Myofascial pelvic pain syndrome in females: Treatment

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©2022 UpToDate®

Myofascial pelvic pain syndrome in females: Treatment

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

Contributor Disclosures

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Mar 2022. | This topic last updated: Apr 22, 2022.

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 "Clinical manifestations and diagnosis of myofascial pelvic pain syndrome in

women".)

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Myofascial pelvic pain syndrome in females: Treatment
● (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 [1,2]. MPPS is
thought to originate at the trigger point [3]. 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 "Clinical manifestations and diagnosis of myofascial pelvic pain syndrome in
women" and "Clinical manifestations and diagnosis of myofascial pelvic pain syndrome in
women", 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
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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

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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
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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:

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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 [4].

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 [5]. 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

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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
[5]. 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) [6]. 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 [7]. 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 [8]. 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) [9]. 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 [10]. 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 [6,11]. 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 [12]. 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 [13].

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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 [14]. 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 [15,16], 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 [17,18]. Data regarding benefit in
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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 [19]. Two small trials reported that gabapentin improved
pain scores [20,21]. For now, its use represents off-label use [17,22]. 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 [23,24]. 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 as much as 50
to 100 mg 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.

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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 [25]. 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".)

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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 [26]. 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

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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 between treatment with vaginal diazepam or placebo [27-30].
In our experience, some patients respond well to vaginal diazepam while others see little or
no benefit.

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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 [28,31]. Vaginal diazepam 5 to 10 mg can be used up to three times daily.

Antimuscarinics — Antimuscarinics can help relieve symptoms of urinary urgency,

frequency, and urgency incontinence that can accompany MPPS but do not directly treat pain.
We prescribe antimuscarinics for women with severe irritative voiding problems that disrupt
daily activities or sleep. Antimuscarinics can provide some symptom control prior to a course
of physical therapy. In our experience, once patients have started to respond to pelvic floor
physical therapy, they do not always need to continue these drugs. If patients do not respond
to these medications, they can be discontinued.

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 [32-36]. 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
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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 [37,38]. 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 [39]. Both lidocaine patch and TPI were
effective in reducing pain compared with placebo. In our practice, we occasionally use
lidocaine patches for women who have pain that is localized to areas on the abdomen, low
back, or hips. The woman 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 [40]. 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 [41]. However, an earlier systematic review of
acupuncture for chronic pelvic pain showed no benefit [42]. More and better trials of
acupuncture are needed. Our limited experience with acupuncture is that it can help improve
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coping and decrease pain perception, at least temporarily. A detailed overview of this
technique can be found separately. (See "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 [43,44]. 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 [45]. 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 [46-50].

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
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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 [51]. 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 [10,52]. 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 [5]. 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

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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 [53-62]. 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 [61-63]. 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 [54]. 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 [55]. 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 [56-60],
with some studies using up to 300 units of BTXA injected into multiple sites in the pelvic
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floor [61-63]. 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 [64].
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 [65].

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 [66-69]. BTXA
can directly block cholinergic neuromuscular transmission and interrupt the cascade of
events that lead to hyperalgesia and allodynia [70,71]. 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 [72]. (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 [65]. 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
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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 [73]. 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

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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 [74-77]. 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
manifestations, course, 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
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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 [78].

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) [5]. 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 [78]. 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
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chronic pain and may exacerbate pain [79]. This association has even been noted in
adolescents [80]. 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 [81]. 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. 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 women", section on
'Diagnostic approach'.)

SOCIETY GUIDELINE LINKS

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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

● Myofascial pelvic pain syndrome (MPPS) is a non-articular musculoskeletal pain disorder

characterized by contracted bands of skeletal muscle that 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.)

● 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.)

● 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. Trial and error with different treatment modalities is often needed to
achieve symptom improvement.

• For women with MPPS, we suggest initial treatment with PFPT (Grade 2C). The initial
evaluation and treatment with PFPT and medical treatment typically requires three to
four months, after which the patient is reassessed. (See 'Pelvic floor physical therapy'
above.)

• For women who are unable to immediately attend PFPT, typically because of severe
pain prohibiting PFPT or for logistic reasons, we suggest trigger point injections (TPI)

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(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.)

• 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.)

• 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.)

• 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.)

• 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.)

● Cognitive behavioral therapy (CBT) is one of the most commonly used and studied
psychological interventions for pain, including vulvar and sexual pain [74-77]. 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.)

● Women with MPPS often develop symptom recurrence months or even years after
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symptoms have quieted. Despite efforts to avoid known triggers, symptom flares can
develop. (See 'Treatment of flares' above.)

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