article about pelvic floor myalgia

[Guest guest]

Is pelvic floor myalgia causing your patient's dyspareunia? Proper evaluation

of a key

muscle group can identify pelvic floor myalgia—an often unsuspected but highly

treatable

cause of insertional dyspareunia and pelvic pain. An expert tells how to proceed

with

diagnosis and treatment.

Publish date: Oct 1, 2005

By: T. Jensen, MD, MPH

Sexual pain disorders among women are important, widespread, but poorly

understood.

Sexual dysfunction affects nearly half (43%) of all American women, according to

an

analysis of data from a 1992 study of sexual behavior. Lack of desire and pain

were cited

most often in this study (the National Health and Social Life Survey).1 Backing

up these

findings, a recent large population-based survey in New England showed that

15.7% of

women had vulvodynia, and several studies have described the widely diverse ways

in

which women with vulvar pain manifest that pain.2-4

As you probably know only too well, providing comprehensive care to women

complaining

of sexual pain is challenging for most busy ob/gyns because most managed

care-oriented

schedules don't leave you enough time for a detailed evaluation and sensitive

discussion.

A classification system based upon a careful and orderly evaluation of these

complaints

provides a framework for treatment and research. Even though idiopathic

localized

(vestibulodynia, or vulvar vestibulitis syndrome) and generalized (dysesthetic

vulvodynia)

vulvodynia make up the bulk of vulvar pain disorders, you must also carefully

evaluate and

discern symptoms that result from anatomic variations, dermatologic conditions,

Bartholin

gland disorders, infectious diseases, and pelvic floor myalgia.4

The problem of superficial dyspareunia appears to come up frequently when women

consult an ob/gyn for unrelated matters. For example, a general ob/gyn practice

in

Portland, Ore., found that vestibular pain occurred in 15% of patients over a

6-month

period, while a more recent prospective observational study of 400 women from

West

Hertfordshire, UK, found that the prevalence of vestibulitis varied from 2.9% to

9.8%,

depending on how stringent the diagnostic criteria and the method of

ascertaining pain

were.5,6 However, since vulvar vestibulitis is defined by two physical signs

(localized

erythema and point tenderness) and one symptom (pain with vaginal entry), it is

unclear

how many of the women in these studies were functionally impacted by insertional

pain.

Investigators still don't completely understand the relationship between

vestibular pain

and entry dyspareunia.

Myofascial pain or vaginismus is defined as myalgia of the levator ani muscle

group

(pubococcygeus, iliococcygeus, and coccygeus). Women having this cause of

vulvodynia

present with increased pelvic floor muscle tone and tenderness. They often

complain of

dyspareunia with difficult vaginal penetration or deep burning pain of the

pelvis or vagina.

While their muscle pain can be isolated, it can also coexist with other vulvar

pain

conditions. At our university referral practice, about half of all new patients

with

vestibulodynia whom we evaluate also have co-existing vaginismus.4

Pelvic floor (levator) myalgia is an important and frequently unrecognized

condition. But

the good news is that it's highly treatable. My goal here is to assist

clinicians evaluating

women with insertional dyspareunia, pelvic pain—or both—in the proper evaluation

of the

pelvic floor muscles and to review treatment options.

Figure 1. Muscles of the urogenital diaphragm (from perineum) Illustration:

Amy /

Art & Science, Inc.

Two layers of muscles exist: the superficial urogenital diaphragm

(bulbocarvernosis,

iliocarvernosis, and transverses perinea) shown in Figure 1 and the deep levator

ani

(pubococcygeus, iliococcygeus, and coccygeus) muscles seen in Figure 2. While

the

urogenital diaphragm group rarely presents in pain syndromes, the structure and

function

of the levator ani are more complicated. In quadrupeds, the levator ani group is

the tail-

wagging muscles (more about that later). In bipedal mammals, however, the

levator ani

group provides support to pelvic and intra-abdominal organs to accommodate the

challenges of gravity in an upright posture. That's why humans and other apes

don't have

tails.

igure 2. Muscles of the pelvic floor : Levator ani group muscles viewed from

the

perineum. Illustration: Amy /Art & Science, Inc.

The thin skeletal muscles of the levator ani group function much like the

diaphragm in

that both are under voluntary and involuntary control. Voluntary control of the

muscles

permits control of bladder and bowel function (or insertional sex) at socially

acceptable

moments. On the other hand, involuntary—or automatic—activation of these muscles

occurs when intra-abdominal pressure increases (standing, coughing, bouncing,

etc.) or in

response to anxiety or stress. Gynecologists recognize the role of the pelvic

floor muscles

primarily when dysfunction leads to urinary and fecal incontinence. Weakness or

damage

to the muscles can occur due to nerve injury or rupture during vaginal delivery.

Since

these skeletal muscles are under voluntary control, conditioning regimens (Kegel

exercises) can strengthen weak muscles and restore function.

Not surprisingly, the levator ani group can undergo pain processes common in

other

muscle groups, including hypertonus, myalgia, overuse, and fatigue. Pathologic

hypertonus and myalgia are often a late development in an insidious chronic

process of

progressive dysfunction. More than 25 years ago, Lamont presented a model that

describes the development of vaginismus (Figure 3).7 A variety of events (poor

lubrication,

anxiety, a vulvar dermatosis, infection) might initiate sexual pain. This leads

to anxiety

with the next attempt at insertional sex. If pain occurs with this encounter,

the cycle is

reinforced. Reflex muscle tightening occurs, leading to overuse strain, the

buildup of lactic

acid, and pain. Considering that these muscles represent the tail-waggers, it's

tempting to

speculate on their connection to our limbic (emotional) cortex. Just as a

Labrador retriever

wags her tail when she is happy, and pulls her tail between her legs when

stressed, these

emotive muscles undergo reflex contraction in response to a stressful situation.

In a

sexual situation the result of this anticipatory contraction may be painful

insertion, or

vaginismus.

Often, by the time a patient walks into your office, the originating factor that

kicked off the

cycle of pain may no longer exist, leaving an isolated case of levator myalgia.

Frequently,

however, vestibulodynia (vulvar vestibulitis) does exist. Whether the levator

myalgia

resulted from—or is the actual cause of—the localized vulvodynia becomes a

" chicken or

the egg " conundrum. In most cases, both conditions warrant treatment.

Clinical evaluation of the pelvic floor muscles

Fgure 4. Q-tip test : A cotton-tipped applicator is used to assess for

localized vulvodynia.

Illustration: DeNapoli

Figure 4. Q-tip test : A cotton-tipped applicator is used to assess for

localized vulvodynia.

Illustration: DeNapoli

To evaluate a woman for the presence of pelvic floor myalgia, you must first

identify and

control any focal vestibular tenderness using the " Q-tip " test (Figure 4).

Expose the vulvar

vestibule and use a small cotton-tipped applicator to assess for focal

tenderness. If

surface pain is identified, you can eliminate it with topical 4% aqueous

lidocaine. We use

large swabs to liberally apply the liquid to the tender areas. Although liquid

lidocaine will

not absorb well through the keratinized tissue of the labia majora or perineum,

the thin,

nonkeratinized epithelium of the vestibule will quickly accept the local

anesthetic. In a

busy practice, consider treating the entire vulvar vestibule using several

lidocaine-soaked

swabs or a saturated gauze sponge. Leave the lidocaine in place while you see

another

patient during the 3 to 5 minutes required to produce adequate surface

analgesia. Then

re-examine the vestibule with the cotton swab, and touch up any areas that

remain

painful.

Figure 5. Performing a pelvic exam : To examine the pelvic floor, insert a

single index

finger of the right hand through the vaginal introitus. Illustration: Amy

/Art &

Science, Inc.

Once the surface pain is under control, you can evaluate the pelvic floor

(Figure 5). Like

any physical exam skill, proficiency at pelvic floor examination takes practice.

I

recommend practicing the exam on normal healthy women during routine annual

exams

to help you understand the typical range of normal pelvic floor tone and muscle

control.

To examine the pelvic floor, insert a single index finger of the right hand

through the

vaginal introitus. With your palm down, the band-like thickness of the right

pubococcygeus should be readily discernable at about 8 o'clock. Palpate the

entire muscle

from its origin on the pubis to the insertion on the coccyx. With practice, the

discrete

bands of the iliococcygeus and coccygeus muscles are palpable dorsocaudally

above the

pubococcygeus as you insert your finger further into the vagina. It may help you

to think

three-dimensionally during the exam by recalling that the iliococcygeus

originates on the

arcuate tendon (white line) of the pelvis overlying the obturator internus, and

the

coccygeus inserts on the ischial spine, a common obstetric landmark. I pronate

my right

hand further to examine the muscles of the left side. If you're left-handed, you

may wish

to perform the exam in a mirror-image fashion, starting with the left pelvic

sidewall.

Palpate and assess the pubococcygeus, iliococcygeus, and coccygeus on both the

right

and left sides for tone and tenderness from origin to insertion at rest and

during an active

contraction. Ordinarily, palpation of these muscles should be pain-free, both in

the

relaxed state and during an active contraction. To isolate the levator muscles

in a

contraction and avoid contractions of the buttocks, I ask patients to " tighten

the muscles

you would use to stop the flow of urine. " Often, a patient is unable to

voluntarily contract

and relax the pelvic floor muscles. In extreme cases, significant hypertonus and

myalgia

may prohibit internal examination even with a single finger.

Over the years I have evaluated several women who paradoxically would relax

muscles

when they tried to contract them—and vice versa (tightened muscles when

instructed to

relax). As you might expect, during an intimate encounter, this reverse

signaling could

result in vaginismus and painful penetration. Treatment is the same as with

hypertonus.

By supinating the examining hand, it is also possible, with practice, to

recognize and

palpate the right obturator internus. The left is more difficult for a

right-handed ob/gyn,

but can be assessed through either extreme pronation or supination. You can

activate the

obturator internus—a muscle frequently involved in chronic pelvic pain

complaints—by

asking a patient to abduct and internally rotate the ipsilateral leg against

light pressure.

Dorsocaudal to the coccygeus, the pyriformis may be palpable to an experienced

examiner

with long fingers.

Treating pelvic floor myalgia

Physical therapy is the recommended treatment for vaginismus. The challenge for

many

practices is finding a physical therapist with the necessary experience and

sensitivity to

approach these patients. However, in recent years, more and more physical

therapists have

become trained and gained expertise in managing pelvic floor complaints by

treating

incontinent patients. The American Physical Therapy Association has a special

interest

section for Women's Health and maintains a Web site (http://

www.womenshealthapta.org/) with resources and training for members, as well as a

list of

providers. Membership in this organization is a good way to determine whether

your

therapist is up-to-date with the skills needed to evaluate and treat these

patients. The

same techniques used to evaluate and strengthen pelvic floor muscles using

biofeedback

techniques are useful in treating hypertonus and vaginismus.

Because vulvar vestibulitis often co-exists with vaginismus, most research

efforts have

evaluated these conditions together. In one prospective study, 22 of 28 subjects

with

vulvar vestibulitis who were followed for 6 months responded well to physical

therapy and

electromyographic biofeedback.8 In a randomized trial of treatment options for

vulvar

vestibulitis, another researcher saw pain significantly diminish among women

treated with

physical therapy.9,10 In addition, a case series of 14 women with vulvar

vestibulitis found

better success rates with vestibulectomy among women with vaginismus who had

been

treated preoperatively with physical therapy.11

Vaginal dilators are an alternative approach, particularly when access to a

skilled physical

therapist is limited. Made of silicone or plastic and available in a variety of

sizes (Figure 6),

they enable a woman to gain confidence, knowledge, and awareness of her vagina

and

pelvic floor muscles in the privacy of her own home. I often introduce the

concept of

dilators by stressing their inert, emotionless status as a desirable

characteristic. In

contrast to an encounter with a sexual partner, dilators should trigger neither

disappointment nor resentment. The goal of vaginal dilator therapy is strictly

clinical; to

discover what triggers the pelvic floor muscles to contract and to develop

strategies to

keep the pelvic floor relaxed and soft. With increased knowledge about her

body's

response, the woman becomes able to gently introduce dilators of progressively

larger

sizes into the vagina. With this knowledge and confidence, the insertion of

dilators

becomes comfortable and routine, and that skill is then transferred to her

sexual activities.

When vaginal dilators are combined with psychosexual counseling, success rates

exceed

97%.12 Less is known about the success of vaginal dilator therapy when an

experienced,

supportive sexual therapist is not available to assist in managing this

condition. In that

event, wait to prescribe this therapy until after you've taken extra time to

review the

correct technique for a patient's home use of vaginal dilators. To reinforce the

concept of

relaxation, we use an instruction sheet and audiotape. The tape is available for

purchase

through the program in Vulvar Health of the Center for Women's Health at OHSU

[http://

www.ohsuhealth.com/cwh/services/vulvar_health.htm] (see " Instructions for

at-home

dilator therapy for vaginismus " ). Finding a good sexual therapist can be tricky.

Consult

with colleagues to explore resources in your own community. Although both the

American

Association of Sex Educators, Counselors, and Therapists

(http://www.aasect.org/) and

The American Board of Sexology (http://www.sexologist.org/) maintain Web sites,

not all

qualified therapists belong to these organizations. You should meet with or call

any

therapist whom you have not used before to discuss treatment goals and approach

to

care.

A novel—and off-label—approach involves botulinum toxin type A (BOTOX) to

selectively

reduce muscle tension.13,14 Although the preliminary data from small case series

are

encouraging, long-term effects and the possibility that overtreatment could

cause pelvic

organ prolapse or incontinence should limit the use of BOTOX for pelvic floor

myalgia to

clinical trials.

The treatment of women with sexual pain disorders represents one of the most

rewarding

aspects of gynecologic care. Restoring sexual function improves quality of life

and fosters

long-term stable relationships. A careful office evaluation of the pelvic floor

can identify

pelvic floor myalgia, a highly treatable cause of dyspareunia.