Greater Boston Urology Blog

Chronic Pelvic Pain Caused by Myofascial Pelvic Pain Syndrome

Dr. Angel Marie Johnson, a urogynecologist and the director of our Women's Health Centers, discusses a source of chronic pelvic pain that she sees in many of her patients: myofascial pelvic pain syndrome (MPPS). 

As always, the information below is educational, not medical advice. If you're a woman dealing with chronic pelvic pain, speak to your PCP and ask for a referral to a urogynecologist. (And if you're in the greater Boston area, click here to schedule an appointment with Dr. Johnson.) 

First, define chronic pelvic pain. 

DR. JOHNSON: Chronic pelvic pain is defined as having pain in the pelvic region for longer than six months. 

What causes chronic pelvic pain? 

DR. JOHNSON: A wide variety of conditions can cause chronic pelvic pain, which is why it's so tricky to treat—and so frustrating for patients with this condition. 

The pelvis is a complex compartment that contains many different structures: the bladder, uterus, vagina, rectum, nerves, and blood vessels. It is also composed of several muscles. A variety of conditions can afflict these different structures and lead to pelvic pain, such as interstitial cystitis, pelvic inflammatory disease, endometriosis, urinary tract infections, ovarian cysts, appendicitis, STDs (and that's an incomplete list). 

When a patient presents with chronic pelvic pain, my first step is to get a detailed explanation of her symptoms. Then, I perform a focused physical exam to help determine the source. 

In your practice, do you tend to see a recurring theme in the underlying conditions/causes of chronic pelvic pain in women? 

DR. JOHNSON: A common source of the chronic pelvic pain in the women I treat is due to myofascial pelvic pain syndrome, which is essentially tight muscles and muscle spasms affecting the pelvic floor. 

Essentially, it would be as if you were performing bicep curls in the gym and you suddenly couldn’t extend your arm. Your arm is flexed and remains flexed. This constant muscle contracture or muscle activation would result in severe pain and distress. Myofascial pelvic pain is as if the vaginal muscles contracted or shortened and then failed to relax. 

Remember, the true function of a muscle comes from its ability to relax and then contract when you need it to. A spastic muscle is dysfunctional. In this case, it can inhibit bladder and bowel emptying, resulting in urinary retention, urinary incontinence, and constipation. Spastic pelvic muscles are one cause of pain with intercourse (dyspareunia). 

What's the treatment for it? 

DR. JOHNSON: It depends on the patient. If I have someone who can tolerate a pelvic exam and I can confirm pelvic muscle spasm by touch, then I will refer the patient directly to pelvic floor physical therapy since that is the first-line treatment. 

However, many patients cannot tolerate the exam or physical therapy, so we'll discuss other treatment options, such as vaginal estrogen cream if pain is due to vaginal dryness. Or I use medications placed in the vagina (such as valium) with the intent to reduce muscle spasms. 

Some patients respond well to nerve blocks and trigger point injections to the pelvic floor. I regularly perform bilateral pudendal nerve blocks where I inject numbing medicine into one of the nerves that supplies feeling to the vagina. The goal of trigger point injections is to provide relief and allow the patient to better tolerate physical therapy. 

There are some people who opt for pelvic floor Botox (yes, the same Botox people inject in their foreheads). The Botox will relax the muscle and allow them to have normal vaginal function and normal rectal function. But Botox doesn't last forever. So you tend to have to repeat it every six to nine months. 

Pelvic pain, whatever the cause, can be extremely debilitating. But here's the good news: there are options. Even if you've been told in the past that there was nothing that could be done, please know that new treatments exist, so don't give up hope. As a urogynecologist, I want to help. So if you're suffering, seek out someone like me. 

Thanks, Dr. Johnson! 

Do you suffer from chronic pelvic pain due to MPPS or something else? Are you in the greater Boston area? If yes, consider making an appointment with Dr. Johnson.

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