Myofascial pelvic pain syndrome in females: Treatment

INTRODUCTION — Myofascial pelvic pain syndrome (MPPS) is a pelvic pain syndrome that is defined by short, tight, tender pelvic floor muscles that can include palpable nodules or trigger points. The treatment of MPPS is multimodal and tailored to the individual patient. Treatment plans typically include physical therapy, pharmacotherapy, and psychological counseling. The general approach is to block or reduce ongoing stimuli that lead to pain, identify and avoid triggers, and treat symptom flares. The process is defined as chronic after six months; however, patients early in the disease course often benefit from the same interventions, and such interventions may prevent the symptoms from becoming chronic.

This topic will discuss the treatment of MPPS. As there are few trials evaluating treatment efficacy in this population, our approach is based on the limited available data and clinical experience. Also, some therapies are extrapolated from the treatment of nonpelvic myofascial pain, such as myofascial pain associated with the back, neck, shoulder, or jaw. Topics related to the clinical manifestations and diagnosis of MPPS and chronic pain syndromes are reviewed separately.

●(See "Myofascial pelvic pain syndrome in females: Clinical manifestations and diagnosis".)

●(See "Evaluation of chronic non-cancer pain in adults".)

●(See "Approach to the management of chronic non-cancer pain in adults".)

In this topic, when discussing study results, we will use the terms "women" or "patients" as they are used in the studies presented. However, we encourage the reader to consider the specific counseling and treatment needs of transgender and gender-diverse individuals.

DEFINITION — MPPS is a non-articular musculoskeletal pain disorder characterized by contracted bands of skeletal muscle that contain discrete, painful nodules, also called trigger points [1-3]. MPPS is thought to originate at the trigger point [4]. A neuropathic component resulting from inflammatory mediator release likely plays a role as well. Patients do not uniformly respond to available treatments, which likely reflects multifactorial sources of pain.

In our experience, the initial pain source is typically the pelvic floor muscles, which then impact the pelvic girdle (hip, low back, lower abdominal muscles). The pain can be perceived internally or become "external" (ie, perceived as abdominal, ischial tuberosity, and/or vulvar pain). (See "Myofascial pelvic pain syndrome in females: Clinical manifestations and diagnosis" and "Myofascial pelvic pain syndrome in females: Clinical manifestations and diagnosis", section on 'Definitions'.)

OUR APPROACH — One goal of treatment is to help women understand that MPPS can be a chronic, waxing and waning condition that may require long-term management. We counsel patients that the etiology, triggers, and risk factors for MPPS are incompletely understood. Women who develop MPPS, especially those with severe symptoms, likely have a predisposition for symptom recurrence in response to certain triggers, including stress, physical trauma, or other painful events such as a urinary tract infection (UTI). In our experience, it is reasonable to expect 80 percent improvement in symptoms following the treatment plan, and the goal for women is fewer and less intense flares of pain. This goal is especially achievable if the symptoms are relatively recent in onset and there are times of relatively decreased pain. An additional long-term goal is to recognize and manage flares early with techniques that the women learn during treatment and that they know will be helpful. This element of control is important to reducing the anxiety that can accompany pain flares. In addition, we help women understand that improvement can be a slow process, and since there is not a "one size fits all" treatment, finding the correct therapy for them can take some trial and error, time, and patience. Based on our clinical experience, we counsel patients who have chronic or more severe symptoms that it may take longer for symptoms to improve and that they will be more likely to need additional treatment modalities.

We apply a multidisciplinary approach that addresses both physiological and psychological aspects of MPPS. Some women undergo surgical evaluation as well. (See "Chronic pelvic pain in adult females: Treatment", section on 'Targeted therapies: Surgical'.)

Initial treatment loop — Treatment interventions do not have to occur in isolation or in a specific sequential order. In general, patients begin with pelvic floor physical therapy (PFPT) to address overall short, tight pelvic floor muscles that are the hallmark finding on examination. In our experience of caring for females with MPPS, PFPT is the one therapy that is needed by all and is the key to reversing some of the changes that occur in MPPS, especially tight painful muscles and alleviation of trigger points. Adjunctive therapy can include local trigger point injections (TPI), medical therapy, and sacral neuromodulation (for symptoms of frequency and urgency that often accompany MPPS and bladder pain). Patients are also prescribed psychological counseling, such as cognitive behavioral therapy and/or sex therapy, to help reduce pain, manage symptoms, restore function, and reduce stress, if needed. Lastly, we aim to help individuals identify and avoid triggers that can cause symptom flares and support them when these flares occur.

●We recommend that all women begin treatment with PFPT. The initial evaluation and treatment with PFPT and medical treatment typically require three to four months, after which the patient is reassessed. Women with moderate to severe symptoms (eg, interfering with daily activities or sleep) can also receive adjunctive medical therapy aimed at reducing their most bothersome symptoms (eg, muscle relaxants for women with disrupted sleep). Women with lower back, hip, or other musculoskeletal issues need to address these areas in combination with PFPT.

•Initial use of external therapy – For individuals who find internal PFPT painful, the physical therapist can start with external work only until the woman reaches a point where internal physical therapy is possible. This is especially true of women who have had a history of sexual abuse. We have also employed yoga targeted at pelvic pain and techniques for self-release of accessible external muscles, particularly for those who experience a long waitlist to get into PFPT. Both allow women to begin simple self-treatment. Individuals who have pain that does not respond may be candidates for onabotulinumtoxinA (BTXA) injections, as discussed in the bullet below.

•Role of telehealth and related modalities – Additionally, since the coronavirus disease 2019 (COVID-19) pandemic caused shutdowns and access to physical therapy was reduced, the authors encourage women to use online resources for stretches and yoga targeting pelvic floor release. Although there is no objective study showing that these resources are effective, patients have reported positive effects in addition to certain levels of control in addressing their symptoms. We plan to formally evaluate outcomes of self-directed pelvic floor releases.

•Supporting data and approach for PFPT are presented in separate discussions.

-(See 'Pelvic floor physical therapy' below.)

-(See "Myofascial pelvic pain syndrome in females: Pelvic floor physical therapy for management".)

●Women who are unable to immediately attend PFPT, typically for logistical reasons or because of severe pain prohibiting PFPT, are offered pharmacotherapy with neuromodulating medications, pelvic floor TPIs, or topical lidocaine gel or muscle relaxers, given primarily at night. Nighttime dosing avoids fatigue and reduces daytime side effects. These treatments can facilitate PFPT or help control symptoms while women are waiting to start PFPT. Rarely, women with severe pelvic floor hypertonicity are offered pelvic floor injections with BTXA first. This is only done if PFPT is impossible to perform because of pelvic floor hypertonicity or other rare circumstances that require pelvic floor relaxation. Pain relief does not necessarily correlate with a relaxed pelvic floor, however, especially if symptoms have been chronic or other sources of pain exist.

●After three to four months of initial treatment, women who are notably improving with PFPT continue treatment until symptoms stabilize. The goal is to have patients improve enough that they can manage symptoms and minor flares with exercises/stretches or treatment initiated at home. This treatment may include short-term muscle relaxers as well. For women taking concomitant medications, some are able to taper or stop their medical therapy once symptoms stabilize, while others need to continue these medications indefinitely due to return of pain when they taper or apprehension about stopping medications.

●Women with minimal or no improvement are reassessed and may be referred for evaluation with a physiatrist or orthopedist to assess for extra-pelvic sources of pain. These women may also be advised to try additional adjunctive medical therapy. If the pelvic floor remains hypertonic, we discuss the benefits and risks of BTXA injections. We reassess these women every three to four months and continue through this treatment loop until symptoms are improved and function is restored to the greatest degree possible. We also may involve a pain specialist at this point to help guide treatments or potential intervention targeting specific nerve roots based on their assessment. The additional involvement of a pain management team, including working with a pain psychologist, is important to attempt desensitization of central pain upregulation.

●We also recommend referral for evaluation and treatment of concomitant psychological symptoms (eg, depression or anxiety, difficulty with sleep).

●For women who are unable to access PFPT, we proceed with mostly medical therapies as well as periodic TPIs, if needed, for flares and if found to be beneficial for the patient, if indicated. Often, oral muscle relaxers or vaginal valium suppositories may help ease flares due to the muscle-relaxing properties of valium. (See 'Vaginal diazepam' below.)

Treatment of concurrent bladder symptoms — Treatment of bladder symptoms, including dysuria, bladder pain, and urgency, is often needed in women with MPPS. These symptoms often coexist with those of MPPS. (See "Interstitial cystitis/bladder pain syndrome: Management".)

Maintenance therapy — Once symptoms are manageable, we educate women to monitor for early signs of a flare and intervene quickly. Although there are limited data, we generally advise a quick return to physical therapy if symptoms do not respond to patient-initiated treatments to prevent a long-term or more severe flare. However, even with early treatment, severe flares may occur, and women may need to go through a new course of treatment and reevaluation for possible underlying pathology. Common triggers include UTI or other infections. It is important to evaluate for other pelvic or gastrointestinal issues.

Management of MPPS can be viewed as long-term control of a chronic underlying predisposition. One challenge in assessing response is that symptoms can improve because of a true treatment effect, because the natural history of the disease includes waxing and waning of symptoms over time, because of the Hawthorne effect (ie, improvement in symptoms simply because the patient is in a clinical trial), because the associated musculoskeletal process resolves, or some combination of these [5].

PELVIC FLOOR PHYSICAL THERAPY — Primary treatment of MPPS involves manual myofascial release and stretching, followed by strengthening of affected areas via pelvic floor physical therapy (PFPT). Ideally, PFPT is performed by a physical therapist with specialized training in soft tissue manipulation and rehabilitation of the pelvis. The importance of finding an experienced pelvic floor physical therapist cannot be overemphasized. There is little benefit from physical therapy regimens that do not include internal vaginal release work in addition to external soft tissue manipulation and trigger point release. It is important that the patient not focus on tightening or strengthening the levator muscles (eg, Kegel exercises or electrical stimulation) early in the course of treatment, as this can worsen symptoms [6]. In addition, an understanding of interrelation of posture, pelvic girdle, and other orthopedic issues and their effect on the pelvic floor is important to ensure all contributing factors are addressed. (See "Myofascial pelvic pain syndrome in females: Pelvic floor physical therapy for management".)

Common components of a treatment session — During a treatment session, the patient lies in the supine position as the physical therapist works to manually release the trigger points and the restricted movement of the connective tissues and muscles of the vagina, abdomen, hips, thighs, lower back, and, in some cases, the rectum. Some therapists use other modalities, such as dry needling, to hasten the release of painful tissue around surgical scars [6]. The details of PFPT for the treatment of myofascial pain are presented separately.

Treatment sessions are usually 45 to 60 minutes and are scheduled once or twice per week for 8 to 12 weeks. Improvement can be apparent after as few as six sessions. However, in our experience, women with chronic pain often require more than 12 weeks of treatment, and some will require treatment up to one year or beyond. The duration of symptoms typically correlates with the time course for treatment (ie, women with symptoms of longer duration often require longer treatment) [7]. After treatment is completed, follow-up sessions may be needed periodically to treat flares of pain. Flares can develop as a result of stress, injury, sexual activity, or other physical activity (eg, prolonged sitting). If the patient has to travel a long distance to see a physical therapist, daily intensive physical therapy for a week (longer if needed) can be useful.

Data supporting PFPT — Data supporting PFPT are limited but reassuring [8]. A trial of 474 women treated with PFPT for multiple pelvic complaints, including pain, reported clinically significant improvement on standardized pelvic floor distress questionnaires after a mean of 9.3 treatment sessions [9]. In a trial that randomly assigned 81 women with interstitial cystitis/painful bladder syndrome to either PFPT or global massage (control), women in the PFPT group had over twice the response rate compared with global massage (59 versus 26 percent) [10]. In addition, a small trial comparing PFPT and trigger point injections in women with pelvic floor myalgia reported a greater than 50 percent improvement in symptoms for each group [11]. Two small prospective observational studies of patients with bladder symptoms and a high tone pelvic floor provided some evidence of benefit from manual myofascial physical therapy [7,12]. Similarly, in a retrospective review of 146 women with myofascial pelvic pain who received transvaginal PFPT, 63 percent of patients reported significant improvement in pain scores [13]. Pain score improvement was proportional to the number of complete physical therapy visits. In contrast to myofascial physical therapy, at least one study has reported that global massage does not appear to be beneficial [14].

Self-treatment and telehealth — Although self-treatment with vaginal dilators or massage devices (commercial name TheraWand) is possible for some women, in our experience, these techniques tend to exacerbate pain early in treatment and do not replace proper myofascial release techniques. As an alternative, a physical therapist can educate the patient's partner about techniques that can be performed at home. For women with trigger points in deeper vaginal muscles, a willing partner may be able to provide hands-on treatment if an experienced therapist is not available locally, preferably after consultation and direction from a knowledgeable physical therapist [15]. We have found that, although self-treatment can help alleviate some symptoms or flares, it is not as effective as assessment and treatment using myofascial release techniques in reversing some of the underlying dysfunction. Telehealth options have become available, but more data need to be collected to assess efficacy. It is unlikely that remote options are a complete substitute for an experienced physical therapist implementing myofascial release techniques.

Yoga as adjunctive treatment — Although the data supporting yoga for MPPS are sparse and often extrapolated from the treatment of other chronic pain syndromes [16,17], we advise yoga therapy, either in person, virtually, or using a recording, that is targeted at pelvic floor pain. This gives women an opportunity to proactively address some of their muscle tightness while waiting to get into PFPT or as an adjunct to physical therapy once started. We recommend only using resources from certified pelvic floor physical therapists.

DRUG TREATMENT

Commonly used — In our practice, first-line oral medications include gabapentin, tricyclic antidepressants, or a muscle relaxant because of their efficacy, tolerability, and relatively safe side effect profile. This list reflects our experience as well as the available literature and is not meant to be applicable to all women with MPPS. In fact, switches are often made due to side effects or lack of efficacy.

Gabapentin — Gabapentin (commercial name Neurontin) is one of our first choice options for medical treatment of neuropathic pain because it has demonstrated efficacy (for treatment of postherpetic neuralgia and diabetic neuropathy), is well tolerated, has few contraindications, and has a wide range of dosing options [18,19]. Data regarding benefit in the treatment of pelvic pain are mixed. One trial of 306 women with chronic pelvic pain treated with gabapentin versus placebo did not show significant improvement in pain or other aspects of the women's lives [20]. Two small trials reported that gabapentin improved pain scores [21,22]. For now, its use represents off-label use [18,23]. A detailed discussion of gabapentin for females with chronic pelvic pain is available elsewhere. (See "Chronic pelvic pain in adult females: Treatment", section on 'Anticonvulsants (gabapentin and pregabalin)'.)

We prescribe gabapentin for women with moderate to severe pelvic or vaginal pain that is chronic and is interfering with sleep or the ability to perform normal daily activities. We initiate therapy with gabapentin 100 mg at bedtime and increase the dose as needed by 100 mg every three to four days, up to 300 mg three times per day. Many women will have a symptom response at lower doses; we give women written instructions on how to slowly increase the dose until they feel relief. The dose may be increased further depending upon the patient's symptoms and ability to tolerate side effects. The maximum tolerated dose in long-term clinical trials is 2400 mg per day in divided doses. It may take four to six weeks to observe an effect. The dose must be tapered over at least one week before it is discontinued. (See "Pharmacologic management of chronic non-cancer pain in adults", section on 'Gabapentin and pregabalin'.)

Tricyclic antidepressants — We find tricyclic antidepressants (TCAs) helpful because they aid sleep, are dosed once a day (bedtime), and can also help relieve symptoms of urinary urgency and frequency. TCAs are commonly prescribed (unlabeled use) for treatment of a variety of chronic pain states, with or without coexisting depression. While there are few data on the use of TCAs for treatment of myofascial pain, the available literature reports treatment benefit [24,25]. Bothersome side effects (eg, anticholinergic effects, moderate to marked sedation) are a limiting factor. (See "Pharmacologic management of chronic non-cancer pain in adults", section on 'Tricyclic antidepressants'.)

When we use a TCA, we generally prescribe amitriptyline or nortriptyline, starting at the lowest dose (10 mg) at bedtime. The dose can be increased by 10 mg weekly to the maximum dose (75 mg for either drug as extrapolated from treatment of other chronic pain syndromes [26,27]) until an acceptable balance between pain relief and side effects is achieved. Other tricyclic antidepressants may be equally effective, and may have a different side effect profile, but data are lacking.

Skeletal muscle relaxants — Cyclobenzaprine is a centrally acting skeletal muscle relaxant that can be useful in relieving pain caused by muscle spasm. While cyclobenzaprine has demonstrated efficacy in the treatment of fibromyalgia or muscle spasm, few studies have specifically examined the effect of cyclobenzaprine on myofascial pain [28]. We have used cyclobenzaprine for women with MPPS, usually in combination with other treatments. We typically start at 5 mg at bedtime and increase to 10 mg if necessary. Most women experience sleepiness with cyclobenzaprine, limiting its use to bedtime. This is often a first-line choice for individuals who prefer not to take a daily medication or to use at the time of pain flares if it is effective for their pain. The sedation effect also helps with sleep. In our practice, we have found the response to cyclobenzaprine and other muscle relaxers to be a potential indicator of response to pelvic onabotulinumtoxinA (BTXA) injections. Response to these medications helps us assess the contribution of hypertonic muscles to a particular patient's pain.

Other skeletal muscle relaxants, such as tizanidine, methocarbamol, and baclofen, are available and are probably as effectively as cyclobenzaprine. Of note, tizanidine has the potential for drug interactions with other commonly used medications (including fluoroquinolones and oral contraceptives). However, tizanidine may be less sedating. For women who are unable to tolerate cyclobenzaprine, we offer a trial of tizanidine. We begin with an oral 2 mg dose up to three times a day and will increase to 4 mg up to three times a day after one to two weeks as needed for symptom control.

Vaginal estrogen — In the authors' experience, atrophic vaginitis can trigger or exacerbate myofascial pain in some women. Estrogen can ameliorate vaginal irritation due to atrophic changes and may reduce vaginal pain and irritative voiding symptoms. For women with evidence of vulvovaginal atrophy, we prescribe low dose vaginal (not systemic) estrogen, which is well tolerated and has minimal systemic effects. As some patients find estrogen creams to be irritating, we prescribe a 10 mcg tablet of vaginal estradiol, inserted into the vagina twice per week at night. We occasionally recommend increasing the dose to three times per week if insufficient effects are seen. Estradiol levels in plasma minimally increase during initial use of vaginal estrogen, although not to premenopausal levels. (See "Genitourinary syndrome of menopause (vulvovaginal atrophy): Clinical manifestations and diagnosis".)

Nonsteroidal anti-inflammatory drugs — While nonsteroidal anti-inflammatory drugs (NSAIDs) are often used in the treatment of chronic pelvic pain caused by endometriosis and in other myofascial pain syndromes, data supporting NSAID use for MPPS are lacking. In our experience, NSAID treatment can be helpful for women with mild symptoms or if there is coexisting musculoskeletal pain [29]. We have found NSAIDs are of limited to no benefit in patients with moderate to severe MPPS or during flares. Of note, women who use NSAIDs for any indication should discontinue them at least three days prior to trigger point or BTXA injections to minimize the risk of bleeding. Risk of chronic NSAID use is presented separately. (See "NSAIDs: Therapeutic use and variability of response in adults".)

Second tier — In our practice, we use the following group of medications in women who have not had an adequate response or are unable to tolerate the medications listed above.

Pregabalin — Pregabalin (commercial name Lyrica) is used for treatment of fibromyalgia. In our experience, some women who do not respond to gabapentin will improve with pregabalin. However, side effects such as forgetfulness, drowsiness, weight gain, lower extremity edema, difficulty thinking clearly, and feeling euphoric limit its use. Pregabalin can be given less frequently (twice daily) than gabapentin (usually three times daily), but side effects can be more troublesome, and it has a small potential for abuse (schedule V drug). In our experience, pregabalin is associated with side effects and patient concerns, and is thus less well-received by patients.

We initiate treatment with pregabalin if moderate to high doses of gabapentin do not improve pain symptoms. Due to potentially bothersome side effects, we initiate treatment with a small dose, 25 mg at bedtime, and then slowly increase to 75 mg twice daily. It may take four to six weeks to observe an effect. Women who are tolerating the medication but not improving during four weeks of treatment can increase the dose (over one week) to 150 mg twice a day, and are again reassessed after four weeks of treatment at the increased dose. Higher doses (up to 450 mg per day) can be used if the medication is well-tolerated but symptoms are not adequately controlled. The drug should be tapered before it is discontinued. (See "Pharmacologic management of chronic non-cancer pain in adults", section on 'Gabapentin and pregabalin'.)

Serotonin-norepinephrine reuptake inhibitors — Serotonin-norepinephrine reuptake inhibitors (SNRIs), including duloxetine (commercial name Cymbalta) and milnacipran (commercial name Savella), are indicated for treatment of fibromyalgia and may be useful off label for women with MPPS. There are no data on the use of SNRIs for the treatment of myofascial pain.

In our practice, we find that a combination of gabapentin or pregabalin, along with an SNRI, is useful to address the centralized nature of neuropathic pain. We offer this combination to women who have moderate to severe pain that affects activities of daily living and who have failed treatment with gabapentin or pregabalin alone. Side effects, such as nausea and vomiting, can be a limiting factor. Starting with a low dose and titrating up slowly can improve tolerability. Consultation with a neurologist, physiatrist, or pain specialist can be helpful for health care providers who are uncomfortable or unfamiliar with these medications. We often partner with these specialists when pain is severe and multimodal or multidrug therapy is needed.

In our practice, we start with low doses of either milnacipran or duloxetine. Milnacipran is started at 12.5 mg once on day 1, then 12.5 mg twice daily on days 2 to 3, 25 mg twice daily on days 4 to 7, then 50 mg twice daily thereafter. Duloxetine is started at 30 mg once daily for one week, then increased to 60 mg once daily. If there is no improvement in pain within six to eight weeks or if the patient develops bothersome side effects, the medication is slowly tapered over two to four weeks, then stopped. Withdrawal-related side effects ("discontinuation syndrome") can occur if patients stop or taper suddenly. Suggestions on management of discontinuation syndrome are discussed separately. (See "Discontinuing antidepressant medications in adults".)

Vaginal diazepam — Vaginal administration of a benzodiazepine, such as diazepam, sometimes in combination with a local anesthetic and muscle relaxant, may reduce pain and muscle spasm, although the data are limited and conflicting. While two small retrospective studies noted an improvement in patient-reported pain scores after treatment with 5 to 10 mg vaginal diazepam, a small trial that assessed vaginal tone with electromyography reported no difference in tone or subjective outcomes between treatment with vaginal diazepam or placebo [30-33]. In our experience, some patients respond well to vaginal diazepam while others see little or no benefit.

We use a compounding pharmacy to suspend the diazepam in silica gel and a fatty acid that melts at body temperature. While whole or crushed diazepam tablets can be inserted directly into the vagina, we do not recommend this approach due to variable absorption and potential risk of oral use and subsequent dependency. However, for women who do not have access to a compounding pharmacy and are able to reliably use the medication only vaginally, we will prescribe diazepam tablets for vaginal insertion. One advantage is that the drug is minimally absorbed into the bloodstream from the vaginal route and thus is associated with fewer side effects [31,34]. Vaginal diazepam 5 to 10 mg can be used up to three times daily.

Treatment of overactive bladder symptoms — Medications that target overactive bladder symptoms (eg, urinary urgency, frequency, and urgency incontinence) can be useful for reducing bladder-specific complaints but do not directly treat pain [35]. The main treatment options are beta-3 adrenergic agonists or antimuscarinic drugs; selection is based on side-effect profile, concomitant medical issues, insurance coverage, drug availability, and cost. Medication can provide some symptom improvement prior to a course of physical therapy. In our experience, once patients have started to respond to pelvic floor physical therapy, they may not need to continue these drugs. If patients do not respond to these medications, they can be discontinued.

Selection and use of these drugs to treat the overactive bladder symptoms are discussed in related content. (See "Urgency urinary incontinence/overactive bladder (OAB) in females: Treatment", section on 'Addition of medication'.)

Third tier — Women whose symptoms do not respond to the treatments listed above are offered the following therapies:

Opioids — Due to the addictive potential of opioids, lack of long-term benefit, and potential side effects such as constipation that can worsen MPPS, we rarely prescribe narcotics. If a patient is already taking narcotics for MPPS or has not responded to other therapies, we manage the patient concurrently with a pain center or a clinician experienced in monitoring long-term use of narcotics. (See "Pharmacologic management of chronic non-cancer pain in adults", section on 'Opioids'.)

Sacral neuromodulation — Sacral neuromodulation (SNM), an implantable electrical stimulation device developed for the treatment of urinary urgency and frequency, has been used to treat multiple types of pelvic pain as well as refractory painful bladder syndrome/interstitial cystitis [36-40]. However, studies of SNM for the treatment of MPPS are lacking. As sacral neuromodulation is an invasive procedure, we only use it for the subpopulation of women with painful bladder syndrome or refractory overactive bladder. In our experience, neuromodulation for urinary urgency and frequency in the setting of myofascial pain is sometimes effective to relieve pain but not enough to warrant its use in the absence of frequency and urgency. Additionally, even if there is a marked improvement of pain, there is often a gradual increase in pain and habituation to the stimulation, despite reprogramming. Therefore, we do not usually recommend sacral neuromodulation as an initial or long-term treatment of MPPS.

Small trials and case reports have reported benefit with the use of neuromodulation in women with neuropathic pelvic pain. They used various modalities, including spinal cord stimulation, dorsal root ganglion stimulation, and peripheral nerve stimulation [41,42]. Larger randomized trials are needed to determine the role of neuromodulation for myofascial pelvic pain. (See "Interstitial cystitis/bladder pain syndrome: Management".)

Other — Additional treatments for MPPS include topical anesthetics and complementary treatments such as acupuncture and cannabis.

Topical anesthetics — A randomized trial compared lidocaine patch with placebo patch and trigger point injection (TPI) with bupivacaine [43]. Both lidocaine patch and TPI were effective in reducing pain compared with placebo. In our practice, we occasionally use lidocaine patches for patients whose pain is localized to areas on the abdomen, low back, or hips. The patch is applied to the site of pain; patients can use up to three patches at a time for up to 12 hours per 24 hours. In the United States, 4 percent lidocaine patches are available without a prescription.

Acupuncture — Acupuncture is a complementary therapy that can play a role in management of musculoskeletal pain. A systematic review evaluated 134 studies of acupuncture or dry needling (no anesthetic injection) for management of myofascial trigger point pain [44]. The review included studies in which one group was treated by needling directly into the myofascial trigger points, while a control group received no treatment, usual care, indirect local dry needling, or a placebo intervention. There was a trend toward treatment efficacy, but major differences in study design, quality, and size limited the ability to analyze combined data. A trial that compared Ashi acupuncture with TPI in 35 women diagnosed with abdominal myofascial pain related to chronic pelvic pain reported similar improvements in pain for both groups [45]. However, an earlier systematic review of acupuncture for chronic pelvic pain showed no benefit [46]. More and better trials of acupuncture are needed. Our limited experience with acupuncture is that it can help improve coping and decrease pain perception, at least temporarily. A detailed overview of this technique can be found separately. (See "Overview of the clinical uses of acupuncture".)

Cannabis — The legalization of medical and recreational marijuana in some areas of the United States has increased its use for all types of pain, including chronic pelvic pain. Studies evaluating cannabis for treatment of MPPS are lacking, although several small studies indicate that women are using it for pain relief [47,48]. The authors do not suggest the use of cannabis for MPPS due to the paucity of data.

INJECTIONS

Trigger point — We use trigger point injections (TPI) to facilitate physical therapy, as injections can improve tolerability for some women, and as short-acting relief for pain flares. Although the injections can be quite uncomfortable, MPPS-related pain is often completely relieved for some duration. As demonstrated with other muscle pain syndromes, TPI can be useful as a diagnostic tool; if the patient's pain improves or resolves after injection, then MPPS is likely the cause [49]. A complete or significant response to a TPI is often a good prognostic indicator. TPIs have demonstrated efficacy in a variety of neuromuscular pain syndromes (including abdominal cutaneous nerve entrapment, muscles and nerves of the pelvis [eg, obturator nerve, piriformis syndrome], sciatica, and headaches) and total levator pain [50-54].

For women with chronic, severe symptoms, even temporary relief from pain can provide a better understanding of the underlying process and motivation to follow through with treatment. We discuss with women that injections are not usually curative or as effective as physical therapy. However, a good response with decreased pain for an interval of time is often a good prognostic sign, indicating that addressing the pelvic floor will be helpful in reducing the pain.

TPIs can be given by any health care provider who is familiar with pelvic floor anatomy, who can assess for trigger points, and who has received training in pudendal block injections. Although some gynecologists and urologists provide this procedure, specialists in Female Pelvic Medicine and Reconstructive Surgery (FPMRS) generally perform the most comprehensive evaluation for trigger points and are often able to inject deeper muscle groups. We locate trigger points by palpating the soft tissues of the pelvic floor and gently applying pressure to areas that feel firm or taut. Clinically, patients are often able to indicate which areas of the muscles are most painful and therefore require injection. Although some clinicians use electromyography or ultrasound to locate trigger points, these modalities do not appear to improve the efficacy of TPIs in studies of nonpelvic trigger points [55]. Further studies are needed to determine if imaging or other modalities provide superior accuracy for TPIs. For clinicians who access some of these muscles transcutaneously, through the gluteus muscles, using ultrasound to access the correct muscle may be helpful. Generally, we have found that accessing the pelvic floor muscles transvaginally is the most efficient and comprehensive way to address all of the affected muscle groups.

The optimal medications and doses for TPIs are not known; mixtures of local anesthetics and glucocorticoids have been associated with reduced pain [11,56]. We prefer bupivacaine, alone or with triamcinolone, because of its long duration of action. For most women, we inject 1 to 3 mL doses of 0.25 percent bupivacaine (maximum total volume 30 to 40 mL, depending on patient's weight) throughout the pelvic floor using a pudendal kit. Trigger points in the abdomen may also be injected, as needed, using a long (at least 1 inch) small gauge (27 g) needle. For select women with focal areas of burning pain near the introitus, we add 40 mg of triamcinolone once monthly for no more than three to four injections.

Some experts use a pudendal block (10 mL of 0.25 percent bupivacaine injected 1 cm inferior to the right and left ischial spines) for temporary relief of myofascial pain [6]. We do not generally use pudendal blocks since most patients get sufficient pain relief with TPIs, although we do also target the area of the pudendal nerve with 1 to 2 mL of Marcaine. Additionally, unlike pudendal blocks, several tender muscle groups are directly injected during TPIs, based on palpation. There is also anecdotal evidence that just introducing a needle into a trigger point (dry needling) can aid with pain control. This may be an added benefit of TPI as opposed to pudendal block.

Duration of pain relief varies, with most patients having at least four hours of relief and some having relief for up to several days. If the injections are immediately followed by physical therapy (within one to two hours), the patient may note more soreness than when injections do not precede the therapy. This is because deeper physical therapy is possible when pain has been eliminated by the injections. Occasionally, a patient will have a flare of pain after the injections and experience no relief. We do not typically repeat injections in these women.

Botulinum toxin — Injection with onabotulinumtoxinA (BTXA) appears to be helpful for women with refractory myofascial pelvic pain [57-66]. Use of BTXA in the pelvic floor is not a US Food and Drug Administration-approved indication, although the body of evidence supports the safety and efficacy of BTXA use in women with pelvic pain syndromes resulting from a short, tight pelvic floor [65-67]. We suggest botulinum toxin A injections for women who are unable to perform pelvic floor physical therapy (PFPT) due to severe pain, for women with persistent pain after six to eight sessions of PFPT, for women who are not making progress with PFPT, or for women with an identifiable muscle spasm that correlates with their symptoms.

●A pilot study of BTXA in 12 women administered a total dose of 40 units of BTXA injected at three concentrations (10 international units/mL, 20 international units/mL, and 100 international units/mL) at four points in the pelvic floor [58]. Visual analog scores for dyspareunia and dysmenorrhea improved significantly at 12 weeks, while there were nonsignificant reductions in nonmenstrual pain and dyschezia. There were no significant differences in pain scores, quality of life, or pelvic floor pressure measurements between the three dilutions of BTXA. Quality of life scores were improved at 12 weeks, although this did not reach statistical significance. There were no reports of new onset urinary or fecal incontinence.

●A trial including 60 women reported that injections of a total dose of 80 units of BTXA (20 international units/mL) significantly reduced dysmenorrhea and dyspareunia-associated pain compared with injections of saline [59]. BTXA reduced nonmenstrual pelvic pain and dyschezia, although this did not reach statistical significance. There were no reports of new urinary or fecal incontinence or urinary retention, although two participants became pregnant; one woman delivered a healthy infant while the other woman's infant was born with a ventriculoseptal defect.

●Several subsequent trials of BTXA have reported similar improvements in pain [60-64], with some studies using up to 300 units of BTXA injected into multiple sites in the pelvic floor [65-67]. A trial of 60 women randomly assigned to either 200 units of BTXA or placebo reported no significant differences in muscle pain scores at two weeks [68]. However, improvement in overall pelvic pain was statistically significant at 4 weeks but not at 12 weeks.

●A meta-analysis that included a total of 257 women treated with BTXA injections of the pelvic floor showed a significant decrease in pain scores, irrespective of BTXA dose, injection technique, or number of injections [69].

Prolonged muscle contraction, spasm, and inappropriately high muscle tone are hypothesized to diminish blood supply and increase oxygen demand of the muscles of the pelvic floor. Ischemic muscle may secrete pain-producing substances, which further sensitize muscle nociceptors, alter receptor field properties, and convert wide-band mechanoreceptors to nociceptors. Although there are some data to support this theory, the true nature of this condition remains unknown and may in fact include multiple different etiologies [70-73]. BTXA can directly block cholinergic neuromuscular transmission and interrupt the cascade of events that lead to hyperalgesia and allodynia [74,75]. BTXA plays a direct role by blocking the alpha- and gamma-motor neurons, thereby preventing the abnormal pattern of muscle contraction (eg, spasm, dystonia) that activates muscle nociceptors and sensitizes the muscle pain system through mediators [76]. (See "Botulinum toxin for treatment of lower urinary tract conditions: Indications and clinical evaluation", section on 'Pelvic pain syndromes'.)

Prior to injection, we counsel patients extensively regarding risks of intrapelvic BTXA injections, including risk of incontinence, weakness, and the rare but serious risk of systemic complications. Side effects can include flu-like symptoms, constipation, urinary retention or incontinence, and fecal incontinence [69]. Others have developed bothersome vaginal or rectal pressure despite resolution of vaginal pain. All of these side effects gradually resolved over approximately three months as the effects of BTXA wore off. (See "Botulinum toxin for treatment of overactive bladder: Injection and complications", section on 'Adverse effects and precautions'.)

We inject 100 to 300 international units of BTXA. Each 100-unit vial is diluted in 10 mL of preservative-free saline, and 1 to 2 mL are injected into each palpable trigger point and tender area throughout the pelvic floor. The dose is based on severity as well as concern for side effects. Most patients tolerate the injections in the office setting, although a subset of patients requires sedation and injections in the operating room. Local application of lidocaine jelly before injection and ice packs after injection may be helpful for injection-related pain. Some women also request premedication with anxiolytics or pain medications for in-office injections. We have tailored our practice to start with 100 units to avoid the side effects and assess relief with the lowest dose. This dose also allows some women who wish to try intrapelvic BTXA to self-pay if it is not covered by insurance.

Most patients begin to feel relief of pain within one to two weeks. Physical therapy and TPIs may be resumed one week after the BTXA injections. We use BTXA alone or in combination with bupivacaine. Either liposomal and regular bupivacaine can be used; choice is determined by availability and cost. Repeat injections of BTXA are considered if the first series of injections was effective and the woman did not have significant side effects, but should not be given sooner than 12 weeks after the previous BTXA injection. The manufacturer recommends no more than 400 units of BTXA (for any indication) per 12 weeks [77]. We do not exceed 300 units. If women receive BTXA in other areas of the body for other indications, we will coordinate timing of injection to be within 10 days.

One potential limitation of BTXA treatment is its cost. Some commercial insurers in the United States do not cover the cost of BTXA for treatment of MPPS, and the cost of self-payment (USD $550 to $700 per 100 unit-vial, with up to three vials needed) is prohibitive in many cases. In these cases, we recommend communicating with the insurer's medical director to advocate for the use of BTXA given the low risk, potential benefits, and limited alternatives to intrapelvic BTXA, especially in those women who have tried multiple other treatments without success.

Glucocorticoid — In our practice, we do not typically inject glucocorticoids as a single agent into the pelvic floor. We prefer a glucocorticoid/anesthetic mixture (injection of 1 to 3 mL bupivacaine 0.25 percent followed by injection of 1 to 2 mL triamcinolone). We inject the anesthetic first, in the targeted areas, followed by injection of the triamcinolone. Separating injections allows better mapping of the areas to be targeted by locating all painful areas and achieving complete resolution of pain, then targeting the steroid accordingly. In our experience, this combination works particularly well for women with entry dyspareunia and for women with urethral burning when administered periurethrally. Anecdotally, approximately 70 percent of women with periurethral or introital burning respond. If a response is noted, we repeat these injections at monthly intervals for up to three to four months.

COGNITIVE BEHAVIORAL THERAPY — Cognitive behavioral therapy (CBT) is one of the most commonly used and studied psychological interventions for pain, including vulvar and sexual pain [78-81]. We encourage patients to participate in a CBT program targeted at treatment of chronic pain syndromes for both symptom reduction and stress management. Women with symptoms suggestive of posttraumatic stress disorder are referred to a mental health specialist for further evaluation and treatment. Access to CBT may be limited by lack of practitioners and/or cost. (See "Overview of psychotherapies", section on 'Cognitive and behavioral therapies' and "Posttraumatic stress disorder in adults: Epidemiology, pathophysiology, clinical features, assessment, and diagnosis" and "Approach to the management of chronic non-cancer pain in adults", section on 'Psychological therapy'.)

TREATMENT OF FLARES — Women with MPPS often develop symptom recurrence months or even years after symptoms have quieted. Despite efforts to avoid known triggers, symptom flares can develop. While we generally treat flares with the approach listed below, the order and type of treatment can vary based on the severity and location of symptoms in a particular patient and also based on which treatments were successful previously. Additionally, these treatments are often encouraged after initial diagnosis while the patient is waiting for pelvic floor physical therapy. Women are instructed to avoid any therapy or manipulation that provokes symptoms.

Conservative treatment — We educate all women with MPPS regarding the use of conservative treatments, such as ice, heat, stretching, self-massage, and exercise, to temporarily relieve the discomfort associated with MPPS flares. Stress management is also an important part of the treatment plan, as chronic daily or intermittent stress can exacerbate muscle tension. Lastly, we reassess their medical therapy and adjust to address the specific flare symptoms.

●Stretch/massage – Patients with accessible trigger points can treat themselves. We instruct our patients to massage, skin roll, and perform scar release in painful areas. Some patients find this more useful than rest, ice, heat, and exercise [82].

Skin rolling is performed by applying a light moisturizing cream or lotion and using both hands to gently grasp sections of skin in the affected area (eg, abdomen, inner or outer thigh) [6]. The skin is rolled gently between the fingers, with the goal being to release restrictions in the underlying connective tissue. A sharp pinching sensation and erythema are common reactions, especially early in treatment.

Similarly, scar release is performed with the fingers grasping the tissue on either side of the scar. The scar should be gently pulled away from the body and rolled between the fingers. The tissue can also be lightly and deeply massaged.

●Ice – Most of our patients find that application of ice to painful areas of the abdomen or perineum provides short-term relief of pain, especially during a flare or after sexual intercourse. Ice can be placed intravaginally by filling a finger of a nonsterile examination glove or a condom and inserting into the vagina. We generally recommend applying ice for no more than 20 minutes at a time.

●Heat – For women who cannot tolerate ice, heat can also be soothing during a flare. A hot water bottle or heating pad may be used, although care must be taken to avoid burns.

●Exercise – Women appear to view exercise as more effective for decreasing muscle pain than men [82]. There is no single exercise proven to reduce pain or tightness related to MPPS. We suggest regimens that include stretching (eg, yoga, Pilates). Exercises to strengthen the core, pelvis, or both should be approached with care, as this can sometimes lead to increased pain.

●Stress management – Anxiety predisposes some women to continuously contract their muscles, including those of the pelvic floor. Depression and anxiety often coexist with chronic pain and may exacerbate pain [83]. This association has even been noted in adolescents [84]. In our experience, uncontrolled anxiety and pain are associated with poorer outcomes and the need for a longer treatment course. Treatment of MPPS, like that of any type of chronic pain, must include management of depression and anxiety. It is important to include a multidisciplinary approach in these women, with the use of psychotherapy or psychopharmacology as needed [85]. Use of stress reduction techniques such as deep breathing, visualization, mindfulness meditation, progressive muscle relaxation, or prayer are suggested, as well.

●Reassess medical therapy – Women experiencing a flare may require additional medical support to help them through the episode. For example, we may prescribe a muscle relaxant for women with muscle spasms, tricyclic antidepressants for women with sleep issues, and increase the dose of gabapentin for women who have previously been well controlled. We often start with a short course of muscle relaxers, especially if they have been effective in the past. Narcotics are seldom helpful and are not advised for a flare.

Bladder pain or irritative voiding symptoms — If painful or irritative voiding symptoms are manifested during a flare of MPPS, a bladder instillation of a local anesthetic and other medications can be helpful. A solution of lidocaine, sodium bicarbonate, and heparin can provide short-term relief. In our practice, we also add triamcinolone to reduce presumed inflammation. Instillations are often done in the office, although patients can learn to administer the solution at home through self-catheterization. (See "Interstitial cystitis/bladder pain syndrome: Management", section on 'Intravesical therapies'.)

Urinary analgesics, such as phenazopyridine or a combination drug of methenamine-sodium phosphate monobasic-phenyl salicylate-methylene blue-hyoscyamine sulfate, can provide temporary relief of dysuria and urgency. Phenazopyridine 100 to 200 mg can be used for up to three times a day for three consecutive days if needed. However, long-term use of phenazopyridine is not recommended due to the theoretic risk of hepatotoxicity. Prior to use, the possibility of urinary tract infection should be excluded. (See "Acute simple cystitis in adult and adolescent females", section on 'Diagnostic approach'.)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Female pelvic pain".)

SUMMARY AND RECOMMENDATIONS

●Definition and pathophysiology – Myofascial pelvic pain syndrome (MPPS) is a non-articular musculoskeletal pain disorder characterized by short/tight bands of skeletal muscle that often contain discrete, painful nodules, also called trigger points. MPPS is thought to originate at the trigger point, although the full etiology is not known. A neuropathic component resulting from inflammatory mediator release likely plays a role as well. Patients do not uniformly respond to available treatments, reflecting multifactorial sources of pain. (See 'Definition' above.)

●Patient education and treatment approach – One goal of treatment is to help women understand that MPPS can be a chronic, waxing and waning condition that may require long-term management. We apply a multidisciplinary approach that addresses both physiological and psychological aspects of MPPS and that is tailored to the individual patient. The general approach is to determine the trigger and then block or reduce ongoing stimuli that lead to pain. (See 'Our approach' above.)

●Initial treatments – Treatment interventions do not have to occur in isolation or in a specific sequential order. In general, patients begin with pelvic floor physical therapy (PFPT) to address overall short, tight pelvic floor muscles that are the hallmark finding on physical examination. Additional treatments, such as medication and trigger point injections, are then added to the PFPT regimen as needed. We generally proceed with treatments in the order listed below. Trial and error with different treatment modalities is often needed to achieve symptom improvement.

•Pelvic floor physical therapy – For women with MPPS, we suggest initial treatment with PFPT (Grade 2C). In our experience, most patients benefit from a trial of PFPT to reduce tight painful muscles and alleviate trigger points. Adjunctive therapy can include local trigger point injections (TPI), medication, botulinum toxin injections, and/or sacral neuromodulation. Initial evaluation and treatment with PFPT typically requires three to four months, after which the patient is reassessed and proceeds through the treatments below as needed. (See 'Pelvic floor physical therapy' above.)

•Trigger point injections – For women who are unable to immediately attend or decline PFPT, typically because of severe pain prohibiting PFPT or for logistic reasons, we suggest trigger point injections (TPI) (Grade 2C). TPIs improve tolerability and enhance the response to physical therapy as well as often accelerate progress. An alternate approach for women who cannot access TPIs is treatment with topical lidocaine gel. (See 'Trigger point' above.)

•Medication – For women with moderate to severe myofascial pelvic pain that is interfering with their usual activities, we suggest gabapentin as first-line pharmacologic therapy (in addition to PFPT) (Grade 2C). Additional first-line medication treatments include pregabalin, tricyclic antidepressants, and muscle relaxants because of their efficacy, tolerability, and relatively safe side effect profile. This list reflects our experience as well as the available literature and is not meant to be applicable to all women with MPPS. (See 'Commonly used' above and 'Gabapentin' above.)

●Reassess for persistent symptoms

•Improvement with PFPT – After three to four months of initial treatment, women who are notably improving with PFPT continue treatment until symptoms stabilize. The goal is to have patients manage symptoms with exercises or treatments that they can perform at home. (See 'Our approach' above.)

•Persistent pain – For women who are unable to receive physical therapy due to severe pain, women with persistent pain after six to eight sessions of physical therapy, women who do not make progress with physical therapy, or for women with an identifiable muscle spasm that correlates with their pain symptoms, we suggest botulinum toxin A injections (Grade 2C). (See 'Botulinum toxin' above.)

•Continued lack of improvement – Women with minimal or no improvement are reassessed and may be referred for an orthopedic evaluation to assess for extra-pelvic sources of pain. These women may also be advised to try additional adjunctive medical therapy. (See 'Our approach' above.)

●Use of cognitive behavioral therapy – Cognitive behavioral therapy (CBT) is one of the most commonly used and studied psychological interventions for pain, including vulvar and sexual pain [78-81]. We encourage patients to participate in a CBT program targeted at treatment of chronic pain syndromes for both symptom reduction and stress management. (See 'Cognitive behavioral therapy' above.)

●Long-term symptom recurrence – Patients with MPPS often develop symptom recurrence months or even years after symptoms have quieted. Despite efforts to avoid known triggers, symptom flares can develop. These patients generally proceed with the treatments that worked best during their prior flare. (See 'Treatment of flares' above.)