Curr Urol Rep (2013) 14:409–417
DOI 10.1007/s11934-013-0360-7
LOWER URINARY TRACT SYMPTOMS AND VOIDING DYSFUNCTION (G BADLANI AND H GOLDMAN, SECTION EDITORS)
Myofascial Trigger Points of the Pelvic Floor: Associations
with Urological Pain Syndromes and Treatment Strategies
Including Injection Therapy
Robert M. Moldwin & Jennifer Yonaitis Fariello
Published online: 14 August 2013
# Springer Science+Business Media New York 2013
Abstract Myofascial trigger points (MTrP), or muscle “con-
traction knots,” of the pelvic floor may be identified in as many
as 85 % of patients suffering from urological, colorectal and
gynecological pelvic pain syndromes; and can be responsible
for some, if not all, symptoms related to these syndromes.
Identification and conservative treatment of MTrPs in these
populations has often been associated with impressive clinical
improvements. In refractory cases, more “aggressive” therapy
with varied trigger point needling techniques, including dry
needling, anesthetic injections, or onabotulinumtoxinA injec-
tions, may be used, in combination with conservative therapies.
Keywords Myofascial pain . Trigger points . Pelvic pain .
Pelvic floor dysfunction . Interstitial cystitis
“Untying a complex knot requires patience, persistence,
and experience.”
Introduction
Myofascial trigger points (MTrPs) of the pelvic floor and
adjacent musculature are frequently identified, along with
“high-tone” pelvic floor dysfunction (HTPFD), in urological,
R. M. Moldwin (*)
Hofstra North Shore-LIJ School of Medicine, Pelvic Pain Treatment
Center, The Arthur Smith Institute for Urology, North Shore-LIJ
Healthcare System, 450 Lakeville Road, Suite M41, New Hyde Park,
NY 11040, USA
e-mail: RMoldwin@gmail.com
J. Y. Fariello
Female & Male Pelvic and Sexual Medicine, The Pelvic and Sexual
Health Institute, 207 N. Broad Street, 4th Floor, Philadelphia, PA
19107, USA
e-mail: jfariello@gmail.com
gynecological, and colorectal pain syndromes. These regions
may enhance the pain of the initial pathology or be the primary
pain generator. Symptoms produced by these regions may
extend beyond pain, adversely affecting voiding, bowel, and
sexual function. Identification of MTrPs and therapeutic in-
tervention is, therefore, essential for optimal patient care.
First-line therapies applied include behavioral modification,
topical heat/cold, muscle relaxants, and physical therapy. This
article will focus upon more aggressive intervention with
needling techniques, including trigger point injections of
MTrPs, which can easily be incorporated into urological
practice.
Characteristics of Trigger Points
Myofascial trigger points (MTrPs) are tender “knots” in taut
muscle bands that produce pain. The pain may be local and/or
referred; and a “twitch response” is elicited when these re-
gions are palpated [1, 2]. MTrPs can be active or latent, the
main differentiating characteristic being whether or not they
are the cause of clinically significant pain [2]. MTrPs of the
pelvic floor are almost invariably accompanied by “high-
tone” pelvic floor muscular dysfunction (HTPDF).
Neurophysiology of Trigger Point Pain
The pain associated with MTrPs may be attributed to high
local concentrations of inflammatory mediators, neuropep-
tides and neurotransmitters. The stimulation of local
nociceptors elicits the local and referred pain of MTrPs [3].
A study by Shah et al. [4] examined the biochemical milieu of
muscle in three subject groups: normal (no pain, no MTrP,
n=3); latent (no pain, MTrP present, n=3); active (pain, MTrP
present, n=3). A microdialysis needle was inserted into the
upper trapezius muscle, where it was then advanced to elicit a
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local twitch response (LTR) in the active and latent groups.
The LTR was confirmed by surface electromyography. Over-
all, the amounts of bradykinin, CGRP, substance P, TNF-α,
IL-β, serotonin and norepinephrine were significantly higher
in the active group than in the latent and normal groups
(P<0.01) Additionally, the pH was significantly lower in the
active group (P<0.03).
Shah et al. [5••] repeated the above study in 2008 and
performed an analysis of the biochemical milieu of the gas-
trocnemius muscle, an uninvolved, remote muscle. Results
concurred with the previous study, with all biochemicals (with
the addition of IL-6 and IL-8) having significantly higher local
concentrations in the active group (n=3) when compared to
the latent (n=3) and normal (n=3) groups. Of particular note
was that the active group had elevated levels of all of these
biochemicals in the uninvolved gastrocnemius muscle com-
pared to the latent and normal groups; indicating that the
inflammatory events associated with MTrPs may extend well
beyond a focal process.
Other relevant pathologies associated with MTrPs appear
to be local nociceptor sensitization, the presence of local
ischemia, and the sustained release of acetylcholine and varied
inflammatory mediators. Collectively, this process is thought
to result in the characteristic local twitch response, contracture
of sarcomeres, and contraction knot [6, 7].
IC/BPS, CP/CPPS, Vulvodynia and MTrPs
The hallmark features of interstitial cystitis/bladder pain syn-
drome (IC/BPS) include urinary urgency, frequency and pel-
vic pain and/or discomfort. Historically, these symptoms were
thought to be solely bladder-based; however, recent evidence
suggests that multiple extravesical pathologies such as
HTPFD and MTrPs may be at play; and in some instances,
may be the primary symptom generators [8]. The same para-
digm shift has occurred for other pain syndromes such as
chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS)
and vulvodynia. This has been underscored by the frequent
failure or suboptimal response to “organ-based” therapies in
these patient groups. These disorders frequently co-exist,
making diagnosis and treatment more complex (Fig. 1).
The presence of MTrPs and HTPFD in the IC/BPS popu-
lation is estimated to be 85 % [9], and may account for pelvic
pain along with irritative and obstructive voiding symptoms.
The presence of myofascial based pain is so commonly en-
countered in the IC/BPS patient, that physical therapy, direct-
ed specifically towards HTPFD, has become part of the
American Urological Association (AUA) Guidelines for IC/
BPS management [10].
Men afflicted with both Category IIIA and IIIB CP/CPPS
have a high prevalence of MTrPs. Berger et al. [11] compared
72 men with CP/CPPS Types IIIA/IIIB to 98 men without
Curr Urol Rep (2013) 14:409–417
Fig. 1 Interrelationships between pelvic pain syndromes. In this scenar-
io, high tone pelvic floor dysfunction (HTPFD) and associated MTrPs
may magnify the symptoms associated with these disorders or may be the
primary symptom generator
pelvic pain for the presence of internal pelvic tender points
(IPTPS) and external pelvic tender points (EPTPS), as well as
prostatic tenderness. Of men with CP/CPPS, 67.3% were found
to have IPTPS compared to 28.7% of men without pain.
Overall, the men in the CP/CPPS group reported significantly
more pain with both IPTPS and EPTPS compared to the control
group (odds ratio 6.25 and 9.59, respectively; p < 0.0001 for
both). This was the first study to demonstrate that men with CP/
CPPS have both internal and external myofascial tender points
associated with an increase in pain in non-prostatic locations.
Berger's group concluded that Type IIIA/IIIB CP/CPPS in-
volves the entire pelvis and is not limited to the prostate; and
furthermore, that labeling CPP in men as "prostatitis" may
misguide clinicians into a limited focus and management plan.
Women with vulvodynia commonly have hypertonus of
the pelvic floor muscles, decreased contractile strength and
MTrPs that may arise from habitual “tensing” or “clenching”
as a defensive reaction toward the pain of penetrative attempts
[12••, 13, 14]. High tone pelvic floor dysfunction has been
postulated to activate vulvar mucosal sensitivity, setting up a
vicious cycle of pain and further muscle dysfunction [15].
Symptoms attributed to muscular dysfunction extend be-
yond pain and often add to the confusion of a therapeutic
target. Urinary urgency, frequency and pain are common
referred sensations derived from a skeletal muscle in the
abdominal wall and pelvic floor musculature. IC/BPS and
CP/CPPS are often associated with MTrPs in the levators,
obturator internus and rectus abdominus [12••]. The confusion
regarding the origin of pain is thought to be related to conver-
gence of afferent C and A-delta fibers from the bladder and
pelvic floor musculature upon second order neurons of the
spinal cord. This viscerosomatic convergence likely plays an
important role in the maintenance, amplification, and referral
Curr Urol Rep (2013) 14:409–417
of pain. In the patient with urological chronic pelvic pain, pain
may be referred from the viscera (bladder) to the muscle,
thereby activating MTrPs. This may be compounded by
guarding maneuvers and valsalva voiding by the patient.
Conversely, the active MTrPs may stimulate and possibly
amplify visceral pain [16].
This complex interaction is thought to be responsible for
difficulties encountered when clinically assessing the site of
pain generators. It is not uncommon for a diagnosis of IC/BPS
to be made on the basis of “bladder symptoms” alone. The
patient fails bladder-based therapy, but symptoms resolve
when MTrPs are identified and therapy directed towards the
pelvic floor musculature is instituted. Furthermore, the pres-
ence of active MTrPs frequently worsens base-line symptoms
of the IC/BPS patient and a vicious cycle begins. In either
case, therapy applied towards HTPFD and amelioration of
MTrPs may be of clinical benefit and emphasizes the impor-
tance of a detailed history and physical examination.
Treatment of MTrPs
The local and/or referred symptoms associated with MTrPs can
be alleviated by various therapies aimed at directly treating the
active MTrPs, but will frequently recur within a few days to
weeks if perpetuating factors are not eliminated [17]. A latent
MTrP can be activated due to chronic muscle fatigue or
overuse, systemic disease, poor posture and body mechanics
or neuromuscular lesions (i.e. sprains, strains, arthritis, vertebral
disc lesions). Activation of a latent MTrP to an active MTrP can
be caused by central or peripheral sensitization; therefore, it has
been strongly recommended to treat both the active MTrP and
underlying etiological lesion [17–20].
Conservative treatments should be employed before more
aggressive therapies and are typically designed to relax the
pelvic floor and surrounding musculature. These may simul-
taneously include:
1. Behavior modification. This may include modalities such
as transvaginal or transrectal biofeedback, paradoxical re-
laxation, and the avoidance of valsalva/ Kegel maneuvers.
2. Aggressive control of constipation. Chronic constipation
is a common finding in patients presenting with chronic
pelvic pain secondary to pelvic floor hypertonicity. When
constipation is present, viscero-visceral convergence with
reference to bladder and bowel pathologies may worsen
both conditions. Both viscera are functionally tied to
pelvic floor activity.
3. Topical heat. As with most muscular “spasms,” topical
heat in the form of warm baths (two times per day>15-
minutes) may be helpful when used with other conserva-
tive strategies. Women are advised to use oatmeal bath,
i.e., Aveeno® to prevent vaginal dryness. In some
411
instances (particularly, for vulvodynia patients), cool
packs may afford better symptom relief.
4. Skeletal muscle relaxants. Low dose muscle relaxants
such as diazepam, cyclobenzaprine, methocarbamol, and
baclofen are all reasonable agents to use side by side with
other conservative therapies.
5. Physical Therapy
Stretching exercises and manual myofascial techniques
are the mainstay of MTrP therapy [21]. Learning tech-
niques of MTrP release empowers patients to effectively
manage their symptoms through a home program.
According to the AUA guidelines for the diagnosis and
management of IC/BPS, manual physical therapy by cli-
nicians appropriately-trained in treating high tone pelvic
floor dysfunction, as well as the avoidance of pelvic floor
strengthening exercises (i.e. Kegels), are recommended as
second-line treatment [10]. Oyama et al. [22] reported that
manual physical therapy helped relax the pelvic floor and
decrease pelvic pain in women with IC/BPS. Weiss [23]
evaluated the effectiveness of manual physical therapy to
the pelvic floor upon subjects with IC/BPS (n=10) and
urgency-frequency syndrome (n=42) one to two times a
week for 8–12 weeks. Thirty-five of 42 (83 %) of those
with urgency-frequency syndrome with or without pain
reported moderate to marked improvement to complete
resolution of symptoms, while 7/10 (70 %) of those with
IC/BPS had moderate to marked improvement of their
symptoms. FitzGerald et al. [24] conducted a multicenter
randomized controlled trial of 81 women with IC/BPS
and demonstrable pelvic floor tenderness. They were
placed into two treatment groups, myofascial physical
therapy (MPT) or global therapeutic massage, (GTM)
for ten treatments. Fifty-nine percent of those in the
MPT group reported moderate or marked improvement
compared to 26 % in the GTM group (p=0.0012). Fitz-
Gerald et al. [25] conducted a multicenter feasibility trial
of 48 subjects with CP/CPPS or IC/BPS (23 [49 %] men
and 24 [51 %] women). Once again, the subjects were
randomized to either the MPT or GTM group for ten
treatments and the global response assessment rate in the
MPT group (57 %) was significantly higher than the GTM
group (21 %) (p=0.03). Optimal education along with
home exercises should be given to patients to avoid a
recurrent injury [3, 7, 20].
Trigger Point Injections
Trigger point injections are typically used as adjuvant therapy
to pharmacotherapy, physical therapy and behavioral therapy.
Therefore, it is recommended they not be used as first-line
treatment, or as monotherapy for chronic pelvic pain. A myr-
iad of medications and techniques may be used for adminis-
tering MTrP injections. The most common are intramuscular
412
infiltration with a local anesthetic or botulinum toxin, or dry
needling.
Typical muscles injected include the iliococcygeus,
pubococcygeus and puborectalis (levator ani), coccygeus,
obturatur inturnus, and superficial and deep transverse
perineii. Identification and injection of extra-pelvic MTrPs
may also yield clinical improvement. Early studies have
shown efficacy in the use of trigger point injections into the
iliopsoas, hip adductors and rectus abdominus muscles for the
treatment of CPP [26, 27].
Contraindications to MTrP injections include local or sys-
temic infection, anticoagulation therapy, bleeding disorders,
allergy to anesthetic agents or botulinum toxin and acute
muscle trauma [1, 28]. Aspirin or nonsteroidal anti-
inflammatory drug use are not contraindications for these
procedures [29].
Dry Needling
Dry needling is an alternative method of MTrP therapy. An-
algesic effect is achieved when the most painful area of the
muscle is penetrated with a fine needle, preferably an acu-
puncture needle, using rapid in-and-out maneuvers [30].
Current literature evaluating the effectiveness and efficacy of
dry needling compared to infiltration of MTrPs with an anes-
thetic solution seems to illustrate it is the needle effect that is
more important than the substance injected [31]. Ay et al. [32]
conducted a randomized controlled trial (RCT) comparing
MTrP injections with 2 cc of 1 % lidocaine (n=40) with dry
needling for cervical pain (n=40). They evaluated patients’
pain, cervical range of motion, and depression pre-treatment,
and at 4 and 12 weeks after treatment. They found statistically
significant improvement in all parameters assessed in both
groups compared to pre-treatment (p<0.05); however, no sig-
nificant differences were found between the group treated with
MTrP lidocaine injection to the group treated with dry needling
(p>0.05).
Dry needling may have beneficial therapeutic effects at
sites distant from the active MTrP as demonstrated by Tsai
et al. [33]. Thirty-five patients with unilateral shoulder pain
caused by MTrPs in the upper trapezius were randomized: the
control group (n=18) received sham subcutaneous dry nee-
dling of the tissue over the MTrP of the extensor carpi radialis
longus, whereas the study group (n=17) received dry needling
directly into the MTrP of the same muscle. Pain and range of
motion parameters were measured before and after treatment.
The study group demonstrated statistically significant im-
provement in pain intensity, cervical spine range of motion,
and the mean pressure threshold for pain (P<0.05) compared
to the control group. The results of this and other similar
studies [34, 35] can be applied to the treatment to patients
with CPP who are too sensitive receive injection/needle ther-
apy in the primary area of their pain.
Curr Urol Rep (2013) 14:409–417
Dry needling has been associated with several ad-
verse effects including post-needling soreness, hemato-
ma, hemorrhage at the needling site and syncopal episodes
[36, 37]. Overall, however, dry needling is considered a
safe treatment when administered by adequately trained
practitioners [38].
Intramuscular Infiltration With A Local Anesthetic
There are few controlled studies on the use of MTrP injections
for pelvic pain; however, these injections are slowly becoming
a mainstay in the treatment of refractory myofascial pelvic
pain. Although the exact mechanism of action is still un-
known, several theories involved in the inactivation of active
MTrPs after injection with a local anesthetic have been pro-
posed: (1) mechanical disruption of muscle fibers and nerve
endings leading to depolarization of nerve endings; (2) inter-
ruption of the positive feedback loop that perpetuates pain; (3)
dilution of nociceptive substances by the infiltrated anesthetic;
(4) vasodilation effect of anesthetic to remove excess metab-
olites; (5) release of endorphins thereby decreasing pain
perception [30, 39] or (6) release of varied nociceptive/
inflammatory biochemicals (see Fig. 2). Infiltration of MTrPs
is preferable to dry needling due to the analgesic effects to the
tissue surrounding the MTrP. Hong [40] compared MTrP
injections with 0.5 % lidocaine to dry needling to the upper
trapezius muscle of 58 patients. Patients were divided into
four groups: group I: MTrP with 0.5 % lidocaine, +LTR
(n=26); group II: dry needling, +LTR (n=15); group Ia: MTrP
with 0.5 % lidocaine, no LTR (n=9); group IIa: dry needling,
no LTR (n=8). Within 2–8 hours post procedure, 42 % of
group I and 100 % of group II reported soreness different from
their original pain. Patients in group II had soreness of signif-
icantly greater intensity and longer duration post-procedure
than group I (P>0.05). Hong surmised that MTrP anesthetic
Fig. 2 Proposed mechanism of action of MTrP injection with a local
anesthetic. Insertion of the needle into the MTrP causes mechanical
disruption of muscle architecture and may result in the release of a variety
of nociceptive/inflammatory biochemicals. (IL-1beta = Interleukin-1beta;
CGRP = Calcitonin Gene-Related Peptide; TNF-alpha = Tumer Necrosis
Factor-alpha)
Curr Urol Rep (2013) 14:409–417
injections are preferable to reduce the intensity and duration of
post-injection soreness. Injections with a local anesthetic can
inactivate trigger points and provide immediate, symptomatic
pain relief that may last for a few hours to several weeks; albeit,
long-lasting relief can only be accomplished when mechanical
and systemic perpetuating factors are also corrected [41].
Techniques of MTrP Injection
Risks, benefits, and alternatives to treatment must be
explained thoroughly to the patient and full informed consent
must be obtained prior to the injections.
The patient is placed in lithotomy position and the area of
needle insertion is prepared with an antiseptic solution. A
thorough internal pelvic floor muscle exam (transrectal or
transvaginal) is done to elicit active MTrPs and identify the
areas to be injected. A 25-guage or 27-guage needle of the
appropriate length, 1.5-inch to 8-inch, is then guided into the
MTrP. The three basic approaches to MTrP injections are
vaginal, subgluteal, and perineal (Fig. 3). A simple “trajecto-
ry” when employing the subgluteal approach is a path inferior
and medial to the ischial tuberosities. In that fashion, the
perineal nerve can first be infiltrated, if desired. The subgluteal
approach relies upon correctly aiming the needle along a
relatively long path towards the palpating finger. A perineal
approach may be particularly useful for trigger points located
near the perineal body, transverse perineal muscles, or the
puborectalis muscle. The MTrP is first palpated, and the
needle is then directed through the perineum toward the MTrP.
When using a transvaginal approach, the use of an Iowa
trumpet may be helpful in preventing fingertip injury [39].
The authors don’t use this instrument, preferring to take
advantage of the easy manipulation that can be achieved with
these high gauge needles. When injecting transvaginally, one
palpates the MTrP and then guides the needle through the
Fig. 3 Common needle trajectories for pelvic floor muscle trigger point
injections in the female patient include transvaginal, transperineal and
paravaginal/subgluteal (medial to the ischial tuberosity). (Note: Circles
denote approximate point of cutaneous penetration)
413
vagina directly into the trigger point. One significant advan-
tage of the transvaginal approach is the close proximity of the
injection site to the trigger point. Additionally, this approach
allows easy access to more deeply seated muscle groups, i.e.,
obturator internus muscles. Often, when the needle is inserted
into the MTrP, a local twitch response (LTR) may be elicited
which the patient may feel at that site and/or at a referred
site(s). The syringe should be aspirated prior to the injection of
the local anesthetic to ensure the needle is not in a blood
vessel. The minimal amount of anesthetic needed should then
be injected into the MTrP, typically no more than 0.25–0.5 per
trigger point. Local anesthetics, particularly the longer acting
agents, are myotoxic/cardiotoxic. Thus, low concentrations
and volumes are used and have been found to be as effective
as higher dosing. The most common anesthetics employed for
injection are lidocaine 2 %, bupivacaine 0.5 %and ropivacaine
0.5 %. Epinephrine-containing local anesthetics are avoided
as these may result in local ischemia that, in turn, may poten-
tiate the formation of MTrPs [42]. Injection of steroids into
MTrPs are to be avoided due to their potential to cause muscle
dimpling and wasting with repeated use. Rarely, does one use
more than 7–10 cc of solution during one treatment session,
(approximately 3.5–5 cc total on each side of the pelvic floor).
The potential for systemic toxicity is low owing to low total
dose of anesthetic agent used. For example, the typical max-
imum dose of bupivacaine is 175 mg compared to the typical
maximum dose used in an injection of 25 mg (5 cc 0.5 %
bupivacaine). A common practice is dilute individual agents
with one another. We typically use a 1:1 solution of 0.5 %
bupivacaine and 2 % lidocaine for our injections (Table 1).
Although more expensive, ropivacaine has the advantage of
being a long acting local anesthetic, similar to bupivacaine,
but with fewer associated systemic adverse effects.
After the initial injection into the MTrP, withdraw the
needle from the trigger point but not completely out of the
Table 1 The typical maximum dose of bupivacaine is 175 mg, compared
to the typical 25 mg maximum dose of bupivacaine given in a myofascial
trigger point injection (MTrP) to the pelvic floor musculature
Comparision of Local Anesthetics
Agent Duration of Typical Max.
Clinical Effect Dose
Lidocaine 30-60 min. 300 mg
Bupivacaine 120-240 min. 175 mg
Ropivacaine 120-360 min. 200 mg
Typical TrP injection
5 cc 0.5% bupivacaine 25 mg bupivacaine
5 cc 2% lidocaine
Moldwin, RM and Fariello, JY (2013)
414
pelvic floor, allow the pain to subside, re-examine the muscles
for additional trigger points and muscle tenderness, redirect
the needle, and repeat the injection and infiltration process
until no further MTrPs are elicited. It is important to remember
to aspirate between needle position changes.
Stretching and/or Theile massage after MTrP injections is
suggested to improve clinical outcomes. These maneuvers may
be performed by the clinician, by patients trained in self therapy,
or physical therapists expert in this field. The anesthetic effect
of MTrP injections can mask discomfort caused by aggressive
internal manual release. Both patients and physical therapists
must, therefore, avoid exerting excessive pressure/stretching
immediately after these injections (Table 2).
Patient education prior to MTrP injections is imperative
and the patient must be fully counseled prior to the procedure.
Therapeutic impact may not be achieved after one injection; it
may take up to three injections to achieve the desired effect.
Patients should be made aware that initial increased pain at the
injection site immediately post-procedure may occur and may
last for up to 24–48 hours. Analgesics and ice may be helpful
during this time.
Side effects of MTrP injections may include infection,
hematoma, syncopal episode or intravascular injections [8,
Table 2 Suggestions for clinicians when administering MTrP injections
to the pelvic floor musculature
Tips for Anesthetic MTrP Injections
• Guide patients step by step through the process. Notify when needle
sticks or change in needle position are to occur, when injections are
to be administered, and when trigger points are to be palpated
• Inform patients that they will likely have a worsening of symptoms
12–24 hours after injections
• Have resuscitative equipment available
• Avoid epinephrine-containing anesthetics
• Avoid injection of steroids into MTrPs
• Inject into the MTrP or most painful area of the muscle
• Give small doses/volumes of anesthetic
• Allow pain to subside prior to proceeding to the next site
• Reassess for additional trigger points and muscle tenderness between
injections
• Aspirate before initial injection and between needle position changes
• Application of cold packs after procedure
• Avoid heat for the first 2 weeks after BTX-A injections
○ Very warm/hot baths and/or showers
○ Jacuzzis
○ Steam rooms
○ Saunas
• Post injection stretching, Theile massage, and/or myofascial release is
suggested, with careful attention to the amount of pressure exerted
• When using anesthetics, plan 2–3 injections 2–6 weeks apart to
determine clinical benefit
Cox B, Durieux ME, and Marcus MAE [53, 54]
Curr Urol Rep (2013) 14:409–417
42]. Intraneural injections with subsequent neural damage
are adverse effects that are extremely rare, ranging from a
1.5/10,000 incidence for major complications that result in
permanent nerve damage to an 8-10 % incidence of transient,
often subclinical, mild mononeuropathies. A recent study of
more than 7,000 nerve blocks showed that only three resulted
in injury related to the injection (0.04 % incidence). This rare
adverse effect is thought to be due to nerve trauma from the
needle, pre-existing pathology, anatomic considerations, ef-
fects of local ischemia and/or effects of preservatives [43].
Patients should also be made aware that while symptomatic
relief may be obtained by nerve blocks, rarely do they provide
a long-lasting “cure” (Table 3).
Botulinum Toxin Type A
Off-label use of onabotulinum toxin type A (Botox; Allergan,
Westport, Ireland) (BTX-A) has shown mixed results in the
treatment of myofascial pain. Most studies have been ham-
pered by small numbers of patients, heterogeneous patient
populations, varied and often low (sub-therapeutic) BTX-A
dosing used, and differing injection sites/techniques. MTrPs
of the pelvic floor presumably ameliorate pain by blocking
acetylcholine release at the neuromuscular junction, thereby
decreasing contraction strength and resting tone of the muscle.
Furthermore, recent studies suggest that BTX-A targets affer-
ent as well as efferent neural pathways [44, 45••, 46].
Table 3 Patients must consent and be fully educated regarding potential
complications of MTrP injection therapy
Complications of Anesthetic MTrP Injections
• Infection
• Hematoma
• Syncopal episode
• Intravascular injection (systemic toxicity)
• Intraneural injection (nerve damage)
Additional Complications of BTX-A MTrP Injections
• Spread of toxin effect weakening nearby muscles
• Allergic reaction
• Increased risk of clinically significant adverse effects from
therapeutic doses in patients with peripheral motor neuropathic
diseases, neuromusclular junction disorders or amyotophic lateral
sclerosis
• Aminoglycosides, anticholinergic agents, muscle relaxants, and other
agents that interfere with neuromuscular transmission should be
used with caution, as untoward adverse effects can be potentiated
with concomitant use of BTX-A
• BTX-A may not work immediately, patients may not see clinical
improvement for 1-3 weeks post-injection; similarly, adverse
effects may not be evident immediately and patients should be
aware they may develop while the BTX-A remains active
Moldwin, RM and Fariello, JY (2013)
Curr Urol Rep (2013) 14:409–417
A 2012 Cochrane review for BTX-A in the treatment of
myofascial pain syndromes extracted four articles, ultimately
stating inconclusive evidence to support the role of BTX-A in
the treatment of myofascial pain syndromes. Conversely, clin-
ical reports on BTX-A’s effectiveness on myofascial pelvic
pain syndromes has been relatively encouraging [47].
BTX-A first showed efficacy in the treatment of pain
associated with levator ani spasm in a study by Jarvis et al.
[48]. Twelve women received BTX-A injections bilaterally to
the pubococcygeus and puborectalis muscles. Patients report-
ed decreased pain and improved quality of life and sexual
functioning from baseline at 4 and 12 weeks post-injection.
This pilot study was followed with a randomized-placebo
controlled trial that randomized women into two groups:
group 1 received 80 U BTX-A into their pelvic floor muscles
(n=30), and group 2 received saline (n=30) [49••]. Pain was
assessed at baseline then monthly for 6 months via visual
analog scale (VAS) and pelvic floor pressures were measured
by vaginal manometry. The women who received BTX-A
reported a significant decrease in dyspareunia (P<0.001),
nonmenstrual pelvic pain (P=0.009) and pelvic floor pres-
sures (P<0.001). The placebo group reported a significant
decrease in dyspareunia (P=0.043), but no significant im-
provement in other parameters.
Gottsch et al. [50] examined the efficacy of BTX-A injec-
tions in men with CP/CPPS in a randomized placebo controlled
trial. Thirteen men received 100U BTX-A injections into the
perineal body and bulbospongiosus muscle and 16 men re-
ceived saline injections. Based on Global Response Assessment
results, at one-month follow-up, there was a 30 % response rate
(moderated or marked improvement) compared to 13 % in the
BTX-A and saline groups, respectively (p=0.0002). Further-
more, although no significant improvement in the total Chronic
Prostatis Symptom Index score occurred in the BTX-A treated
group compared to controls, the pain subdomain score did show
significant improvement in treated patients. Just as important,
no patient reported side effects such as urinary retention, urinary
or fecal incontinence, or systemic effects. These “modest”
effects without “cure” were not unexpected given the complex-
ity of pain, confounding factors (comorbid conditions, varied
emotional reserve, other regions of muscular dysfunction) and
the use of these injections as monotherapy.
The technique used for BTX-A MTrP into the pelvic floor
muscles is the same as that used for anesthetic MTrP injec-
tions. BTX-A should be given no sooner than every 3 months.
Repeat injections appear to be equally efficacious [51•]; how-
ever, use of high doses at frequent intervals may result in the
development of neutralizing antibodies, ultimately abolishing
its clinical effect.
As with anesthetic MTrP injections and dry needling, ad-
junctive stretching, physical therapy and myofascial release is
critical to maximize the benefits of BTX-A injections. The
goal is to strengthen supporting muscles and correct postural
415
asymmetry in order to enable pelvic stabilization. Neuromus-
cular re-education will aid in breaking the pain cycle [52].
Additional side effects of BTX-A MTrP injections are pain
at the injection site, malaise and flu-like symptoms [42]. BTX-
A spread well beyond the site of injection may occur and
produce various toxic effects, some of which can be life threat-
ening. To date, no reviewed studies concerning pelvic floor
injections have reported these effects. BTX-A is a labile protein
that breaks down in heat; therefore patients should be instructed
to avoid very warm/hot baths and/or showers, jacuzzis, steam
rooms and/or saunas for the first 2 weeks after injection. BTX-
A is should be used with caution in patients with a with
neuromuscular transmission disorders (i.e. myasthenia gravis)
and amyotrophic lateral sclerosis; those receiving aminoglyco-
sides, other agents interfering with neuromuscular transmis-
sion, muscle relaxants, or anticholinergic agents [46].
Conclusion
The identification of MTrPs of the pelvic floor and surround-
ing musculature is crucial to the care of the interstitial cystitis/
bladder pain syndrome patient and those with related disor-
ders. These regions may be primary or secondary sources of
pain and other symptoms. Conservative therapy of these con-
traction “knots” and the surrounding hypertonic musculature
is essential for optimal outcomes. Trigger point injections are
a more aggressive therapy that may yield impressive clinical
results and can be easily performed in the office setting.
Compliance with Ethics Guidelines
Conflict of Interest Dr. Robert M. Moldwin reported no potential
conflicts of interest relevant to this article.
Dr. Jennifer Yonaitis Fariello reported serving as a sub-investigator in an
institutional trial funded by Allergan, Inc: "A Pilot Study: Botulinum Toxin
Type A Injections into Pelvic Floor Muscles for Patients with Refractory
High Tone Pelvic Floor Dysfunction" (Whitmore KE, Kellogg-Spadt S,
Fariello JY, Iorio J, El-Khawand D, O'Hare P). Dr. Fariello did not receive
any financial compensation for involvement in this trial.
Human and Animal Rights and Informed Consent This article does
not contain any studies with human or animal subjects performed by any
of the authors.
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