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Treatment of myofascial pelvic pain syndrome in women

Leah K Moynihan, RNC, MSN
Eman Elkadry, MD, FACOG
Section Editor
Linda Brubaker, MD, FACOG
Deputy Editor
Kristen Eckler, MD, FACOG


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 non-pelvic 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 "Clinical manifestations and diagnosis of myofascial pelvic pain syndrome in women".)

(See "Evaluation of chronic pain in adults".)

(See "Overview of the treatment of chronic non-cancer pain".)

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Literature review current through: Nov 2017. | This topic last updated: Sep 22, 2017.
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  1. Simons DG, Travell JG, Simons PT. Upper half of body. In: Travell and Simons' Myofascial Pain and Dysfunction: The Trigger Point Manual, 2nd ed, Williams & Wilkins, Baltimore 1999.
  2. The 2015 EAU guidelines on chronic pelvic pain. http://www.uroweb.org/guidelines/online-guidelines/ (Accessed on November 22, 2015).
  3. Jafri MS. Mechanisms of Myofascial Pain. Int Sch Res Notices 2014; 2014.
  4. Turner JA, Deyo RA, Loeser JD, et al. The importance of placebo effects in pain treatment and research. JAMA 1994; 271:1609.
  5. FitzGerald MP, Kotarinos R. Rehabilitation of the short pelvic floor. II: Treatment of the patient with the short pelvic floor. Int Urogynecol J Pelvic Floor Dysfunct 2003; 14:269.
  6. Weiss JM. Pelvic floor myofascial trigger points: manual therapy for interstitial cystitis and the urgency-frequency syndrome. J Urol 2001; 166:2226.
  7. Fisher KA. Management of dyspareunia and associated levator ani muscle overactivity. Phys Ther 2007; 87:935.
  8. FitzGerald MP, Payne CK, Lukacz ES, et al. Randomized multicenter clinical trial of myofascial physical therapy in women with interstitial cystitis/painful bladder syndrome and pelvic floor tenderness. J Urol 2012; 187:2113.
  9. Zoorob D, South M, Karram M, et al. A pilot randomized trial of levator injections versus physical therapy for treatment of pelvic floor myalgia and sexual pain. Int Urogynecol J 2015; 26:845.
  10. Oyama IA, Rejba A, Lukban JC, et al. Modified Thiele massage as therapeutic intervention for female patients with interstitial cystitis and high-tone pelvic floor dysfunction. Urology 2004; 64:862.
  11. Bedaiwy MA, Patterson B, Mahajan S. Prevalence of myofascial chronic pelvic pain and the effectiveness of pelvic floor physical therapy. J Reprod Med 2013; 58:504.
  12. FitzGerald MP, Anderson RU, Potts J, et al. Randomized multicenter feasibility trial of myofascial physical therapy for the treatment of urological chronic pelvic pain syndromes. J Urol 2009; 182:570.
  13. Misirlioglu TO, Akgun K, Palamar D, et al. Piriformis syndrome: comparison of the effectiveness of local anesthetic and corticosteroid injections: a double-blinded, randomized controlled study. Pain Physician 2015; 18:163.
  14. Oor JE, Ünlü Ç, Hazebroek EJ. A systematic review of the treatment for abdominal cutaneous nerve entrapment syndrome. Am J Surg 2016; 212:165.
  15. Fritz J, Chhabra A, Wang KC, Carrino JA. Magnetic resonance neurography-guided nerve blocks for the diagnosis and treatment of chronic pelvic pain syndrome. Neuroimaging Clin N Am 2014; 24:211.
  16. Innovative Program Targets Five Common Pain Syndromes With Non-opioid Alternatives. ED Manag 2016; 28:61.
  17. Sabatke S, Scola RH, Paiva ES, Kowacs PA. Injecction of trigger points in the temporal muscles of patients with miofascial syndrome. Arq Neuropsiquiatr 2015; 73:861.
  18. Niraj G, Collett BJ, Bone M. Ultrasound-guided trigger point injection: first description of changes visible on ultrasound scanning in the muscle containing the trigger point. Br J Anaesth 2011; 107:474.
  19. Langford CF, Udvari Nagy S, Ghoniem GM. Levator ani trigger point injections: An underutilized treatment for chronic pelvic pain. Neurourol Urodyn 2007; 26:59.
  20. Soares A, Andriolo RB, Atallah AN, da Silva EM. Botulinum toxin for myofascial pain syndromes in adults. Cochrane Database Syst Rev 2014; :CD007533.
  21. Jarvis SK, Abbott JA, Lenart MB, et al. Pilot study of botulinum toxin type A in the treatment of chronic pelvic pain associated with spasm of the levator ani muscles. Aust N Z J Obstet Gynaecol 2004; 44:46.
  22. Abbott JA, Jarvis SK, Lyons SD, et al. Botulinum toxin type A for chronic pain and pelvic floor spasm in women: a randomized controlled trial. Obstet Gynecol 2006; 108:915.
  23. Yoon H, Chung WS, Shim BS. Botulinum toxin A for the management of vulvodynia. Int J Impot Res 2007; 19:84.
  24. Dykstra DD, Presthus J. Botulinum toxin type A for the treatment of provoked vestibulodynia: an open-label, pilot study. J Reprod Med 2006; 51:467.
  25. Thomson AJ, Jarvis SK, Lenart M, et al. The use of botulinum toxin type A (BOTOX) as treatment for intractable chronic pelvic pain associated with spasm of the levator ani muscles. BJOG 2005; 112:247.
  26. Romito S, Bottanelli M, Pellegrini M, et al. Botulinum toxin for the treatment of genital pain syndromes. Gynecol Obstet Invest 2004; 58:164.
  27. Ghazizadeh S, Nikzad M. Botulinum toxin in the treatment of refractory vaginismus. Obstet Gynecol 2004; 104:922.
  28. Morrissey D, El-Khawand D, Ginzburg N, et al. Botulinum Toxin A Injections Into Pelvic Floor Muscles Under Electromyographic Guidance for Women With Refractory High-Tone Pelvic Floor Dysfunction: A 6-Month Prospective Pilot Study. Female Pelvic Med Reconstr Surg 2015; 21:277.
  29. Adelowo A, Hacker MR, Shapiro A, et al. Botulinum toxin type A (BOTOX) for refractory myofascial pelvic pain. Female Pelvic Med Reconstr Surg 2013; 19:288.
  30. Halder GE, Scott L, Wyman A, et al. Botox combined with myofascial release physical therapy as a treatment for myofascial pelvic pain. Investig Clin Urol 2017; 58:134.
  31. Graven-Nielsen T, Mense S. The peripheral apparatus of muscle pain: evidence from animal and human studies. Clin J Pain 2001; 17:2.
  32. Issberner U, Reeh PW, Steen KH. Pain due to tissue acidosis: a mechanism for inflammatory and ischemic myalgia? Neurosci Lett 1996; 208:191.
  33. Hong CZ, Simons DG. Pathophysiologic and electrophysiologic mechanisms of myofascial trigger points. Arch Phys Med Rehabil 1998; 79:863.
  34. Bron C, Dommerholt JD. Etiology of myofascial trigger points. Curr Pain Headache Rep 2012; 16:439.
  35. Volknandt W. The synaptic vesicle and its targets. Neuroscience 1995; 64:277.
  36. Erbguth FJ, Naumann M. Historical aspects of botulinum toxin: Justinus Kerner (1786-1862) and the "sausage poison". Neurology 1999; 53:1850.
  37. Knutson GA. The role of the gamma-motor system in increasing muscle tone and muscle pain syndromes: a review of the Johansson/Sojka hypothesis. J Manipulative Physiol Ther 2000; 23:564.
  38. Botox- onabotulinumtoxina injection, powder, lyophilized, for solution. US Food and Drug Administration (FDA) approved product information. Revised April 11, 2017. US National Library of Medicine. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=33d066a9-34ff-4a1a-b38b-d10983df3300 (Accessed on May 08, 2017).
  39. Gapapentin capsule. US Food and Drug Administration (FDA) approved product information. Revised March, 2014. US National Library of Medicine. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=0936a88f-b569-49c4-951b-14e8f6273b53 (Accessed on May 09, 2017).
  40. Salah S, Thomas L, Ram S, et al. Systematic Review and Meta-analysis of the Efficacy of Oral Medications Compared with Placebo Treatment in the Management of Postherpetic Neuralgia. J Oral Facial Pain Headache Summer; 30:255.
  41. Moore RA, Wiffen PJ, Derry S, et al. Gabapentin for chronic neuropathic pain and fibromyalgia in adults. Cochrane Database Syst Rev 2014; :CD007938.
  42. Manfredini D, Landi N, Tognini F, et al. Muscle relaxants in the treatment of myofascial face pain. A literature review. Minerva Stomatol 2004; 53:305.
  43. Melis M, Secci S. Diagnosis and treatment of atypical odontalgia: a review of the literature and two case reports. J Contemp Dent Pract 2007; 8:81.
  44. Practice bulletin no. 114: management of endometriosis. Obstet Gynecol 2010; 116:223.
  45. Rogalski MJ, Kellogg-Spadt S, Hoffmann AR, et al. Retrospective chart review of vaginal diazepam suppository use in high-tone pelvic floor dysfunction. Int Urogynecol J 2010; 21:895.
  46. Carrico DJ, Peters KM. Vaginal diazepam use with urogenital pain/pelvic floor dysfunction: serum diazepam levels and efficacy data. Urol Nurs 2011; 31:279.
  47. Crisp CC, Vaccaro CM, Estanol MV, et al. Intra-vaginal diazepam for high-tone pelvic floor dysfunction: a randomized placebo-controlled trial. Int Urogynecol J 2013; 24:1915.
  48. Tofferi JK, Jackson JL, O'Malley PG. Treatment of fibromyalgia with cyclobenzaprine: A meta-analysis. Arthritis Rheum 2004; 51:9.
  49. Nickel JC, Herschorn S, Whitmore KE, et al. Pentosan polysulfate sodium for treatment of interstitial cystitis/bladder pain syndrome: insights from a randomized, double-blind, placebo controlled study. J Urol 2015; 193:857.
  50. Evans RJ. Treatment approaches for interstitial cystitis: multimodality therapy. Rev Urol 2002; 4 Suppl 1:S16.
  51. Zuidema X, Breel J, Wille F. S3 Dorsal Root Ganglion/Nerve Root Stimulation for Refractory Postsurgical Perineal Pain: Technical Aspects of Anchorless Sacral Transforaminal Lead Placement. Case Rep Neurol Med 2016; 2016:8926578.
  52. Wang R, Lefevre R. Management of Urinary and Fecal Incontinence in Patients With Complex Regional Pain Syndrome. Female Pelvic Med Reconstr Surg 2016; 22:e14.
  53. Hill AJ, Paraiso MF. Resolution of Chronic Vulvar Pruritus With Replacement of a Neuromodulation Device. J Minim Invasive Gynecol 2015; 22:889.
  54. Valovska A, Peccora CD, Philip CN, et al. Sacral neuromodulation as a treatment for pudendal neuralgia. Pain Physician 2014; 17:E645.
  55. Laviana A, Jellison F, Kim JH. Sacral neuromodulation for refractory overactive bladder, interstitial cystitis, and painful bladder syndrome. Neurosurg Clin N Am 2014; 25:33.
  56. Affaitati G, Fabrizio A, Savini A, et al. A randomized, controlled study comparing a lidocaine patch, a placebo patch, and anesthetic injection for treatment of trigger points in patients with myofascial pain syndrome: evaluation of pain and somatic pain thresholds. Clin Ther 2009; 31:705.
  57. Tough EA, White AR, Cummings TM, et al. Acupuncture and dry needling in the management of myofascial trigger point pain: a systematic review and meta-analysis of randomised controlled trials. Eur J Pain 2009; 13:3.
  58. Küçük EV, Suçeken FY, Bindayı A, et al. Effectiveness of acupuncture on chronic prostatitis-chronic pelvic pain syndrome category IIIB patients: a prospective, randomized, nonblinded, clinical trial. Urology 2015; 85:636.
  59. Goldstein AT, Pukall CF, Brown C, et al. Vulvodynia: Assessment and Treatment. J Sex Med 2016; 13:572.
  60. Goldfinger C, Pukall CF, Thibault-Gagnon S, et al. Effectiveness of Cognitive-Behavioral Therapy and Physical Therapy for Provoked Vestibulodynia: A Randomized Pilot Study. J Sex Med 2016; 13:88.
  61. Lindström S, Kvist LJ. Treatment of Provoked Vulvodynia in a Swedish cohort using desensitization exercises and cognitive behavioral therapy. BMC Womens Health 2015; 15:108.
  62. Nelson P, Apte G, Justiz R 3rd, et al. Chronic female pelvic pain--part 2: differential diagnosis and management. Pain Pract 2012; 12:111.
  63. Dannecker EA, Knoll V, Robinson ME. Sex differences in muscle pain: self-care behaviors and effects on daily activities. J Pain 2008; 9:200.
  64. Roth RS, Punch MR, Bachman JE. Patient beliefs about pain diagnosis in chronic pelvic pain: relation to pain experience, mood and disability. J Reprod Med 2011; 56:123.
  65. Hoftun GB, Romundstad PR, Rygg M. Factors associated with adolescent chronic non-specific pain, chronic multisite pain, and chronic pain with high disability: the Young-HUNT Study 2008. J Pain 2012; 13:874.
  66. Meltzer-Brody S, Leserman J. Psychiatric comorbidity in women with chronic pelvic pain. CNS Spectr 2011; 16:29.