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Int Urogynecol J (2014) 25:677–682
DOI 10.1007/s00192-013-2280-y
ORIGINAL ARTICLE
Does fibromyalgia influence symptoms bothering from pelvic
organ prolapse?
Kerrie Adams & Blake Osmundsen & W. Thomas Gregory
Received: 11 September 2013 /Accepted: 8 November 2013 /Published online: 6 December 2013
# The International Urogynecological Association 2013
Abstract
Introduction and hypothesis Determine if women with fibro-
myalgia report increased bother from pelvic organ prolapse
compared with women without fibromyalgia.
Methods We performed a cross-sectional study of women
with symptomatic prolapse on consultation with a private
urogynecology practice within a 46-month period. After
matching for age, women with a diagnosis of fibromyalgia
were compared with a reference group of women without
fibromyalgia. Demographic, POPQ examination, medical
history, and pelvic floor symptom data (PFDI, PFIQ, and
PISQ-12) were collected. Our primary outcome was to
compare the mean Pelvic Floor Distress Inventory (PFDI)
scores of women with and without fibromyalgia.
Results The prevalence of fibromyalgia in women evaluated
for initial urogynecology consultation during the study period
was 114 out of 1,113 (7%). Women with fibro-myalgia
reported significantly higher symptom bother scores related
to pelvic organ prolapse, defecatory dys-function, urinary
symptoms, and sexual function: PFDI (p =0.005), PFIQ (p
=0.010), and PISQ (p =0.018) . Women with fibromyalgia
were found to have a higher BMI (p=0.008) and were more
likely to report a history of sexual abuse, OR 3.1 (95% CI
1.3, 7.9), and have levator myalgia on examination, OR 3.8
(95% CI 1.5, 9.1). In a linear regression analysis, levator
myalgia was found to be the significant factor associated
with pelvic floor symptom bother.
K. Adams (*) : B. Osmundsen : WT Gregory
Oregon Health & Science University, Mail code: L466, 3181 SW
Sam Jackson Park Road, Portland, OR 97239-3098, USA
e-mail: kerrie.adams@med.navy.mil
WT Gregory e-
mail: gregoryt@ohsu.edu
Conclusions In women with symptomatic prolapse, fibro-
myalgia is associated with an increased risk of levator
myalgia and 50 % more symptoms bother from pelvic floor
disorders.
Keywords Central sensitization. Fibromyalgia. Levator
myalgia. Pelvic floor. Prolapse. Symptom bother
Introduction
Fibromyalgia is characterized by chronic widespread pain
and generally includes one or more concomitant symptoms
including fatigue, sleep disturbances, cognitive dysfunction,
anxiety and/or depression [1, 2]. Fibromyalgia is one of the
most common chronic widespread pain disorders in the
United States affecting more than 5 million Americans (2–
5% of the adult population), with a predisposition for women
[3, 4].
The most recognized pathological mechanism in
fibromyalgia is centrally mediated augmentation of pain and
sensory processes [5–7]. Individuals with fibromyalgia have
been found to increase levels of neurotransmitters, which
increase pain transmission in the spine and brain, as well
as low levels of inhibitory neurotransmitters, contributing to
deficient descending analgesia [8]. Patients with fibromyalgia
have been noted to exhibit heightened responses to sensory
input including heat, cold, electrical stimuli, and hypertonic
saline infusion [6, 7]. Previous studies have indicated that
women with fibromyalgia report increased bother from
lower uri-nary tract symptoms than women without
fibromyalgia [9]. Anecdotally, patients with fibromyalgia
have a height-ened degree of bother from prolapse that is
found to be objectively less pronounced on examination;
However, to our knowledge, this relationship has not been
evaluated before this study.
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The goal of this study is to compare the degree of bother
from pelvic organ prolapse in patients with and without
fibro-myalgia. We hypothesize that the diagnosis of
fibromyalgia might be associated with a greater degree of
bother from prolapse and other pelvic floor disorders.
Materials and methods
This is a retrospective cross-sectional study of patients
referred to a community-based Urogynecology practice
associated with a Female Pelvic Medicine and
Reconstructive Surgery (FPMRS) fellowship program.
These patients are referred to and evaluated by this practice
for various pelvic floor conditions including prolapse, urinary
incontinence, overactive bladder, recurrent cystitis, painful
bladder, and pelvic pain. This practice uses an IRB-approved
clinical data repository (Northwest Female Pelvic Medicine
clinical database IRB # 7247) from which the data for this
study were queried. The repository is used to track surgical
outcomes, patient demographics, and characteristics,
including pertinent urogynecology baseline characteristics,
examination findings, surgical complications, and validated
symptom bother measurements including the Pelvic Floor
Distress Inventory (PFDI), the Pelvic Floor Impact Question-
naire (PFIQ), and the Pelvic Organ Prolapse and
Incontinence Sexual Function Questionnaire (PISQ-12).
Medical history is routinely collected at each consultation
through a self-reported non-validated questionnaire tool.
The medical co-morbidities evaluated in our study are listed
as “boxes” or categories on the questionnaire (fibromyalgia,
hypertension, pelvic pain, etc.), and patients are asked to
self-report or self-identify a medical condition by choosing
from given categories or writing on a specific condition.
After IRB approval for this specific project (IRB #8221),
we queried our database for women presenting for initial
urogynecology consultation within a 46-month time period
(April 2008 to February 2012). Our study is focused on
women reporting symptoms of pelvic organ prolapse;
There-fore, we selected women who answered “yes” to “do
you usually have a bulge or something falling out that you
can see or feel in the vaginal area?” (question #3 on the
Pelvic Organ Prolapse Distress Inventory subscale of the
short version PFDI; Fig. 1). Patients without symptoms of a
vaginal bulge and incomplete symptom questionnaires were
excluded from the study.
Within the group of patients reporting a vaginal bulge on
initial consultation we identified women with a self-
reported diagnosis of fibromyalgia and a reference group of
women without fibromyalgia. From preliminary data we
found that women with fibromyalgia with symptoms of pelvic
organ prolapse were significantly younger than women
without fibromyalgia. Therefore, in order to correct
Int Urogynecol J (2014) 25:677–682
Initial consultation
Apr 2008-Feb 2012
n=1113
History of Fibromyalgia n=114
Symptomatic prolapse
Question#3 on the POPDI “Do
you usually have a bulge or something
falling out that you can see or feel in the vaginal area?”
Yes
n=417
Women with Women without
Fibromyalgia Fibromyalgia
n=43 n=86
Demographics
Exam findings
Symptom Scores
Fig. 1 Project scheme
for the difference in age amongst groups, subjects in the
reference group were age-matched within an interval of 5
years to the fibromyalgia group and chosen in a 2:1 ratio.
Demographic, POPQ examination, medical history, and
PFDI, PFIQ, and PISQ-12 scores were recorded within the
data repository at the time of consultation. It is standard of
care within our practice to assess symptom bother scores
at the time of initial consultation through the above-
mentioned questionnaires. In addition, levator myalgia and
vulvodynia are routinely assessed and documented during
initial examinations. Levator myalgia, or pelvic floor tension
myalgia, is characterized by a hypertonic and short-ened
pelvic floor with myofascial trigger points throughout the
musculature [10]. In our study, levator myalgia is defined as
any pain with light palpation of any of the pelvic floor muscle
groups (pubococcygeus, iliococcygeus, and obturator
internus) [11]. During light palpation, the patient was asked
if she felt pain. If pain was present from one or all muscle
groups, this response was categorized as levator myalgia
“present.” If no pain was elicited from any of the muscle
groups, this response was categorized as levator myalgia
“absent.” Vulvodynia is defined as pain with the light touch
of a cotton swab at any point along the distribution of the
vestibule or vulva; also recorded as “present” or “absent”
[12]. The objective measurement of prolapse in our study
was defined as the POPQ value (not including genital hiatus
[GH], perineal body [PB] or total
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Int Urogynecol J (2014) 25:677–682 679

vaginal length [TVL]) that was the largest, regardless of the
vaginal compartment contributing to the value.
The primary outcome of this study is to compare mean
PFDI scores in women with and without self-reported fibro-
myalgia in a population of women with symptomatic pro-lapse.
Secondary outcomes include comparing the leading
edge of the prolapse, the presence of levator myalgia and
vulvodynia on examination, and a self-reported history of
sexual abuse and depression.
In preparation for this project, we performed a preliminary
limited query of our entire repository. From that, we learned
that, in women with complaints of prolapse, who also reported
a diagnosis of fibromyalgia, 36 % of them had less than (but
not equal to) ICS stage 2 prolapse/support. In contrast, in
women with complaints of prolapse, but no fibromyalgia, only
9.5% had less than stage 2 support. Therefore, based on the
anticipated 25 % difference between the groups, we chose to
perform the most extensive analysis on 43 patients in the
fibromyalgia arm and 86 patients in the reference group
(80% power, alpha 0.05).
We used independent t tests for continuous variables and
Chi-squared analysis for categorical variables. Fisher's exact
test was used for categorical variables in which sample sizes
they were small. A multiple linear regression was performed to
investigate the relationship between symptom bother scores
and the leading edge of the prolapse, with significant variables
found in the univariate analysis.
Results
One thousand one hundred and thirteen patients were seen for
an initial urogynecology consultation during the 46-month
time period. One hundred and fourteen (7%) women reported
a diagnosis of fibromyalgia. Four hundred and seventeen
(37%) reported feeling or seeing a bulge at their initial
consultation. Of the women with symptomatic prolapse, 43
(10%) indicated a history of fibromyalgia. All 417 patients
were found to have past medical history information documented
at the time of consultation. Five patients (1.2) did not
complete the PFDI and were excluded from the study.
Mean BMI differed between groups: women with fibro-myalgia
had a larger mean BMI of 30.5 kg/m2 (SD 8.4) and
those without fibromyalgia 27.6 kg/m2 (SD 5.3; p =0.006;
Table 1). Consistent with the Pacific Northwest, the majority
of subjects were Caucasian/white and this was not different
between groups. Significantly more women with fibromyalgia
reported a history of sexual abuse OR 3.1 (95% CI 1.3, 7.9).
Our primary outcome of mean pelvic floor symptom
bother scores differed significantly between groups (Table 2).
Women with fibromyalgia reported approximately 50%
more pelvic floor symptoms bother and impact of quality
of life measured with validated pelvic floor questionnaires
(PFDI and PFIQ) compared with women without fibromyalgia.
Symptom scores in women with fibromyalgia were
significantly higher on all PFDI subscales evaluating urinary
symptoms (Urogenital Distress Inventory, UDI), defecatory
symptoms (Colorectal-Anal Distress Inventory, CRADI), and
prolapse symptoms (Pelvic Organ Prolapse Distress Inventory,
POPDI; Table 2). Women with fibromyalgia reported
lower mean PISQ score (sexual function) than women
without fibromyalgia (p=0.018).
Despite more symptoms bothering from prolapse, women with
fibromyalgia were found to have less objectively measured
pelvic descent on examination, with the leading edge of the
prolapse found to be +0.3 (SD 1.7) in women with fibromyalgia
and +0.9 (SD 1.8) in women without fibromyalgia
(p=0.045; Table 3). The presence of levator myalgia differed
between groups: 36% of women with fibromyalgia were
found to have levator myalgia compared with 13 % of women
without fibromyalgia, OR 3.7 (95% CI 1.5, 9.1). six women
with fibromyalgia and 3 women without fibromyalgia did

Table 1 Demographics
Demographics Patients with Patients without p value OR (95% CI)
fibromyalgia (n =43) fibromyalgia (n =86)

Age 58 (12.7) 58 (12.7) .981

parity 2.3 (1.5) 2.5 (1.2) 0.52

BMI 30.5 (8.4) 27.1 (5.3) 0.008

Ethnicity
Caucasian 41 (95) 81 (94) 0.989
Other 2 (5) 4 (6)
Menopausal 27 (66) 52 (66) .139 1.21 (0.53, 2.75)
HRT 14 (38) 15 (19) 0.024 2.68 (1.12, 6.39)
Sexually active 15 (35) 51 (60) 0.035 0.44 (0.20, 0.95)
History of sexual abuse 13 (38) 13 (16) 0.010 3.12 (1.29, 7.87)
to
Values represented as mean History of depression 20 (46) 29 (34) 0.173 1.68 (0.79, 3.55)
(SD), number (%)
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680 Int Urogynecol J (2014) 25:677–682

Table 2 Pelvic floor symptom bother scores Discussion

Symptomsa Patients with Patients without p value Adjusted

fibromyalgia fibromyalgia pvalue* In this study, 7% of women referred to a urogynecology
(n =43) (n =86) practice reported a diagnosis of fibromyalgia. When
accounting for co-morbidities associated with fibromyalgia,
Total PFDI 145.0 (63.3) 37.9 110.5 (64.5) 0.005 0.080
we learn that the presence of levator myalgia contributes
CRADI (22.6) 55.4 28.5 (2.9) 0.019
significantly to pelvic floor symptom bother and sexual
UDI (29.1) 51.6 38.9 (30.1) <0.001
function. Our data suggest that women with fibromyalgia
POPDI (26.9) 104.8 42.4 (23.1) 0.028
report increased bother from prolapse and pelvic floor
PFIQ (83.7) 22.52 63.1 (71.3) 0.010 0.280
disorders not exclusively because of a diagnosis of fibro-
PISQ (10.5) 27.61 (7.5) 0.018 0.062
myalgia, but because of the co-occurring condition of
PFDI Pelvic Floor Distress Inventory, CRADI Colorectal-Anal Distress
levator myalgia. Although our data did not support our
Inventory, UDI Urogenital Distress Inventory, POPDI Pelvic Organ hypothesis that the diagnosis of fibromyalgia influences
Prolapse Distress Inventory, PFIQ Pelvic Floor Impact Questionnaire, pelvic floor symptom bother, our findings are clinically
PISQ Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire
relevant. Levator myalgia is a prevalent condition within a
*Adjusted for BMI, depression, leading edge of POPQ, and levator urogynecology practice, and is reported to be 24 % of a
myalgia
to
referral population [11]. Similar to our study with fibro-myalgia,
Values represented as mean (SD)
women with levator myalgia report elevated
bother from pelvic floor disorders compared with women
do not have documented levator muscle examinations. muscle without painful pelvic floor musculature [11]. Understand-ing
strength measured on the Brinks scale and the presence of that women with fibromyalgia are at risk of levator
vulvodynia did not differ between groups. myalgia, and therefore, at risk of elevated bother from
In previous studies, women with levator myalgia and women pelvic floor disorders will facilitate awareness and adequate
with depression were noted to report higher symptoms bothering treatment of pelvic floor disorders in this population
from pelvic floor disorders [11, 13]. We sought to understand of women.
the effect of depression and levator myalgia on the relationship Fibromyalgia is associated with several painful conditions,
between fibromyalgia and pelvic floor symptom bother. We including painful bladder syndrome, dysmenorrhea,
performed a limited manual entry linear regression using PFDI, vulvodynia, irritable bowel syndrome, and migraine head-aches
PFIQ, and PSIQ as the dependent variables in three separate [14]. The concept of central sensitization has been
models, and the leading edge of the POP, depression, diagnosis introduced as a common pathological pathway for these co-
of fibromyalgia, BMI, and the presence of levator myalgia occurring syndromes. Central sensitization occurs when
as independent variables. The PFDI model is shown in chronic noxious stimuli in the peripheral nervous system lead
Table 4; the remaining symptom score models are not to an up-regulation of central pain pathways [14]. Up-regulated
shown, but are similar in construction and results. In our pain pathways lead to “wind up” or a progressive
regression model, pelvic floor symptom bother is significantly increase in overall pain perception. Levator myalgia may be
related to fibromyalgia until the presence of levator considered another manifestation of central sensitization, not
myalgia is added into the model. The relationship between only when considering symptoms of pain, but as this study
levator myalgia and symptom bother is nearly twice that of suggests, from symptoms of pelvic pressure, vaginal bulge,
fibromyalgia and depression and symptoms bother. In our and urinary and defecatory dysfunction.
population of women with symptomatic prolapse, levator Previous studies have demonstrated that the degree of
myalgia also had more of an influence on symptoms bothering bother of a “vaginal bulge” or prolapse significantly increases
than objective examination findings or POPQ examination. when the prolapse is at or beyond the hymen (0 on the POPQ

Table 3 Physical examination

Physical examination Patients with Patients without p value OR (95% CI)
fibromyalgia (n =43) fibromyalgia (n =86)

Leading edge of the prolapse 0.26 (1.7) 0.95 (1.8) 0.045

(POPQ)
Brinks score 9.0 (1.9) 8.9 (1.9) 0.92

At or beyond the hymen 28 (65) 64 (75) 0.23 0.61 (0.28, 1.36)

Presence of LM 15 (36) 11 (13) 0.003 3.74 (1.53, 9.14)
to
Values represented as mean Vulvodynia 15 (35) 25 (30) 0.53 1.29 (0.59, 2.81)
(SD), number (%)
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Int Urogynecol J (2014) 25:677–682 681

Table 4 Regression analysis

model Coefficients p value 95.0 % confidence interval for B
PFDI (R2 =0.18)

b standard error Lower bound Upper bound

1 (Constant) 113,305 7,124 0.000 99,194 127,416

Fibromyalgia 37,083 12,500 0.004 12,324 61,843

2 (Constant) 76,448 25,538 0.003 25,858 127,039

Fibromyalgia 32,195 12,851 0.014 6,738 57,653

BMI 1,361 .906 0.136 –0.434 3,157
3 (Constant) 72,394 25,373 0.005 22,126 122,661

Fibromyalgia 29,753 12,789 0.022 4,417 55,090

BMI 1,234 0.900 0.173 –0.549 3,016

depression 21,992 11,977 0.069 ÿ1,736 45,720

4 (Constant) 76,809 25,605 0.003 26,076 127,543

Fibromyalgia 28,064 12,847 0.031 2,609 53,519

BMI 1,257 0.898 0.164 ÿ0.523 3,037

Depression 18,169 12,389 0.145 ÿ6,378 42,716

Leading edge POPQ ÿ3.898 (Constant) 3,309 0.241 ÿ10,454 2,659

5 73,415 24,962 0.004 23,951 122,879

Fibromyalgia 22,409 12,686 0.080 ÿ2,728 47,547

BMI 1,037 0.879 0.240 –0.704 2,778

Depression 22,752 12,183 0.064 ÿ1,390 46,894

Leading edge POPQ ÿ1.608 Levator 3,334 0.631 ÿ8,213 4,998

myalgia 40,098 14,995 0.009 10,385 69,811

examination) [13]. Surgical therapy for prolapse is generally
considered after conservative management has failed and
when the degree of bother or symptoms of the prolapse are
perceived to be greater than the risks of surgery. Owing to
Increased bother, women with levator myalgia and fibromy-
algia may prefer treatment for prolapse at a stage of decent
that would typically be considered less significant. In fact,
our data demonstrate that if a patient carries a diagnosis of
fibromyalgia, 35% of women reporting a bulge will have
a leading edge of prolapse within the hymen. Available
surgical options may not improve the bulge sensation in
these patients and may lead to a mismatch between patient
and physician expectations. The patient with fibromyalgia
and levator myalgia may anticipate unattainable results
from prolapse interventions if her levator myalgia is left
undiagnosed or untreated.
To our knowledge, this study is the first to address the
impact of fibromyalgia on symptoms bothering from pelvic organ
prolapse. Its strengths include the use of a reference group
without fibromyalgia and the use of validated questionnaires
to quantify symptoms bother. Limitations of the study lie
within the observational and retrospective design and the
samplesize; larger prospective studies are needed to further
understand the true relationship among fibromyalgia, levator
myalgia, and pelvic floor disorders. Our study is limited based
on its reliance on a self-reported diagnosis of fibromyalgia.
Without a standardized diagnosis criterion for inclusion into
the fibromyalgia group, the fibromyalgia patient population
may be mis-represented. Furthermore, this study does not
address the severity of fibromyalgia symptoms and its impact
on pelvic floor disorders.
Our study has shown that fibromyalgia is a prevalent
condition within a urogynecology patient population with
clinical relevance regarding pelvic floor disorders. Addressing
fibromyalgia symptoms and levator myalgia within an uro-
gynecology practice is important and worthwhile. Fibromyalgia
is a chronic condition in which patient education is
paramount in treatment success. Drugs such as pregablin,
gabapentin, and fluoxetine are FDA approved for use in
fibromyalgia. In addition, exercise and cognitive behavioral
therapy have been proven to be effective in reducing pain
in patients with fibromyalgia [5]. Treatment of levator
myalgia with myofascial physical therapy has been shown
to be effective [15, 16]. Typical myofascial physical therapy
includes weekly hour-long visits involving tissue manipulation
of connective tissue abnormalities and myofascial trigger
points in the abdominal wall, thighs, and back, as well as
internal palpation through the vagina. Recommending treatment-
ment for fibromyalgia and levator myalgia is relatively un-
complicated and may prove advantageous prior to invasive
treatment of pelvic floor disorders.
Conflicts of interest None.
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682
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