A pilot randomized trial of levator injections versus physical therapy for treatment of pelvic floor myalgia and sexual pain

Myofascial pelvic pain: the forgotten player in chronic pelvic pain

PURPOSE OF REVIEW

In this review article, we discuss myofascial-related chronic pelvic pain, pathophysiology, symptomology, and management options.

RECENT FINDINGS

Despite high prevalence of myofascial pelvic pain, screening is not routinely performed by providers. Treatment modalities include pelvic floor physical therapy, pelvic floor trigger point injections with anesthetics or botulinum toxin A and cryotherapy. Other adjunct modalities, such as muscle relaxants and intravaginal benzodiazepines, are used, but data regarding their effectiveness is sparse.

SUMMARY

Myofascial pelvic pain is an important, though overlooked component of chronic pelvic pain. Multimodal, multidisciplinary approach including patient education, pelvic floor physical therapy, and trigger point injections is the mainstay of the management of myofascial pelvic pain.

Trigger point injections followed by immediate myofascial release in the treatment of pelvic floor tension myalgia

PURPOSE

Pelvic floor physical therapy (PFPT) is first-line therapy for treatment of pelvic floor tension myalgia (PFTM). Pelvic floor trigger point injections (PFTPI) are added if symptoms are refractive to conservative therapy or if patients experience a flare. The primary objective was to determine if a session of physical therapy with myofascial release immediately following PFTPI provides improved pain relief compared to trigger point injection alone.

METHODS

This was a retrospective cohort analysis of 87 female patients with PFTM who underwent PFTPI alone or PFTPI immediately followed by PFPT. Visual analog scale (VAS) pain scores were recorded pre-treatment and 2 weeks post-treatment. The primary outcome was the change in VAS between patients who received PFTPI alone and those who received PFTPI followed by myofascial release.

RESULTS

Of the 87 patients in this study, 22 received PFTPI alone and 65 patients received PFTPI followed by PFPT. The median pre-treatment VAS score was 8 for both groups. The median post-treatment score was 6 for the PFTPI only group and 4 for the PFTPI followed by PFPT group, showing a median change in VAS score of 2 and 4, respectively (p = 0.042). Seventy-seven percent of patients in the PFTPI followed by PFPT group had a VAS score improvement of 3 or more, while 45% of patients in the PFTPI only group had a VAS score improvement greater than 3 (p = 0.008).

CONCLUSION

PFTPI immediately followed by PFPT offered more improvement in pain for patients with PFTM. This may be due to greater tolerance of myofascial release immediately following injections.

Non-pharmacological therapies for treating chronic pelvic pain in women: A review

Chronic pelvic pain (CPP) is an intricate condition with multiple etiologies that lead to indefinite pain mechanisms. Physicians and researchers are challenged in its treatment, and the combined therapy of pharmacologic and non-pharmacologic treatment has been recognized as a multidisciplinary approach cited by guidelines and adopted in clinical practice. As an alternative therapy for CPP, non-pharmacologic therapies benefit patients and deserve further study. This study reviews the literature published from January 1991 to April 2022 on non-pharmacologic therapies for CPP in adult women. Based on a survey, this review found that the most commonly used non-pharmacological therapies for CPP include pelvic floor physical therapy, psychotherapy, acupuncture, neuromodulation, and dietary therapy. By evaluating the efficacy and safety of each therapy, this study concluded that non-pharmacological therapies should be included in the initial treatment plan because of their high degree of safety and low rate of side effects. To fill the lack of data on non-pharmacologic therapies for CPP, this study provides evidence that may guide treatment and pain management.

Clinical Management of Chronic Pelvic Pain in Endometriosis Unresponsive to Conventional Therapy

Background: Although several treatments are currently available for chronic pelvic pain, 30–60% of patients do not respond to them. Therefore, these therapeutic options require a better understanding of the mechanisms underlying endometriosis-induced pain. This study focuses on pain management after failure of conventional therapy. Methods: We reviewed clinical data from 46 patients with endometriosis and chronic pelvic pain unresponsive to conventional therapies at Puerta de Hierro University Hospital Madrid, Spain from 2018 to 2021. Demographic data, clinical and exploratory findings, treatment received, and outcomes were collected. Results: Median age was 41.5 years, and median pain intensity was VAS: 7.8/10. Nociceptive pain and neuropathic pain were identified in 98% and 70% of patients, respectively. The most common symptom was abdominal pain (78.2%) followed by pain with sexual intercourse (65.2%), rectal pain (52.1%), and urologic pain (36.9%). A total of 43% of patients responded to treatment with neuromodulators. Combined therapies for myofascial pain syndrome, as well as treatment of visceral pain with inferior or superior hypogastric plexus blocks, proved to be very beneficial. S3 pulsed radiofrequency (PRF) plus inferior hypogastric plexus block or botulinum toxin enabled us to prolong response time by more than 3.5 months. Conclusion: Treatment of the unresponsive patient should be interdisciplinary. Depending on the history and exploratory findings, therapy should preferably be combined with neuromodulators, myofascial pain therapies, and S3 PRF plus inferior hypogastric plexus blockade.

Therapeutic interventions to urologic chronic pelvic pain syndrome and UPOINT system for clinical phenotyping: How far are we?

The assessment and management of urologic chronic pelvic pain syndrome (UCPPS), is controversial. It is classified by voiding symptoms, pelvic pain, and bladder pain, which is weekly treated, weekly understood, and bothersome. In the aspect of clinical efforts and research to help people with this syndrome have been hampered by the deficiency of a widely reliable, accepted, and a valuable tool to evaluate the patient symptoms and quality of life (QoL) impact. However, the etiology comes into sight is multifactorial, and available treatment options have been imprecise considerably in present years. We compiled the published literature on the assessment of the syndrome, a tentative role of pharmacological and non-pharmacological (conservative, alternative, and invasive therapy) interventions in eradicating the disease as well as improving symptoms. The previously published literature on animal models has established the association of immune systems in the etiology, pathogenesis, and progression of the disease. The UPOINT system for clinical phenotyping of UCPPS patients has six predefined domains that direct multimodal therapy, which would lead to significant symptom improvement in the medical field. The narrative review aims to scrutinize the fluctuating scientist's views on the evaluation of patient and multimodal treatment of the UPOINT system.

Effect of Vaginal Stretching and Photobiomodulation Therapy on Sexual Function in Women with Pelvic Floor Myofascial Pain - A Randomized Clinical Trial

BACKGROUND

Spasm or increased tonus of the pelvic floor muscles (PFM) can cause myofascial pain (MP), which may result in painful intercourse and sexual dysfunction.

AIM

The effect of vaginal stretching (VS) with photobiomodulation therapy (PBMT) is compared to VS with sham PBMT in overall sexual function, rate and severity of painful intercourse at baseline and after treatment in women with pelvic floor MP.

METHODS

A double-blind randomized clinical trial of 103 women with MP: 1 group received 10 sessions of VS with PBMT (4 Joules of near-infrared light-808 nm at 3 points), and the other group received VS with sham PBMT.

OUTCOMES

Impact of treatment was measured by the number of women experiencing painful intercourse, Pain severity was measured by Visual Analog Scale and sexual function was assessed by the FSFI questionnaire. Variables were assessed at baseline and after ten sessions in the intervention groups.

RESULTS

After treatment, the number of women experiencing painful intercourse was significantly lower in both the VS with PBMT group (90.2-55%, P = .001), and VS with sham PBMT group (86.6-46.2%, P < .001). There was a significant reduction in pain measure by Visual Analog Scale (P < .001, [VS with PBMT group: P = .002; VS with sham PBMT group: P < .001]). There was a significant decrease in the number of participants with sexual dysfunction (FSFI score ≤26.55) after the treatment in the VS with PBMT group (92.2-74.5%, P = .003) and in the VS with sham PBMT group (90.4-76.9%, P = .035). Both groups showed improvement in the FSFI pain domain after treatment (P < .001, [VS with PBMT group: P = .038; VS with sham PBMT group: P = .005]). Only the VS with sham PBMT group had a significant increase in FSFI desire and total score (P < .001) after treatment.

CLINICAL IMPLICATIONS

We found that VS associated or not with PBMT may be effective in reducing complaints of painful intercourse, alleviating pain severity, and reducing the number of women with pelvic floor MP suffering from sexual dysfunction.

STRENGTHS & LIMITATIONS

Strengths of this study are the randomized design and use of validated questionnaires. Limitation of the study is the lack of a long follow-up period and the lack of a usual care comparison group hampers generalizability of the results.

CONCLUSION

VS only and VS with PBMT have short-term efficacy in reducing painful intercourse and reducing a number of women with sexual dysfunction.

Managing Female Sexual Pain

Female sexual pain disorder or genito-pelvic pain/penetration disorder (GPPPD), previously known as dyspareunia, is defined as persistent or recurrent symptoms with one or more of the following for at least 6 months: marked vulvovaginal or pelvic pain during penetrative intercourse or penetration attempts, marked fear or anxiety about vulvovaginal or pelvic pain in anticipation of, during, or as a result of penetration, and marked tensing or tightening of the pelvic floor muscles during attempted vaginal penetration. In this review, we discuss etiology, diagnosis, and treatment for common disorders that cause GPPD.

Bupivacaine Use After Posterior Colporrhaphy to Reduce Postoperative Pain: A Multicenter, Double-Blinded, Placebo-Controlled, Randomized Clinical Trial

OBJECTIVE

The aim of this study was to determine if injection of bupivacaine into levator muscles after posterior colporrhaphy reduces postoperative pain.

METHODS

This study was a multicenter, double-blinded, placebo-controlled, randomized clinical trial of 130 participants, comparing bilateral infiltration of puborectalis and iliococcygeus muscles with 0.5% bupivacaine without epinephrine or normal saline after vaginal prolapse repair that included a posterior colporrhaphy. Primary outcome was the 24-hour cumulative Visual Analog Scale (VAS) pain score (measured as a sum of VAS pain scores at postoperative hours 0, 4, 8, 16, and 24) across intervention allocations. Secondary outcomes include the individual VAS pain scores per postoperative times 0, 4, 8, 16, and 24 hours and at 1 and 2 weeks, morphine equivalent use, postoperative void trial success, and time to first bowel movement.

RESULTS

Sixty-eight participants received bupivacaine, and 62 participants received normal saline. No significant differences were identified in the 24-hour postoperative cumulative VAS pain scores for the bupivacaine and normal saline arms, 19 and 18 (P = 0.71); individual pain scores per each postoperative assessment time; opiate use (24-hour use was 42 vs 48, P = 0.39; 48-hour use was 75 vs 37, P = 0.09); length of hospital stay (26 hours vs 22 hours, P = 0.069); hours to passing void trial (10 hours vs 12 hours, P = 0.17); or hours to first postoperative bowel movement (18 hours vs 12 hours, P = 0.78).

CONCLUSIONS

Use of bupivacaine for muscle block after posterior colporrhaphy does not reduce postoperative pain, opiate use, and time to first bowel movement, or increase void trial success.

Interventional treatment for myofascial pelvic floor pain in women: systematic review with meta-analysis

INTRODUCTION AND HYPOTHESIS

Female myofascial pain (MFP) of the pelvic floor muscles (PFM) is a subtype of chronic pelvic pain associated with urinary, anorectal, and sexual symptoms, such as dyspareunia. Treatment remains poorly discussed, and we hypothesized that different treatments could improve outcomes versus placebo or no treatment.

METHODS

A systematic review (CRD 42020201419) was performed in June 2020 using the following databases: PubMed, Cochrane Library, Web of Science, Embase, Scopus, BVSalud, Clinicaltrials.gov , and PEDro, including randomized clinical trials related to MPF of PFM. Primary outcome was pain after treatment, and secondary outcomes were quality of life and sexual function. Risk of bias and quality of evidence (GRADE criteria) were evaluated. Meta-analysis for continuous variables was performed (mean difference between baseline and treatment and post-treatment mean between groups).

RESULTS

Five studies were included (n = 218). Final mean VAS score (GRADE: very low) after 4 weeks of treatment (p = 0.14) and the mean difference from baseline and 4 weeks (p = 0.66) between groups were not different between the intervention and control groups. Quality of life according to the SF-12 questionnaire (GRADE: very low) followed the same pattern. However, sexual function (GRADE: low) according to the total FSFI score (MD = -5.07 [-8.31, -1.84], p < 0.01, i² = 0%) and the arousal, orgasm, and pain domains improved in the intervention groups when the mean difference from baseline and 4 weeks was compared with controls.

CONCLUSION

Pain and quality of life after 4 weeks of heterogeneous intervention differed between the intervention and control groups in sexual function: FSFI in studies improved in almost all domains. VAS (in three studies) and SF-12 (in two studies) failed to demonstrate differences.

Compliance With Pelvic Floor Physical Therapy in Patients Diagnosed With High-Tone Pelvic Floor Disorders

OBJECTIVE

The primary objective of this study was to describe patient compliance with pelvic floor physical therapy (PFPT) for high-tone pelvic floor disorders (HTPFD) and to compare patients who are compliant with prescribed therapy to those who are not. The secondary objective is to describe second-line treatments offered for HTPFD for returning patients.

METHODS

This is a retrospective cohort study of women with a HTPFD who were prescribed PFPT at a tertiary care referral center. Patients were excluded if they had a primary diagnosis of urinary incontinence, had undergone prior PFPT, or if PFPT was part of preoperative planning. Noncompliance with PFPT was defined as not being formally discharged from therapy by the treating therapist.

RESULTS

Data on PFPT compliance were available for 662 patients (87.3%). A total of 128 patients (19.4%) were fully compliant. Noncompliant patients were more likely to smoke and to have mental health disease compared with compliant patients (18% vs 8.7%, P = 0.01, and 50.4% vs 37.5%, P = 0.009, respectively). A total of 285 patients (43.1%) returned to their prescribing provider. Noncompliant patients were less likely to return to their provider: 63.4% versus 29.7%, P = <0.0001. Of the patients who returned, 183 (64.2%) were offered second-line treatment.

CONCLUSIONS

Only 1 in 5 patients referred to PFPT for management of a high-tone pelvic floor disorder is compliant with the recommended therapy. Patients who are noncompliant are less likely to return to their prescribing provider, and less than half of referred patients return. Sixty percent of patients who return are offered second-line treatment.

Interdisciplinary Teams in Endometriosis Care

Endometriosis-associated chronic pelvic pain can at times be a complex problem that is resistant to standard medical and surgical therapies. Multiple comorbidities and central sensitization may be at play and must be recognized with the help of a thorough history and physical examination. If a complex pain problem is identified, most endometriosis expert reviews and guidelines recommend multidisciplinary care. However, there are no specific recommendations about what should be the components of this approach and how that type of team care should be delivered. There is evidence showing the effectiveness of specific interventions such as pain education, physical therapy, psychological therapies, and pharmacotherapies for the treatment of chronic pain. Interdisciplinary team models have been well studied and validated in other chronic pain conditions such as low back pain. The published evidence in support of interdisciplinary teams for endometriosis-associated chronic pain is more limited but appears promising. Based on the available evidence, a model for an interdisciplinary team approach for endometriosis care is outlined.

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 ().

Factors Associated With Nonadherence to Pelvic Floor Physical Therapy Referral for the Treatment of Pelvic Pain in Women

BACKGROUND

Patients with pelvic pain due to pelvic floor myofascial pain syndrome are often referred for pelvic floor physical therapy, the primary treatment option. However, many patients do not adhere to the treatment.

OBJECTIVE

The purpose of this study was to examine the adherence rate and outcomes of patients referred for physical therapy for pelvic floor myofascial pain syndrome and identify risk factors associated with nonadherence.

DESIGN

This was a retrospective cohort study.

METHODS

ICD-9 codes were used to identify a cohort of patients with pelvic floor myofascial pain syndrome during a 2-year time period within a single provider's clinical practice. Medical records were abstracted to obtain information on referral to physical therapy, associated comorbidities and demographics, and clinical outcomes. "Primary outcomes" was defined as attendance of at least 1 visit. Secondary outcomes included attendance of at least 6 physical therapist visits and overall improvement in pain. Statistical analysis was performed using chi-square, Fisher exact, and independent t tests. Nonparametric comparisons were performed using Wilcoxon signed rank test. Multivariate analysis was completed to adjust for confounders.

RESULTS

Of the 205 patients, 140 (68%) attended at least 1 session with physical therapy. At least 6 visits were attended by 68 (33%) patients. Factors associated with poor adherence included parity and a preexisting psychiatric diagnosis. The odds of attending at least 1 visit were 0.75 (95% confidence interval = 0.62-0.90) and 0.44 (95% confidence interval = 0.21-0.90), respectively. Patients who attended ≥ 6 visits were more likely to have private insurance (78%) and travel shorter distances to a therapist (mean = 16 miles vs 22). Patients with an improvement in pain (compared with those who were unchanged) attended an average of 3 extra physical therapist visits (mean = 6.9 vs 3.1).

LIMITATIONS

Limitations include reliance on medical records for data integrity; a patient population derived from a single clinic, reducing the generalizability of the results; the age of the data (2010-2012); and the likely interrelatedness of many of the variables. It is possible that maternal parity and psychiatric diagnoses are partial surrogates for social, logistic, or economic constraints and patient confidence.

CONCLUSIONS

Initial adherence to pelvic floor physical therapy was less likely for multiparous women and women with a history of psychiatric diagnosis. Persistent adherence was more likely with private insurance or if the physical therapist location was closer. Pain improvement correlated with increased number of physical therapist sessions.

Traditional Biofeedback vs. Pelvic Floor Physical Therapy-Is One Clearly Superior?

PURPOSE OF REVIEW

Pelvic floor physical therapy is a worldwide accepted therapy that has been exclusively used to manage many pelvic floor disorders in adults and children. The aim of this review is to suggest to clinicians an updated understanding of this therapeutic approach in management of children with non-neuropathic voiding dysfunction.

RECENT FINDINGS

Today, pelvic floor muscle training through biofeedback is widely used as a part of a voiding retraining program aiming to help children with voiding dysfunction which is caused by pelvic floor overactivity. Biofeedback on its own, without a pelvic floor training component, is not an effective treatment. Biofeedback is an adjunct to the pelvic floor training. In the current review, we develop the role of pelvic floor physical therapy in management of children with non-neuropathic voiding dysfunction and compare it with biofeedback therapy alone.

Deep Dyspareunia: Review of Pathophysiology and Proposed Future Research Priorities

INTRODUCTION

Dyspareunia has been traditionally divided into superficial (introital) dyspareunia and deep dyspareunia (pain with deep penetration). While deep dyspareunia can coexist with a variety of conditions, recent work in endometriosis has demonstrated that coexistence does not necessarily imply causation. Therefore, a reconsideration of the literature is required to clarify the pathophysiology of deep dyspareunia.

AIMS

To review the pathophysiology of deep dyspareunia, and to propose future research priorities.

METHODS

A narrative review after appraisal of published frameworks and literature search with the terms (dyspareunia AND endometriosis), (dyspareunia AND deep), (dyspareunia AND (pathophysiology OR etiology)).

MAIN OUTCOME VARIABLE

Deep dyspareunia (present/absent or along a pain severity scale).

RESULTS

The narrative review demonstrates potential etiologies for deep dyspareunia, including gynecologic-, urologic-, gastrointestinal-, nervous system-, psychological-, and musculoskeletal system-related disorders. These etiologies can be classified according to anatomic mechanism, such as contact with a tender pouch of Douglas, uterus-cervix, bladder, or pelvic floor, with deep penetration. Etiologies of deep dyspareunia can also be stratified into 4 categories, as previously proposed for endometriosis specifically, to personalize management: type I (primarily gynecologic), type II (nongynecologic comorbid conditions), type III (central sensitization and genito-pelvic pain/penetration disorder), and type IV (mixed). We also identified gaps in the literature, such as lack of a validated patient-reported questionnaire or an objective measurement tool for deep dyspareunia and clinical trials not powered for sexual outcomes.

CONCLUSION

We propose the following research priorities for deep dyspareunia: deep dyspareunia measurement tools, inclusion of the population avoiding intercourse due to deep dyspareunia, nongynecologic conditions in the generation of deep dyspareunia, exploration of sociocultural factors, clinical trials with adequate power for deep dyspareunia outcomes, partner variables, female sexual response, pathways between psychological factors and deep dyspareunia, and personalized approaches to deep dyspareunia. Orr N, Wahl K, Joannou A, et al. Deep Dyspareunia: Review of Pathophysiology and Proposed Future Research Priorities. Sex Med Rev 2020;8:3-17.

The Role of Physical Therapy in Sexual Health in Men and Women: Evaluation and Treatment

INTRODUCTION

Many conditions of pelvic and sexual dysfunction can be addressed successfully through pelvic floor physical therapy (PFPT) through various manual therapy techniques, neuromuscular reeducation, and behavioral modifications. The field of pelvic rehabilitation, including sexual health, continues to advance to modify these techniques according to a biopsychosocial model.

AIM

To provide an update on peer-reviewed literature on the role of PFPT in the evaluation and treatment of pelvic and sexual dysfunctions in men and women owing to the overactive and the underactive pelvic floor.

METHODS

A literature review to provide an update on the advances of a neuromusculoskeletal approach to PFPT evaluation and treatment.

MAIN OUTCOME MEASURE

The use and advancement of PFPT methods can help in successfully treating pelvic and sexual disorders.

RESULTS

PFPT for pelvic muscle overactivity and underactivity has been proven to be a successful option for pelvic and sexual dysfunction. Understanding the role of the organs, nerves, fascia, and musculoskeletal system in the abdomino-pelvic and lumbo-sacro-hip region and how pelvic floor physical therapists can effectively evaluate and treat pelvic and sexual health. It is important for the treating practitioner to know when to refer to PFPT.

CONCLUSION

Neuromusculoskeletal causes of pelvic floor disorders affect a substantial proportion of men, women, and children and PFPT is a successful and non-invasive option. Pelvic floor examination by healthcare practitioners is essential in identifying when to refer to PFPT. Use of a biopsychosocial model is important for the overall well-being of each patient. Further research is needed. Stein A, Sauder SK, Reale J. The role of physical therapy in sexual health in men and women: Evaluation and treatment. Sex Med Rev 2019;7:46-56.

The Efficacy of Manual Therapy for Treatment of Dyspareunia in Females: A Systematic Review

Background

Pelvic floor physical therapy is a noninvasive option for relieving pain associated with dyspareunia, genital pain associated with sexual intercourse. Manual therapy is a clinical approach used by physical therapists to mobilize soft tissues, reduce pain, and improve function. To date, the systematic efficacy of manual therapy for treating dyspareunia has not been investigated.

Objective

To examine the efficacy of manual therapy in reducing pelvic pain among females with dyspareunia.

Study Design

Systematic review.

Methods

A systematic literature search was conducted in MEDLINE, EMBASE, and CINAHL databases for articles published between June 1997 and June 2018. Articles were reviewed and selected on the basis of defined inclusion and exclusion criteria. The articles were assessed for quality using the PEDro and Modified Downs and Black scales.

Results

Three observational studies and 1 randomized clinical trial met inclusion criteria. The primary outcome measured was the pain subscale of the Female Sexual Function Index. All studies showed significant improvements in the pain domain of the Female Sexual Function Index (P < .5), corroborating manual therapy as a viable treatment in relieving pain associated with dyspareunia. However, the quality across studies ranged from poor to good.

Conclusions

Although these findings support the use of manual therapy for alleviating pain with intercourse, few studies exist to authenticate this claim. Moreover, the available studies were characterized by small sample sizes and were variable in methodological quality. More extensive research is needed to establish the efficacy of manual therapy for dyspareunia and the specific mechanisms by which manual therapy is beneficial.

The role of nonpharmacologic therapies in management of chronic pelvic pain: what to do when surgery fails

PURPOSE OF REVIEW

To provide an update on nonsurgical and nonpharmacologic strategies for the management of chronic pelvic pain (CPP).

RECENT FINDINGS

Effective treatment of patients with CPP requires a multifaceted approach, with thoughtful consideration of surgical, pharmacologic, and nonpharmacologic strategies. Evidence for physical therapy and trigger point injections for treatment of myofascial components of CPP is increasing. Neuromodulation techniques, such as percutaneous tibial nerve stimulation and transcutaneous electrical stimulation, have limited but favorable preliminary data in patients with CPP. Behavioral strategies, such as exercise, cognitive behavioral therapy, and mindfulness, have demonstrated significant improvements in pain, function and quality of life in patients with a variety of chronic pain conditions and are promising avenues for future research in CPP.

SUMMARY

Nonpharmacologic therapies are important adjuncts to surgical and pharmacologic treatment for CPP and should be considered integral to a comprehensive treatment approach.

Current best practice management of interstitial cystitis/bladder pain syndrome

Introduction

Over the last 100 years, the terminology and diagnosis criteria for interstitial cystitis have evolved. Many therapeutic options have changed, but others have endured. This article will review the idea of separating 'classic' Hunner lesion interstitial cystitis (HL IC) from non-Hunner lesion interstitial cystitis and bladder pain syndrome (N-HL IC/BPS) and their respective treatment algorithms.

Methods/Results

A literature search was performed to identify articles and research on HL IC and N-HL IC/BPS including definitions, etiological theories, and treatments. This article is an overview of the existing literature. We also offer insight into how HL IC and N-HL IC/BPS are approached at our tertiary referral center. Additionally, American Urological Association guidelines have been integrated and newer treatment modalities and research will be introduced at the conclusion.

Conclusion

The AUA guidelines have mapped out a stepwise fashion to treat IC/BPS; at our institution we separate patients with HL IC from those with N-HL IC/BPS prior to them entering a treatment pathway. We identify the rarer patient with HL as having classic 'IC'; this cystoscopic finding is critical in guiding treatment. We believe HL IC is a distinct disease from N-HL IC/BPS and therapy should focus on the bladder. The vast majority of patients with N-HL IC/BPS need management of their pelvic floor muscles as the primary therapy, complemented by bladder-directed therapies as needed as well as a multidisciplinary team to manage a variety of other regional/systemic symptoms. Ongoing research into IC/BPS will help us better understand the pathophysiology and phenotypes of this complex disease while exciting and novel research studies are developing promising treatments.

An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for the assessment of sexual health of women with pelvic floor dysfunction

AIMS

The terminology in current use for sexual function and dysfunction in women with pelvic floor disorders lacks uniformity, which leads to uncertainty, confusion, and unintended ambiguity. The terminology for the sexual health of women with pelvic floor dysfunction needs to be collated in a clinically-based consensus report.

METHODS

This report combines the input of members of the Standardization and Terminology Committees of two International Organizations, the International Urogynecological Association (IUGA), and the International Continence Society (ICS), assisted at intervals by many external referees. Internal and external review was developed to exhaustively examine each definition, with decision-making by collective opinion (consensus). Importantly, this report is not meant to replace, but rather complement current terminology used in other fields for female sexual health and to clarify terms specific to women with pelvic floor dysfunction.

RESULTS

A clinically based terminology report for sexual health in women with pelvic floor dysfunction encompassing over 100 separate definitions, has been developed. Key aims have been to make the terminology interpretable by practitioners, trainees, and researchers in female pelvic floor dysfunction. Interval review (5-10 years) is anticipated to keep the document updated and as widely acceptable as possible.

CONCLUSION

A consensus-based terminology report for female sexual health in women with pelvic floor dysfunction has been produced aimed at being a significant aid to clinical practice and a stimulus for research.

Physiotherapy for pelvic pain and female sexual dysfunction: an untapped resource

Introduction and hypothesis

Chronic pelvic pain (CPP) in women is a complex syndrome. Pain sensation and intensity often do not correspond with the identified lesion location but are felt elsewhere, leading to muskuloskeletal and myofascial disorders and sexual dysfunction (SD). Although physical aspects are prevalent, they are often underdiagnosed and undertreated due to lack of understanding regarding its origin and distribution. Frequently, patients experience pelvic pain as psychological distress resulting in physical complaints, leading clinicians to prescribe medication or surgical intervention to correct or alleviate these symptoms, often with insufficient results. Because pelvic floor muscle disorders contribute significantly to CPP and SD, there is rationale for physiotherapy. However, physiotherapy is a widely underused and untapped resource, which has its place in the multidisciplinary approach to these health problems.

Methods

Computer-aided and manual searches and methodological quality assessment were carried out for meta-analyses, systematic reviews, and randomized controlled trials (RCTs) published between 1990 and 2017 investigating classification, assessment, and (physiotherapeutic) treatment of pelvic pain and/or female SD defined by the keywords below. Expert opinions were sought via interviews.

Results

Due to a lack of sufficient relevant medical information, referral data, and test results, focused physiotherapy is difficult to administer adequately. However, recent quality studies indicate significant clinical effects of physiotherapy for CPP and female SD, and experts advocate a multidisciplinary approach that includes physiotherapy.

Conclusions

Because of its holistic approach, physiotherapy can contribute significantly to the multidisciplinary assessment and treatment of CPP and female SD.

Utility of trigger point injection as an adjunct to physical therapy in men with chronic prostatitis/chronic pelvic pain syndrome

Background

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is often associated with pelvic floor muscle spasm. While pelvic floor physical therapy (PFPT) is effective, some men are unable to resolve their symptoms and have residual trigger points (TPs). TP injection has been used for treatment in several neuromuscular pain syndromes. The objective of this study was to examine the efficacy and side effects of TP injection in men with CP/CPPS and pelvic floor spasm refractory to PT.

Methods

Using an IRB approved Men’s Health Registry we reviewed the records of all men with a diagnosis of CP/CPPS who received at least 1 TP injection. Patients were phenotyped with UPOINT (all had the “T” domain for tenderness of muscle) and symptoms measured with the NIH Chronic Prostatitis Symptom Index (CPSI). Response was measured by a 5-point Global Response Assessment (GRA) and change in CPSI (paired t-test). For pelvic TPs, a pudendal block was done in lithotomy position and then each TP was identified transrectally by palpation. A nerve block needle was passed through the perineum into the TP confirmed by palpation. Between 0.5–1 cc was injected into each TP of a local anesthetic mixture (30:70 of 2% lidocaine and 0.25% bupivacaine). For anterior TPs, an ultrasound guided ilioinguinal block was done first and then each TP injected by direct palpation through the abdominal skin. Men were offered up to three sets of injections separated by 6 weeks each.

Results

We identified 37 patients who had a total of 68 procedures. Three men had no follow-up after their first injection and were included for side effects but not included for outcome. The indication was failure to progress on PT in 33, recurrent symptoms in 1 and refusal to do PT in 3. Mean age was 43.7 years (range 21–70 years) and median UPOINT domains was 3 (range 1–5). Initial CPSI was pain 13.7±3.4, urinary 5.3±2.2, quality of life 9.8±2.1 and total 28.8±6.0. 16 men had 1 injection, 11 had 2 and 10 had 3. All had pelvic TPs injected and 9 also had anterior TPs. By GRA, 12 had significant improvement (35.3%), 10 had some improvement (29.4%), 11 had no change (32.3%) and 1 was worse (2.9%). Mean CPSI dropped from 28.8±6.0 to 21.8±7.2 (P<0.0001). 18 men had a drop of 6 or more points in CPSI (53%). Of note, none of 3 men who were noncompliant with PT had benefit. 3 men had temporary numbness in the lateral thigh after the injection (4.4%) and 1 had difficulty weight bearing on 1 leg for about 30 minutes.

Conclusions

TP injection in CP/CPPS patients as an adjunct to PT is well tolerated and leads to symptom improvement in about half. Durability and long term results are yet to be determined.

Trigger Point Injections for Pelvic Floor Myofascial Spasm Refractive to Primary Therapy

Introduction

A retrospective chart review was conducted of visual analog scale (VAS) scores completed before and after trigger point injections (TPIs) for pelvic floor myofascial spasm to evaluate response.

Methods

Sixty-eight female patients who underwent TPIs from October 9, 2007 to March 12, 2015 were included. The primary end point was the difference between scores. Secondary analyses were conducted for patients who needed repeat TPIs. Descriptive and paired t test analyses were used.

Results

The key result was an improvement in VAS scores for 65% (44/68) of patients (p<0.0001). The median pre-injection VAS score was 7 (1 to 10), (mean 6.3). The median post-injection VAS score was 4 (0 to 9), (mean 4.3). The median difference between scores in patients who improved was 3 (1 to 8), (mean 3.6). Seventeen of 68 (25%) patients needed repeat TPI, and the median time between injections was 1.5 months (1 to 7 months), (mean 2.2 months). When analyzing pre-injection VAS scores in patients who underwent subsequent repeat injection when compared to patients who did not require repeat injection, there was no difference (p = 0.32). In addition, the differences between pre- and post-injection VAS scores in the patients who underwent repeat injection and those who did not was not significant (p = 0.26).

Conclusions

We report on 68 women who underwent TPIs, with an improvement in VAS pain scores in 65%. It appears that TPIs for pelvic floor myofascial spasm are successful in reducing pain scores for patients who are refractory to primary therapy.

Perspective on Physical Therapist Management of Functional Constipation

Functional constipation is a common bowel disorder leading to activity restrictions and reduced health-related quality of life. Typically, this condition is initially managed with prescription of laxatives or fiber supplementation, or both. However, these interventions are often ineffective and fail to address the underlying pathophysiology and impairments contributing to this condition. Physical therapists possess the knowledge and skills to diagnose and manage a wide range of musculoskeletal and motor coordination impairments that may contribute to functional constipation. Relevant anatomic, physiologic, and behavioral contributors to functional constipation are discussed with regard to specific constipation diagnoses. A framework for physical therapist examination of impairments that can affect gastrointestinal function, including postural, respiratory, musculoskeletal, neuromuscular, and behavioral impairments, is offered. Within the context of diagnosis-specific patient cases, multifaceted interventions are described as they relate to impairments underlying functional constipation type. The current state of evidence to support these interventions and patient recommendations is summarized. This perspective article aims not only to heighten physical therapists' awareness and management of this condition, but also to stimulate clinical questioning that will open avenues for future research to improve patient care.

What Does Electromyography Tell Us About Dyspareunia?

INTRODUCTION

Emergent evidence suggests that pelvic floor muscle (PFM) dysfunction contributes to dyspareunia, the experience of pain on vaginal penetration. Electromyography (EMG) is a valuable tool for the assessment of neuromuscular control and could be very useful in enhancing our understanding of PFM involvement in sexual function and in conditions such as dyspareunia. However, PFM EMG must be interpreted within the context of the many factors that can influence findings.

AIM

To outline the main factors to consider when evaluating PFM EMG for female sexual function and dyspareunia and to synthesize the literature in which EMG has been acquired and interpreted appropriately in this context.

METHODS

Standards for the acquisition and interpretation of EMG were retrieved and consulted. An exhaustive search of four electronic databases (Embase, CINAHL, PubMed, and PsycLit) and hand searching references from relevant articles were performed to locate articles relevant to PFM involvement in sexual function and in dyspareunia in which EMG was used as a primary outcome. Study outcomes were evaluated within the context of the appropriate application and interpretation of EMG and their contribution to knowledge.

MAIN OUTCOME MEASURES

A synthesis of the evidence was used to present the current state of knowledge on PFM involvement in sexual function and in dyspareunia.

RESULTS

Few standards documents and no practice guidelines for the acquisition and interpretation of PFM EMG are available. Some cohort studies with small samples of women have described the role of the PFMs in female sexual function. The literature on PFM involvement in dyspareunia also is limited, with outcomes suggesting that higher than normal tonic activation and higher than normal reflex responses might be present in the superficial PFM layer and might be characteristic features of dyspareunia. The data are less clear on the involvement of the deep layer of the PFMs in dyspareunia.

CONCLUSION

Guidelines for the application and interpretation of PFM EMG in the context of sexual function and dyspareunia are needed. When interpreted within the context of their strengths and limitations, EMG data have contributed valuable information to our understanding of PFM involvement in dyspareunia. The literature to date suggests that the superficial PFMs might have higher than normal tone and exaggerated responses to tactile or penetrative provocation in at least some women with dyspareunia. McLean L, Brooks K. What Does Electromyography Tell Us About Dyspareunia? Sex Med Rev 2017;5:282-294.

Anorectal and Pelvic Pain

Although pelvic pain is a symptom of several structural anorectal and pelvic disorders (eg, anal fissure, endometriosis, and pelvic inflammatory disease), this comprehensive review will focus on the 3 most common nonstructural, or functional, disorders associated with pelvic pain: functional anorectal pain (ie, levator ani syndrome, unspecified anorectal pain, and proctalgia fugax), interstitial cystitis/bladder pain syndrome, and chronic prostatitis/chronic pelvic pain syndrome. The first 2 conditions occur in both sexes, while the latter occurs only in men. They are defined by symptoms, supplemented with levator tenderness (levator ani syndrome) and bladder mucosal inflammation (interstitial cystitis). Although distinct, these conditions share several similarities, including associations with dysfunctional voiding or defecation, comorbid conditions (eg, fibromyalgia, depression), impaired quality of life, and increased health care utilization. Several factors, including pelvic floor muscle tension, peripheral inflammation, peripheral and central sensitization, and psychosocial factors, have been implicated in the pathogenesis. The management is tailored to symptoms, is partly supported by clinical trials, and includes multidisciplinary approaches such as lifestyle modifications and pharmacological, behavioral, and physical therapy. Opioids should be avoided, and surgical treatment has a limited role, primarily in refractory interstitial cystitis.