UCSF UC San Francisco Previously Published Works Title Recognizing myofascial pelvic pain in the female patient with chronic pelvic pain. Permalink https://escholarship.org/uc/item/6rz7g5b9 Journal Journal of obstetric, gynecologic, and neonatal nursing : JOGNN, 41(5) ISSN 0884-2175 Authors Pastore, Elizabeth A Katzman, Wendy B Publication Date 2012-09-01 DOI 10.1111/j.1552-6909.2012.01404.x Peer reviewed eScholarship.org Powered by the California Digital Library University of California JOGNN I N F OCUS Recognizing Myofascial Pelvic Pain in the Female Patient with Chronic Pelvic Pain Elizabeth A. Pastore and Wendy B. Katzman Correspondence ABSTRACT Elizabeth A. Pastore PT, Myofascial pelvic pain (MFPP) is a major component of chronic pelvic pain (CPP) and often is not properly identified MA, COMT, Lizanne by health care providers. The hallmark diagnostic indicator of MFPP is myofascial trigger points in the pelvic floor Pastore Physical Therapy, 224-A Weller musculature that refer pain to adjacent sites. Effective treatments are available to reduce MFPP, including myofascial Street, Petaluma, CA 94952. trigger point release, biofeedback, and electrical stimulation. An interdisciplinary team is essential for identifying and [email protected] successfully treating MFPP. JOGNN, 41, 680-691; 2012. DOI: 10.1111/j.1552-6909.2012.01404.x Accepted March 2012 Keywords myofascial pelvic pain chronic pelvic pain myofascial trigger points yofascial pelvic pain (MFPP) is a frequently a precursor or sequela to urological, gynecolog- Elizabeth A. Pastore PT, M unrecognized and untreated component of ical, and colorectal medical conditions or other MA, COMT is the owner of chronic pelvic pain (CPP). Prevalence estimates musculo-skeletal-neural issues. The hallmark di- Lizanne Pastore Physical Therapy based in Petaluma, range from as low as 14% to 23% of women agnostic indicator of MFPP is the presence of CA. with CPP have myofascial pelvic pain (Tu, As- myofascial trigger points (MTrPs) in the muscles Wendy B. Katzman PT, Sanie, & Steege, 2006) to as high as 78% among of the pelvic floor and remotely. A number of re- DPTSc, OCS, is an women with interstitial cystitis (Bassaly et al., 2010; cent studies in the CPP literature have demon- associate professor in the Doggweiler-Wiygul, 2004; Itza et al., 2010). In a strated the existence of MTrPs or hypertonic pelvic Department of Physical recent review, researchers found that very few floor muscles in a variety of medical conditions Therapy and Rehabilitation Science, University of providers actually perform a vaginal digital pal- of distinctly different origins (Bassaly et al., 2010; California, San Francisco, pation of pelvic floor muscles during routine gy- Bendana et al., 2009; Chiarioni, Nardo, Vantini, San Francisco, CA. necological exams to examine for the presence of Romito, & Whitehead, 2010; Doggweiler-Wiygul myofascial pelvic pain and trigger points (Kavva- & Wiygul, 2002; Gentilcore-Saulnier, McLean, dias, Baessler, & Schuessler, 2011). An estimated Goldfinger, Pukall, & Chamberlain, 2010). For in- 10% to 15% of women’s gynecologic consultations stance, myofascial pain is often overlooked by are secondary to CPP, and 40% of gynecologic la- first-line health care providers as either a primary paroscopies are performed to determine a cause or contributing source of pain for conditions such of CPP (Paulson & Delgado, 2005). Pelvic pain as urgency/frequency, irritable bowel syndrome patients often attend numerous visits to different (IBS), interstitial cystitis/painful bladder syndrome health care providers before being properly diag- (IC/PBS), urge incontinence, constipation, dys- nosed. Identification and treatment of the myofas- pareunia, endometriosis, vulvodynia, coccygody- cial component of CPP is needed to effectively nia, pudendal neuralgia, proctalgia fugax, or post- manage this complex, often multifaceted problem. surgical or birthing pelvic pain (Apte et al., 2011; Butrick, 2009; Doggweiler-Wiygul, 2004; Neville, Myofascial pelvic pain, sometimes called myofas- Fitzgerald, Mallinson, Badillo, & Hynes, 2010). cial pelvic pain syndrome, refers to pain found in Our goal with this article is to educate obstetric the pelvic floor musculature and connecting fas- and gynecologic nurses about MFPP as a critical The authors report no con- cia. This syndrome exists alone with no concomi- component of CPP, provide an overview of how flict of interest or relevant financial relationships. tant medical pathology, or it may exist as either to screen women with CPP for suspected MFPP, 680 C 2012 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses http://jognn.awhonn.org Pastore, E. A. and Katzman, W. B. I N F OCUS and describe current evidence-based physi- cal therapy treatments and appropriate use of Myofascial pelvic pain is a frequently unrecognized and referrals. untreated component of chronic pelvic pain. Overview of Myofascial Pelvic Pain Etiology of Myofascial Trigger Points Myofascial Trigger Points The development and perpetuation of MFPP Myofascial pain syndrome, a recognized medi- and MTrPs can be explained by a variety of cal diagnosis among pain specialists, is charac- mechanical, nutritional, metabolic, and psycho- terized by adverse symptoms caused by tender logical factors that affect muscular strain, cir- points and MTrPs in skeletal muscles (Harden, culation, and pain. Mechanical factors such as Bruehl, Gass, Niemiec, & Barbick, 2000; Itza et al., direct trauma, chronic poor posture or body me- 2010; Simons, Travell, & Simons, 1999a, 1999b). chanics, ergonomic stressors, joint hypermobility, Myofascial trigger points are localized, often ex- leg length discrepancy, scoliosis, and pelvic tor- tremely painful lumps or nodules in the muscles sion can increase muscular strain (Fernandez-de- or associated connective tissue known as fascia Las-Penas, Alonso-Blanco, & Miangolarra, 2006; and are classified as either active or latent. Active Fricton, Auvinen, Dykstra, & Schiffman, 1985; MTrPs produce local or referred pain or sensory Simons et al., 1999b; Treaster, Marras, Burr, disturbances, whereas latent MTrPs will not trigger Sheedy, & Hart, 2006). In the woman expe- symptoms unless activated by an exacerbating riencing CPP, these mechanical factors may physical, emotional, or other associated stressor occur from prior surgeries, birthing trauma, child- (Dommerholt, 2005). The pain is often reproduced hood falls, injuries, accidents, illnesses, physi- when the muscle is compressed or stretched. An cal or sexual abuse, and repetitive movement MTrP is found within a taut band in the muscle patterns. Such events can be the preexisting and typically refers pain in a predictable pattern trauma that leads to future myofascial dysfunc- when palpated. Often women with MTrPs will re- tion (Doggweiler-Wiygul, 2004; Montenegro, Vas- spond with an increased sensitivity to pain, known concelos, Candido Dos Reis, Nogueira, & Poli- as hyperalgesia. In addition, women report pain Neto, 2008; Simons et al., 1999b). Women with from stimuli that are not normally painful, de- CPP have reported more musculoskeletal impair- fined as allodynia (Vecchiet, 1994, 1998; Vecchiet ments than women without CPP (Kavvadias, 2011; et al., 1990). Muscles with trigger points are Tu, Holt, Gonzales, & Fitzgerald, 2008), and one often weak, stiff, and have restricted range of group of researchers reported 85% of patients motion (Lucas, 2004; Weissmann, 2000). Fre- with CPP had musculoskeletal dysfunction and quently, impaired circulation in tissues surround- postural changes that contributed to their CPP ing trigger points, and autonomic disturbances, (Montenegro et al., 2008). A commonly accepted such as lacrimation and piloerection (goose hypothesis is that these musculoskeletal impair- bumps), may be present (Dommerholt, 2005; ments cause muscular strain due to low-level Ge, Madeleine, Cairns, & Arendt-Nielsen, 2006; static exertion of the muscle during prolonged mo- Lidbeck, 2002; Munglani, 2000; Simons et al., tor tasks, or result from mechanical factors cre- 1999a). ating muscle pain and injury (Henneman, Som- jen, & Carpenter, 1965). Muscular strain can also Myofascial trigger points can develop in any of the cause decreased circulation, localized hypoxia, pelvic floor muscles, and these trigger points usu- and ischemia (Armstrong, 1990; Hagg, 2003; Ot- ally refer sensation or pain to adjacent sites. These ten, 1988). These conditions can all result in the referral patterns do not present in classic nerve or formation of MTrPs (Sjogaard, Jorgensen, Ekner, & dermatomal regions, although characteristic refer- Sogaard, 2000; Sjogaard & Sogaard, 1998). Once ral patterns for pelvic MTrPs have been well docu- established, MTrPs can continue to be an ongo- mented (see Table 1). The perineum, vagina, ure- ing source of peripheral pain contributing to cen- thra, and rectum are common referral sites for the tral sensitization, a priming of the nervous system, pelvic floor muscles, but women may complain of making it more sensitive to painful stimuli (Dom- pain in the abdomen, back, thorax, hip/buttocks, merholt, 2005; Lidbeck, 2002; Munglani, 2000). and lower leg (Simons et al., 1999b). The lower abdominal region is a very common referral site Myofascial trigger points can remain latent for for levator ani trigger points, making it possible years, so identifying the original etiology is of- to confuse gynecologic, gastrointestinal, and my- ten challenging. Healthy tissues are designed to ofascial