Curr Urol Rep (2013) 14:409–417 DOI 10.1007/s11934-013-0360-7
LOWER URINARY TRACT SYMPTOMS AND VOIDING DYSFUNCTION (G BADLANI AND H GOLDMAN, SECTION EDITORS)
Myofascial Trigger Points of the Pelvic Floor: Associations with Urological Pain Syndromes and Treatment Strategies Including Injection Therapy Robert M. Moldwin & Jennifer Yonaitis Fariello
Published online: 14 August 2013 # Springer Science+Business Media New York 2013
Abstract Myofascial trigger points (MTrP), or muscle “contraction knots,” of the pelvic floor may be identified in as many as 85 % of patients suffering from urological, colorectal and gynecological pelvic pain syndromes; and can be responsible for some, if not all, symptoms related to these syndromes. Identification and conservative treatment of MTrPs in these populations has often been associated with impressive clinical improvements. In refractory cases, more “aggressive” therapy with varied trigger point needling techniques, including dry needling, anesthetic injections, or onabotulinumtoxinA injections, may be used, in combination with conservative therapies.
gynecological, and colorectal pain syndromes. These regions may enhance the pain of the initial pathology or be the primary pain generator. Symptoms produced by these regions may extend beyond pain, adversely affecting voiding, bowel, and sexual function. Identification of MTrPs and therapeutic intervention is, therefore, essential for optimal patient care. First-line therapies applied include behavioral modification, topical heat/cold, muscle relaxants, and physical therapy. This article will focus upon more aggressive intervention with needling techniques, including trigger point injections of MTrPs, which can easily be incorporated into urological practice.
Keywords Myofascial pain . Trigger points . Pelvic pain . Pelvic floor dysfunction . Interstitial cystitis Characteristics of Trigger Points “Untying a complex knot requires patience, persistence, and experience.”
Introduction Myofascial trigger points (MTrPs) of the pelvic floor and adjacent musculature are frequently identified, along with “high-tone” pelvic floor dysfunction (HTPFD), in urological,
Myofascial trigger points (MTrPs) are tender “knots” in taut muscle bands that produce pain. The pain may be local and/or referred; and a “twitch response” is elicited when these regions are palpated [1, 2]. MTrPs can be active or latent, the main differentiating characteristic being whether or not they are the cause of clinically significant pain [2]. MTrPs of the pelvic floor are almost invariably accompanied by “hightone” pelvic floor muscular dysfunction (HTPDF).
Neurophysiology of Trigger Point Pain R. M. Moldwin (*) Hofstra North Shore-LIJ School of Medicine, Pelvic Pain Treatment Center, The Arthur Smith Institute for Urology, North Shore-LIJ Healthcare System, 450 Lakeville Road, Suite M41, New Hyde Park, NY 11040, USA e-mail:
[email protected] J. Y. Fariello Female & Male Pelvic and Sexual Medicine, The Pelvic and Sexual Health Institute, 207 N. Broad Street, 4th Floor, Philadelphia, PA 19107, USA e-mail:
[email protected]
The pain associated with MTrPs may be attributed to high local concentrations of inflammatory mediators, neuropeptides and neurotransmitters. The stimulation of local nociceptors elicits the local and referred pain of MTrPs [3]. A study by Shah et al. [4] examined the biochemical milieu of muscle in three subject groups: normal (no pain, no MTrP, n=3); latent (no pain, MTrP present, n=3); active (pain, MTrP present, n=3). A microdialysis needle was inserted into the upper trapezius muscle, where it was then advanced to elicit a
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local twitch response (LTR) in the active and latent groups. The LTR was confirmed by surface electromyography. Overall, the amounts of bradykinin, CGRP, substance P, TNF-α, IL-β, serotonin and norepinephrine were significantly higher in the active group than in the latent and normal groups (P
