Welcome to today's webinar, I'm Dr. Jennifer Burns, the moderator for today's webinar. Before we begin, I'd like to share that we will take questions at the end of the webinar, but you can submit them anytime by typing them into the Q&A section located at the bottom of the event window. Today's webinar is entitled Pelvic Floor Myofascial Pain and Dysfunction, Etiologies, Associated Symptoms, and Strategies for Assessment, and is being presented by Dr. Melanie Meister and Dr. Jerry Lauder. Dr. Meister completed her Obstetrics and Gynecology Residency and Female Pelvic Medicine and Reconstructive Surgery Fellowship at Washington University in St. Louis. She completed her Master of Science in Clinical Investigation as a fellow at WashU. The focus of her master's thesis and bulk of her clinical research center on the pelvic floor myofascial pain and dysfunction, its role in other pelvic floor disorder symptoms, and the development and standardization of a clinical examination to assess for pelvic floor myofascial pain and or dysfunction in patients presenting with pelvic floor complaints. After fellowship, Dr. Meister joined the faculty at the University of Kansas School of Medicine, where she is an assistant professor in the Department of Obstetrics and Gynecology. Dr. Lauder is the Division Director of Female Pelvic Medicine and Reconstructive Surgery at Washington University in St. Louis and the Assistant Fellowship Director. He completed a three-year fellowship in Female Pelvic Medicine and Reconstructive Surgery at the University of Pittsburgh in Pittsburgh, Pennsylvania, as well as a master's in clinical research. Dr. Lauder has had clinical and research interest in pelvic floor myofascial dysfunction and pain throughout his career and helped develop and validate the standardized pelvic floor myofascial examination. Thank you both for being here. We're looking forward to your presentation. Thank you. Thank you, Dr. Burns, and thank you, everyone, for joining us for this webinar. We're really excited to have the opportunity to present on pelvic floor myofascial pain and dysfunction. Neither of us have any financial disclosures. So the objectives of our talk are to review the anatomy and function of the muscles of the pelvic floor, to discuss the pathophysiology and development of myofascial dysfunction and pain within the pelvic floor muscles, to describe the etiology and prevalence of pelvic floor myofascial pain by reviewing some of the current literature, to discuss pelvic floor symptoms associated with and related to underlying pelvic floor myofascial pain, and to describe and demonstrate a standardized screening pelvic floor myofascial examination for clinical use. We'll also touch on some treatment options toward the end. So we will start with a review of the anatomy and function of the muscles of the pelvic floor. The pelvic floor is composed of muscles, ligaments, and fascia, all enclosed within the bony pelvis. It's bounded cranially by the peritoneum of the pelvic viscera and caudally by the skin of the vulva and perineum. The pelvic floor is involved in pelvic organ support, sphincter action for the bladder and bowel, sexual activity and pregnancy and delivery. The components of the pelvic floor provide passive stability to the bony pelvis through a mechanism termed form closure, which essentially refers to their collective compressive force. The pelvic floor musculature consists of both superficial and deep layers. The superficial layers are not visible in this picture, but include the ischiocavernosis, vulvocavernosis, and transverse perineal muscles. We're going to spend the majority of our time focusing on the deeper layer, which includes the levator ani muscles and coccygeus muscles. These, along with the endopelvic fascia, comprise the pelvic diaphragm. Now, as everyone knows, the levator ani is a group of three striated muscle that includes the pubococcygeus, the puborectalis, and the iliococcygeus muscles. The pubococcygeus originates from the pubic bone and anterior portion of the arcus tendineus and inserts on the coccyx. It functions to support and maintain pelvic floor tone when standing erect, and it must relax during voiding. The puborectalis originates just below the pubococcygeus and forms a sling around the rectum. This contributes to the anorectal angle at rest and aids in fecal continence. The iliococcygeus originates along the posterior portion of the arcus tendineus and ischial spine and inserts on the coccyx. And together, these muscles form a horizontal shelf to stabilize the upper vagina and prevent downward forces on the perineal body. The muscles of the levator ani are composed of primarily type I or slow-twitch muscle fibers, and this makes up about two-thirds of the muscle fibers of the levator ani. And this is important because it enables tonic contraction to close the urogenital hiatus and elevate the pelvic organs. The coccygeus muscle is located more posteriorly, originates at the ischial spine, and inserts on the coccyx. The coccygeus muscle is contiguous with the sacrospinous ligament and provides support to the posterior pelvic floor. Other relevant muscles in and around the pelvic floor include the piriformis, back here, which originates at the anterior sacrum and inserts on the greater trochanter of the femur. This involves lateral rotation when the thigh is extended and abduction of the thigh when the thigh is flexed. And then another important muscle we'll discuss is the obturator internus, which arises from the ilium, ischium, and obturator membrane, and also inserts on the posterior surface of the greater trochanter. The obturator internus functions in external rotation of the hip. So the arcus tendineus fascia pelvis is an important anatomic structure to the pelvic floor, so I'm going to pause and talk about it just for a minute. This is a condensation of the fascia overlying the obturator internus muscle, and it extends from the pubic symphysis all the way back to the ischial spine. And as I mentioned earlier, fibers of the levator ani muscle originate directly from this fascial structure, which is a unique factor or a unique feature of this muscle group. Few muscles originate directly from fascial structures. Now, importantly, the muscles of the pelvic floor end up functioning as a unit rather than individually, and they have sort of regional functional demands. And in order to better understand the unique functions of these muscles, we can look at fiber length and sarcomere length. So if you look at fiber length, you'll see there's significant variation in fiber length across the regions of the pelvic floor muscles. And longer fiber length enables greater excursion or change from contraction to elongation. The pubovisceral muscle, you'll see, has the greatest fiber length and therefore the greatest capacity for excursion, which is important to facilitate vaginal delivery. Additionally, the muscles of the pelvic floor have a significantly shorter sarcomere length compared to other skeletal muscles, so they can produce a greater force when stretched. When we look at these and we look at the fiber composition and the fiber length and sarcomere length, we see that pelvic floor muscles together are capable of generating about 35 newtons of force when they're functioning as a unit. Now, because of the centralized location of the pelvic floor, these structures are involved in musculoskeletal support, both of the upper and the lower body, and they actively transmit forces between the two. The pelvic floor muscles act both passively and actively to support the pelvic floor and maintain upright posture in humans. They also work synergistically with the transverse abdominis muscles and the gluteus maximus muscles to provide baseline tone and support to the pelvic floor. And then, of course, with increased intra-abdominal pressure, these muscles reflexively contract. Now, contraction of these muscles results in cranial and anterior motion of the pelvic floor, which you see depicted by this blue arrow, which leads to closure of the vagina as well as the urethral and anal sphincters to promote continence. In turn, then, these muscles must relax to release passive continence mechanisms and allow for micturition and defecation. Relaxation of the pelvic floor results in an increase in the anorectal angle to enable adequate rectal emptying. In addition to the role in continence, these muscles also contribute to sexual functioning – sexual function, excuse me – and, of course, pregnancy and delivery. During sexual orgasm, the pelvic muscles undergo repetitive muscle contraction. And during pregnancy, these muscles bear increased load because of the physiologic changes of pregnancy. And then, during delivery, must stretch to accommodate passage of the fetus. So now, at this point, I want to pause briefly and review some terminology. Unfortunately, a variety of terms have been used to describe function and dysfunction of the muscles of the pelvic floor. In 2005, the International Continent Society published some standardized terminology for pelvic floor function and dysfunction, which you can see here. These terms are largely self-explanatory, but I'm going to go ahead and define each of them. These are the same terms in a table format. I've listed voluntary and involuntary action across the top and contraction and relaxation down the side. So voluntary contraction occurs on demand and is palpable in response to a request to lift or squeeze. This can be characterized as absent, weak, normal, or strong. Involuntary contraction precedes an increase in intra-abdominal pressure, like a cough, and this would be characterized as either absent or present. Voluntary relaxation occurs on demand after contraction and is characterized as either absent, partial, or complete. And finally, involuntary relaxation occurs when straining, for example, when bearing down during defecation, and is characterized as either absent or present. Terms related to dysfunction are also fairly self-explanatory. A non-contracting pelvic floor refers to the absence of voluntary or involuntary contraction. A non-relaxing pelvic floor refers to the absence of voluntary or involuntary relaxation. And patients with a non-contracting, non-relaxing pelvic floor demonstrate no palpable voluntary or involuntary contraction or relaxation. Of note, these categories of dysfunction only refer to muscle activity. They do not depend on the presence or absence of patient symptoms. The ICS then goes on to define conditions which do require the presence of characteristic symptoms associated with specific signs. So, these include normal pelvic floor muscles, where voluntary and involuntary contraction and relaxation are all present. Voluntary contraction is normal. Voluntary relaxation is complete. And involuntary contraction and relaxation are both present. Overactive pelvic floor muscles do not relax, or they actually paradoxically contract when they should be relaxing. Typical symptoms here include voiding dysfunction, obstructed defecation, or dyspareunia. Underactive pelvic floor muscles cannot voluntarily contract when they should. Typical symptoms here would be urinary or fecal incontinence. And finally, patients with non-functioning pelvic floor muscles have no palpable pelvic floor muscle action. Symptoms could include any of the previously mentioned, and these patients typically have a non-contracting, non-relaxing pelvic floor on exam. The ICS does not have terminology related to the finding of pain in these muscles, but several terms are present in the literature, including pelvic floor myopassial pain, which is how we choose to refer to this, as well as levator ani-myalgia, levator ani-asbesticity, and high-tone pelvic floor dysfunction. Okay, so now that we've reviewed the anatomy and the function of the pelvic floor muscles and a little bit of terminology, let's move on to discuss dysfunction in these muscles and the development of pelvic floor myofascial pain. Myofascial pain, in general, is a chronic musculoskeletal pain disorder that's characterized by pain arising within muscle and fascia. These patients typically have contracted bands of skeletal muscle, and within these contracted bands are discrete painful nodules called trigger points. The presence of trigger points produces pain both locally, but can also refer pain to distant sites, and the presence of trigger points are truly the hallmark of myofascial pain. Trigger points can be active, meaning they're spontaneously painful, or latent, which means they're only tender when palpated, and importantly, trigger points can actually remain latent for many years until they're reactivated and can far outlast the original insult that led to trigger point formation in the first place. With palpation of trigger points, some patients actually experience autonomic symptoms like regional vasoconstriction, perspiration, or pyloerection. Myofascial pain has been described classically in the neck, upper back, face, and jaw, and in the pelvis, myofascial pain most often arises in the muscles and connective tissue of the internal hip, so the obturator internus muscle, and the levator ani. Some authors have also described characteristic trigger points in the coccygeus and the piriformis muscles. Trigger points in the pelvic floor muscles typically refer pain to the vagina, perineum, bladder, or rectum. This schematic depicts development of myofascial trigger points. It's thought to occur through a two-stage process, so first, with injury to the muscle fibers, there's a release and accumulation of inflammatory neurotransmitters and inflammatory mediators that leads to a metabolic imbalance within the muscle, and this can actually promote prolonged or sustained muscle contraction, which can lead to contraction-induced hypoxia, which can ultimately lead to muscle ischemia, trigger point development, and pain. There's also some evidence to suggest that dysfunction at the level of the motor endplate itself may contribute to the development of trigger points, which manifests as increased acetylcholine at the motor endplate, either because of excess acetylcholine release, acetylcholinesterase deficiency, or increased activity and sensitivity of the nicotinic receptors at the postsynaptic terminal. Another factor that's likely involved in the pathophysiology of myofascial pain is central sensitization. Central sensitization is a form of neural adaptation that is present in many chronic pain conditions and underlies the finding of coexisting symptoms or coexisting pain syndromes like fibromyalgia, chronic pelvic pain, IBS, interstitial cystitis, bladder pain syndrome. So ordinarily, with palpation of a tender muscle, the signal is transmitted through the spinal cord to the brain and the pain is sensed centrally. However, with persistent pain and therefore persistent stimulation, there are actually changes in this neuronal pathway that lead to increased neuronal excitability, increased awareness of painful stimuli, and expansion of the receptive fields such that normally non-painful stimuli can be perceived as painful. Additionally, prolonged nociceptive input from myofascial trigger points could lead to similar maladaptive changes in the central nervous system, and because of this, the longer an individual has pain, the more likely it is to persist, and in some cases, the harder it is to treat. The pelvic floor seems to be at particular risk of developing myofascial pain and trigger points. We already discussed the centralized location and therefore participation in activity and forces between the upper and lower body, as well as the variety of physiologic functions of the pelvic floor muscles. Additionally, these muscles contract eccentrically, which means they contract while lengthening or bearing load, which is a frequent source of musculoskeletal injuries elsewhere in the body. We also know that the pelvic floor muscles can be affected by physiologic and psychologic stress, especially in women. Okay, so now we're going to move on to discuss the etiology and prevalence of pelvic floor myofascial pain by reviewing some current literature. As I mentioned before, myofascial pain is commonly identified in regions outside of the body, both in men and in women. It's been estimated that myofascial pain is present in about 15% of the general population and 93% of people with localized pain. Somewhere between 25% and 54% of asymptomatic Americans are estimated to have latent trigger points. Myofascial pain in general is more common in women than men, and the incidence peaks somewhere between age 40 and 50. And myofascial pain syndromes represent a primary cause of functional disability and absenteeism. When we look at prevalence estimates reported in the literature for pelvic floor myofascial pain, the estimates vary widely. Depending on the population studied, prevalence estimates vary from anywhere as low as 17% in a population of pain-free controls to as high as 87% in a population of patients with interstitial cystitis. Even among populations of patients with chronic pelvic pain, estimates are highly variable, from 22% to 81%. This variability in prevalence estimates likely occurs for a number of reasons, including the population being studied, which we just discussed. Additionally, we're lacking a consistent definition of pelvic floor myofascial pain and, more simply, lacking a consistent term for this condition. Like I mentioned earlier, pelvic floor myofascial pain is becoming more common, but historically other terms have been used to refer to this condition as well. Additionally, there's no specified threshold for the severity of pain that constitutes clinically significant pain. Some authors report the finding of any tenderness to be diagnostic, while others use a numeric threshold, for example, 4 out of 10 in severity. Many agree that a big problem with prevalence estimates is due to inadequate training of healthcare providers. For example, providers less experienced with myofascial pain as a source often look to visceral explanations, which may ultimately subject patients to unnecessary tests, procedures, surgery, etc. And unfortunately, a validated examination has not existed for the assessment or evaluation of the pelvic floor muscles, which likely contributes to lack of physician or provider awareness. Okay, and now I'm going to turn things over to Dr. Lowderm. Yes. Thanks, Melanie. And so while we're doing this, we're going to leave the control of Melanie's screen so if there's a delay, just realize that's why or what's going on. So now we're going to discuss the pelvic floor symptoms associated with and related to underlying pelvic floor myofascial pain. And in order to understand how pelvic floor myofascial pain may be related to underlying pelvic floor symptoms, we need to understand a little more about the pathophysiology of these symptoms. And as Melanie mentioned, central sensitization underlies many chronic pain disorders and is likely a large driver of the finding of pelvic floor myofascial pain in women with chronic pelvic pain. Viscerosomatic convergence and anatomic proximity may help explain the relationship between pelvic floor myofascial pain and pelvic floor symptoms in women without chronic pelvic pain. Viscerosomatic convergence is also called the convergence projection theory. And essentially, afferent fibers from somatic structures, in our case the pelvic floor muscles via the pudendal nerve, converge with afferent fibers from visceral structures, for example the bladder, at the same dorsal horn in the spinal cord before ascending for cortical interpretation. Because of the proximity of the fibers in the dorsal horn, crosstalk can occur. With irritable pelvic floor myofascial tissue, then, there's increased afferent input to the sacral spinal cord and resulting crosstalk at the level of the dorsal horn, leading to perception of pain arising from one or both structures. Anatomic proximity may also explain the finding of concurrent symptoms. You'll recognize this image from the earlier part of the talk from where the bladder and bowels, but in this, from before, where the bladder and bowels have been cut away. But in this image below, we see the proximity of the visceral structures to the pelvic floor muscles. In fact, with bladder filling, the bladder comes to rest on the obturator internus and levator ani muscles. This is a video from an office cystoscopy, and I'm sorry, both because of Zoom and being an older image, it's a little kind of jumpy. But we hope this will better illustrate this theory. This patient's bladder has been filled, and we are looking at the right lateral wall of the bladder. Her right leg is being passively rotated laterally, and we see the impression of the right obturator internus muscle belly on the wall of the bladder itself. One could imagine the trigger points or tender points in this muscle, which are activated through transvaginal palpation on exam, could also be activated when the bladder or another visceral structure comes in contact with these muscles leading to stimulation of these trigger points, which may manifest as pain with bladder filling or the sensation of urgency or frequency. In addition, recent fMRI work has confirmed that both reflex and voluntary pelvic floor muscle contractions occur at terminal bladder filling. So another potential explanation is that pelvic floor muscle activation with a full bladder may contribute to these trigger points during muscle contraction. Pelvic floor myofascial dysfunction is being recognized in a significant proportion of patients presenting for evaluation of other non-pain pelvic floor disorders and appears to influence the severity of their symptoms. In 2013, Adams and colleagues reported the prevalence of levator myalgia of 24% among women referred to a university-based urogynecology practice for pelvic floor disorders, not necessarily pain, and found that these patients reported greater symptom bother related to prolapse, defecatory dysfunction, and urinary symptoms compared to patients who were not found to have levator myalgia. Dixon et al. in a retrospective chart review found that among patients with pelvic or in prolapse, pelvic floor myofascial pain was found in 32% of these patients, and these patients had a greater degree of symptom bother despite having a lower mean stage of prolapse than those without pain. So even though they had more severe symptoms of pressure and heaviness, which are often attributed to prolapse alone, they actually had less severe prolapse, suggesting that something else, likely pelvic floor myofascial pain, is actually driving these symptoms in this group. In a retrospective study we performed at Wash U prior to the study, the examination development led by Melanie, which is a fellow, we had similar findings, namely that pelvic floor myofascial pain was highly prevalent among patients presenting for evaluation of pelvic floor symptoms. We found those present in approximately 85% of patients. Pelvic floor myofascial score distributions were examined in the full sample and stratified by pain as a presenting complaint using box plots and proportions. The left side of the graph actually represents scores from women without any type of pain as the chief complaint compared to the box plots on the right, which were from women that had pain either as the chief complaint or one of their presenting symptoms. Women without a complaint of pelvic pain had mean pelvic floor myofascial pain scores on average only one point lower than women with a chief complaint of pain at each site, demonstrating that pelvic floor myofascial trigger points for pain with palpation is very common in women presenting with pelvic floor disorders and thus should be screened for as it may be playing a role in other pelvic floor disorder symptoms. So, in this study, these are some more results from the study. Here we looked at associations between obturator internus and levator adenine pain scores and POPD6 scores. Pelvic floor myofascial severity, each site was significantly correlated with pressure in the lower abdomen, pelvic heaviness, and having to push on the vagina or around the rectum to have a bowel movement. These correlations were typically strongest in the right obturator internus. Pelvic floor myofascial severity was not correlated with seeing or feeling a bulge except for in the left levator adenine, a feeling of incomplete bladder emptying, or having to push up on a bulge to start or complete urination. So, this pelvic floor myofascial severity at each site examined and overall was significantly correlated with the POPD6 total score as well as a subjective summary score we developed, including questions pertaining just to the sensations of pressure, heaviness, and incomplete emptying. We also created an objective summary score, including questions related to a bulge that can be seen or felt, or the need to push on a bulge in the vaginal area to complete urination, which was significantly correlated with leading edge in POPQ stage, but not pelvic floor myofascial pain severity. And here we look at the correlations between pelvic floor myofascial pain severity and degree of urinary symptom bother using the UDI6. And after controlling for menopausal status, overall pelvic floor myofascial pain severity was significantly correlated with pain or discomfort in the lower abdominal and genital region. Pain in the right obturator internus was significantly correlated with difficulty emptying and overall UDI6 scores. Pain in the left levator was significantly correlated with difficulty emptying. And there was no correlation between pelvic floor myofascial pain and urine leakage related to stress urinary incontinence symptoms, such as coughing, sneezing, laughing, or small amounts of urine leakage. Pelvic floor myofascial pain in the right obturator internus was significantly correlated with total UDI6 scores, but this was largely driven by pain or discomfort in the lower abdomen genital region. So in summary, we found that not only do we see an association between the presence of pelvic floor myofascial pain and pelvic floor symptoms, we also found a significant correlation between the severity of the pelvic floor myofascial pain on the exam and the degree of pelvic floor symptom bother, such that those with more severe pelvic floor myofascial pain reported greater symptom bother from these pelvic floor symptoms. So now we want to describe the standardized screening pelvic floor myofascial examination for clinical use, and we had Funmi add on the link to a video that we created that actually walks people through the exam using both animation as well as a standardized patient, so we definitely invite you to take a look at that video. So again, as Mellie mentioned, due to the absence of a standardized and reproducible screening examination for pelvic floor myofascial pain, we set out to develop an examination protocol. I think it's important to point out that we use screening and not diagnostic, because definitely if you talk to somebody in physical medicine or physical and rehabilitation medicine, a diagnostic musculoskeletal exam is very detailed and can often be time-consuming and difficult to perform. And what we really wanted was a screening examination to identify myofascial pain, and particularly in patients without pelvic pain or baseline pelvic pain, so that we could identify these sites and determine whether they're contributing to their pelvic floor disorder symptoms. So we first conducted a systematic review of studies describing pelvic floor muscle examinations for trigger points for myofascial pain to identify the common and important steps. Our goals were to improve on the inconsistencies that we identify in the literature and standardize a pelvic floor myofascial exam that was easily reproducible. And we'll review those steps of the exam in a minute. Just prior to our paper coming out in 2018, the MAP Network, or the Multidisciplinary Approach to the Study of Chronic Pelvic Pain, published an examination strategy for use in both men and women with known underlying chronic pelvic pain. And I think that's an important difference. They included internal and external sites similar to what we have, but they made no attempt to standardize the depth of palpation among examiners and only scored their findings as tenderness present versus absent. Again, minimal description is provided in the text for localizing each site, although they do show or provide this clock face diagram to illustrate the direction of palpation for each muscle, and that's in the right upper corner of the exam. So, as part of our validation or standardizing and development study, we used a cross-sectional analysis of all patients presenting to our clinic from November 2017 to March 2018, and examinations were performed on enrolled patients by paired independent examiners blinded to the results of the other examination. And the agreement between scores from each examiner was calculated using percent agreement at external sites and Spearman rank correlation coefficient in internal sites. And the number of painful sites on the external examination was compared to internal pain scores using the Cochran-Armitage trend test and Fisher's exact test. The protocol for the pelvic floor myofascial screening exam was developed through collaboration through FPRS surgeons in our division as well as women's health physical therapists at our institution in a very iterative process. Once the protocol was developed, the examination was tested in one simulated patient, and a simulated patient was selected for this step as they are accustomed to undergoing multiple pelvic examinations in a single setting by providers and able to provide real-time specific feedback and were able to help us compare pressure applied between different examiners. The protocol was revised based on feedback from the simulated patient and repeated on the same simulated patient in a separate encounter at which time consensus was confirmed amongst the participating physicians. We then implemented that in our practice. One thing that we felt was important was to assess and measure pressure. So we used a force-sensing resistor to standardize the amount of pressure applied to the muscles in internal examination, and the device we used records the pressure applied from the examining finger on the muscles and is displayed as both a waveform and quantitatively as pounds of force. This device has not been approved for this indication, but functioned well when tested. And from the outset, we did not intend to use the device as part of the final proposal. If there was a device that worked like that, it would be great because you really repetitively measure it. But like I said, it was not supposed, it was not planned to be part of the final proposed screening examination. And so we then performed an interim analysis after the first 16 patients were enrolled to measure and compare pressure used on internal examination. So at that time, the pressure applied on the internal, so the obturator internus and the levator anti-muscles bilaterally, was found to be consistent among examiners. And the use of the force-sensing resistor was discontinued for the remainder of the study. Pressure was also standardized on all examinations by single-digit palpation of an area of the mid-thigh, which was found to be consistent with applied internal pressure when measured using the force-sensing resistor during examination development. So we'll walk you through the protocol now. And the final examination protocol begins with the external examination. The patient is seated on the examination table with both feet resting on the floor. The sacroiliac joints are identified and palpated bilaterally. The patient is then asked to recline to dorsal lithotomy with her feet in the footrests. The point just medial to the anterior superior iliac spine, which corresponds to the insertion of the medial medial. The medial medial corresponds to the insertion of the iliacus muscles then identified and palpated bilaterally. Finally, the insertion points of the rectus abdominis muscles at the superior aspect of the pubic symphysis are palpated. And these sites were included both based on clinical experience over the years and the role that they also play in pelvic floor muscle, both insertion and related pain. And this was, like I said, also, I mean, based on clinical experience but also with input from the PTs. For each external site, the patient is asked whether palpation at the site elicits pain and pain at these sites were recorded as a yes, no. The patient is then oriented to the internal examination. And the examiner uses a single digit of the non-dominant hand to depress the mid-thigh, which corresponds to the mid-muscle belly of the rectus femoris. And this provides a reference for the pressure of palpation the patient expects internally and demonstrates that palpation of a skeletal muscle is typically sensed as pressure, not pain. At this time, she is also oriented to the verbal pain rating scale used to score to the degree of discomfort at each site. The sensation of pressure analogous to that sensed with palpation of the mid-thigh is scored zero. Any discomfort beyond the sensation of pressure is given a score from one to 10 with one corresponding to mild discomfort and 10 to severe pain. If the patient reports pain with palpation of the mid-thigh, another skeletal muscle site that does not elicit pain is selected. The index finger of the dominant hand is used to palpate the internal muscles, once in the center of the muscle belly, and then in a sweeping motion along the length of the muscle in the direction of the orientation of the muscle fibers. And the examination proceeds counterclockwise from right obturator internus, right levator ani, left levator ani, and then left obturator internus. And so these are some data from the study. Thirty-five patients were included or enrolled. The majority were Caucasian, postmenopausal, and slightly overweight. All patients reported some degree of bothersome urinary symptoms, and about a quarter had symptoms of pelvic organ prolapse, according to the chief complaint. No patients included in this sample presented specifically for evaluation of pelvic pain. However, about a little under a third did report dyspareunia when asked as part of their comprehensive history. So as far as the pressure standardization, force on the internal examination, which was measured, again, on the first half of participants using the force-sensing resistor, was similar between the four examiners. A maximal force of about 1.04 to 1.37 pounds was used by all examiners with an average of 0.46 to 0.55 pounds. And so at mid-thigh, a palpation with 1 to 1.3 pounds or maximal pressure, which we tested, resulted in a depression in the tissue of a depth of one centimeter, while palpation with 0.5 pounds, which was average force, resulted in tissue depression of about 5.5 millimeters. And this was found to be consistent among examiners and between patients. And what I tell the learners when they're learning this exam, if you want to get an idea of how much pressure to apply, if you press your finger on a solid countertip and you see blanching of your nail bed to about 2 to 3 millimeters, that's about the amount of force that this would equate to. So one-third to one-half of patients had tenderness to palpation at each external site, and this was similar between examiners. Median pain scores were slightly higher in the obturator internus muscles compared to the levator ani muscles bilaterally, and this is what we see clinically. For each site, the median pain score with palpation along the length of the muscle was equivalent or slightly higher than the median score on palpation of the muscle belly. And we found that patients tended to report tender points near muscle origin or insertion, and palpation in the center of the muscle body may miss these points. So there was agreement was high at external and internal sites. And so that's one of the reasons that we incorporated, and this was feedback from PTs at one of the combined AUGs, IUGA meetings, that we really stress first palpating mid-muscle belly and then moving along in the length of the muscle, and you take the highest pain score at those sites. We identified an association between tenderness at one or more external sites and pelvic floor myofascial pain of 4 to 10 or greater on the internal sites. So external sites were predictive of internal sites. So based on this finding, providers with less experience performing internal pelvic examinations may still be able to screen for possible pelvic floor myofascial pain using the external examination only and refer patients to pelvic floor physical therapy. So now we're going to go over some treatment strategies, and the good news is many of these pelvic floor symptoms resolve or improve when pelvic floor myofascial pain is addressed. I'm not going to spend a lot of time reviewing treatment strategies because this wasn't the focus of the talk, but I'll highlight the big ones here. Importantly, many of these therapies work well when combined, and pain refractory to these treatments can be very difficult to treat. I think importantly, and I really stress this to our patients, is that pelvic floor myofascial pain is often a chronic condition that can be managed but may flare. Flares may be triggered by things like stress, physical trauma, or inflammatory events like urinary tract infections, and flares typically involve reactivation of those latent trigger points we discussed before. So one of the mainstays of treatment is pelvic floor physical therapy, and the approach is highly variable depending on the therapist's training and background. So I really encourage providers to get to know the PTs in the area, what their training was. I hate to say it, but they do kind of a weekend course versus they do a residency. And what their background is as far as are they myofascial release predominantly, or are they movement-based in their PT training? Because based on that, you may decide which kind of PTs to send for the high-tone pelvic floor. One of the things we also tell patients is if they're doing Kegel exercises, it actually may worsen their symptoms, and I liken it to having a bicep strain and going to the gym and continuing to do curls. It may actually make that muscle inflammation worse. So we usually tell them to stop doing those until they're under the care of the PT and are recommended to do those. Another thing that we use both before patients get to PT and in conjunction with this and actually learned it from our PTs here, but is vaginal cryotherapy. And cryotherapy is a therapeutic application of a device or substance to the body to reduce temperature, so i.e. icing. You know, this slows nerve conduction velocity, which further contributes to pain reduction, and it's been shown to be effective in treating musculoskeletal injuries elsewhere. And so what we typically recommend is these are 15-mil conical tubes that we buy and give to our patients. We have them mixed with about 3 mLs of isopropyl alcohol and the rest tap water, and they keep them in their freezer, so it won't freeze solid. And then once a day, they insert one of the two tubes at a time sequentially, and so the whole icing process takes about 12 to 15 minutes. We anecdotally and in practice, we've found that this is the best way to do it. Anecdotally and in practice, we've found it to be very effective, and we're actually in the process of formally studying that now. If you've looked online, you may have already seen it. Pam, the inventor of the gel mold, this product is available online, and basically, again, it's a molded gel that can be placed in the freezer. I looked it up, and some folks repeated or reported good results with it. Other folks reported that the gel patent begins to leak over time, which is problematic, obviously, but definitely, it's already out there about using icing intravaginally for this pelvic pain. Other modalities, of course, include pharmacotherapy, incisor modulators, muscle relaxants, vaginal diazepam. One caution about that is that patients can get systemic levels of benzodiazepines when placed vaginally, so just be aware of that and caution patients, especially if they're using other medications that may interact with benzodiazepines. I think cognitive behavioral therapy is really important, especially in patients that truly have chronic pelvic pain and in patients that have a history of physical or sexual abuse. So I think it's an important component. And then also trigger point injections. And again, those may aid in both diagnosis, as if you inject the muscles and the trigger points and it relieves the pain, that helps give you an idea of what's going on and also reassurance to the patient. It also is a short-term treatment. Typically, it's a transvaginal injection with the local anesthetic, and typically with steroids, can be a useful adjunct to physical therapy and may allow more physical therapy to be done, more aggressive physical therapy to be done when patients couldn't previously tolerate it. And also there's been studies looking at dry needling of the muscle may be effective. I want to get through one study that came out 2019 in the Gold Journal, and this is Bartlett et al performed a retrospective chart review of women with chronic pelvic pain treated in office for muscle injections. So a lot of times when I do these, I have done them under sedation or when I've done Botox under sedation just due to the pain, but these were all done in office. They used a numeric rating scale of zero to 10 at each muscle site. And they calculated the total pain scale, which was the sum of the highest score on each side. The regimen was up to the doctor, but most of them used one of the canes, lidocaine, rupivacaine, bupivacaine, plus or minus 40 milligrams of triamcinolone. Some folks used botulinum toxin in addition. They used a 25-gauge, seven-inch spinal needle through an Iowa trumpet, which I thought was very novel, and I'll show you a picture of that in a minute. And they did on average about three to five injections per side, so about six to 10 total, if bilaterally, and the injected volume ranged from one to five mLs. So this is a picture of the Iowa nasal trumpet. I actually ordered one from a surgical supply company, and I really like it because it allows you to guide the needle and decrease the risk of self-stick, which is one of the reasons also I've done it in the operating room under sedation in the past. Just to go ahead and advance. I think the biggest take-home from this was they found that in their serial injections that it took up to about four to where they saw their maximum benefit. And so obviously they measured pre- and post-trigger-point injection, the significant change at each site, but at four is where they saw the maximum benefit. And then this was just looking at both the patients that had bilateral injections versus unilateral injections. And for unilateral injections, they saw their maximum benefit after two injections. And again, for the bilateral, it took about four serial injections. What was interesting was that only the total amount of local anesthetic injected has a significant effect on change in total levator ANI scores. And they found that total volume to be around 19 mLs or more. And so 19 mLs or more over all the sites was associated with significant clinical improvement, whereas anything less than that in the group that did not see improvement was on average about 15 to 16 mLs. And what also I thought was interesting was neither the type of anesthetic nor the number of injections, nor current or past pelvic floor PT was associated with symptom improvements. So their summary was that transvaginal trigger-point injections are a rapidly effective therapy for treating high tone pelvic floor in patients with chronic pelvic pain. I think you'd really, based on their results, need to look at about 20 mLs over all the sites if done bilaterally. So this is, we're not gonna really talk about this significantly as botulinum toxin is not FDA approved for pelvic floor myofascial pain. But as we know, its mechanism of action is inhibiting presynaptic release of acetylcholine near muscular junction, which leads to reduced muscle tone. Inhibition of further muscle spasm. And it's definitely been used for muscle spasticity and myofascial pain elsewhere in the body. And as their, to really summarize the evidence, Melanie and our group performed a systematic review and meta-analysis of all the studies looking at pelvic floor myofascial injections with botulinum toxin. And the meta-analysis did show that it, on average, overall resulted in improved pain. And so hopefully at some point in the future, it will be FDA approved for this indication. But otherwise, maybe it can continue to be used off labial when possible. So I think the take-home points for this are that pelvic floor myofascial pain is common among patients with chronic pelvic pain and those with pelvic floor symptoms. And we believe that pelvic floor myofascial pain may be a significant driver of symptoms in a subset of patients with pelvic floor disorders. And that so physicians evaluating women with pelvic pain or pelvic floor symptoms should consider pelvic floor myofascial pain in their differential diagnosis. And now there are a couple options, but there's a standardized literature-based and reproducible examination for assessment of pelvic floor myofascial pain. It's very brief to perform. And I include it as part of my standard intake exam for all new patients. And the treatment of pelvic floor myofascial pain often results in an improvement in coexisting pelvic floor symptoms that are typically not been attributed to those, been typically attributed to the bladder or prolapse when it may be, as mentioned, the pelvic floor. So again, thank you for all of your attention. And we look forward to the question and answer session. Thank you, Drs. Louder and Meister for your presentation. We have a few minutes for questions. You can submit your questions in the Q&A section at the bottom of the event window. We do have a few questions already. Our first question that we're going to address is from Dr. Alperin. Are there any data to address the impact of the trans-optrator mid urethral sling or single incision slings on the OI and or pelvic floor muscle tonicity function or myofascial pain? So, great question, Mariana. I mean, not that I'm aware of, and correct me if I'm wrong, but I, in my practice, that's one of the main reasons I have, I don't do the trans-optrator sling because essentially that it passes, those slings pass through the obturator internus very near the origin. And kind of when I came out of fellowship and started in practice, and when a lot of the mesh complications were first presenting, found that patients had significant obturator pain when either the vaginal prolapse procedure or the trans-obturator sling, whichever product it was, was passed through those muscles. So, I clinical or anecdotally and clinically, I would agree with that. Unfortunately, I am not aware of data that shows that. I'm not either, but I agree. Anecdotally, it seems like those patients do have a higher degree of myofascial dysfunction on exam. And with removal of the slings, I've seen a significant improvement. Unfortunately, I think due to the muscle injury, it can be a slow recovery from it. Thank you. We also have two questions from Dr. Nahira on some physical exam findings. First, are there any thoughts on why some patients with myofascial pelvic pain may have some lower abdominal or umbilical pain with palpation of the puborectalis muscle? And then also have either be noticed limitations in abduction of patient's thighs with their knees bent and feet together in a patient's who have some myofascial pain. How about I'll take the first one. I'll let Melanie handle the second one. So, I mean, I think that likely is referred pain when you press on the puborectalis and they have pain at the umbilicus. I mean, I think that's referred pain and probably kind of part of the whole viscerosomatic convergence. Now let's, I mean, unless you're ready for the next one, Melanie, let me read through it again. Oh yeah, I don't know how to see it. Dr. Burns, can you repeat the second question? Yeah, so Dr. Nahira said, before I perform a pelvic exam, I check patients for their ability to abduct their thighs. He noticed that patients with myofascial pelvic pain tend to have limitations in abduction beyond 110 degrees with knees bent and feet together. And just wondered if you found similar things in your patients. I think that's an interesting observation and I haven't specifically looked, but I'm not surprised in thinking about the orientation of these muscles and the muscles that are involved in the pelvic floor and also often affected by myofascial pain, certainly, especially with internal hip effects with the obturator internus, certainly these patients could have some degree of limited hip mobility and definitely would believe that that occurs. And I agree completely with Melanie's answer. And I also think that, you know, muscle pain and weakness can be affected with both, you know, contraction of the muscle, which that maneuver would be contracting the obturator internus as well as elongation. So whether it's a function of a weak muscle or painful muscle, hard to say. It'd be a great question for a physical therapist as well. Great, thank you. Our next question is from Dr. Blomquist. Do you think there is any correlation with levator anti-evulsion as a result of vaginal delivery and subsequent development of myofascial pain? Yes. Likely, yeah. Very likely. And in fact, I mean, I would love to look at, I mean, whether it's the screening exam or, you know, in combination, this exam in combination with the lower vaginal exam that Janice Miller developed assessing for muscle defects and look for both, you know, the presence of defects, either on palpation or under ultrasound and muscle pain after delivery. And then at time points after that to see when either the recovery is or when the pain develops. But I mean, yeah, I definitely think that birth injury is a leading cause for myofascial pain in most women. Great. We had another question on, for some of the information you presented earlier, do you recall the subspecialties of the physicians performing some of the public floor exams in the data that you reported? In our data? Or in the other studies? I think it was in the other studies. The other studies were, the other studies were sort of a smattering of gynecologists, physical medicine and rehabilitation physicians. I think there were a couple with urologists. It was a wide variety, and urogynecologists. So general gynecologists, but also urogynecologists. Great. What was the time interval between injections and the trigger point injection series in the study that you discussed? I think it ranged, but I think on average was in a couple of weeks. I mean, definitely in my practice. I mean, some folks can, especially with the steroid, you may see three to four weeks. I mean, I've had some patients with so severe pain that we've actually had them come in weekly. And obviously I would back off the Triamcinolone in those situations and mainly use the lidocaine. But I think it was, I mean, it kind of in the three to four week range, if I remember correctly. Great. Have you, either of you noticed any correlation between low estrogen states like early menopause or chronic progesterone use with increased risk of high tone pelvic floor dysfunction? I haven't looked or I haven't thought about that specifically or looked very carefully at that. But I think patients with low estrogen are likely to have some degree of vaginal atrophy, which could certainly contribute to discomfort. And it could be that discomfort ultimately leads to trigger point formation and kind of sets the ball rolling. Alternatively, there may be co-existent symptoms. I don't know. Dr. Ladner, have you had? Well, no, and I mean, Mariana could easily jump on to this answer as well. You know, I mean, we do know there are estrogen receptors in the levator adenine muscles and both in the combination of muscle loss with age starting around age 30, which is not related to estrogen, but also, I mean, potentially at least with menopause and beyond, whether that plays an increased role in or increased rate of muscle mass loss, it's hard to say, but less muscle mass will mean more or fewer muscle fibers doing more work, which may also, you know, lead to trigger point or strain injury and trigger point development. So, I mean, it needs to be studied, but could definitely potentially play a role. Another participant commented on an experience with transvaginal mesh complications associated with myofascial pain and mesh contraction. Have you had a lot of patients with similar findings or history? I found that most patients with mesh complications have some degree of myofascial pain on exam, moderate to severe, sort of similar to the response to the trans-operator sling question, but yes, evaluating patients with mesh complications, most of them do have myofascial dysfunction. And unfortunately, those, to me, in my practice has been some of the patients that have had the most refractory pelvic pain. So, I mean, they may see significant improvement once you release that banding that is going from one obturator to the other, but still with palpation, you know, they may still have pain. So, often prolonged PT, icing, and, you know, sometimes injections with the trigger point injections or sometimes Botox. That leads really nicely into our next question. Another participant was wondering if you ever utilized pudendal nerve blocks for the pelvic myofascial pain concurrently with Botox? Well, let me say, I mean, there've been a couple of places or a couple of patients that I have when we definitely thought that there might be a component of pudendal neuralgia, but it's not been a regular, it's not something I've done regularly. Not to say it may not work, but. And have either of you found any patients that you thought maybe had a postoperative neuroma or neuritis instead of pelvic floor myofascial pain? Was that our next question? I mean, so post-op, so say that question again, because, I mean, I've had a patient where it ended up being pudendal neuralgia and, you know, but when I worked with a pain specialist, I mean, we decided that, you know, we probably need to treat both. And so that patient, you know, did get a pudendal nerve, bilateral pudendal nerve block. And she had previously gotten really good relief from pelvic floor Botox, but then her insurance wouldn't cover it anymore. So I've definitely had cases where, a few cases where I thought it was just pelvic floor, but it ended up being pudendal nerve or pudendal neuralgia. So I think it's definitely something, if they have the other typical symptoms of it, to screen for and check and consider. But sorry, was there something about a postoperative in your eye? I missed that part. Yeah, I think they had just been asking specifically about if you found any neuromas or neuritis for some of your patients. I know I had one patient who had been referred to me who had a prior TOT sling and she developed a neuroma and had to go in and have it surgically addressed. And now is having all sorts of chronic pain and seeing physical therapy and is getting definitely some relief from that. So I suspect maybe that's where the question's coming from. I see what you're saying. You know, I mean, I hopefully have not missed one of those. I mean, that could always be the case. And I guess my question, was it seen on MRI or how did they determine it was a neuroma and neuritis? From the patient that had been referred to me, it was diagnosed on MRI. And when she came to me, she had already had surgical resection and developed some recurrent prolapse. So she was kind of coming to see what her options were for recurrent prolapse after her mastectomy that she had had. But I don't have much information from the participant that asked this question. I think it was a great point. And I definitely think, I mean, for in cases where the patient doesn't get the relief, I expect that they would get from removing the sling. I think following up with an MRI is a great idea and that would be, obviously you could assess for that. Awesome. And I think we just have one more question I'd like us to address because I know we're running a little late. Dr. McDermott said at the University of Toronto, we're routinely using vaginal or rectal suppositories of compounded gabapentin, 100 milligrams with baclofen, 10 milligrams, one to four times per day. She's reporting some great results in place of vaginal diazepam. Do you use any other types of medical suppositories beyond the Valium that you had mentioned with any sort of success? I don't, but I'm really interested in that. Is she going to publish that or studying that? Yeah, I mean, and I used to use vaginal diazepam more. And then when I had a couple of patients that had systemic levels drawn or they had blood tests because they were taking other medications and they had blood levels drawn and they realized that they could become systemic and systemic to significant levels. That in combination with, and I think this was also found in the study presented a couple of years ago that they're not as effective at myofascial symptom improvement. I've really kind of gotten away from those, but it is an option to consider. I agree with Melanie. I hope that it's being studied because I think it would be very important data to have. Great. On behalf of the Augs Education Committee, I'd like to thank Drs. Lauder and Meister and everyone for joining us today. Our next webinar is entitled Conundrums in Urethral Diverticula and will be presented by Dr. Vasavada on October 14th. So we'll look forward to seeing you again there. Thanks. Well, thank you all.

pelvic floor myofascial pain

pelvic floor dysfunction

Dr. Melanie Meister

Dr. Jerry Lauder

muscles of the pelvic floor

myofascial dysfunction

etiology of pelvic floor pain

prevalence of pelvic floor myofascial pain

screening pelvic floor myofascial examination

treatment strategies for myofascial pain