Myofascial Pelvic Pain

Treatment of Chronic Pelvic pain

Cristiane Carboni, PT
Master in Pelvic Floor Rehabilitation/ University of Barcelona-Spain
Master in Rehabilitation Science/ UFCSPA-Brazil
Specialist in Women’s Health - CREFITO
Specialist in Human Sexuality - SBRASH
Coordinator of Pelvic Floor post graduation - Faculdade Inspirar Porto
Alegre
Scientific Board of “Instituto lado a lado pela vida”
Member of ICS PT Committee
Director of the “School of Physiotherapy”
Myofascial Pelvic Pain

ICS Rio de Janeiro 2014

Myofascial Pelvic Pain
Regional pain disorder that affects the muscles and fascia, in such a way that the muscles involved
have a trigger point (TrP)

• Pain produced and maintained by one or more active TrPs.

• The TrP is located within a taut band of the muscle or its fascia.
• The taut band and the TrP can be palpated, which provokes referred pain.
• The ability of the affected muscle to stretch is restricted.
• Segmental changes coexist with symptoms of: local changes in the skin, increased sweating,
changes in local temperature, and sometimes small local edemas.

David G. Simons. Understanding effective treatments of myofascial trigger points. Journal of Bodywork and Movement Therapies.2002.6 (2),
81-88. Travell J, Simons D. Dolor y disfunción miofascial. El Manual de los Puntos Gatillo. Vol. 1.1999 pp. 138-152. Ed. Panamericana.
Myofascial Pelvic Pain
• Contraction Tension Spasm

• In the contraction of • If the contracting and • Muscle spasm is by definition a

the skeletal muscle relaxing muscle does not sudden and involuntary
fibers, the shortening return to its original size, contraction of a muscle or a
of the sarcomeres a constant residual group of muscles, accompanied
occurs: the actin residual muscle tension by pain and restriction in
filaments "slide" over state, resulting in a movement. The presence of
those of myosin. reduction of muscle muscle spasm is very much
elasticity. related to emotional tension.
 Myofascial Pain
Low back, hip, buttock, abdominal wall,
and pelvic floor muscle dysfunction

Inciting Pain Event: uterus, ovary, bowel, bladder, muscles, nerves

LOCAL MUSCLE TENSION

Initial Event
Secondary Muscle “Adaptations”: Resolves (naturally
Lower back, buttocks, hips, pelvic floor or with treatment)

Hypertonus and tenderness are common

6
Myofascial Pelvic Pain – Symptoms
 Fear Avoidance Model
(Catastrophizing)
CPP

(Main, et al., BMJ, 2002; Alappattu & Bishop, 2011; Martin, Johnson,
8
Wechter, Leserman, & Zolnoun, 2011).
Therapeutic Pain Neuroscience Education in the
treatment of Chronic Pelvic Pain
Therapeutic Pain Neuroscience Education in the
treatment of Chronic Pelvic Pain

Louw A, Puentedura EJ. Therapeutic neuroscience education - Teaching patients about pain. International Spine and Pain Institute USA 2013. Louw A, Diener I, Butler DS,
Puentedura EJ. Systematic review: The effect of neuroscience education on pain, disability, anxiety, and stress in chronic musculoskeletal pain. Arch Phys Med Rehabil (2011)
92:2041-2056). Moseley GL, Butler DS. Explain pain supercharged. Noigroup South Australia 2017. Smart KM, et al. The discriminative validity of "nocicepetive," "peripheral
neuropathic," and "central sensitization" as mechanism-based classifications of musculoskeletal pain. Clin J Pain 2011;27(8):655-663.
Internal TrPs of the pelvic floor, typical referred
pain, and resulting symptoms.
 M. bulbo-spongiosus M. ischiocavernosus

Corpo Perineal
ou Centro Tendíneo
Do Períneo M. Superficial transversus

External anal sphincter muscle

Pain in the anus, in the anterior
part of the pelvis close to the
pubis, in the posterior part of the
anal sphincter.
Diafragma Urogenital

M. Transverso
Profundo do Períneo
 Internal obturator muscle
Pain referred to the hip,
vulvar, urethral. May
simulate a pudendal nerve
entrapment, and since the
nerve and the muscle are
intimately related, palpation
of the area causes a burning
and intense pain.

Arco Tendíneo
M. levator ani
da
Fáscia Pélvica
Levator ani muscle M. Puboretal Pain referred to the
urethra and the bladder,
lower abdomen. Increased
urinary frequency and
urgency.

M.Iliococcygeus
M. PuboCoccígeo
Pain referred to the lateral
wall, perineum, and anal
Pain referred to the lateral wall, perineum, and anal sphincter. Posterior portionsphincter.
– Sensation of a golf
Sensation of ball in
a golf
the rectum. – Pain during and after ejaculation. – Pain after defecation. External ballanal sphincter
in the rectum.muscle –
Pain after
Pain in the anus. – Pain in the anterior part of the pelvis close to the pubis. – Paindefecation.
in the posterior part of the
anal sphincter. – Tingling and burning in the anal area
Fáscia
Retovagina
l
 Fáscia
Pubocervical
(vesicovaginal)

vagina
 Uretra

Bexiga

Colo Uterino
Anel Pericervical (cérvix)
Nível das
Espinhas
Isquiáticas
Ligamentos
Cardinais
 Ligamento
Ligamento Pubouretral (Pubovesical)
Uretropélvico

Ligamento
Úterosacro
Beyond the pelvic Floor
Quadratus lumborum muscle

– Inguinal pain, in the lower abdomen,

referred to the hip, low back pain.

Iliopsoas muscle

– Low back pain, Inguinal, the front of

the leg.
Rectus abdominis muscle

– Pain in the lower abdomen. – Low back

pain.

Abdominal oblique muscle

– Pain radiating to stomach, ribs, inguinal

pain.
Abdominal
• Voiding dysfunction, dyspareunia, obstructed defecation (sphincter non-
release, sometimes called anismus) and perineal and perianal pain are
associated problems. Many of these patients, frequently are young and
very fit, have an over-active abdominal wall that is not released to allow
PF relaxation.

• Thompson J,O’Sullivan P, Bri!aN, et al.

• Richardson, C, Jull, G, Hodges, P and Hides, J (1999). ICS Rio de Janeiro 2014 2005.Differences in muscle activation patterns
Therapeutic Exercise for Spinal Segmental Stabilization during pelvic floor muscle contraction and valsalva
in Low Back Pain, Churchill Livingstone, Edinburgh. manouevre.Neurourol and Urodyn.
 The role of the abdomen and trunk
• The urge to urinate and excessively frequent micturition may be caused
by trigger points (TrPs) located in the lower abdominal muscles, and
those TrPs may both weaken and provoke a partial contraction of these
muscles.

Trigger Points and Muscle

Chains in Osteopathy
Por Philipp Richter,Eric U.
Hebgen

ICS Rio de Janeiro 2014

Travel JG, Simons DG. Myofascial pain and dysfunction. The trigger point manual, vol 1.
Williams and Wilkins, Baltimore; 1983, P 15, 671.
Beyond the pelvic Floor

ICS Rio de Janeiro 2014

• For every type of trigger point therapy, the goal is to restore normal
resting muscle length and a full range of motion, which is achieved first
by passive stretching and then by active effort under a light load.

ICS Rio de Janeiro 2014

Músculos
• Bulboesponjoso – Auxilia na expulsão do sêmen durante ejaculação.

• Isquicavernoso – Fornece maior rigidez ao pênis durante a fase

rígida da ereção.

3
3
Pyramidalis muscle Pain
in the bladder and
urethra, around the
pubic bone, referred to
the sacroiliac joint,
buttock and hip that
increase when standing
and sitting. – Pinched
sciatic nerve pain with
neurological
compression symptoms.
3
5
EMG Biofeedback for downtraining
4
1
 Case Study
• 36 year old woman with chronic bladder pain and urgency.
• 4 year history of recurrent UTI with negative cultures
• Cystitis symptoms now chronic with no recent response to multiple
antibiotics/anticholinergics
• Perceived bladder pain improves with voiding
• Voids 14 times per day 4 times per night
• Urgency but no incontinence
• Also complains of constipation
• Painful sexual intercourse
• Pain in the lower left side of the belly
Case Study - Exams

• Negative colonoscopy
• Urodynamic – 300 ml max capacity – No UI, NO OAB – Urinary
hesitancy – EMG (external anal sphincter) deficit of relaxation during
voiding – residual of 45 ml
• Normal Echography
• Negative Cystoscopy
 Case Study - Inspection
• No prolapses
• Q-tip test showing provoked vulvodynia
• Pelvic Floor – Normal tonus in rest, good contraction but relaxation
deficit- don't hold 5s
• Contractures and trigger points at psoas and abdominal muscles
 Case Study
Is it possible that this patient has multiple pain generators?

More Detail

– Location of pain?
– Severity of pain?
– Duration of pain?
– Pain constant or related to activity?
– Radiation of pain?
– Does it hurt when painful area is touched?
– History of hernia repair, diabetes, herpes?
Case Study - Treatment
More Information...
• Entry and deep dyspareunia
• Can’t wear tight pants
• Tampons are painful
• Vaginal burning after urination
• No labial/introital abnormaliHes

• What is wrong???
 Case Study - Treatment
Treated with:

Amitriptyline and Skeletal muscle relaxants

Pelvic Floor PT

Manual therapy – negative biofeedback- behavior therapy -

Bowel Regime – Topical Heat

Progressively returning to physical activity.

 Thank you!

criscarboni@hotmail.com
www.mundodoassoalhopelvico.com
@mundodoassoalhopelvico