Trigger point injections are a treatment for women with pelvic or bladder pain caused by a short, tight pelvic floor. There are several ways that trigger point injections can be useful. The injections can be used as a diagnostic tool. In women with severe pelvic pain, the injections can provide near-complete temporary pain relief and motivation to follow through with treatment. The injections can be used to accelerate progress when used in combination with physical therapy. Women who do not make adequate progress, who reach a plateau, or who cannot tolerate pelvic floor physical therapy can be injected one to two hours before PT. This allows the therapist to work more deeply on the affected muscles and tissues. Injections can be used in women who are having a flare of pain. Breaking the pain cycle can often reduce pain for hours to days after the injection. Trigger point injections can be done in an office setting by using the following supplies. Three to five 10cc syringes of 0.25% Marcane. A Pudendal kit. A 1 1⁄4 inch 27 gauge needle. Gauze. And 2% Lidocaine and a Lidojet. The Lidocaine gel is optional, but can be helpful to reduce the pain associated with the injection. In our office, we pre-fill and label syringes with Marcane to minimize the time required to set up supplies. The woman should be asked to empty her bladder and undress from the waist down. She is then asked to lie in the dorsal lithotomy position. If needed, a Lidojet is used to instill 2% Lidocaine gel into the vagina. A gauze is placed at the vaginal opening to prevent the gel from leaking out. The patient is asked to remain lying down for 5 to 10 minutes. If the woman has abdominal or hip pain, trigger points in these areas can be injected with a 1 1⁄4 inch 27 gauge needle attached to a 10cc syringe of Marcane. It's important to inject deeply, aspirating before each injection. The provider should perform a manual exam with a lubricated finger to confirm which areas of the pelvic floor are tight and painful. This exam can vary from one week to the next. While some studies have described the use of electromyography or ultrasound to locate trigger points, there is no clear evidence that these techniques are superior to a manual exam. Muscle groups that can be injected include the pubovaginalis, pubococcygeus, iliococcygeus, and iliopsoas. There is no need to prepare the vagina with an antimicrobial solution like povidone iodine. Attach the Marcane-filled syringe to the trumpet and needle. Be careful not to over-tighten this connection as it can be difficult to change the syringe. If the needle is over-tightened, use a kelly or ring forceps to detach the needle. Hold the syringe with the dominant hand and use a finger from the non-dominant hand to locate the first injection site. Be sure to hold the trumpet so that the needle is shielded. This helps to minimize the risk of a needle stick injury. Injecting at one centimeter inferior to the ischial spine provides a pudendal block and can decrease pain with subsequent injections. Remember to use a kelly or ring forceps. Remove the finger, press the trumpet gently against the pelvic floor, and advance the needle. Aspirate to be sure you're not in a blood vessel, and then inject approximately one to two cc's of Marcane. If needed, hold pressure until bleeding slows. Finish injecting on the same side until all tender spots have been injected. Some patients will need a break after a few injections, while others want to feel better. Communicate as you're injecting to assess her preferences. After you've injected the palpable tender points, perform a digital exam again to assess for any remaining tender areas. If needed, you can inject these remaining areas with the pudendal kit or a 27-gauge, 1 1⁄4-inch needle. We inject most patients with between 10 and 30 cc's of Marcane. We do not inject more than 50 cc's. The maximum recommended dose of Marcane is two milligrams per kilogram. If there is bleeding, use a finger and gauze to hold pressure to the area. If the bleeding is heavy, pack the vagina with gauze and ask the woman to lie down for five to ten minutes. Then remove the gauze and check for active bleeding. We give our patients a pad and disposable ice pack at the end of the visit. Repeat injections can be scheduled once weekly. While trigger point injections are a safe procedure in most cases, side effects can occur. The most common side effects include temporary loss of bladder control, temporary loss of sensation in the leg, and systemic absorption of Marcane. This can cause a metallic taste in the mouth or ringing in the ears. Less common side effects include pain in the lower back, excessive bleeding or formation of a hematoma, infection at the site of injection, and systemic toxicity with intravascular administration. In summary, pelvic floor trigger point injections are a valuable skill for any provider who cares for women with pelvic pain. The injections are safe and effective and can provide much needed relief for women with pelvic floor pain.

trigger point injections

pelvic floor

bladder pain

diagnostic tool

pain relief