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Beth Shelly PT

July 16, 2017

Current ICS definition

Pelvic Floor Muscle Pain also known as Pelvic Floor Myalgia - pain in the muscles of the pelvic floor (perineal or levator ani). (1) It is further subdivided in this document to specify location as follows:
  • Intra-pelvic Muscle Pain (pain in the pelvic side wall muscles - obturator internus, piriformis, coccygeus)
  • Anterior Pelvic/Lower Abdominal Muscle Pain (pain in the rectus abdominus, oblique or transverse abdominus muscles, described below the umbilicus)
  • Posterior Pelvic/Buttock Muscle Pain (pain in the gluteal muscles)
The ICS standard document also describes Levator Ani Syndrome (the term may refer to the same syndrome as ´pelvic floor muscle pain syndrome´/’tension myalgia of the PFM’) as pain with sitting and pain with defecation.
These terms appear in the musculoskeletal domain.

Other terms
In the past the term "pelvic pain" was limited to organ dysfunction. Current research and professional association guidelines firmly support the role of the musculoskeletal system in pelvic pain.

The International Association for the Study of Pain (IASP) lists the definition of pelvic floor muscle pain syndrome - "the occurrence of persistent or recurrent, episodic, pelvic floor pain." They go on to further clarify - "There is no proven well defined local pathology. It is often associated with negative cognitive, behavioral, sexual or emotional consequences as well as with symptoms suggestive of lower urinary tract, sexual, bowel or gynecological dysfunction. This syndrome may be associated with overactivity of or trigger points within the pelvic floor muscles. Trigger points may also be found in multiple muscles, such as the abdominal, thigh and paraspinal muscles and even muscles not directly related to the pelvis." (2) This document also defines "muscle tension pain" as a sustained muscle tension.

The European Association of Urology (EAU) also has well respected published guidelines on pelvic pain terminology. They also list pelvic floor muscle as a possible end organ syndrome under the musculoskeletal domain. (3)
Perspectives and controversies
There are currently several terms in the standard documents which essentially mean the same:
  • pelvic floor muscle pain (syndrome)
  • pelvic floor myalgia / tension myalgia
  • levator ani syndrome
Which term should authors / medical practitioner use? Is it not possible to agree on one term? The word myalgia means muscle pain but seems it would be easier for non English speaking practitioners to understand the simple term "muscle pain". Tension myalgia implies the mechanism is related to increased muscle activity. This is often the case but not always - trigger points are electrically silent but very painful and can contribute to pelvic floor muscle pain. Levetor ani syndrome implies the dysfunction is only in the levetor ani muscle group. This is also very common but not always the case. I would suggest only using pelvic floor muscle pain and direct authors to clarify the location and mechanism separately.

Mechanism

As noted by the IASP the mechanism of pelvic floor pain is unclear and most likely involves several mechanisms. Muscle pain is determined by palpating the muscle and asking the patient for sensations felt. Any muscle can generate pain if enough pressure is applied. Myalgia refers to generation of pain with light to moderate palpation which would not be painful to most people. Pain is often related to increased muscle activity but in some cases the painful muscle is electrically silent and surface EMG cannot detect increased activity. This might include trigger points although the term trigger point is controversial as there is little agreement about the location and measurement of trigger points. (4) The ICS standard document (1) defines several other key terms related to pelvic floor muscle pain including: muscle tone, hypertonicity, tension, spasm, cramp, tender point, trigger point. Readers are encouraged to refer to that document.

Symptoms of pelvic floor muscle pain include: urinary/defecatory dysfunction, dyspareunia, pain with sitting, bulging sensation, dermal cutaneous allodynia, tenderness (local and/or referred to another pelvic location).

There is no single tool which is able to measure all components of muscle tone. Some tools may be able to measure aspects of tone such as contractility, stiffness or elasticity. Most medical practitioners use palpation of the muscle to judge tension and pain. Instrumented methods may have a role in the valid and reliable evaluation of muscle tone e.g. surface electromyography, dynamometry, real-time ultrasound, eleastometry, myotonometry.

Therapies

There are many treatments for Pelvic Floor Muscle Pain including: massage, EMG relaxation training, alignment of pelvic joints with joint mobilization or similar techniques, dry needling and injection, dilator training, cognitive behavioral therapy, and more. Most treatments have little evidence and studies remain to be completed to direct treatment choices.


References
(1) R. Doggweiler, K. E. Whitmore, J. M. Meijlink, M. J. Drake, H. Frawley, J. Nordling, P. Hanno, M. O. Fraser, Y. Homma, G. Garrido, M.J. Gomes, S. Elneil, J. P. van de Merwe, A. T. L. Lin, H. Tomoe. A Standard for Terminology in Chronic Pelvic Pain Syndromes: A Report from the Chronic Pelvic Pain Working Group of the International Continence Society. Neurourol Urodyn. 2017 Apr;36(4):984-1008.

(2) Baranowski AP, Berger R, Buffington T, Collett B, Emmanuel A, Fall M, Hanno P, Howard F, Hughes J, Nickel JC, Nordling J, Tripp D, Vincent K, Wesselmann U, Williams AC. International Association for the Study of Pain (IASP) Classification of Chronic Pain. Descriptions of Chronic Pain Syndromes and Definitions of Pain Terms, Second Edition (Revised 2011).

(3) Engeler DS, Baranowski AP, Dinis-Oliveira P, Elneil S, Hughes J, Messelink EJ, et al. The 2013 EAU guidelines on chronic pelvic pain: is management of chronic pelvic pain a habit, a philosophy, or a science? 10 years of development. Eur Urol. 2013;64(3):431-9.

(4) Lucas N, Macaskill P, Irwig L, Moran R, Bogduk N. Reliability of Physical Examination for Diagnosis of Myofascial Trigger Points. A Systematic Review of the Literature Clin J Pain 2009;25:80–89

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