Myofascial Pelvic Floor Pain: Diagnosis and Treatment
Diagnosis
The diagnosis of myofascial pelvic floor pain is established by identifying myofascial trigger points in the pelvic floor musculature on physical examination that reproduce the patient's pain pattern. 1
Key Diagnostic Features
Pain quality: Deep, aching, or burning pain that may be constant or intermittent, localized to the pelvic floor region 2
Physical examination findings: Palpable tenderness, banding, or trigger points in the pelvic floor musculature that refer pain to adjacent sites 3, 1
Associated findings: Muscle contractures, painful scars, and connective tissue restrictions in the pelvic, abdominal, or hip regions 3
Comprehensive musculoskeletal assessment: Evaluate not just the pelvic floor but also surrounding abdominal, hip, and lower back structures, as myofascial pain is often multifactorial 4
Treatment Algorithm
First-Line Treatment (Offer to All Patients)
Manual physical therapy techniques should be offered as the primary treatment for all patients with pelvic floor tenderness. 5, 6
Specific techniques include: Maneuvers to resolve muscular trigger points, techniques to lengthen muscle contractures, and release of painful scars and connective tissue restrictions 3, 5
Treatment protocol: 10 sessions of 60 minutes over 12 weeks, which achieves moderate or marked improvement in 59% of patients 3, 2
Critical caveat: Avoid Kegel exercises and pelvic floor strengthening exercises, as they worsen symptoms by increasing muscle tension in already hypertonic pelvic floor muscles 3, 5
Adjunctive First-Line Measures
Patient education: Explain the nature of myofascial pelvic pain and set realistic treatment expectations 5
Self-care practices: Modify fluid intake, avoid bladder irritants, prevent constipation 5
Thermal therapy: Apply heat or cold over the pelvic region and perineum for symptomatic relief 5
Relaxation techniques: Target pelvic floor muscle relaxation specifically 5
Pharmacological Management (Concurrent with Physical Therapy)
NSAIDs: First-line pharmacological option for pain management 5, 6
Muscle relaxants: Reduce pelvic floor muscle tension 5
Tricyclic antidepressants (TCAs): Modulate pain and improve sleep 5, 6
Anticonvulsants (gabapentin, pregabalin): For neuropathic pain components 5, 6
Topical treatments: Lidocaine patches and diclofenac patches are preferred for safety and provide symptomatic relief 6, 2
Important Pharmacological Caveats
Avoid strong opioids: They should not be used for myofascial pain management 6
Avoid corticosteroids: They have no role in isolated myofascial pain syndrome unless concomitant joint pathology exists 6
Interventional Treatments (For Refractory Cases Only)
Trigger point injections: Consider only after conservative measures have failed, and patients must continue concurrent physical therapy 2, 7
Botulinum toxin A injections: May be used for refractory pelvic floor trigger points 7
Avoid peripheral nerve blocks: Should not be used for long-term treatment 6, 2
Advanced Modalities (Limited Evidence)
TENS: May be considered for persistent pain, though evidence is inconclusive 5
Dorsal column stimulation: For chronic pelvic pain unresponsive to other treatments 5
Acupuncture: Limited evidence supporting efficacy 5
Cryotherapy: Emerging treatment option 7
Treatment Monitoring
Measure functionality as the primary endpoint rather than numerical pain ratings 5
Regularly reassess treatment efficacy and discontinue ineffective interventions 5
Multidisciplinary approach: Coordinate care between physicians, physical therapists, and mental health providers for optimal outcomes 7, 4, 8