, Embase, CINAHL, PsycINFO, and Scopus to identify relevant studies. Studies were eligible if pelvic pain and PFM tone outcome measures were reported among women aged >18 years. The National Heart, Lung, and Blood Institute's Quality Assessment Tool for Observational Cohort and Cross-sectional Studies was used to assess study quality. Studies were pooled by assessment of PFM tone via a random effects model. Associations between the presence of pelvic pain and PFM tone were assessed with odds ratio (OR), while linear associations were assessed with Pearson or Spearman correlation.

OUTCOMES

Pelvic pain measures (intensity, threshold, and frequency) and resting PFM tone in women with PNCPP, as evaluated by any clinical assessment method or tool.

RESULTS

Twenty-four studies were included in this review. The presence of pelvic pain was significantly associated with increased PFM tone as assessed by digital palpation (OR, 2.85; 95% CI, 1.66-4.89). Pelvic pain intensity was inversely but weakly associated with PFM flexibility when evaluated through dynamometry (r = -0.29; 95% CI, -0.42 to -0.17). However, no significant associations were found between pelvic pain and PFM tone when measured with other objective assessment methods.

CLINICAL IMPLICATIONS

Pelvic pain and increased PFM tone may not be directly associated; alternatively, a nonlinear association may exist. A range of biopsychosocial factors may mediate or moderate the association, and clinicians may need to consider these factors when assessing women with PNCPP.

STRENGTHS AND LIMITATIONS

This review was reported according to the PRISMA guidelines. All possible findings from relevant theses and conference abstracts were considered in our search. However, nonlinear associations between pelvic pain and increased PFM tone were not assessed as part of this review.

CONCLUSION

Pelvic pain may be linearly associated with increased PFM tone and decreased PFM flexibility when measured with digital palpation or dynamometry; however, this association was not observed when other aspects of PFM tone were assessed through objective methods. Future studies are required using robust assessment methods to measure PFM tone and analyses that account for other biopsychosocial factors that may influence the association.

[Pelvic exam in gynecology and obstetrics: Guidelines for clinical practice]

OBJECTIVE

To provide guidelines for the pelvic clinical exam in gynecology and obstetrics.

MATERIAL AND METHODS

A multidisciplinary experts consensus committee of 45 experts was formed, including representatives of patients' associations and users of the health system. The entire guidelines process was conducted independently of any funding. The authors were advised to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized.

METHODS

The committee studied 40 questions within 4 fields for symptomatic or asymptomatic women (emergency conditions, gynecological consultation, gynecological diseases, obstetrics, and pregnancy). Each question was formulated in a PICO (Patients, Intervention, Comparison, Outcome) format and the evidence profiles were produced. The literature review and recommendations were made according to the GRADE® methodology.

RESULTS

The experts' synthesis work and the application of the GRADE method resulted in 27 recommendations. Among the formalized recommendations, 17 present a strong agreement, 7 a weak agreement and 3 an expert consensus agreement. Thirteen questions resulted in an absence of recommendation due to lack of evidence in the literature.

CONCLUSIONS

The need to perform clinical examination in gynecological and obstetrics patients was specified in 27 pre-defined situations based on scientific evidence. More research is required to investigate the benefit in other cases.

Is there a difference in pelvic floor muscle tone between women with and without pelvic pain? A systematic review and meta-analysis

BACKGROUND

Alterations in pelvic floor muscle (PFM) function have been observed in women with persistent noncancer pelvic pain (PNCPP) as compared with women without PNCPP; however, the literature presents conflicting findings regarding differences in PFM tone between women with and without PNCPP.

AIM

To systematically review the literature comparing PFM tone in women with and without PNCPP.

METHODS

MEDLINE, Embase, Emcare, CINAHL, PsycINFO, and Scopus were searched from inception to June 2021 for relevant studies. Studies were included that reported PFM tone data in women aged ≥18 years with and without PNCPP. The risk of bias was assessed with the National Heart, Lung, and Blood Institute Quality Assessment Tool. Standardized mean differences (SMDs) for PFM tone measures were calculated via random effects models.

OUTCOMES

Resting PFM tone parameters, including myoelectrical activity, resistance, morphometry, stiffness, flexibility, relaxation, and intravaginal pressure, measured by any clinical examination method or tool.

RESULTS

Twenty-one studies met the inclusion criteria. Seven PFM tone parameters were measured. Meta-analyses were conducted for myoelectrical activity, resistance, and anterior-posterior diameter of the levator hiatus. Myoelectrical activity and resistance were higher in women with PNCPP than in women without (SMD = 1.32 [95% CI, 0.36-2.29] and SMD = 2.05 [95% CI, 1.03-3.06], respectively). Women with PNCPP also had a smaller anterior-posterior diameter of the levator hiatus as compared with women without (SMD = -0.34 [95% CI, -0.51 to -0.16]). Meta-analyses were not performed for the remaining PFM tone parameters due to an insufficient number of studies; however, results of these studies suggested greater PFM stiffness and reduced PFM flexibility in women with PNCPP than in women without.

CLINICAL IMPLICATIONS

Available evidence suggests that women with PNCPP have increased PFM tone, which could be targeted by treatments.

STRENGTHS AND LIMITATIONS

A comprehensive search strategy was used with no restriction on language or date to review studies evaluating PFM tone parameters between women with and without PNCPP. However, meta-analyses were not undertaken for all parameters because few included studies measured the same PFM tone properties. There was variability in the methods used to assess PFM tone, all of which have some limitations.

CONCLUSION

Women with PNCPP have higher PFM tone than women without PNCPP; therefore, future research is required to understand the strength of the relationship between pelvic pain and PFM tone and to investigate the effect of treatment modalities to reduce PFM tone on pelvic pain in this population.

Myofascial Pelvic Pain: Best Orientation and Clinical Practice. Position of the European Association of Urology Guidelines Panel on Chronic Pelvic Pain

CONTEXT

Despite the high prevalence of a myofascial pain component in chronic pelvic pain (CPP) syndromes, awareness and management of this component are lacking among health care providers.

OBJECTIVE

To summarize the current state of the art for the management of myofascial pain in chronic primary pelvic pain syndromes (CPPPS) according to scientific research and input from experts from the European Association of Urology (EAU) guidelines panel on CPP.

EVIDENCE ACQUISITION

A narrative review was undertaken using three sources: (1) information in the EAU guidelines on CPP; (2) information retrieved from the literature on research published in the past 3 yr on myofascial pelvic pain; and (3) expert opinion from panel members.

EVIDENCE SYNTHESIS

Studies confirm a high prevalence of a myofascial pain component in CPPPS. Examination of the pelvic floor muscles should follow published recommendations to standardize findings and disseminate the procedure. Treatment of pelvic floor muscle dysfunction and pain in the context of CPP was found to contribute to CPP control and is feasible via different physiotherapy techniques. A multidisciplinary approach is the most effective.

CONCLUSIONS

Despite its high prevalence, the myofascial component of CPP has been underevaluated and undertreated to date. Myofascial pain must be assessed in all patients with CPPPS. Treatment of the myofascial pain component is relevant for global treatment success. Further studies are imperative to reinforce and better define the role of each physiotherapy technique in CPPPS.

PATIENT SUMMARY

Pain and inflammation of the body's muscle and soft tissues (myofascial pain) frequently occurs in pelvic pain syndromes. Its presence must be evaluated to optimize management for each patient. If diagnosed, myofascial pain should be treated.

A systematic review of diagnostic tests to detect pelvic floor myofascial pain

INTRODUCTION AND HYPOTHESIS

Myofascial pain arising from pelvic floor muscles occurs in women with vaginismus, interstitial cystitis and endometriosis but is often overlooked. The aim is to examine alternative diagnostic tests to detect pelvic floor myofascial pain compared with standardized vaginal palpation of pelvic floor muscles as the reference test.

METHODS

A systematic review was prospectively conducted (PROSPERO-CRD42020183092) according to PRISMA guidelines. Databases searched included Ovid Medline 1946-, Embase 1957-, Scopus 1960-, Cochrane Combined, Clinical trials, Google Scholar (top 200 articles), Web of Science, TRIP, BIOSIS, DARE, CINHAL, EmCare, PEDro, ProQuest and EBSCOhost up to July 2020. Articles were independently screened by two authors and assessed for bias using QUASDAS-2 tool.

RESULTS

A total of 26,778 articles were screened and 177 were selected for full text review, of which 5 were selected for final analysis. Five studies included 9694 participants of which 1628 had pelvic floor myofascial pain. Only one study reported data to calculate sensitivities and specificities of the index test, which utilized a score of > 40 on the Central Sensitization Inventory to detect women with pelvic floor myofascial pain and revealed a sensitivity of 34.8% and a specificity of 84.9% compared to the reference test.

CONCLUSIONS

This systematic review did not reveal any diagnostic test superior to the pre-defined reference test. There is a lack of consensus on the definition of pelvic floor myofascial pain and a lack of a validated diagnostic criteria which must be addressed to progress with meaningful research in this field.

Factors Associated With Myofascial Dysfunction of the Pelvic Floor Muscles in Women With Urinary Incontinence: A Cross-Sectional Study

OBJECTIVES

This study aimed to evaluate the prevalence and associated factors of pelvic floor myofascial dysfunction (PFMD) in women with urinary incontinence (UI).

METHODS

A cross-sectional study was performed. Pelvic floor myofascial dysfunction was defined by pain of any intensity during palpation of the pelvic floor muscles and strength assessed by the modified Oxford scale, and was classified in grade I (mild pain), grade II (moderate), and grade III (severe). Univariate and multivariate analyses were calculated (5% significance level) to seek for the associated factors of PFMD.

RESULTS

A total of 234 women with UI were included, 121 women in the PFMD group and 113 in the control group. The mean ages were 52.1 ± 10.2 and 53 ± 8.1 years, respectively. Pelvic floor myofascial dysfunction was more frequent among non-White women, and women with PFMD presented more dyspareunia and recurrent urinary tract infection. There was a higher frequency of mixed UI (MUI; 89.2%) in the PFMD group and stress UI (31.9%) in the control group. The prevalence of PFMD was 51.7%, with 10.6% of patients categorized into grade I, 18.8% in grade II, and 22.2% in grade III. In women with PFMD, there is an inverse relation between pain and muscle strength, with the highest strength values (3, 4, and 5) being in grade I (P = 0.028). The multivariate analysis has shown that women with MUI had a risk 4.9 times greater (adjusted odds ratio, 4.93 [2.34-10.42]; P < 0.001) of having PFMD, and non-White women had a 2.1-fold increased risk (adjusted odds ratio, 2.07 [1.10-3.91]; P = 0.024) of presenting with PFMD.

CONCLUSIONS

A high prevalence of PFMD was found among women with UI. Mixed UI and non-White race were the associated factors of PFMD.

Management of chronic primary pelvic pain syndromes

Management of chronic pelvic pain (CPP) remains a huge challenge for care providers and a major burden for healthcare systems. Treating chronic pain that has no obvious cause warrants an understanding of the difficulties in managing these conditions. Chronic pain has recently been accepted as a disease in its own right by the World Health Organization, with chronic pain without obvious cause being classified as chronic primary pain. Despite innumerable treatments that have been proposed and tried to date for CPP, unimodal therapeutic options are mostly unsuccessful, especially in unselected individuals. In contrast, individualised multimodal management of CPP seems the most promising approach and may lead to an acceptable situation for a large proportion of patients. In the present review, the interdisciplinary and interprofessional European Association of Urology Chronic Pelvic Pain Guideline Group gives a contemporary overview of the most important concepts to successfully diagnose and treat this challenging disease.

An International Continence Society (ICS) report on the terminology for pelvic floor muscle assessment

INTRODUCTION

The terminology for female and male pelvic floor muscle (PFM) assessment has expanded considerably since the first PFM function and dysfunction standardization of terminology document in 2005. New terms have entered assessment reports, and new investigations to measure PFM function and dysfunction have been developed. An update of this terminology was required to comprehensively document the terms and their definitions, and to describe the assessment method and interpretation of the finding, to standardize assessment procedures and aid diagnostic decision making.

METHODS

This report combines the input of members of the Standardisation Committee of the International Continence Society (ICS) Working Group 16, with contributions from recognized experts in the field and external referees. A logical, sequential, clinically directed assessment framework was created against which the assessment process was mapped. Within categories and subclassifications, each term was assigned a numeric coding. A transparent process of 12 rounds of full working group and external review was undertaken to exhaustively examine each definition, plus additional extensive internal development, with decision making by collective opinion (consensus).

RESULTS

A Terminology Report for the symptoms, signs, investigations, and diagnoses associated with PFM function and dysfunction, encompassing 185 separate definitions/descriptors, has been developed. It is clinically based with the most common assessment processes defined. Clarity and user-friendliness have been key aims to make it interpretable by clinicians and researchers of different disciplines.

CONCLUSION

A consensus-based Terminology Report for assessment of PFM function and dysfunction has been produced to aid clinical practice and be a stimulus for research.

Chronic Pelvic Pain: ACOG Practice Bulletin, Number 218

Chronic pelvic pain is a common, burdensome, and costly condition that disproportionately affects women. Diagnosis and initial management of chronic pelvic pain in women are within the scope of practice of specialists in obstetrics and gynecology. The challenging complexity of chronic pelvic pain care can be addressed by increased visit time using appropriate coding modifiers, as well as identification of multidisciplinary team members within the practice or by facilitated referral. This Practice Bulletin addresses the diagnosis and management of chronic pelvic pain that is not completely explained by identifiable pathology of the gynecologic, urologic, or gastrointestinal organ systems. When evidence on chronic pelvic pain treatment is limited, recommendations are extrapolated from treatment of other chronic pain conditions to help guide management. The evaluation and management of potential gynecologic etiologies of pelvic pain (ie, endometriosis, adenomyosis, leiomyomas, adnexal pathology, vulvar disorders) are discussed in other publications of the American College of Obstetricians and Gynecologists ().

Pelvic floor muscle tenderness on digital palpation among women: convergent validity with central sensitization

BACKGROUND

Tenderness on palpation of the pelvic floor muscles (PFMs) is a clinical assessment tool used alongside other tests to identify PFM involvement in pelvic complaints including pelvic pain. Although reliability of PFM tenderness has been determined, validity has yet to be established.

OBJECTIVES

To assess convergent validity of PFM tenderness on digital palpation with the presence of central pain mechanism, as determined by a score of greater than 40 on the Central Sensitization Inventory (CSI). A secondary objective was to assess the agreement between PFM tenderness and self-reported symptoms of PFM sensitivity.

METHODS

Participants completed a battery of self-report questions, the CSI, and various physical assessments (blinded assessors). Convergent validity was assessed between tenderness on palpation and the CSI. Kappa statistics were used to determine agreement between tenderness on palpation and self-reported perineal pain, urinary urgency, dyspareunia, and dysmenorrhea.

RESULTS

Ninety-nine female participants with hip or back pain and at least one self-reported symptom of pelvic floor dysfunction were included in the study (mean age 40.56±12.72 years). Convergent validity was found between PFM tenderness on palpation and scores greater than 40 on the CSI (X₁²=4.2,p=0.04). There was poor agreement between tenderness on palpation with dyspareunia (agreement 62.83%, Kappa=0.27), dysmenorrhea (agreement 55.75%, Kappa=0.14), or perineal pain (agreement 53.04%, Kappa=0.10).

CONCLUSIONS

PFM tenderness on digital palpation confirmed convergent validity with CSI scores, suggesting central pain mechanisms. Clinicians may need to consider the role of central pain mechanisms in their clinical decision making when treating PFM dysfunction.

Predictors of Pelvic Floor Muscle Dysfunction Among Women With Lumbopelvic Pain

BACKGROUND

There is evidence to suggest that a large proportion of individuals seeking care for lumbopelvic pain also have pelvic floor muscle dysfunction (PFMD). Because the majority of physical therapists do not have the requisite training to adequately assess pelvic floor musculature, determining predictors of PFMD could be clinically useful.

OBJECTIVE

The objective was to establish a combination of factors (self-report and physical) predictive of PFMD in women with lumbopelvic pain.

DESIGN

This was a cross-sectional study.

METHODS

Participants completed a battery of self-report and physical assessments (masked assessors). Three clinical findings characterized PFMD: weakness of the pelvic floor, lack of coordination of the pelvic floor, and pelvic floor muscle tenderness on palpation (bilateral obturator internus). Univariate and multivariate logistic regression analyses were used to determine the extent to which different predictors were associated with PFMD.

RESULTS

One hundred eight women with self-reported lumbopelvic pain (within the past week) were included in the study (mean age = 40.4 years; SD = 12.6 years). None of the examined factors predicted pelvic floor muscle weakness. Two factors independently predicted pelvic floor muscle tenderness on palpation: very strong and/or uncontrollable urinary urges (odds ratio [OR] = 2.93; 95% confidence interval [CI] = 1.13-7.59) and Central Sensitization Inventory scores of 40 or greater (OR = 3.13; 95% CI = 1.08-9.10).

LIMITATIONS

The sample consisted of young women, some of whom were not actively seeking care. Additionally, the technique for assessing pelvic floor muscle tenderness on palpation requires further validation.

CONCLUSIONS

Women who have lumbopelvic pain, uncontrollable urinary urgency, and central sensitization were, on average, 2 times more likely to test positive for pelvic floor muscle tenderness on palpation. Further studies are needed to validate and extend these findings.

How Does Myofascial Physical Therapy Attenuate Pain in Chronic Pelvic Pain Syndrome?

Background

Chronic pelvic pain syndrome (CPPS) is a multifactorial disorder comprising structural and functional muscular abnormalities, a dysfunctional pain system, and psychological distress. Myofascial physical Therapy (MPT) that is targeted at improving pelvic muscle functioning is considered a first line nonpharmacological treatment for CPPS, although the precise mechanisms that lead to symptoms alleviation have not yet been elucidated.

Purpose

This longitudinal study aimed to examine the local and systemic effects of MPT intervention, including biopsychophysiological processes, among CPPS patients.

Methods

The study included 50 CPPS women. Morphologic assessment of the levator ani and quantitative sensory testing of the pain system were applied alongside with evaluation of pain-related psychological factors using designated questionnaires. All measures were evaluated both before and after MPT in 39 patients. The long-term effects of MPT were evaluated by clinical pain reports obtained at 3 and 9 months following MPT that were compared with a nontreated group of 11 untreated CPPS women.

Results

Along with an improvement in the clinical pain intensity (p = 0.001) and sensitivity to experimental pain tests (p = 0.001) following MPT, the results also indicate that MPT has anatomical, psychological, and social therapeutic effects (p = 0.04; p = 0.001; p = 0.01, respectively). Furthermore, clinical pain evaluation at 3 and 9 months after MPT revealed a significant improvement in women who received treatment (p = 0.001).

Conclusions

The findings of this pilot study suggest multisystemic (direct and indirect anatomical, neurophysiological, and psychological) effects of MPT on the multifactorial pain disorder of CPPS and therefore place MPT as a mechanism-based intervention.

A Narrative Review of Musculoskeletal Impairments Associated With Nonspecific Chronic Pelvic Pain

The purpose of this narrative review is to present the evidence relating to musculoskeletal impairments found in people with nonspecific chronic pelvic pain (CPP). The musculoskeletal impairments assessed in this review include pelvic floor muscle: performance, resting state, strength, activation, posture and movement patterns. A search was performed systematically using PubMed, Cochrane, CINAHL, Embase, and Web of Science databases from 1998 to 2018 to identify studies reporting the relationship between nonspecific CPP and musculoskeletal impairments of the hip, pelvis, and trunk. The search resulted in 2106 articles that were screened by two authors. Remaining articles were screened by an additional two authors for inclusion in this review. Thirty-one articles remained after initial screening. Full-text publications were reviewed and an additional 25 articles were excluded. Six additional articles were located through review of the reference lists of included articles. The final review included 12 publications. Seven of these studies were cross-sectional cohorts or case-control comparing patients with CPP to asymptomatic controls. The level of evidence for the studies included in this review was low at Levels 4 and 5. We were unable to draw clear conclusions regarding the relationships of musculoskeletal impairments and CPP because validity and use of terms and assessments were inconsistent. Further research is needed with standardized definitions and measurements to better understand the musculoskeletal system as it relates to nonspecific CPP.

Enhancing Pelvic Health: Optimizing the Services Provided by Primary Health Care Teams in Ontario by Integrating Physiotherapists

Purpose: The purpose of this review was threefold: (1) to outline the current landscape of service provision for two common pelvic floor disorders, urinary incontinence (UI) and pelvic organ prolapse (POP); (2) to describe common pelvic floor dysfunctions (UI and POP) and the associated evidence-based, conservative care; and (3) to present the potential to integrate physiotherapists into inter-professional primary health care teams to optimize the provision of care for these disorders. Method: A literature review was undertaken and a case study was developed to describe evidence-informed conservative care for pelvic floor dysfunctions. Results: A variety of models exist to treat pelvic floor disorders. Physiotherapists and nurses are key care providers, and their scope and care provision overlaps. In Ontario specifically, both nurses and physiotherapists with additional postgraduate training in pelvic floor disorders are integrated into primary health care, but only to a very limited degree, and they are arguably well positioned to leverage their skills in their respective scopes of practice to optimize the provision of pelvic health care. Conclusions: Physiotherapists and nurses are shown to be key providers of effective, conservative care to promote pelvic health. There is an opportunity to integrate these types of provider into primary care organizations in Ontario; this collaborative care could translate into improved outcomes for patients and the health care system at large.

Physical examination techniques for the assessment of pelvic floor myofascial pain: a systematic review

BACKGROUND

Myofascial pain is characterized by the presence of trigger points, tenderness to palpation, and local or referred pain, and commonly involves the pelvic floor muscles in men and women. Pelvic floor myofascial pain in the absence of local or referred pain has also been observed in patients with lower urinary tract symptoms, and we have found that many patients report an improvement in these symptoms after receiving myofascial-targeted pelvic floor physical therapy.

OBJECTIVE

We sought to systematically review the literature for examination techniques used to assess pelvic floor myofascial pain in women.

STUDY DESIGN

We performed a systematic literature search using strategies for the concepts of pelvic floor disorders, myofascial pain, and diagnosis in Ovid MEDLINE 1946-, Embase 1947-, Scopus 1960-, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effects, and Cochrane Database of Systematic Reviews. Articles were screened by 3 authors and included if they contained a description of a pelvic myofascial physical examination.

RESULTS

In all, 55 studies met our inclusion criteria. Overall, examination components varied significantly among the included studies and were frequently undefined. A consensus examination guideline was developed based on the available data and includes use of a single digit (62%, 34/55) to perform transvaginal palpation (75%, 41/55) of the levator ani (87%, 48/55) and obturator internus (45%, 25/55) muscles with a patient-reported scale to assess the level of pain to palpation (51%, 28/55).

CONCLUSION

Physical examination methods to evaluate pelvic musculature for presence of myofascial pain varied significantly and were often undefined. Given the known role of pelvic floor myofascial pain in chronic pelvic pain and link between pelvic floor myofascial pain and lower urinary tract symptoms, physicians should be trained to evaluate for pelvic floor myofascial pain as part of their physical examination in patients presenting with these symptoms. Therefore, the development and standardization of a reliable and reproducible examination is needed.

Clinical functional evaluation of female's pelvic floor: integrative review

Abstract Introduction: The effectiveness of pelvic floor muscle training (PFMT) depends on the correct prescription of intensity, repetition and endurance of muscle contractions, which are provided by an adequate assessment of pelvic floor muscle. Objective: Verify the techniques, resources and strategies used for clinical functional evaluation of female pelvic floor (PF) described in literature. Methods: It’s an integrative review of published studies and books from 2010 until December 2015. Relevant articles with complete description of PF evaluation were found through the use of Scielo, LILACS, PubMed and Medline databases. Results: 34 articles that fulfilled all the criteria were selected. Conclusion: The most used techniques, resources and strategies were: anamnesis, physical examination, measurement of pelvic floor muscle activity using Modified Oxford Scale or perineometry, and use of questionnaires to analyze patient's perspective of their own symptoms. Thus, we could use the parameters obtained in the evaluation to plan an ideal PFMT for each patient, so the physiotherapist would have a good database to analyze the evolution and define the end of therapy.

Association between lumbopelvic pain and pelvic floor dysfunction in women: A cross sectional study

BACKGROUND

The prevalence, cost and disability associated with lumbopelvic pain continues to rise despite the range of available therapeutic interventions, indicating a deficiency in current approaches. A literature base highlighting a correlation between lumbopelvic pain and pelvic floor function is developing; however, the features that characterize this correlation have yet to be fully established.

PURPOSE

The purpose of this study was to determine the prevalence and characteristics of pelvic floor muscle function among women with lumbopelvic pain.

METHODS

A cross-sectional study was conducted on non-pregnant women presenting with lumbopelvic pain to one of seven outpatient orthopaedic clinics in Canada. Potential participants underwent a screening process to assess for pelvic floor muscle dysfunction.

RESULTS

A total of 182 women were recruited and 97 were excluded, leaving 85 participants (n = 85). Of these, 95.3% were determined to have some form of pelvic floor dysfunction. Specifically, 71% of the participants had pelvic floor muscle tenderness, 66% had pelvic floor weakness and 41% were found to have a pelvic organ prolapse. Participants with combined low back pain and pelvic girdle pain presented with higher levels of disability and increased characteristics of pelvic floor dysfunction.

CONCLUSIONS

Our findings corroborate and extend recent research supporting the hypothesis that a high proportion of pelvic floor muscle dysfunction is present among women with lumbopelvic pain. Specifically, increased pelvic floor muscle pressure-pain sensitivity represented the most frequent characteristic, the clinical implications of which require further study.

Pain, psychological distress and motor pattern in women with provoked vestibulodynia (PVD) – symptom characteristics and therapy suggestions

Background and aims:

Provoked vestibulodynia (PVD) represent a longstanding pain syndrome that affects large numbers of women worldwide. However, no standardized guidelines for PVD treatment exist. In a cross-sectional pilot study we examined 30 PVD patients on multidimensional parameters including pain, psychological distress and quality of movement, in order to obtain a broader understanding of the somatic and psychological symptoms in PVD, and for the future to develop better interventions. Additionally, we compare the findings to previously published results regarding the same parameters in women with chronic pelvic pain (CPP).

Methods:

Thirty women with PVD recruited from a tertiary care university clinic of gynecology were assessed for demographic data, pain intensity (VAS), psychological distress (GHQ-30 and Tampa scale of Kinesophobia) and quality of movement (standardized Mensendieck test, SMT).

Results:

Average age of the PVD women was 24.7±3.60 years, 60% of them were in permanent relationships, all were nulliparous, none had been subjected to surgical procedures, 100% were working full or part time and 90% were educated to at least undergraduate level. Mean VAS score was 7.77±1.97 (mean±SD), kinesiophobia 24.4±3.95 and anxiety domain of GHQ-30 9.73±4.06. SMT scores were particularly low for the domains of respiration and gait (less than 50% of optimal scores).

Conclusions:

PVD women display reduced quality of movement, especially for gait and respiration patterns, increased level of anxiety and high average pain scores. These findings are similar to what we have previously reported in CPP patients. However, in contrast to CPP group, PVD women are on average younger, have higher work participation, higher education level and have not been subjected to surgical procedures.

Implications:

Since PVD women display similar, although somewhat less severe, symptom profile than CPP, we suggest that a multidimensional approach to treatment, such as “somatocognitive therapy” should be investigated in this group as it has previously been shown to be promising in treatment of CPP.

Chronic Pelvic Pain: Assessment, Evaluation, and Objectivation

Chronic Pelvic Pain (CPP) and Chronic Pelvic Pain Syndrome (CPPS) have a significant impact on men and women of reproductive and nonreproductive age, with a considerable burden on overall quality of life (QoL) and on psychological, functional, and behavioural status. Moreover, diagnostic and therapeutic difficulties are remarkable features in many patients. Therefore evaluation, assessment and objectivation tools are often necessary to properly address each patient and consequently his/her clinical needs. Here we review the different tools for pain assessment, evaluation, and objectivation; specific features regarding CPP/CPPS will be highlighted. Also, recent findings disclosed with neuroimaging investigations will be reviewed as they provide new insights into CPP/CPPS pathophysiology and may serve as a tool for CPP assessment and objectivation.

Overactive pelvic floor muscles (OPFM): improving diagnostic accuracy with clinical examination and functional studies

Background

To identify the functional correlation of overactive pelvic floor muscles (OPFM) with cystoscopic and fluoroscopic urodynamic studies (FUDS), including urethral pressure measurements.

Methods

Patients refractory to conservative therapy including bladder retraining, medications and pelvic muscle exercises for a variety of gamut of storage and voiding disorders were evaluated. Prospective data for 201 patients across both genders who underwent flexible cystoscopy and urodynamics for lower urinary tract symptoms (LUTS) refractory to conservative management between 01 Jan 2014 and 01 Jan 2016 was collected. Factors studied included history of LUTS, voiding patterns, physical examination, cystoscopic findings and functional studies, with maximum urethral closing pressure (MUCP).

Results

A total of 201 were patients recruited. The 85 were diagnosed with OPFM based on clinical presentation and presence of pelvic floor tenderness on examination. Significant differences were noted on functional studies with FUDS and urethral pressure measurement. Subjects with pelvic floor tenderness were found to have a higher (MUCP) at 93.1 cm H2O compared to 80.6 cm H2O (P=0.015).

Conclusions

There are distinct characteristics of OPFM on clinical examination and functional studies, in particular MUCP. In patients refractory to conservative treatments, specific urodynamics tests are useful in sub-categorising patients. When OPFM is diagnosed, the impact on patient management is significant, and targeted intervention with pelvic floor physiotherapy is central in the multimodal approach of this complex condition.

Do Vulvodynia TCM Patterns Differ by Pain Types? Beginning Evidence Supporting the Concept

INTRODUCTION

Vulvodynia affects a maximum of 14 million U.S. women; however, it has not been adequately characterized. Traditional Chinese Medicine (TCM) offers pattern diagnoses that may be considered vulvodynia phenotypes and may guide the development of more targeted treatments.

OBJECTIVES

In women with vulvodynia, to explore relationships between the TCM patterns and pain.

DESIGN/METHODS

In an exploratory study, 36 women diagnosed with vulvodynia had a TCM assessment and completed the Short Form McGill Pain Questionnaire (SF-MPQ).

RESULTS

All 36 women were diagnosed with one of the two TCM patterns (excess heat [n = 28] or excess cold [n = 8]). Although not statistically significant, (1) the excess heat pattern group had a higher mean sensory score (14.4 ± 6.0) and mean affective pain score (4.1 ± 2.8) (more pain) compared with the mean sensory score (13.3 ± 5.9) and mean affective score (3.3 ± 1.8) of the excess cold pattern group; (2) there was a higher mean score for neuropathic sensory descriptors in the excess heat pattern group (1.55 ± .58) compared with the excess cold pattern group (1.16 ± 0.72); and (3) there was a higher mean score for nociceptive sensory descriptors in the excess cold pattern group (1.23 ± 0.45) compared with the excess heat pattern group (1.14 ± 0.62). The difference in the hot-burning mean score between the two TCM pattern groups was statistically significant (t [34] = 6.55, p < 0.0001).

CONCLUSION

Intriguing trends were observed in the pain scores for the two TCM pattern groups. The possibility that TCM pattern groups have different types of pain (neuropathic vs. nociceptive) deserves further research in larger samples. If these exploratory findings are confirmed, the characterization of TCM patterns could lead to new treatments for vulvodynia.

Multimodal nociceptive mechanisms underlying chronic pelvic pain

OBJECTIVE

We sought to evaluate candidate mechanisms underlying the pelvic floor dysfunction in women with chronic pelvic pain (CPP) and/or painful bladder syndrome (PBS)/interstitial cystitis. Notably, prior studies have not consistently controlled for potential confounding by psychological or anatomical factors.

STUDY DESIGN

As part of a larger study on pelvic floor pain dysfunction and bladder pain sensitivity, we compared a measure of mechanical pain sensitivity, pressure pain thresholds (PPTs), between women with pelvic pain and pain-free controls. We also assessed a novel pain measure using degree and duration of postexam pain aftersensation, and conducted structural and functional assessments of the pelvic floor to account for any potential confounding. Phenotypic specificity of pelvic floor measures was assessed with receiver operator characteristic curves adjusted for prevalence.

RESULTS

A total of 23 women with CPP, 23 women with PBS, and 42 pain-free controls completed the study. Women with CPP or PBS exhibited enhanced pain sensitivity with lower PPTs (1.18 [interquartile range, 0.87-1.41] kg/cm(2)) than pain-free participants (1.48 [1.11-1.76] kg/cm(2); P < .001) and prolonged pain aftersensation (3.5 [0-9] vs 0 [0-1] minutes; P < .001). Although genital hiatus (P < .01) was wider in women with CPP there were no consistently observed group differences in pelvic floor anatomy, muscle tone, or strength. The combination of PPTs and aftersensation duration correlated with severity of pelvic floor tenderness (R(2), 41-51; P < .01). Even after adjustment for prevalence, the combined metrics discriminated pain-free controls from women with CPP or PBS (area under the curve, 0.87).

CONCLUSION

Both experimental assessment of pelvic floor pain thresholds and measurement of sustained pain are independently associated with pelvic pain phenotypes. These findings suggest systematic clinical assessment of the time course of provoked pain symptoms, which occurs over seconds for mechanical pain thresholds vs minutes for aftersensation pain, would be helpful in identifying the fundamental mechanisms of pelvic floor pain. Longitudinal studies of therapies differentially targeting these discrete mechanisms are needed to confirm their clinical significance.