Version July 2025
INTRODUCTION —
Pelvic floor physical therapy describes a variety of treatments utilized by physical therapists with advanced training to manage pelvic floor dysfunction. Pelvic floor dysfunction is a global term describing conditions such as pelvic organ prolapse, fecal or urinary incontinence, overactive bladder wet or dry, lower urinary tract symptoms (LUTS), and chronic pelvic pain, including myofascial pelvic pain. Myofascial pelvic pain syndrome is a pain disorder the pelvic floor musculature, connective tissue of the pelvis, and the associated fascia. Pain symptoms are attributed to short, tight, tender pelvic floor muscles, which may contain myofascial trigger points.
This topic provides an overview of the conceptual framework from which pelvic floor physical therapists approach the myofascial component of pelvic pain syndromes. It is intended to inform clinicians who refer patients for this intervention. Related content on clinical manifestations, diagnosis, and treatment approaches are presented separately.
●(See "Myofascial pelvic pain syndrome in females: Clinical manifestations and diagnosis".)
●(See "Myofascial pelvic pain syndrome in females: Treatment".)
In this topic, when discussing study results, we will use the terms "woman/en" or "patient(s)" as they are used in the studies presented. We encourage the reader to consider the specific counseling and treatment needs of transgender and gender-expansive individuals.
ETIOLOGY OF MYOFASCIAL PELVIC PAIN —
Patients with myofascial pain syndrome often describe their muscles as having increased fatiguability, stiffness, a sense of perceived weakness, pain with movement, and/or limited range of motion. In response, the individual tends to want to protect the involved muscle groups, which may result in the development of poor postures and patterns of persistent guarding contraction [1]. These changes and imbalances can then result in myofascial pelvic pain as well as myofascial trigger points within local muscles of the pelvis or distant muscles that refer to the pelvis.
●Possible etiology – Viscerosomatic convergence explains how persistent noxious visceral input can establish a sensitized spinal segment producing areas of allodynia, hyperalgesia, and referred pain with associated somatic dysfunction [2]. (See "Myofascial pelvic pain syndrome in females: Clinical manifestations and diagnosis", section on 'Pathogenesis'.)
●Associated symptoms and conditions – Myofascial pelvic pain is frequently associated with other chronic pain conditions such as interstitial cystitis/bladder pain syndrome, endometriosis, dysmenorrhea, migraine, and complex regional pain syndrome [3-9]. It has also been associated with such pelvic floor disorders as urinary incontinence, lower urinary tract symptoms, defecatory dysfunction and pelvic organ prolapse [10-12]. Constipation, or rectal evacuation disorder (RED), is strongly associated with myofascial pelvic pain and can be the primary factor in the etiology of the patient's constipation [13].
REFERRAL TO PHYSICAL THERAPY —
Clinicians can contact the American Physical Therapy Association for a listing of physical therapists in their area that specialize in the management of pelvic floor dysfunction. The clinician and physical therapist should have a good working relationship so that the physical therapist can communicate with the clinician when medical support is required to facilitate treatment, such as with injections or needling procedures.
PATIENT EVALUATION
Components of examination — Three major areas included in a physical therapy evaluation are the musculoskeletal system, pelvic floor muscles, and pelvic soft tissue. Several groups have developed standardized, reproducible screening examinations for assessment of pelvic floor myofascial pain [14,15].
●Musculoskeletal system – The musculoskeletal evaluation includes assessment of posture, gait, range of motion of the spine and extremities, length and strength relationship of relevant muscles, and documentation of pain distribution. Specific muscles are assessed for myofascial trigger points, and the patient is assessed for postural disorders. Compared with control women without pelvic pain, women with perineal pelvic pain have been reported to have more postural abnormalities, including thoraco-lumbar hinge syndrome, pelvic instability, pelvic-pedal quadrilateral dysfunction, and paravertebral muscle hypertonia [16]. It is not known if the postural abnormalities result from the pelvic pain syndrome or contribute to it. A retrospective case-control study reported a higher incidence of generalized hypermobility spectrum disorder in a chronic myofascial pelvic pain population [17]. Reis et al have reported a characteristic altered posture of increased anterior pelvic tilt and a posterior displacement of the body in women with urinary incontinence and myofascial dysfunction of the pelvic floor muscles [18].
●Pelvic floor muscles – The pelvic floor musculature is evaluated by inserting one or two fingers into the vagina or rectum and palpating the pelvic muscles. An instrumented evaluation of the pelvic floor, such as surface electromyography, pressure biofeedback, or a force-sensing resistor referred to as an algometer, may be utilized to obtain additional objective information about strength and/or tension/stiffness [15]. In a systematic review performed by Kapurubandara et al, it was determined that a standardized physical vaginal assessment to evaluate pelvic floor myofascial dysfunction provides good inter- and intrarater reliability and is the preferred evaluation tool until new research proves otherwise [19]. (See 'Abdominal and pelvic musculature' below.)
●Soft tissue – The soft tissue evaluation involves manually assessing areas of connective tissue for trophic changes and restrictions, muscles and other tissues for myofascial trigger points, and neural tissue for irritability and mobility. In the Multidisciplinary Approach to the Study of Chronic Pelvic Research Network Epidemiology and Phenotyping (MAPP) study, both men and women with urologic pelvic pain syndromes were more likely than comparator patients with fibromyalgia and healthy control patients to have tenderness of the pelvis (perineal body, levator ani, obturator internus, perineal muscles, and pelvic organs on bimanual examination), bony pelvis (symphysis pubis, posterior iliac spine, and coccyx), and extra pelvic regional tenderness (abdomen, flank, and back) [14].
Pain mapping diagrams — Working with the patient to create a pain map is a useful tool for locating trigger points (see 'Trigger points' below). The patient is asked to draw the locations of her pain on a body diagram. In addition, the character of the pain and other symptoms should be noted using colors or symbols (eg, red or B for burning pain, blue or I for itching, green or A for aching) (figure 1). Severity of pain is noted using a scale of 0 (no pain) to 10 (excruciating pain). The clinician can use the same type of diagram to document her/his objective findings of trophic changes, connective tissue restrictions, tenderness, scar tissue and trigger points. This form becomes a permanent part of the medical record and serves as a valuable tool for documenting changes and evaluating progress.
Posture — Poor posture can lead to excessive strain on muscles and other soft tissues that can predispose the individual to injury and pain. Chronic poor posturing can lead to stretch weakness of muscles and supporting connective tissues, adaptive shortening of muscle and connective tissue structures, and the development of trigger points [1]. Altered neural dynamics may develop as a result of stretch and/or compression of neural tissue in association with pain. Postural dysfunction or movement imbalance can also result from abnormal mechanical tensions (imbalances) in muscles and their related fascia, which can create trigger points and their associated pain [20]. In either case, the postural strain must be identified and resolved.
Postural assessment is both dynamic and static. Examples include:
●Static evaluation – Static posture evaluation might reveal common structural inadequacies, such as leg length discrepancies or shortened muscle groups that maintain poor alignment of body structures. Excessive lumbar spine lordosis with an anterior pelvic tilt has been labeled the "typical pelvic pain posture" [21]. Patients with pelvic floor myofascial dysfunction have an increased anterior pelvic tilt and a posterior displacement of the body as a whole [18].
•From a side-standing view, are the ear, shoulder, hip, knee, and ankle on the same vertical line?
•On frontal and back standing views, are the head and spine held straight and the arms equidistant from the waist?
•Are the shoulders, hips, and knees at the same height? Does the upper or lower back curve excessively?
•Do both kneecaps face straight ahead?
●Dynamic evaluation – For the dynamic assessment, the patient is observed walking, moving from sit to stand, and ascending and descending stairs. These activities are evaluated to observe dynamic postural adaptations that might be related to pain with movement.
Range of motion — The purpose of range of motion assessment is to determine whether there is any specific joint structure dysfunction. Evaluation includes both osteokinematic movements (eg, extension, flexion, adduction, abduction, or rotation of bones at joints) and arthrokinematic movements (ie, small gliding, rolling, or spinning movements occurring between joint surfaces).
In patients with myofascial pelvic pain, the trunk and lower extremity joints should be evaluated with special attention to the lumbopelvic complex, including the sacrococcygeal joint, symphysis pubis, and hip joints. Muscle length is evaluated simultaneously with range of motion testing, which can be done both actively and passively. Adaptive muscle shortening is one source of decreased range of motion, but trigger points will also limit range of motion of a muscle through inhibition.
Health care practitioners, when evaluating patients with a suspected myofascial pelvic pain syndrome, should query the patient about joint hypermobility [17]. The use of a five-part questionnaire, followed by a Beighton scale for those who screen positive, is suggested in the evaluation process [22,23]. This information will allow for an individualized management of the patient that has myofascial pelvic pain associated with a diagnosis of generalized hypermobility spectrum disorder.
Abdominal and pelvic musculature — All muscles that directly relate to the pelvis (28 muscles have direct attachments to the pelvis) and those that refer to the pelvis should be evaluated, with special attention to the abdominal musculature because of its intimate relationship with pelvic floor function. Although coactivation of the abdominal and pelvic muscles is usually normal and advantageous, abnormally overactive or irritated abdominal wall musculature from trigger points such as surgical scars can provoke chronically active pelvic floor musculature [24]. The abdominal wall should also be evaluated for a diastasis of the rectus abdominus muscles. (See "Rectus abdominis diastasis".)
To assess the pelvic floor muscles, one or two of the examiner's fingers are inserted into the vagina/rectum and brought laterally as they palpate the tissue from the posterior midline to the lateral pelvic side walls and then anteriorly. When the pelvic floor is short and tight, there may be difficulty in admitting the lubricated examining fingers into the vagina, even with full patient cooperation. After entering the vagina/rectum, the examining finger is palpating for taut bands, scar tissue, and assessing the mobility of the vagina/rectum on the underlying pelvic floor. Tight pelvic floor muscles form bulky, firm shelves of muscle, often with multiple taut bands that feel like "violin strings," which may have trigger points. Pressure onto the most tender area of these bands is usually painful, often with radiation of pain into the lower abdomen or hip, vagina/rectum, bladder, or urethra. This may elicit the patient's pain, especially when the active trigger point is provoked.
Since muscle dysfunction can occur on either end of the length-tension curve of muscle function (the muscle is either too long or too short), it is important to determine where in the contraction-relaxation cycle a problem is occurring before initiating a treatment protocol. To do this, the manual pelvic floor examination is divided into two components: dynamic and passive.
The dynamic aspect is the digital palpation of the pelvic floor musculature during an active concentric contraction. Is the patient able to isolate and actively perform a shortening contraction of the levator ani? If so, what is the strength, range of motion, and quality of the contraction? Differences between the two sides should also be noted. The strength can be described by using a manual muscle test scale such as the Brink scale, which is a four-point scale in three categories: contraction pressure, vertical displacement of the examiner's fingers, and duration of the squeeze [25]. The quality of the contraction can be described as smooth, jerky, or cog wheel recruitment of muscle fibers. The range of motion refers to the amount of movement noted during a shortening and lengthening contraction of the pelvic floor.
After the shortening contraction, patients are asked to relax the concentric contraction and whether or not they feel the post-shortening contraction muscle relaxation ("can you feel your muscles letting go?"). The range of motion, speed, and quality of the post-shortening contraction relaxation should also be noted. Is the post-shortening contraction relaxation equal to the shortening contraction? Assessing the eccentric (lengthening) contraction dynamically is done by asking the patient to drop or let the pelvic floor go, as if initiating urination; no shortening contraction is executed with this activity. A Valsalva maneuver, straining, or pushing is not acceptable. Assessing post-lengthening contraction relaxation is done passively by digital palpation of the soft tissue structures during the return to the resting position. Again, the patient is questioned as to her awareness of the motion. A thorough soft tissue evaluation includes methodical palpation of the soft tissues, muscles for trigger points, neural irritability, and palpation of connective tissue for restrictions and scars. Palpation normally produces a sensation of pressure; pain upon digital palpation and/or passive movement of the soft tissues is abnormal.
If available, a biofeedback instrument can be used to supplement this evaluation. Options include surface electromyography or measurement of pressure with transvaginal or transrectal probes. There are no standards for either of these forms of assessment, but the information gained helps to objectively monitor the patient's progress once treatment has been initiated.
Soft tissue assessment — Evaluation of a patient with myofascial pelvic pain syndrome includes a comprehensive palpatory soft tissue assessment of connective tissues of the abdominal wall, inguinal ligaments, suprapubic area, lower back, buttocks, vulva, and lower extremities. Changes in skin color, contour, temperature, elasticity, turgor, and bulk should be noted. A reddish-brown discoloration of the skin can occur in the viscera-somatic areas of referral secondary to the trophic changes associated with the reflex vasoconstriction as well as with prolonged mechanical compression of the microvasculature. Bright red skin flares, known as dermographia, can occur with the palpation of the abnormal area.
Soft tissue palpation is performed with a light and a deep touch. Use of a small amount of massage cream facilitates this examination. The clinician uses a light touch to make a tactile assessment of the quality of the skin and its ability to move, as well as its texture, temperature, and turgor. Reflex vasoconstriction in the referral zones for myofascial trigger points and visceral pathology can create sensitization causing significant pain even with light touch. The skin and soft tissue, including any scars, are also rolled between the examining fingers to assess the mobility between layers.
The deeper subcutaneous and muscular tissues are palpated to assess tension/stiffness, irritability, consistency, viscoelastic properties, shear (ie, the assessment of movement between tissue layers), and fluid content. Any textural changes in the fascial layers should also be noted. The soft tissue layers should be fluid, moving freely with other subcutaneous tissues. Connective tissue restrictions (ie, thickening and resistance to pulling, stretching, shearing and skin rolling), also known as subcutaneous panniculosis, develop in the subcutaneous tissues of the referral zones associated with visceral pain and myofascial trigger points. Trophic changes (eg, tissue changes as a result of the interruption of nutrition) in the somatic area of referred pain of a visceral nature or trigger point occur as a result of reflex induced vasoconstriction. Descriptive words, such as compressible-rigid, rough-smooth, and circumscribed-diffuse, are used to document the changes noted in the tissues.
Examination of tissues with significant restrictions causes sharp/ripping/tearing pain despite relatively mild manual pressure [24]. Palpation of a small tender mass (like a wad of chewing gum) within the subcutaneous tissue may produce pain [24]. The location of scar tissue is documented and the scar is assessed for mobility and the production of pain, local or referred.
Trigger points — Trigger points are described as localized painful regions within muscle resulting from maintained contractions of localized sarcomeres. These localized areas can develop as a result of acute overload to the muscle, direct muscle trauma, repetitive overuse of muscle, psychological stress, and visceral disorders [26]. Trigger points can produce pain in referral zones when palpated. Muscles containing trigger points are usually short, weak, fatigue easily, and relax slowly [24]. Trigger points can be found in skin, scar tissue, fascia and ligaments throughout the pelvic floor.
●Criteria – Proposed minimal criteria for the diagnosis of a myofascial trigger point include a hypersensitive area or nodule in a taut band of muscle along with either referred pain, a local twitch response, and/or restricted range of motion and pain during contraction [27].
●Identification based on symptom location – Muscles directly related to, or that refer to, the pelvis are assessed for trigger points. Trigger points within the muscles of the pelvic floor, hip girdle, and abdominal wall produce symptoms that range from vague suprapubic or pelvic discomfort to severe pain. Trigger points within the adductor magnus can refer pain into the central pelvis while a trigger point in the levator ani may refer pain to the vagina. Trigger points in the urogenital diaphragm may refer to the bladder or urethra.
●Possible etiology – The physiology of trigger-point formation has been an ongoing topic of discussion for years. One proposal is that "the failure of protective feedback mechanisms results in a cascade of events following intensive, acute, events, such as trauma, or following chronic, repetitive, fatiguing muscle activity" [28]. This theory provides a possible explanation as to how trigger points are created in myofascial pelvic pain. Specifically, the normal feedback mechanisms that protect muscles during chronic, repetitive, and/or fatiguing muscle activity do not function normally, and result in trigger points.
●Associated symptoms – Through a somatovisceral reflex, myofascial trigger points can imitate visceral pain and symptoms, such as lower urinary tract symptoms, and could even prompt visceral pathology [26,29]. A visceral disease process such as endometriosis can activate myofascial trigger points in the somatic referral zone associated with the organ, a viscerosomatic reflex [7]. Pain and other symptoms could persist after the visceral condition has been resolved. Another example would be the continued lower urinary tract symptoms after an acute bacterial cystitis has been resolved with antibiotics.
To locate a trigger point, the clinician palpates perpendicular to the fiber orientation of the muscle being assessed. When a taut band is felt, the palpating finger is turned to become parallel to the direction of the muscle fibers and used to find the most painful spot within the taut band. Ideally, when the clinician locates the trigger point, a local twitch response is produced in addition to reproduction of the patient's pain.
Peripheral nerves — The specific nerves that should be evaluated are the pudendal and the posterior femoral cutaneous nerves. The connective tissues innervated by these nerves may be the most likely source of symptoms [30]. In the setting of minimal inflammation, pain tends to develop as a result of ischemia. Connective tissue changes resulting from ischemia can cause restrictive processes that may then lead to painful abnormal impulse generating sites. As an example, the cutaneous referral zone for the bladder is the entire saddle area of the lower trunk [31]. When connective tissue changes are present because of the visceral reference to the skin, mechanical compression of the microvasculature by the elastic bands of undergarments at the thigh crease or excessive uninterrupted sitting can cause an ischemic compromise to branches of the posterior femoral cutaneous nerve and result in pain. This must be considered when patients have a diagnosis of a vulvar pain syndrome or when there is a complaint of pain in sitting in the saddle area or with complaints of "sits bone pain" (ischial tuberosities).
Clinical assessment is accomplished by manually assessing the mobility of the nerve in its anatomical distribution. The pudendal nerve is most easily palpated internally at the ischial spine as it enters Alcock's canal. Some discomfort is normal, but a lowered threshold of pain may indicate that there is some compromise to the nerve's mobility. This could be due to a nerve entrapment or may be related to ischemia of the connective tissue that surrounds it. Irritability of a nerve may also be assessed by distraction of the tissue with active contraction of the related musculature.
With the patient in a prone position, distraction of the posterior thigh crease (the normal anatomical path of the perineal branch of the posterior femoral cutaneous nerve on its way to the perineal tissues) away from the body followed by asking the patient to actively simultaneously knee flex and hip extend will assess the ability of the nerve to move. The nervous system should have pain-free mobility 20 percent further than at its resting state [30].
REHABILITATION
General approach — A comprehensive treatment program of muscle, joint and myofascial techniques should be individualized to address the specific dysfunctions noted during the patient evaluation. Important components of treatment are instruction in a home exercise program and self-management techniques. In addition, cognitive behavioral therapy is important to change the conditioned responses that may have developed as a result of the chronic pain state.
An individualized therapeutic exercise program is required to address any structural dysfunctions. Treatment sessions typically are one hour on a weekly basis. Re-evaluation is done after 10 treatments to determine if progress has been sufficient for physical therapy to continue [32]. The total duration of treatment often depends on how long the patient has been symptomatic; some patients require a year or more of weekly therapy.
Initial treatment can be painful; the pace of treatment should be adjusted to the tolerance of the patient. Patients who are very symptomatic may have more frequent treatments, and patients who travel from far away for treatment can undergo daily treatments of two hours, for a week at a time, if tolerable. Trigger point injections and/or dry needling may be useful to facilitate the resolution of the trigger point. Treatment plans also typically include pain neuroscience education, manual therapy, and a progressive therapeutic exercise program [33].
Components of treatment include:
●Myofascial manipulation including manual trigger point release, injections and dry needling
●Neural mobilization and stretching
●Rehabilitation of extrapelvic musculoskeletal abnormalities: neuromuscular reeducation and active/passive stretching
●Connective tissue manipulation
●Scar tissue mobilization
●Transvaginal/transrectal manual therapy
●Pelvic floor muscle reeducation
Extrapelvic musculoskeletal abnormalities are addressed using standard physical therapy and orthopedic rehabilitation techniques.
During rehabilitation, it is important to avoid activities that are known to exacerbate the patient's condition, such as Kegel exercises, vaginal coitus, prolonged sitting and wearing underwear with elastic around the legs or tight jeans. If a significant diastasis recti is present (eg, more than 3 cm above the umbilicus and more than a few millimeters apart below the umbilicus [24]), it should be corrected with a progressive abdominal strengthening program. A compromised abdominal wall will not react reflexively as it should, thus limiting the ability of strengthening exercises to maximize pelvic floor muscle function [34].
Procedures — Myofascial manipulation, trigger point release techniques, connective tissue manipulation and neural mobilization and stretching of the extra-pelvic structures are done first in a prone position and then in supine. During a treatment session, the patient lies in a hook-lying position (supine with the hips and knees bent) as the physical therapist works internally to manually release the trigger points and the restricted movement of the connective tissues and muscles associated with the vagina, and/or the rectum. First, short muscle groups in the pelvis or elsewhere are lengthened using soft tissue techniques and passive and active exercises. After the muscles have lengthened, strengthening exercises can be initiated.
Manual joint mobilization techniques are utilized to treat arthrokinematic limitations of specific joints. Areas of structural hypomobility are mobilized while areas of hypermobility are stabilized through exercise and external supports. These interventions should facilitate normalization of osteokinematic movement of the joint.
Myofascial/connective tissue manipulation — Connective tissue restrictions associated with the viscero-somatic/somato-visceral reflex and trigger points are treated with connective tissue manipulation. This is a superficial form of myofascial manipulation that utilizes pulling strokes on the skin and subcutaneous tissues to achieve reflex and local effects. This manipulation results in improved circulation to viscera, supporting tissues, muscles and nerves. All connective tissue from the nipple line to the lower leg, anterior and posterior, is treated. These manual techniques can be combined with dry needling release connective tissue restrictions.
In a prospective study of 39 women with chronic pelvic pain who received either myofascial physical therapy or routine care, the myofascial pelvic therapy group had improved pain intensity and sensitivity as well as reported anatomic, neurophysiologic, and psychological therapeutic effects [35]. Other studies have reported this treatment is associated with reductions in pain, improvements in anxiety and depression, and improved quality of life and sexual function [36,37].
Release of scars — Abdominal and perineal scars with any connective tissue restriction require release. Manual methods for softening and release of scars includes strumming across and stroking along the scar, as well as rolling the scar between fingers and thumbs and adding distraction when possible [32]. Dry needling and local anesthetic injections are also used to facilitate scar tissue mobilization [38]. The scar should be manually manipulated until it is fluid in its movement over underlying tissues.
Treatment of trigger points
Transvaginal release techniques — Trigger points are treated with transvaginal manual release techniques alone or in combination with injections or dry needling. If injections or dry needling are used, they are administered just prior to manual therapy performed by the physical therapist [32]. (See 'Trigger point injections' below.)
●Manual barrier release – Barrier release is the preferred method for manual trigger point pressure release. Initially, progressive pressure is applied into the trigger point until tissue resistance (barrier) is noted and the patient is uncomfortable; the pressure is maintained until the barrier releases. Pressure is increased again until a new tissue barrier is felt. This technique can be enhanced by combining it with other techniques, such as contract/relax, postisometric relaxation, and reciprocal inhibition.
●Additional techniques – In the contract/relax technique, the patient is asked to isotonically contract the levator against the resistance of the therapist's finger; elongation of the muscle is enhanced by the therapist as the patient relaxes the muscle [32]. For postisometric relaxation, the levator ani is contracted isometrically against the resistance of the transvaginal/rectal finger; this finger then assists with the lengthening process during complete voluntary relaxation. Reciprocal inhibition is the relaxation of an agonist muscle during contraction of the antagonistic muscle. Asking the patient to inhale while the pelvic floor trigger point is being manually treated is also a form of reciprocal inhibition that can facilitate its release.
Trigger point injections — Trigger point injections are commonly used as an adjunct to physical therapy for patients with myofascial pelvic pain. Commonly used agents are local anesthetic combined with glucocorticoids or botulinum toxin. In a multicenter trial that treated 80 individuals with either combined botulinum toxin and local anesthetic injections or local anesthetic injections alone, both groups reported similar improvements the Patient Global Impression of Improvement (PGI-I) scores at 60 days [39].
Detailed discussion of trigger point injections, agents, and outcomes data are available in related content. (See "Myofascial pelvic pain syndrome in females: Treatment", section on 'Injections'.)
Dry needling — Trigger point dry needling or injections may decrease the excitability of the central nervous system by reducing the peripheral nociception from the trigger point, reducing dorsal horn activity, and regulating brainstem areas [33]. Dry needling has also been reported to decrease the noxious substances present near an active trigger point, thereby decreasing the role these substances may have in the perpetuation of the trigger point [40].
Exercise — An individualized therapeutic exercise program is designed to treat the specific muscle groups involved and address any other musculoskeletal dysfunctions.
●Stretching exercises – After treating myofascial trigger points with the procedures above, therapy continues by putting the muscle through its full available pain-free range of motion. An individualized home exercise program is designed for each patient to utilize the changes made during therapy and to facilitate greater changes during the next therapy session.
•Abdominal wall – Stretching exercises are the mainstay of an exercise program for abdominal wall muscles with acute trigger points. After the trigger points are resolved, progressive abdominal strengthening is started.
•Pelvic floor – After pelvic floor treatment, next steps may include reflex pelvic floor inhibition that progresses to active pelvic floor lengthening and, ultimately, patient-performed myofascial and connective tissue manipulation. In a trial of 68 patients with myofascial pelvic pain with trigger points comparing self-myofascial release combined plus biofeedback and electrical stimulation with biofeedback and electrical stimulation alone, combined treatment resulted in reduced pain intensity and degree of activation of the trigger points in the levator ani and obturator internus, but not the piriformis and coccygeus, at 12 weeks from treatment [41].
●Strength and aerobic exercise – Once the pelvic floor is lengthened, a comprehensive strengthening exercise program may be developed. Family members or significant others may be taught to do some of the myofascial and connective tissue manipulation techniques. One observational study reported that movement-based physical therapy reduced patients' lower urinary tract symptoms [42].
Manual treatment of myofascial and connective tissue attempts to reverse the neural reflex that has caused the vasoconstriction in the muscle, connective, or visceral tissues. Patients are advised to do at least 30 minutes of fast walking daily. If the vasoconstriction in the lower quadrant is reflexively being reversed, any form of aerobic activity will increase the vascularization in the area based on supply and demand properties of the body. Supporting data come from a trial comparing water exercise versus usual care for women with myofascial pain after mastectomy for breast cancer; women who performed the low-intensity water exercises reported reduced shoulder, neck, and axillary pain as well as fewer trigger points [43].
Ineffective treatments — Small trials of vaginal cryotherapy and radiofrequency modulation have reported pain reduction similar to that of the control treatments. In a trial including 163 patients comparing vagina cryotherapy with a room-temperature control, both treatments reduced pain but the difference between the two was not significant [44]. In a different trial that evaluated the effectiveness of six sessions of novel radiofrequency modulation with ten sessions of multimodal physical therapy (manual therapy, biofeedback, and transcutaneous electrical stimulation), both treatments similarly reduced myofascial pelvic pain symptoms, although the radiofrequency therapy required fewer treatments [45].
TREATMENT OF SYMPTOM FLARE —
Patients experiencing a symptom flare may describe pain that hurts much more than baseline but does not progress further. In our practice, we repeat the conservative treatment that initially provided benefit and include/add trigger point injections if the patient does not respond as expected. Injections should be considered earlier rather than later. We start with manual therapy and local anesthetic injections and proceed to botulinum if the trigger point is recalcitrant to the first injections.
OUTCOME —
Given that the resolution of the patient's symptoms is the expected outcome of physical therapy, the clinician should expect positive changes within 10 visits. The therapist reevaluates the patient every 10 visits to assess progress and determine if therapy should continue. When the progress is not as expected, the physical therapist and clinician should collectively analyze the treatment approach.
The physical therapist's approach to the evaluation and treatment of chronic pelvic pain has not been evaluated rigorously. Retrospective observational studies on the management of myofascial pelvic pain syndrome with manual techniques report that 50 to 72 percent of patients describe moderate to marked improvement or complete resolution in symptoms [46,47]. Data from two randomized trials support manual myofascial physical therapy for the treatment of chronic pelvic pain with urologic symptoms. Both trials found that the positive responder rate was significantly higher with manual myofascial physical therapy compared with therapeutic massage (57 versus 21 percent in one trial) [48]. The pilot study that included men and women had a 57 percent positive responder rate for the physical therapy treatment group, while the therapeutic massage treatment arm’s positive responder rate was only 21 percent. Study subjects of the second larger trial were women who had a 59 percent positive responder rate [49]. In a prospective cohort study of women with myofascial pelvic floor disorders, with urinary urgency and frequency-predominant symptoms, nearly 63 percent reported a positive response to treatment with pelvic floor physical therapy [50]. More trials of the diagnostic and therapeutic approach to these patients are needed.
FOLLOW-UP —
The next steps are based on the patient's response to treatment.
●Significant improvement or symptom resolution – Patients whose symptoms improve are educated about activities to avoid and stretches to do if any latent trigger points become active again or if a painful pelvic stimulus occurs (eg, urinary tract infection) in order to avoid relapsing into a protective guarding pattern that may have been instrumental in causing the problem. For example, an activity to avoid would be straining with voiding or repeated contractions of the pelvic floor at the end of voiding to "squeeze out" all they can, or the systemic guarding with any painful condition, which will reflexively recruit the pelvic floor.
●No or limited improvement – Patients who do not respond to pelvic floor physical therapy after 8 to 10 weeks should be reevaluated, possibly with additional testing or radiographic imaging [32]. For example, patients with associated urologic symptoms and very little improvement after 10 treatments may be evaluated with cystoscopy or magnetic resonance imaging to rule out a urethral diverticulum (see "Urethral diverticulum in females"). Patients with underlying skeletal abnormalities may benefit from osteopathic manipulation.
SOCIETY GUIDELINE LINKS —
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".)
INFORMATION FOR PATIENTS —
UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topic (see "Patient education: Vaginismus (The Basics)")
SUMMARY AND RECOMMENDATIONS
●Description – Pelvic floor physical therapy describes a variety of treatments utilized by physical therapists with advanced training to manage pelvic floor dysfunction. Pelvic floor dysfunction is a global term describing conditions such as pelvic organ prolapse; fecal or urinary incontinence; overactive bladder wet or dry; lower urinary tract symptoms (LUTS); and chronic pelvic pain, including myofascial pelvic pain. Myofascial pelvic pain syndrome is a pain disorder of the pelvic floor musculature, connective tissue of the pelvis, and the associated fascia. (See 'Introduction' above.)
●Evaluation – Patients with a diagnosis of myofascial pelvic pain syndrome receive a comprehensive structural and soft tissue and pelvic floor evaluation and pain mapping. Three major areas included in the evaluation are the musculoskeletal system, pelvic floor muscles, and pelvic soft tissue. (See 'Patient evaluation' above.)
●Approach to rehabilitation – Treatment programs are individualized to address the specific dysfunctions noted on the evaluation. Structural dysfunctions are treated primarily with an individualized therapeutic exercise program, while soft tissue dysfunction is managed with manual techniques to treat the connective tissue restrictions, trigger points, and neural restrictions. (See 'Rehabilitation' above.)
●Outcome – We suggest pelvic floor physical therapy for relief of myofascial pelvic pain (Grade 2C). Observational data have reported that 50 to 70 percent of patients will experience marked improvement or complete resolution of symptoms and the risk of harm is low. (See 'Outcome' above.)
●Follow-up care – Patients whose symptoms improve are educated about activities to avoid and stretches to do if any latent trigger points become active again or if a painful pelvic stimulus occurs (eg, urinary tract infection) in order to avoid symptom relapse. Patients whose symptoms do not improve are re-evaluated. (See 'Follow-up' above.)
