Myofascial Pain in the Pelvis

What is myofascial pain?

The term “myofascial” refers to the tissue made up of muscle and its surrounding connective tissue.  The fascia is a strong, ribbon-like tissue (such as the “gristle” in meat) that runs along muscle and connects it to bone.  It usually looks white or greyish in meat.  When a muscle becomes irritated and tightens, the fascia also becomes irritated as the body sends out fluids and cells in the immune system to address the injury.  The chemicals that are released by the body when an injury is sensed cause inflammation and pain in the area.  Myofascial pain refers to pain centered in the muscles and connective tissue.
What is myofascial pain in the pelvis?  Where does it come from?
The pelvis is literally the bottom of the torso.  The bony pelvis is formed by the pubic bones, sitting bones and what we commonly call the “hip bones”, although the wings of the pelvis do not actually form the hip.  The femur (leg bone) connects to the lower side of the pelvic bones below the “wings” of the pelvis (where you put your hands on your hips).  Inside of the pelvic bones a cone-shaped “bowl” of muscles is found.  Those muscles are connected to everything that allows us to sit up, stand, walk, bend over, and move in space.  They also help hold everything inside the body.  Those muscles are constantly active, or “in tone”.  They are always just mildly contracted, unlike most muscles that are not contracting when at rest.  For this reason, when a problem occurs that changes the balance of the body (a minor injury, such as a sore hip or knee, or sore back are examples of problems like this) the pelvic muscles must compensate in order to keep the body upright and moving.  Some of the muscles must contract more tightly.  In time, they become fatigued and sore, but because they are never really able to relax, they may not have the opportunity to heal.  As this problem continues, inflammation occurs in the tissue as the area senses damage.  Pain then begins, like a sore muscle.  It can feel like burning, cramping, aching, stabbing, stinging, or a combination of these things.  It is often mistaken for pain in an organ such as the ovary, the uterus, the bladder, the vagina, or the rectum.  The pain often coincides with the specific muscle or group of muscles that are affected.  Common causes of myofascial pain in the pelvis include travel (particularly long trips), new exercise regimens (especially bicycle riding or spinning), physical exertion (such as moving furniture or lifting something), and injury or accident (falls, etc).

How is Myofascial Pain diagnosed?

Because it can not be seen by an x-ray, ultrasound, CT scan or MRI, it must be diagnosed by physical examination as well as a thorough history review.  A pelvic examination including a thorough evaluation of each of the muscles in the pelvis via vaginal and rectal examination as well as an abdominal evaluation and back evaluation provide the means to arrive at the diagnosis.  The muscles are extremely tender to touch, and even light touch can cause significant discomfort.  The muscles typically feel taut (“violin strings”) to the examiner.  Often, the pain being experienced can be reproduced by touching the muscles that are in spasm.  This usually confirms the diagnosis.  Imaging studies are typically negative or have incidental and nonspecific findings that do not explain the symptoms.
Myofascial pain is often NOT diagnosed or misdiagnosed as a number of other problems, such as pelvic prolapse, urinary tract infection, pelvic infection, colitis, ovarian cysts, vaginitis, irritable bowel, overactive bladder, to name a few.  It is not uncommon to see a woman who has undergone “corrective” surgery, such as prolapse surgery, hysterectomy, oophorectomy, bladder surgery, etc, to no avail with no improvement, or unfortunately, a worsening of her symptoms after such treatment.  While it is certainly possible to have other conditions such as prolapse, fibroids, infection, irritable bowel, endometriosis, or ovarian cysts along with myofascial pain, it is critical to understand that treating those conditions will not necessarily improve the myofascial pain.  Because surgery is traumatic to tissues and causes inflammation, it can worsen myofascial pain.  For this reason the myofascial pain must be treated in order to achieve relief.

How is Myofascial Pain treated?

A program of specialized pelvic floor physical therapy must be undertaken with a trained professional in order to achieve optimal results.  In addition, appropriate relaxation techniques should be undertaken:
  1. Hot baths in Epsom Salt (about 1 handful per tub of water) for 20 minutes each day can help soothe and relax aching contracted muscles.
  2. Muscle relaxants such as a low dose Valium (diazepam), baclofen, tizanidine or other appropriate muscle relaxant can sometimes be helpful.
  3. Avoid irritating activities (high heels, bicycling or spinning, explosive start-stop exercises)
  4. Gentle yoga or stretching, preferably under the guidance of a teacher knowledgeable in pelvic floor disorders.
  5. Chiropractic or osteopathic treatment with a competent specialist who understands the interactions of the sacrum and pelvis with the rest of the body.
  6. Mindfulness/meditative techniques designed to assist with whole body relaxation.
  7. Acupuncture may also be helpful in assisting with relaxation and reducing pain and inflammation.
After undergoing an appropriate therapy program, the vast majority of patients experience significant relief.  Patients who were initially skeptical of the diagnosis and treatment plan typically return smiling and happy that they are feeling better.  The best part of all of it is that this can be accomplished without surgery, and usually with little or no medication.  If a surgical problem coexists, it can then be addressed with less concern for worsening the problem, and if there is a postoperative recurrence of the myofascial pain the appropriate treatment plan is already in place.

Linda Kiley, MD

Dr. Kiley is a Board Certified subspecialist in Female Pelvic Medicine and Reconstructive Surgery, and is also Board Certified in general Obstetrics and Gynecology.

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