Welcome to the AUG's urogynecology webinar series. I'm Dr. Padma Khandadai. I am a member of the AUG's education committee and the moderator for today's webinar, which is entitled Pelvic Floor, Myofascial Pelvic Pain and Dysfunction. So our speaker today is Dr. Melanie Meister. Dr. Meister is an assistant professor in female pelvic medicine and reconstructive surgery. I guess we're back to urogynecology though now. At the University of Kansas, she completed her obstetrics and gynecology residency as well as her urogynecology fellowship at Washington University in St. Louis, where she earned her master's of science and clinical investigation through the Washington University Clinical Research Training Center. Her research focuses on pelvic floor disorders in women, including pelvic floor myofascial pain, pelvic organ prolapse, lower urinary tract symptoms and recurrent urinary tract infections. She has a particular clinical and research interest in the prevalence of pelvic floor disorder symptoms in adult women with pelvic floor myofascial pain, the correlation between these symptoms and non-surgical approaches to address pelvic floor myofascial pain. So just as a reminder, the presentation will run about 45 minutes and the last 15 minutes of the webinar will be dedicated to Q&A. Before we begin, there are some housekeeping items to go over. So AUGS designates the live activity for a maximum of 1.0 AMA Category 1 credits. So in order to claim your CME credit, you must log into the AUGS e-learning portal and complete the evaluation following the completion of the webinar. This webinar is being recorded and live streamed and a recording of the webinar will be made available in the AUGS e-learning portal. Please use the Q&A feature of the Zoom webinar to ask any questions of the speaker and we'll answer them at the end of the presentation. You can use the chat feature if you have any technical issues and we have an AUGS staff member who will be monitoring the chat and can assist. So without further ado, Dr. Meister, the floor is yours. Thank you and good evening, everyone. I'd like to start by just thanking the AUGS Education Committee for the invitation to speak on pelvic floor pain and dysfunction. As Padma said, my name is Melanie Meister and I'm a urogynecologist at the University of Kansas. These are my disclosures. The objectives of the webinar tonight are to describe the pathophysiology and development of myofascial dysfunction and pain within the pelvic floor muscles, to discuss the association between pelvic floor myofascial pain and pelvic floor symptoms, including lower urinary tract symptoms and chronic pelvic pain, and to describe some treatment strategies to address pelvic floor myofascial pain and associated symptoms. Now I will be focusing my presentation on pelvic floor myofascial pain and its relationship to several pelvic floor disorder symptoms and chronic pain conditions. But before we start, I just want to acknowledge there are a variety of other conditions that can contribute to pelvic symptoms and serve as a source of pain within the pelvis, including conditions like vaginal atrophy, vulvodynia, and vulvar dermatoses like lichen sclerosis. And a full discussion of these conditions is beyond the scope of this talk, but certainly would factor into the evaluation and treatment considerations if they were present. Myofascial pain is a chronic regional musculoskeletal pain disorder characterized by localized tenderness within muscles and fascia. These patients typically have contracted bands of skeletal muscle, and within these contracted bands are discrete painful nodules or trigger points. Historically, the presence of trigger points has been the hallmark of myofascial pain. The prevalence of myofascial pain throughout the body has been estimated anywhere from 30% to 85% of the general population, with prevalence estimates varying by location and symptoms. The prevalence in adults with chronic neck pain is estimated close to 55%, and 85% of adults with chronic back pain. Myofascial pain in general is more common in women than men, and the incidence peaks anywhere between ages 40 and 50. Recently, there's been some debate within the pain literature over the presence or reality of trigger points, but regardless, studies investigating the electrophysiological and chemical status of affected muscles do support the existence of discrete microenvironments within these areas that contribute to the generation of pain. Inflammatory mediators, neuropeptides, and cytokines are concentrated around active myofascial trigger points. Compared to latent trigger points in yellow and normal muscle in red, the local biochemical environment around active trigger points demonstrates a lower pH and significantly higher concentrations of a variety of pro-inflammatory cytokines, consistent with local ischemia and hypoxia within the muscles. Higher levels of these substances in active trigger points helps explain the local tenderness and referred pain of myofascial trigger points. And really, it's the combination of the acidic pH and the pro-inflammatory mediators at these active trigger points that also contributes to the segmental spread of nociceptive input within the spinal cord and may lead to the activation of multiple receptive fields. Clinically, trigger points are identifiable as localized areas of tenderness within taut bands of muscle. Palpation of these sites results in tenderness locally and typically refers pain within a consistent pattern. So within the pelvic floor, trigger points may refer pain to the urethra, the vagina, the rectum, the sacrum or coccyx, and even to the low back, lower abdomen, and posterior thighs. Trigger points can be active, meaning they're spontaneously painful, or they can be latent, which means they're only tender when palpated. Treatment of active trigger points leads to improvement or resolution of the resultant pain from palpation of those points. When we talk about the zone of reference, we're really referring to the area of perceived pain referred by the irritable trigger point. Patients usually describe their pain as a dull ache, but it really can fluctuate in intensity. Pain within myofascial trigger points may be alleviated by massage, anesthetics or needling. We also see changes to the affected muscle beyond the trigger point. These muscles may fatigue more easily or be associated with subjective weakness. These muscles usually are painful when stretched, and as a result, patients may actually adapt poor posture or sustained contraction of the muscles to reduce their pain. Patients may also restrict their range of motion in an attempt to alleviate their pain, which can actually lead to perpetuation of trigger points within the affected muscle and the development of trigger points within the nearby muscles. So as a result, these patients can actually end up with overlapping areas of pain and changes in their pain referral pattern as some of the trigger points become activated and others inactive. Interestingly, in women with myofascial pain and urinary incontinence, we see postural alterations as compared to women with urinary incontinence without myofascial pain. This is an interesting study performed by Reese and colleagues where they did postural analysis on women presenting with a complaint of urinary incontinence. And women within this sample who were found to also have myofascial pain demonstrated a greater anterior pelvic tilt, which we can see here, and posterior displacement of the body. Now this was just a cross-sectional analysis, so we can't determine whether the presence of pain led to postural changes as a compensatory measure or if the postural changes led to the development of myofascial pain. Other researchers have postulated that anterior pelvic tilt actually changes the position of the pelvic floor muscles within the pelvic cavity, increasing the tension on the pelvic floor muscles, and predisposing to the development of trigger points. An anterior pelvic tilt may also alter the length of the coccygeus muscle or the posterior portion of the levator ani. And in other studies, postural changes in the pelvis away from neutral in either direction have also been associated with increased pelvic floor muscle activity. The diagnosis of myofascial pain anywhere in the body can be challenging as classic diagnostic studies are often unremarkable. Usually these patients do not demonstrate neurologic deficits unless there is also an associated nerve entrapment. Blood and urine studies are usually normal. Imaging studies, even including MRI, usually don't reveal any pathologic changes in the muscle or the connective tissue. And routine clinical EMG studies usually do not show significant abnormalities. Now there are some specialized EMGs that can demonstrate a difference, but usually the routine tests aren't significantly different. The specific etiology of myofascial pain remains incompletely understood, but there is a general agreement that excessive acetylcholine release underlies the pathology. This acetylcholine excess may result from muscle injury either from a single traumatic event or repetitive microtrauma. But what results is prolonged or sustained muscle contraction and contraction-induced hypoxia. This then can lead to muscle ischemia, trigger point development, and pain. In addition to physical and mechanical stress, development of active trigger points has also been associated with systemic and psychological stressors, probably again as a result of changes in systemic levels of cytokines and neurotransmitters. Myofascial pain and muscle dysfunction has also been shown to develop after prolonged immobilization, which leads to pathologic changes in the connective tissue, ultimately resulting in abnormally arranged collagen fibrils, which leads to increased stiffness within the muscle and trigger point formation. So really it's the functional state of the muscle and the balance between activity, rest, injury, and healing that appears to be important in the pathophysiology of this condition. And as we move to the pelvic floor, the pelvic floor muscles really seem to be at particular risk of developing myofascial pain for a number of reasons. Because of their centralized location, these structures are involved in musculoskeletal support of both the upper and the lower body, and they have to work synergistically with the transversus abdominis and the gluteus maximus to support the pelvic floor and maintain upright posture. The pelvic floor muscles have unique functional demands. They balance a role between providing support to the pelvic viscera and at the same time allowing movements of contents from one cavity to another. These muscles must withstand physiologic stress associated with increases in intra-abdominal pressure that happen with everyday activities, and they must maintain their tension to oppose excessively increased intra-abdominal pressure that occurs with actions like coughing and jumping, which you can see is associated with a significant increase in intra-abdominal pressure over baseline. But even activities like sitting and standing are associated with a nearly tenfold increase in intra-abdominal pressure over baseline, and the pelvic floor muscles have to compensate for that as well. These muscles, not surprisingly, are further stressed during pregnancy when increased force is placed on the pelvic floor because of increased body mass, lengthened abdominal muscles, increase in the lumbar lordosis, increased pelvic width and tilt, and hormonally mediated joint laxity. And then lastly, eccentric contraction, which refers to contraction of a lengthening muscle or contraction of a muscle while it's bearing a load, is a common cause of musculoskeletal injury elsewhere in the body and happens, unfortunately, frequently in the pelvis, which I'll talk about in a minute. The pelvic floor musculature, as we know, consists of superficial and deep layers. When we talk about the superficial layers, we're referring to the ischiocavernosis, pulvocavernosis, and transverse perineal muscles, while the deeper layer includes the levator ani and the coccygeus muscle, as well as the obturator internus. We're going to focus on the deeper layer, as myofascial pain in the pelvis most often arises within the obturator internus and the levator ani. Characteristic trigger points have also been described in the coccygeus and the piriformis muscles. So, as we all know, the levator ani is a group of three striated muscles, including the pubococcygeus, the puborectalis, which is also called the pubovisceral muscle, and the iliococcygeus muscles. The levator ani is composed of primarily type I or slow twitch muscle fibers, which results in tonic contraction to close the urogenital hiatus and elevate the pelvic organs. Importantly, the pelvic floor muscles function as a unit with regional functional demands, so we don't usually see or think about the pubococcygeus muscle functioning independently from the iliococcygeus muscle, for example. But when Tuttle and colleagues looked at fiber length, they found a significant variation across regions of the pelvic floor muscles. Longer fiber length enables greater excursion or change in maximum elongation to maximum contraction, and they found that the pubovisceral muscle had the longest muscle fibers and thus the greatest capacity for excursion. This is particularly important for this muscle as it undergoes significant excursion to accommodate vaginal delivery, for example. Additionally, compared to other skeletal muscles, the muscles of the pelvic floor had significantly shorter sarcomere lengths, and as a result, they can produce a greater force when stretched. This is physiologically advantageous because these muscles have to counteract increases in intra-abdominal pressure and resist elongation during normal use, but again, this eccentric contraction may be a source of myofascial trigger point formation. Based on their findings, this group calculated that these muscles are capable of generating about 35 newtons of force when functioning as a unit, which is sufficient for most activities of daily living, but intra-abdominal pressure during more strenuous activities like jumping may exceed this maximum tension generated by the muscles and predispose to development of pain or trigger points. And then really, any impairment to the structure of these muscles or increase in functional demands may lead to the development of myofascial pain. Eccentric contraction and overextension of muscle fibers beyond their optimum length tension ratio are common in the muscles of the pelvic floor, and again, probably the most obvious time we see this is in the pelvis is with vaginal delivery. I think this study is beautiful in how it illustrates the uneven lengthening of the muscles of the levator ani needed to accommodate the passage of the fetal head during the second stage of labor. So diagnosis of myofascial pain and pelvic floor myofascial pain in particular can be challenging and is unfortunately often overlooked for a variety of reasons. First, we are lacking a consistent definition of pelvic floor myofascial pain, and even more simply, lacking a consistent term for this condition. While the term pelvic floor myofascial pain or varieties of those words have been used more commonly in the literature, historically, this condition has also been referred to as levator myalgia, high tone pelvic floor dysfunction, and others. Importantly, among the terms I've listed, only pelvic floor myalgia and high tone pelvic floor dysfunction have associated ICD codes, which limits our ability to conduct prevalence estimates using coded data. Additionally, these terms are not synonymous. Tone and pain are not interchangeable. A muscle can be high tone without being painful, and likewise, painful trigger points can exist within muscles that are not globally hypertonic. Additionally, we lack validated diagnostic criteria. Transvaginal palpation is currently the most widely used method of diagnosis, and in a 2022 systematic review, no diagnostic test was found to be superior to transvaginal palpation. While we've developed an evidence-based and standardized examination, it's not routinely implemented across providers. Unfortunately, few physicians, including OBGYNs, are trained to consider the pelvic floor as a potential source of patient's symptoms, and often their symptoms end up attributed to end organs, which may even result in unnecessary surgery. And we've already reviewed some of the challenges associated with trigger points. So like I said, a validated examination does not yet exist for assessment or evaluation of the pelvic floor muscles, and there's significant variation in examination strategies, although more recent publications do offer more detailed descriptions of the examinations they've used to identify and categorize women as having pelvic floor myofascial pain. Additionally, validation of any examination strategy is challenging because there's not a gold standard for diagnosis. In 2018, the MAP Network, the Multidisciplinary Approach to the Study of Chronic Pelvic Pain, which, as most of you know, is an NIH-sponsored research consortium for studying urologic chronic pelvic pain in men and women, published their examination strategy, again, for use in both men and women with urologic chronic pelvic pain. They included internal and external sites, but didn't standardize or describe an attempt to standardize the depth of palpation among their examiners, and they only scored findings for tenderness as either present or absent. The examiner applied finger pressure to each point to produce a discernible movement of the muscle or the organ, but again, minimal description is provided for locating the muscles to palpate. They do provide this nice clock face diagram, which can be helpful for identification of the muscle. Simultaneous to the work by the MAP Network, our group attempted to improve on the inconsistencies we identified in the literature and developed our own version of a standardized pelvic floor examination. We were able to demonstrate reproducibility among the providers in our practice, and the examination includes the assessment of four external sites as well as internal sites, including the bilateral obturator internus and levator ani. We begin with an assessment of the right obturator internus and proceed counterclockwise to the right levator ani, left levator ani, and left obturator internus. We recommend palpating along the length of the muscle fiber in the direction of the muscle fibers in order to fully evaluate for the presence of trigger points, because often trigger points are detected near the origin or the insertion of the muscle rather than in the center of the muscle belly. You'll notice we advocate or recommend evaluation of the levator ani as a group without trying to distinguish pain or trigger points within the individual muscle components. So now I'd like to transition from our discussion of the pathophysiology of pelvic floor myofascial pain and begin to explore the association between pelvic floor myofascial pain and pelvic floor disorder symptoms. This is an emerging area of study and I'll be focusing primarily on the symptoms listed here, including prolapse, lower urinary tract symptoms, including interstitial cystitis or bladder pain syndrome, as well as chronic pelvic pain. This table was taken from a retrospective study of new patients presenting to one urogynecology clinic where they identified pelvic floor myofascial pain in 50% of the patients and found it to be associated with dysuria, urinary urgency frequency, and pelvic pain. The prevalence of pelvic floor myofascial pain among women presenting with pelvic organ prolapse symptoms was investigated in a retrospective review by Dixon and colleagues published in 2019. Of 539 patients included in their sample, the prevalence of pelvic floor myofascial pain was 32%. Interestingly, women with pelvic floor myofascial pain on examination reported overall greater bother from their prolapse symptoms despite having an overall lower stage of prolapse. These women were significantly more likely to report lower abdominal pressure, heaviness or dullness in the pelvic area, and pain or discomfort in the lower pelvic region. There was no difference in the sensation of a vaginal bulge, and like I said, they were statistically significantly less likely to have prolapse beyond the hymen. In a retrospective review of patients presenting with pelvic floor symptoms at our institution, we looked at associations between the severity of pelvic floor myofascial pain on examination and prolapse symptoms. We found pelvic floor myofascial pain severity to be 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, but not correlated with seeing or feeling a vaginal bulge, a sensation of incomplete emptying, or having to push on a bulge to start or complete urination. Similarly, pelvic floor myofascial pain severity was not correlated with POPQ stage in our sample either. Overall, the data suggests that the presence of pelvic floor myofascial pain is associated with some subjective symptoms of prolapse and may even be a driver of these symptoms for some women, particularly those who are found to have less advanced objective prolapse on exam. Pelvic floor myofascial pain has also been found to be prevalent in women presenting for evaluation of a variety of lower urinary tract symptoms, including urinary urgency and frequency, mixed urinary incontinence, a sensation of incomplete emptying, dysuria, and UTI symptoms. I will discuss the association with interstitial cystitis in later slides. In a cross-sectional study of women presenting for evaluation of urinary incontinence, one study estimated a prevalence of pelvic floor myofascial pain over 50% among women. And the presence of pelvic floor myofascial pain in that study seemed to be a driver of urinary urgency symptoms because they found women with mixed urinary incontinence had a 4.9 adjusted odds ratio of having pelvic floor myofascial pain compared to women with isolated stress incontinence. In the retrospective study I referenced a few slides ago, similarly, 50% of new patients presenting for evaluation were found to have pelvic floor myofascial pain on examination. Symptoms of dysuria, pelvic pain, and urinary frequency were significantly more common in women with pelvic floor myofascial pain compared to those without. In another population of women presenting for evaluation of bothersome urinary symptoms, Ackerman and colleagues identified a subset of women with a constellation that they called the persistency symptoms. Again, this was a constellation of bothersome lower urinary tract symptoms, including urinary urgency, frequency, pelvic pressure, and a sensation of incomplete bladder emptying without urgency incontinence or bladder pain symptoms characteristic of overactive bladder or interstitial cystitis, respectively. These patients demonstrated pelvic floor hypertonicity and trigger points on examination but did not have a subjective complaint of pain. They coined this phenotype myofascial frequency symptoms. These patients also demonstrated more dyspareunia than the other cohort. Pelvic floor muscle dysfunction has long been associated with interstitial cystitis, bladder pain syndrome, but evaluation for pelvic floor muscle dysfunction within this population has historically received little attention. This is changing, thanks in part to research by the MAP Network and others. Several studies have identified a high prevalence of pelvic floor myofascial pain and trigger points in women with a diagnosis of interstitial cystitis, with prevalence estimates anywhere from 78 to 85%. As we know, there is significant heterogeneity in symptoms in patients with a diagnosis of interstitial cystitis. In women with interstitial cystitis with Hunter's lesions, bladder directed therapies are often effective. But in those without Hunter's lesions, bladder directed therapies continue to provide suboptimal results. These women do, however, show improvement with pelvic floor directed therapies like pelvic floor physical therapy and probably represent a subset of patients with interstitial cystitis, bladder pain syndrome. Additionally, the presence of myofascial trigger points has been found to exacerbate pain symptoms in women with interstitial cystitis. This figure that I'm showing down here came from patients in the ICEPAC trial, which was a cross-sectional study about evaluating the autonomic and psychophysiologic characteristics of patients with interstitial cystitis, bladder pain syndrome, myofascial pain, and healthy controls. Here, researchers evaluated pinprick sensation in the pelvic dermatome and found that patients with interstitial cystitis demonstrate hyperalgesia in all pelvic dermatomes. And this was even more prominent in women with both interstitial cystitis and myofascial pelvic pain, supporting this idea that pain symptoms are exacerbated in a setting of myofascial trigger points. Women with interstitial cystitis and myofascial pain also had higher overall pain levels and pain associated with bladder filling compared to women with interstitial cystitis alone, again, demonstrating this exacerbation of pain symptoms in women with concomitant symptoms. You and colleagues mapped the myofascial trigger points in another group of women with interstitial cystitis and found the most painful sites to be the obturator internus and puborectalis muscles. They categorized the severity of myofascial pain in their population and found that patients with more severe pelvic floor myofascial pain had higher rates of dyspareunia, a higher overall number of myofascial pain sites, and higher O'Leary-Santz scores, indicating more severe interstitial cystitis symptoms. Additionally, they found that higher myofascial pain severity was associated with a lower subjective treatment success, but no difference in bladder function or pathophysiology. Patients with interstitial cystitis have also been found to have shortened pelvic floor muscles and higher resting pelvic floor muscle tone compared to controls. In these HCL MRI images, we clearly see the shortened puborectalis muscle in the patients with interstitial cystitis compared to control. And collectively, patients with interstitial cystitis in this study were found to have shorter puborectalis length overall. Root mean square, which we see up here, is measured on EMG and is a timed domain variable that uses an estimate of the amplitude of the signal, in this case, coming from the muscle. A higher root mean square represents greater net activation of motor units and is used as a marker of muscle tone. At rest, patients with interstitial cystitis demonstrated significantly higher signal amplitude and thus higher pelvic floor muscle tone as compared to controls. Apart from interstitial cystitis, pelvic floor myofascial pain is also associated with other chronic pain conditions. Worldwide, up to 26% of women are suffering from chronic pelvic pain, which accounts for approximately 40% of laparoscopies and 12% of hysterectomies in the United States every year. Myofascial trigger points have been identified in women with endometriosis, vulvodynia, irritable bowel syndrome, and defecatory dysfunction, coxysgenia, urethral syndrome, and dysmenorrhea. Like in interstitial cystitis, myofascial trigger points compound the pain experienced with each of these conditions. Hypertonic but weak pelvic floor muscles and myofascial trigger points are commonly found in women with vulvodynia. In cases like this, the trigger points likely arise as a result of habitual tensing or clenching the pelvic floor muscles to guard against pain associated with vaginal penetration. Again, similar to women with interstitial cystitis, women with other forms of chronic pelvic pain have been found to have increased tone in their pelvic floor muscles at rest and with contraction. Among studies that have evaluated pelvic floor muscles in women with these conditions, myofascial trigger points have been found to be quite prevalent in more than 80% of women with primary dysmenorrhea, 86% of women having a hysterectomy for chronic pelvic pain, and in 94% of women with biopsy-proven endometriosis. Unfortunately, once formed, if not treated, myofascial trigger points can become a self-sustaining source of pain that persists even after the original insult is resolved. For many women with these conditions, though, their symptoms do improve with pelvic floor directed therapies. Among the cohort of women undergoing minimally invasive hysterectomy for chronic pelvic pain, women with comorbid pain conditions including dysmenorrhea, back pain, and fibromyalgia were significantly more likely to have myofascial pain on examination. And women with myofascial pain were more likely to use opiates, muscle relaxants, antidepressants, NSAIDs, benzodiazepines, Tylenol, and anticonvulsants all for pain relief before surgery. Though hysterectomy may be indicated for chronic pelvic pain, it may temporarily worsen myofascial pain in the immediate postoperative period and is worthy of a discussion with the patient. Now, importantly, while myofascial pain begins as a peripheral pain experience in response to the presence of trigger points within the muscle, the association with other chronic pain conditions and the amplification of symptoms in patients with comorbid conditions likely results from a variety of mechanisms including viscerosomatic convergence, viscero-viscero convergence or cross sensitization, and then ultimately central sensitization. So viscero-viscero convergence arises as a result of innervation between unique visceral structures that converge at the same level of the spinal cord. This can lead to difficulty differentiating the source of pain and enabling activity or inflammation in one organ to actually hypersensitize the other organ. With viscerosomatic convergence, persistent visceral nociceptive stimuli, which we can see in conditions like interstitial cystitis or endometriosis, can lead to noxious somatic stimulation, which manifests as pelvic pain or pelvic floor muscle hypertonicity. Conversely, persistent somatic input from pelvic floor myofascial trigger points can lead to visceral dysfunction, manifesting as lower urinary tract symptoms or constipation. Additionally, the anatomic proximity and the interaction of the pelvic floor muscles and pelvic viscera may also contribute to these interrelated symptoms. In this cystoscopic image, we can clearly see the impression of the obturator internus muscle on the full bladder. If myofascial trigger points were present within this muscle, they could be activated with bladder filling, leading to local and referred pain, which could be perceived as related to the bladder itself. Eventually, persistent input from visceral and somatic structures into the central nervous system can enhance responsiveness and decrease pain inhibition, leading to hypersensitivity and central sensitization, which unfortunately can have implications for treatment. We will finish up tonight by discussing treatment strategies for pelvic floor myofascial pain. Pelvic floor physical therapy really is the first-line treatment and the mainstay of treatment for women with pelvic floor myofascial pain. It is highly effective, with improvement in myofascial pain scores in more than 60%. I usually tell people that this condition is not one that we treat and it goes away forever. It's one of chronic management, but pelvic floor physical therapy really is that mainstay of treatment. Importantly, among women with some of the associated symptoms we just discussed, several studies document improvement in those symptoms as well when pelvic floor myofascial pain is addressed with pelvic floor physical therapy. For example, bladder pain and lower urinary tract symptoms improve in up to 70% of women with interstitial cystitis and myofascial pain. Urgency and frequency symptoms improve in up to 84% of women with overactive bladder. Other symptoms associated with chronic pain conditions, including depression and anxiety, as well as dyspareunia, have also been shown to improve with pelvic floor physical therapy. Now, I recognize there are some challenges to pelvic floor physical therapy. Access to therapy is limited for some patients by proximity of a qualified pelvic floor physical therapist, cost, or lack of insurance coverage. Additionally, there exists a wide variation in treatment protocols and physical therapist training, background, and approach. Some data suggest improvement proportional to the number of physical therapy visits completed and a minimum of at least three necessary to see some degree of improvement. Although treatment protocols vary, the inclusion of myofascial release appears to improve outcomes. Now, myofascial release usually refers to manual techniques like deep pressure massage, stretching, joint mobilization, and trigger point release. Trigger point release is where digital pressure is applied directly to the myofascial trigger point. Studies have incorporated self-myofascial release with the use of vaginal wands or dilators and have demonstrated similar improvements. And this is really important because this might be an opportunity to increase access to this therapy for people who live a distance from qualified pelvic floor physical therapists. Pelvic floor physical therapists often incorporate teaching about strategies to help manage pain, including breathing and relaxation exercises, or behavioral modifications to address other symptoms like urgency and frequency, which might also explain some of the improvement in their associated symptoms. In addition to myofascial release, there are several other adjuncts to pelvic floor physical therapy that have been shown to be beneficial in the treatment of pelvic floor myofascial pain and associated symptoms. A variety of medications are often used, including NSAIDs, muscle relaxants, neuromodulators, and antidepressants. Electrical stimulation, or eSTIM, is a method of therapy where a small electrical current is used to contract the pelvic floor and assist the patient in activation of the proper muscles. Biofeedback uses a pressure sensor that's placed in the vagina, the rectum, or even on the perineum to provide audible and or visual feedback of the strength and duration of the muscle contraction, and this is usually used in conjunction with eSTIM. Cognitive behavioral therapy can be very helpful, particularly for patients with comorbid depression and anxiety or in women with a history of abuse or post-traumatic stress disorder. And trigger point injections can also be a useful adjunct to pelvic floor physical therapy, and I will expand on those in just a minute. Muscle relaxants are frequently used for myofascial pain throughout the body in an attempt to address the hypertonicity of the muscle. Despite their widespread use, though, there's limited data for use of muscle relaxants, particularly in pelvic floor myofascial pain. Generally, when we think about muscle relaxants, they're broadly classified into two categories, either antispasticity agents or antispasmodics. Benzodiazepines promote binding of the inhibitory neurotransmitter GABA to its receptor throughout the central nervous system, and benzodiazepines exhibit both antispastic and antispasmodic activities. As a result, though, these agents are associated with risks, including sedation, drug-drug interaction, the potential for abuse, and for benzodiazepines in particular, they enhance the respiratory depression seen with opioids. Diazepam is the benzodiazepine or muscle relaxant that has been most widely studied in patients with pelvic floor myofascial pain. Diazepam can be administered either orally for systemic dosing or vaginally. Ideally, vaginal administration is in the form of a compounded suppository that's made using a powdered diazepam in a polyethylene glycol base. If a compounding pharmacy is unavailable or inaccessible because of cost, vaginal administration of oral tablets has been described. We have to be careful with that, though, because the pharmacokinetic data for vaginal administration of oral tablets is not available. And so we don't really know much about peak serum concentration or duration of effect. Compounded vaginal diazepam reaches its peak serum concentration after three hours compared to two hours with oral diazepam. And the overall peak serum concentration is lower for vaginally administered diazepam. Additionally, the half-life for vaginal diazepam is longer at 82 hours compared to 44 hours for oral diazepam. As a result, vaginal diazepam is generally associated with fewer side effects and systemic symptoms. There have been no studies to date on oral diazepam for pelvic floor myofascial pain, but studies in women with pelvic floor dysfunction associated with constipation do not demonstrate any benefit over physical therapy with e-stim and biofeedback. Several small studies have investigated vaginal diazepam for pelvic floor myofascial pain, and these have shown mixed results. Cyclobenzaprine is a well-studied muscle relaxant and widely used in patients with fibromyalgia. There's no data on the use of cyclobenzaprine for pelvic floor myofascial pain, and a 2009 Cochrane review concluded there was insufficient data to support the use of cyclobenzaprine for general myofascial pain. Other commonly used muscle relaxants include tizanidine and methocarbamol, although there's really very little data on the utility of these medications for myofascial pain in general or pelvic floor myofascial pain in particular. As I mentioned earlier, dry needling and trigger point injections are common adjuncts to pelvic floor physical therapy. In fact, many pelvic floor physical therapists perform dry needling as a part of their therapy in the hopes that this helps downregulate the guarding reflex and enable more intensive myofascial release, as well as hopefully lead to symptomatic improvement. The idea with dry needling is that needling of the hypercontracted muscle or the trigger point leads to a mechanical disruption and interruption of the sensory signals characteristic of myofascial trigger points. For dry needling, a solid acupuncture needle is used and is either left in place or is moved in and out repeatedly over a few minutes. Although there have been no prospective studies of dry needling in the pelvis, dry needling elsewhere is similar in efficacy to wet needling or use of a local anesthetic, although the use of the local anesthetic usually prolongs the duration of effect. Risks associated with dry needling include soreness at the needle site, hematoma or hemorrhage, and sinkable episodes. Trigger point injections, also called wet needling, involves injection of a local anesthetic with or without a steroid into the myofascial trigger point. These can provide immediate symptomatic pain relief that can last for a few hours to several weeks. The exact mechanism underlying improvement with myofascial trigger point injections remains incompletely understood, although a number of theories for this mechanism have been proposed, including disruption of the muscle fibers and nerve endings at the site of pain, interruption of that positive feedback loop that's perpetuating the pain, vasodilation to remove excess metabolites, and dilution of the nociceptive substances by the anesthetic, and then release of endorphins or other inflammatory biochemicals. Typically for these, injections are performed with a 25 or a 27-gauge needle. The transvaginal approach is common, although the pelvic floor muscles can also be accessed with a subgluteal or perineal approach. Some advocate the use of an Iowa trumpet if the transvaginal approach is used, simply for safety. Now, the decision or the argument about whether to include steroids as part of the trigger point injection is debated. The argument against steroids is that this could lead to muscle dimpling and wasting with repeated use, and certainly that would be a consideration if these trigger point injections are being performed repeatedly or in short intervals. Alternatively, some argue that the incorporation of the steroid actually prolongs the duration of effect, enabling less frequent trigger point injections. One study investigating transvaginal trigger point injections for the treatment of myofascial pain in women with chronic pelvic pain demonstrated a 72% improvement after injection of a combination of bupivacaine, lidocaine, and triamcinolone, with a sustained improvement at three months in 33% of their population. Patients should be counseled that they may actually experience an initial increase in their pain at the injection site over the first 12 to 24 hours that may persist for 24 to 48 hours. Risks of trigger point injections include infection, hematoma, syncopal episodes, or intravascular injection. Vagelinum toxin is a neurotoxin that inhibits acetylcholine release at the neuromuscular junction and is a common treatment for neuromuscular conditions resulting from excess muscle activity and frequently used for myofascial pain throughout the body. Randomized controlled trials for vagelinum toxin and myofascial pain elsewhere have demonstrated mixed results. And although the use is increasing for treatment of pelvic floor myofascial pain, the data still remain limited. Of note, pelvic floor injection of vagelinum toxin is off-label and as a result is often reserved for refractory cases because for some cases that can be difficult or expensive, difficult for coverage or expensive for the patient. We published a systematic review and meta-analysis on the use of vagelinum toxin for pelvic floor myofascial pain and found a statistically significant reduction in pain scores at six weeks that persisted to 12. Statistically significant improvement was also noted in other symptoms including dyspareunia, dyskinesia, and quality of life. Now although this is proving to be a pretty promising treatment, there's still a lot we don't know about optimal management with vagelinum toxin. This includes the optimal dose, the number of sites including the dose per site, the location of injection, and the timing of retreatment. Various methods for localizing the site of infection have been reported including transvaginal palpation which is very commonly used, EMG or ultrasound, but studies comparing efficacy of the various methods have not been done. Some studies involve the use of co-therapy including either a local anesthetic or a pudendal block although data are limited to support one practice over another. And risks often reported include transient worsening of the pain, constipation, injection site infection, urinary tract infection, urinary retention, and fecal incontinence. In the last minute or two, I just want to highlight some additional modalities that are mentioned in the myofascial pain literature. The data for each of these is really limited to a single study or anecdotal reports but they're interesting and I thought worthy of discussion. Photobiomodulation therapy uses LEDs without thermal effects and the theory here is that light absorption in the biological tissue can promote analgesia, increase endogenous opioid production, and improve local blood flow. In a small study, there was no improvement with photobiomodulation over vaginal stretching alone though. Radiofrequency modulation therapy involves shortwave diathermy and radiofrequency induced muscle contraction to promote tissue remodeling, neovascularization, vasodilation, and elastin fiber regeneration. When compared to e-stim and biofeedback alone, there was not an added improvement with the addition of radiofrequency modulation therapy. Extracorporeal shockwave therapy, which is used to treat kidney stones or is the non-invasive application of high energy acoustic waves, is undergoing a prospective trial right now actually. Topical heat is frequently used for musculoskeletal conditions throughout the body and for musculoskeletal conditions in the pelvis, baths are usually recommended as the sort of ideal method for applying the heat. Although there are no studies investigating the utility of warm baths or topical heat in pelvic floor myofascial pain, this intervention is relatively low risk and may be helpful. Cryotherapy, conversely, refers to therapeutic cooling of the tissue to promote pain relief and recovery, so this is icing. In the pelvis, cryotherapy can be applied to the perineum or actually intravaginally. At our institution, we conducted a pilot trial of women with pelvic floor myofascial pain and found an improvement in pain scores with both a single cryotherapy session and two weeks of daily cryotherapy. Magnesium-based trigger point injections have been studied in comparison to standard lidocaine-based trigger point injections, and the idea here is that calcium release can perpetuate pathologic myocyte contraction, and potentially this could be inhibited with the inclusion of magnesium. However, there was no improvement with these magnesium-based trigger point injections over standard lidocaine. And then pudendal blocks have been studied but are really commonly reported as co-therapy, and these are probably beneficial in patients who have concomitant pudendal neuralgia. There's little comparative data, though, for women who don't have a component of that neurologic condition. So wrapping up our discussion tonight of pelvic floor myofascial pain, I want to leave you with just a few take-home points. Myofascial pain is characterized by the presence of trigger points with tenderness to palpation, and the pelvic floor is really at risk because of its structural and physiologic demands that occur throughout life. Myofascial trigger points have been identified in patients with a variety of pelvic floor disorder symptoms, including non-pain conditions. Pelvic floor physical therapy is the first-line treatment due to its low risk and its high likelihood of benefit, and some emerging therapies are showing promise. And pelvic floor directed therapies, including pelvic floor physical therapy, lead to an improvement in other associated symptoms as well. I have several pages of references here, and I'm happy to take any questions. Dr. Meister, that was an excellent discussion and really helps to validate a lot of the things that I do too, so I'm really glad to have you give this talk. We do have quite a few questions in our Q&A, so I'm going to go through a few of them as time sits. I do want to mention that Beth Shelley posted a link, and we can send that for the ICS Standardization of Terminology and Pelvic Floor Muscle Assessment. It's in the 2021 Neuro Urology and Urodynamics Journal, and so it has a lot more of the standardization of terms, so at least amongst us, we can be using the same terminology. So one of the questions that was asked was a couple questions about Botox. So what protocol do you like to use for Botox? And just to kind of piggyback off of that, are there any particular CPT codes that you use, and what kind of barriers from insurance do you encounter? All good questions. I have not had much luck getting these Botox injections covered by insurance. In my practice, I typically do these in the office, so in the outpatient setting. In that case, the procedure is often covered, and the patients then are responsible for paying for the cost of Botox out-of-pocket. For my patients who've had this therapy or are interested in this therapy, they find that to be a valuable or a reasonable expense. There's not data to support my practice here, but I tend to use a standard trigger point injection first with a mixture of topical or a local anesthetic and a steroid as sort of a diagnostic and maybe an idea about whether that's actually going to help them before we proceed with the expense of the Botox. If they have some benefit to their pain, even if short-lived, from the local trigger point injection, then we hope at least that they have a better response or better likelihood of responding to the Botox. In terms of my protocol for the Botox itself, I usually start with somewhere between 1 and 200 units, kind of depending on the patient. If we need to go up with subsequent treatments because of an incomplete response or recurrence of their symptoms early, I can and I do. Usually, I use about 10 to 20 units per injection site, and I map, if you will, their locations of trigger points on exam. I do an exam, and we identify their trigger points at the start and then identify them and inject those directly with the Botox, which is why I like to do it in the office. Most of them can tolerate it, and then they can provide the feedback about the location. In patients who can't tolerate it, I do do it in the operating room too. And then just as the follow-up to that, any particular CPT codes that you use for Botox injections? No, I use the CPT code for a trigger point injection, which is divided by less than three muscles or more than three, or three or more muscles, and I almost always inject more than three. But then again, the patient is charged directly for the Botox by my institution. So wish I had a better, if anybody else has tricks, I would love to hear them. I have used the chemical denervation CPT code, because sometimes the reimbursement's a little bit better, but same here, in that I have the patients pay for their own Botox, and then the procedure itself gets covered using one of those codes. Another question we had, again, regarding trigger point injections and Botox we could add too, but how do you incorporate pelvic physical therapy into your protocol of trigger point injections and Botox injection? That's a great question, and that is a caveat that I give most of my patients, is again, the pelvic floor physical therapy is sort of the mainstay. We have that going, and then we do these additional adjunct treatments on top of it. I like to, because some people experience an initial sort of flare or initial pain with the trigger point injections, I like to try to time them so that they have a visit with their pelvic floor physical therapist like two to three days after their scheduled trigger point injection. It doesn't always work that way, but I find that if they have the trigger point injection, and then a couple of days later have that follow-up visit with the pelvic floor physical therapy, they can make a little bit more progress at that subsequent visit. Okay, and then another question from Dr. Barnes regarding Botox. Do you reserve Botox only for spastic and tense muscles, or do you do it for tenderness in the absence of spastic muscles? I do not reserve it solely for spastic muscles, but I do inject the Botox into trigger points. So if there's a patient with flaccid or weak muscles who doesn't have the presence of trigger points, I wouldn't be doing Botox. But like I said, trigger points can be present even in a muscle that's not globally hypertonic. So it's not a requirement in my opinion to have a completely spastic muscle if they have those top bands or trigger points within the muscle that are causing pain. And another attendee asked the question, if you were using oral Valium intravaginally, how do you instruct the patient to take it, for example, if the cost is too high for a compounding pharmacy? You know, admittedly, I don't really prescribe that. But I have spoken with others who do, and they usually recommend just simply placement of the oral tablet in the vagina. Usually, folks I've talked to suggest trying it in the evening or when the patient knows they're going to be home and not driving or operating machinery in case there's some sedation effect or something from the medication. But it's not something I use routinely in my practice. So I can't provide much more than that. I'm sorry. Okay. And another question that was posed was, when you talk to patients about pelvic physical therapy, what kind of definition of pelvic physical therapy are you talking about with patients? As we know, there's a variety of different techniques. So what are you asking the patients to look for and what are you most interested in your patients receiving? So I am pretty lucky. I have a great group of local pelvic floor physical therapists, both at my institution and then some community-based ones around where I practice. And so at this point, I have a pretty good idea about what their therapy entails. And I highly encourage my patients with pelvic floor myofascial pain to kind of get to one of the physical therapists that I know and who I work with other patients with. But if that's not possible or they're seeking care from someone else, I talk to them about this should be an individual session working one-on-one with a female physical therapist. I would expect her to do some internal work. So putting a finger in the vagina to feel the muscles, feel the tension in the muscles, identify areas that are tender like I did on exam, and then help give you some exercises and potentially perform some manual therapy to help alleviate that tension or work through those painful spots or something like that. And then I encourage patients, especially if they're seeing a physical therapist that I'm not familiar with, to let me know how it's going. And if they feel, it can take several sessions to really see an improvement, but if they feel like they're attending sessions and they're not getting an improvement or they're not getting internal work, then I would encourage them to maybe try a different physical therapist with a different approach. Okay. Do you use gabapentin, Lyrica, or tricyclic antidepressants to treat your patient? I would say not routinely, but I have patients who use those medications and do find improvement in their symptoms. In fact, I had somebody just the other day who had just started Lyrica and had a significant improvement in her pain before she saw me even. So, you know, I think there is some role for that, particularly if there's a neuronally-mediated component of their pain. It's just not part of my routine treatment algorithm. And I don't think there's much data for those agents in pelvic floor myofascial pain to date, although it would be good study. All right. That brings us to the end of our webinar. I want to thank Dr. Meister for this excellent discussion. There were so many questions in the chat that I wasn't able to get to. So on behalf of AUGS, I'd like to thank our faculty, Dr. Melanie Meister for this excellent webinar. Be sure to register for our upcoming webinars. Next week, we have part two of the AUGS coding webinar series. And on April 3rd, join Drs. Sana Ansari and Jessica Hirosh as they discuss a webinar entitled Let's Talk About Urethral Pain. Follow AUGS on Twitter or Instagram and check out our website for information about all the upcoming webinars. And we thank you all for joining and participating. And I hope you have a great evening.

Dr. Melanie Meister

female pelvic medicine

pelvic floor myofascial pain

pathophysiology

pelvic floor physical therapy

lower urinary tract symptoms

chronic pelvic pain

trigger point injections

Botox injections