9/29/2019 High Tone Pelvic Floor Dysfunction October 2019 Types of PFM dysfunction Two categories of pelvic floor muscle dysfunction seen in the literature: • Hypertonicity, known as high-tone pelvic floor (HTPFD). Sometimes referred to as levator myalgia. • Hypotonicity, known as low-tone pelvic floor (LTPFD). • Hypertonic pelvic floor muscles are shortened, painful, have trigger points or tender points, taut bands, high resting baselines, and may be in spasm. High tone PF dysfunction - HTPFD HTPFD is related to the following (not and exhaustive list): • Pelvic pain – including chronic pelvic pain (CPP) • Dyspareunia • Interstitial cystitis (IC) • Vulvodynia/vaginismus • Endometriosis • Scars, adhesions • Lichens schlerosus • Irritable bowel syndrome (IBS) • Prostatitis • Pudendal neuralgia • Coccydynia • Bowel, bladder and intimacy issues • Can result from trauma to hip, sexual abuse 1 9/29/2019 Definition of HTPFD • High-tone pelvic floor dysfunction is defined as hypertonicity of the levator ani complex and pain upon attempted penetration, squeeze, or palpation of the vaginal and pelvic musculature. Rogalski MJ et al (2010). Int Urogynecol J 21:895–899 Prevalence • While the prevalence of HTPFD is unknown, it is largely believed to be under diagnosed. • Contributing factors include an elusive presentation, anxiety or embarrassment causing hesitation in seeking care, and lack of provider awareness of the condition. • Has a significant impact on QOL Crisp et al., Int Urogynecol J. 2013;24(11):1915-23. Hypertonic Pelvic Floor Dysfunction - Defined • Resting EMG ≥2.0 microvolts (μv) sEMG excepted from Hetrick et al., Neurourol Urogyn. 2006;25(1):46-9. 2 9/29/2019 Patient Presentation • Symptoms may manifest as muscle pain in the groin, low back, or gluteal region, which may radiate to the hip and sacrum. • The patient may complain of dyspareunia (painful penetration), urinary or bowel dysfunction, and elimination difficulty • These women/men may present with pelvic pain characterized by an increase in pain with internal examination, which may lead to unprovoked vaginal/pelvic pain due to levator hypercontractility. Chronic Pelvic Pain • Chronic pelvic pain is defined as pain that occurs below the umbilicus (belly button) that lasts for at least six months. It may or may not be associated with menstrual periods. • Chronic pelvic pain may be a symptom caused by one or more different conditions. Chronic Pelvic Pain (CPP) “A Headache in the Pelvis” “lower genitourinary symptoms, particularly pain in the perineum or genitalia, voiding symptoms, such as dysuria or frequency, and sexual dysfunction…” National Institutes of Health Definition Krieger; JAMA 282:236, 1999 3 9/29/2019 Introduction • Pelvic pain has multifactorial etiology • Overlapping cerebral representation for somatic and visceral structures • Multiple stakeholders involved in evaluation and management Pelvic pain statistics… • Most common form of chronic pain in women of childbearing age in U.S at per annum cost of $881.5 million on outpatient management • Women with pelvic pain report lower QOL than other types of chronic pain (e.g. back pain) • Hysterectomy most common surgery in U.S.; C-section 2nd-most common • According to the CDC the three most common reportable STIs—chlamydia, gonorrhea and syphilis • It is estimated that 1 in 20 sexually active young women aged 14-24 years has chlamydia. • In women, undiagnosed and untreated chlamydia and gonorrhea can lead to pelvic inflammatory disease. (PID) – risk factor for CPP and infertility Differential diagnosis • Trigger points/Myofascial pain syndrome • Referred visceral pain • SI joint dysfunction and other osseous elements of the hip, back and pelvis • Nerve entrapment post-surgery • Hip girdle restriction • Lumbar radicular pain 4 9/29/2019 Gynecologic origins • 24%-86% of cases of pelvic pain • Endometriosis is diagnosis in 52% of these • Intra-abdominal adhesions in 10%-51% • Endometriosis, adhesions and fibroids do not cause pain in all patients • 50% of women have no known historical cause for adhesions • More than 50% of adhesions have nerve fibers in them (Tulandi 1998, Kligman 1993) Myofascial pain syndromes • Hypersensitive, painful, taut bands in skeletal muscle • Characteristic referral pattern of pain on palpation • Associated autonomic dysfunction? Harden R et al., Clin J Pain 2000 5 9/29/2019 Active TP • A focus of hyperirritability in a muscle or its fascia that is symptomatic with respect to pain; it refers a pattern of pain at rest and/or on motion that is specific for the muscle Associated TP • Associated TP - A focus of hyperirritability in a muscle or its fascia that develops in response to compensatory overload, shortened range, or referred phenomena caused by trigger point activity in another muscle. • AKA: Satellite and Secondary TP’s 6 9/29/2019 Latent TP • A focus of hyperirritability in muscle or its fascia that is clinically quiet/dormant with respect to spontaneous pain; it is painful only when palpated. Potential Causes of TPs • Acute/chronic injury or illness • Excessive repetitive movements • Chilling of the muscle • Nervous tension or stress • Tender point of long duration • Active primary point causing secondary TP • Latent TP activated by any of the previous Initiators of myofascial pain • Postulated – chronic microtrauma – sleep disorders/ fatigue – macrotrauma – systemic influences (thyroid, nutritional dysfunction) – psychosocial stress Travell & Simons Myofascial Pain and Dysfunction, 1992 7 9/29/2019 Dyspareunia • Dyspareunia, a persistent or recurrent vulvovaginal pain associated with sexual intercourse. • Prevalence in premenopausal women range from 10% to 20% • As many as 60 percent of women experience dyspareunia when the term is broadly defined as episodes of pain with intercourse. Interstitial Cystitis Interstitial cystitis (IC), is a bladder condition that usually consists of multiple symptoms: •Recurring pelvic pain •Pressure or discomfort in the bladder/pelvic region •Urinary frequency •Urinary urgency IC may also be referred to as painful bladder syndrome (PBS), bladder pain syndrome (BPS), and chronic pelvic pain. 2 subtypes •Ulcerative – Hunner’s ulcers -which are red, bleeding areas on the bladder wall •Non-ulcerative (90%) - presents with pinpoint hemorrhages, also known as glomerulations, in the bladder. www.ichelp.org Vulvodynia & Associated Symptoms • Vulvodynia is chronic vulvar pain without an identifiable cause. • Most women with localized vulvodynia have Provoked Vestibulodynia (PVD), in which pain occurs during or after pressure is applied to the vestibule, e.g., with: – sexual intercourse, – tampon insertion, – a gynecologic examination, – prolonged sitting, and/or – wearing fitted pants. https://www.nva.org/what-is-vulvodynia/ 8 9/29/2019 Vaginismus • Vaginismus is vaginal tightness, due to involuntary spasm of the pelvic floor muscles and perineal muscles that surround the outer third of the vagina. This leads to discomfort, burning, pain, penetration problems, or complete inability to have intercourse. • This involuntary spastic contraction is a reflex response that is stimulated by imagined, anticipated, or real attempts at vaginal penetration. • May be due to surgical or sexual trauma – Protective response https://www.vaginismus.com/vaginismus-symptoms/ Vaginismus – Associated Symptoms • Burning or stinging with tightness during sex • Difficult or impossible penetration, entry pain, uncomfortable insertion of penis • Unconsummated marriage • Ongoing sexual discomfort or pain following childbirth, yeast/urinary infections, STDs, IC, hysterectomy, cancer and surgeries, rape, menopause, or other issues • Ongoing sexual pain of unknown origin, with no apparent cause • Difficulty inserting tampons or undergoing a pelvic/gynecological exam • Spasms in other body muscle groups (legs, lower back, etc.) and/or halted breathing during attempts at intercourse • Avoidance of sex due to pain and/or failure https://www.vaginismus.com/vaginismus-symptoms/ Endometriosis • It occurs when tissue similar to the endometrium (the lining of the uterus) is found outside the uterus on other parts of the body. • Endometriosis affects 176 million women worldwide, and 1 in 10 girls and women in the US. • Endometriosis usually causes symptoms during reproductive years (~12-60 years old), however many women and girls are undiagnosed. • Endometriosis affects women equally across all racial/ethnic and socioeconomic backgrounds. https://www.endofound.org/endometriosis 9 9/29/2019 Endometriosis – Associated Symptoms • Most common is pain which usually occurs during menstruation. • Other symptoms include: – “Killer cramps” – cramps that do not go away with NSAIDS and/or impede the activities of daily living – Long periods – periods that last longer than 7 days – Heavy menstrual flow – having to change your pad or tampon every hour to two hours throughout most of your period – Bowel and urinary disorders – including but not limited to painful urination or bowel movements, frequent urge to urinate, or diarrhea – Nausea or vomiting – Pain during sexual activities – Infertility https://www.endofound.org/endometriosis Irritable Bowel Syndrome • IBS affects the large intestine. • It can cause abdominal cramping, bloating, and a change in bowel habits – Constipation – Diarrhea • It affects women x2> men • Usually in those <45 yrs Pudendal Neuralgia • Pudendal Neuralgia is a painful neuropathic condition that is caused by inflammation of the pudendal nerve • Pelvic pain with sitting