What type of physician performs Botox (Botulinum toxin) injections to the ischiococcygeus muscle?

Physician Specialty for Botox Injections to the Ischiococcygeus Muscle

Pelvic floor medicine specialists, including urogynecologists, colorectal surgeons, and physiatrists with pelvic floor expertise, perform Botox injections to the ischiococcygeus muscle, typically using ultrasound or EMG guidance for precise needle placement into this deep pelvic floor muscle.

Primary Specialists Who Perform This Procedure

Urogynecologists and Pelvic Floor Specialists

• These physicians most commonly perform Botox injections into pelvic floor muscles, including the ischiococcygeus (also called coccygeus), for chronic pelvic pain associated with pelvic floor muscle spasm 1
• The procedure requires expertise in pelvic floor anatomy and typically uses conscious sedation with image guidance 1

Colorectal Surgeons

• Colorectal surgeons perform Botox injections into pelvic floor muscles, particularly for outlet-type constipation and puborectalis syndrome, using ultrasonographic guidance for precise injection 2
• They have extensive experience with anal sphincter and pelvic floor muscle injections, achieving symptomatic improvement in approximately 79% of patients with pelvic floor spasm 2

Physiatrists (Physical Medicine and Rehabilitation)

• Physiatrists perform Botox injections for muscle spasticity and pain conditions, including pelvic floor dysfunction 3
• They utilize EMG guidance and neurostimulation techniques to ensure accurate needle placement 4

Technical Approach and Guidance Methods

Image Guidance Requirements

• Ultrasound guidance is the most commonly used technique, allowing real-time visualization of the needle entering the target muscle and ensuring precise toxin delivery 1, 4, 2
• EMG-guided nerve stimulation under ultrasound can be used for complex pelvic floor muscles like obturator internus, which shares anatomical proximity with the ischiococcygeus 4
• Precise injection technique is critical because the ischiococcygeus is a deep pelvic floor muscle that cannot be reliably accessed without imaging 4

Typical Dosing and Technique

• Standard dosing ranges from 40-60 units of onabotulinumtoxinA (Botox) injected bilaterally into pelvic floor muscles 1, 2
• The toxin is typically diluted 2:1 with normal saline for easier injection and broader muscle distribution 5
• Multiple injection sites (typically bilateral) are used to achieve adequate muscle coverage 1

Clinical Context for This Procedure

Primary Indications

• Chronic pelvic pain with objective pelvic floor muscle hypertonicity lasting at least 2 years 1
• Pelvic floor muscle spasm causing dyspareunia, dysmenorrhea, or non-menstrual pelvic pain 1
• Outlet-type constipation from puborectalis syndrome or pelvic floor dysfunction 2

Expected Outcomes

• Significant reduction in resting pelvic floor muscle pressure (37% reduction at 4 weeks, 25% maintained at 12 weeks) 1
• Improvement in pain scores, particularly for dyspareunia and dysmenorrhea 1
• Effects are temporary, lasting approximately 3 months, and repeat injections may be necessary 6, 2

Important Caveats

Procedure Complexity

• This is not a simple office procedure that general practitioners perform—it requires specialized training in pelvic floor anatomy and image-guided injection techniques 4
• The ischiococcygeus muscle is located deep in the pelvis, making blind injection inappropriate and potentially dangerous 4

Sedation Requirements

• Conscious sedation is typically required due to the invasive nature of deep pelvic floor muscle injections 1
• This necessitates an appropriate clinical setting with monitoring capabilities 1