Pelvic Floor Muscle Spasm and Myalgia Amanda Clark MD MCR Female Pelvic Medicine and Reconstructive Surgery Urogynecology Lead. Kaiser Permanente NW Affiliate Associate Professor, OHSU Disclosures Financial-None Personal: Thanks to Jillian Romm RN, LCSW Sandra Gallagher PT Amy Choate PT Sandra Hall LCSW Many, many patients who have shared their insights into this work Learning Objectives  Background, Diagnosis and Treatment  Teach you to be “personal trainers” and “coaches” for the pelvic floor  Be confident in your diagnosis and avoid unnecessary testing and surgery  CT, MRI, Colonoscopy, Urodynamics, Cystoscopy, Diagnostic Laparoscopy, Hysterectomy, Adhesiolysis, Interstim, etc.  Limit “frequent flying” and ED visits  Avoid recommending surgery—especially Urogyn! The New York Times THINK LIKE A DOCTOR SEPTEMBER 6, 2013 Think Like a Doctor: The Gymnast’s Big Belly Solved  Abdominal Phrenic Dyssynergia  Pelvic Floor Dysfunction  Answers by:  Dr. Ann Clark, an OB-GYN in Louisville, Ky  Dr. Carrie Richardson from Chicago Evolution of the “Floor” Muscle images Prevalence  Levator Myalgia present 24% of 5,618 urogyn pelvic exams at OHSU  Associated with     Fibromyalgia Depression History of sexual abuse Use of narcotic medications Levator Myalgia-Why Bother?, Kerrie Adams, W. Thomas Gregory, Blake Osmundsen, Amanda Clark, International Urogynecology Journal, Volume 24 Number 4 April 2013 PAIN!! Pain Stress Spasm Spasm Pain Pain Spasm Spasm Tension Pain Symptoms  Pain—pelvic, low back, hip, leg  Dyspareunia, Vulvar Pain, Dysmenorrhea  Urinary Frequency (Bladder pain—Interstitial Cystitis)  Voiding Difficulty, Stress and Urge Incontinence  Constipation (IBS)  Defecation Difficulty Diagnosis  With 2 fingers in the vagina, ask the patient to squeeze as if trying to avoid passing gas  One hand on the abdomen to assess Valsalva  Palpate muscles to elicit pain  To learn normal vs. abnormal, assess muscle function during EVERY pelvic exam Diagnosis  For extra credit, check the obturator internus muscle  Put one hand on the OUTSIDE of her knee and ask her to push  This muscle is often painful  Demonstrating leg muscle pain is helpful in building the case for PT Treatment: Pelvic Floor Physical Therapy  RCT comparing PFM PT to Generalized Massage  10 sessions in each group  59% response rate for PFM PT  26% response rate for Generalized Massage  P = 0.0012 Fitzgerald, MP, et. al., Randomized Multicenter Feasibility Trial of Myofascial Physical Therapy for the Treatment of Urological Chronic Pelvic Pain Syndromes, J Urol 2013;189: S75-S85. DOI: http://dx.doi.org/10.1016/j.juro.2012.11.018 Ancillary Treatments  Vaginal estrogen—reduces post-menopausal proliferation of small surface nerve fibers  Miralax—aim to keep bowel movements soft and easy to pass  Nifedipine/Lidocaine 0.3/1.5% topical ointment for anal spasm (at compounding pharmacies) apply a small amount to anus tid and 5 minutes before and after bowel movements  Nortriptyline, gabapentin for chronic pain Ancillary Treatments  Avoid activities that aggravate pain—unwind the cycle of pain and spasm  Limiting intercourse early may allow earlier resumption of comfortable intercourse  Consider activities that promote generalized relaxation—massage, Feldenkreis, restorative yoga  Try to identify stressor that promote physical tension Treatment: Pelvic Floor Physical Therapy Limitations  Patients are unwilling to accept PT  Patients push us toward diagnostic tests and surgery  Often are our most difficult patients to manage  Must address emotional issues that underlie PFM pain Lessons Learned from Balint  Balint is a group learning experience focused on the doctor-patient relationship  A case is presented where the focus is on a difficulty in the relationship  Group members are encouraged to consider the emotions that doctors and patients bring to a relationship  Professionally, we aim to practice non-judgmentally, but we seldom feel non-judgmental Pelvic Floor Muscles & Feelings Why did I come here? The doctors never help me. Will this one have an answer? No, of course not. I’m crazy to even be here! Pelvic Pain! Arghh! I can never help these women. The visit will take forever. There goes my schedule. I HATE PAIN PATIENTS!! I feel like there is a knife in my vagina! Of course I do, who can poop with a knife in their vagina? She doesn’t understand how bad this hurts! Already I can tell—this doctor can’t help me! Does it hurt when you urinate? Do you have trouble with constipation? She isn’t answering my questions. How can I figure this out? I can’t help her if she can’t answer the simplest question! The pain is horrible! There has to be something you can do! This pain is horrible! Your exam is normal. I don’t think you need surgery. He doesn’t care about me. He is just saying this to get rid of me. I know that I’m right. Why isn’t she happy to know that she is OK? Physical therapy? My pain is real!! He is just trying to get rid of me. Alone. Abandoned again!. I can trust no one. Why did I try? I can send you to physical therapy. Sometimes they can help with pelvic pain. This is getting worse. How can I get out of this room? “The Boss” thinks I can do this in 20 minutes? Multi-disciplinary Team Approach MD-PT-PTA-LCSW  Each team member provides their expertise in an integrated manner, with full understanding of nature and importance of each role     Emotional Support for patients and each other Whole body muscle relaxation Direct pelvic floor muscle therapy Direct physical therapy for “neighbor” muscles in low back, abdomen, hips and legs The emotional subtexts of pelvic pain  Hx of emotional and sexual abuse A thin veneer of hope often overlies  Diminished sense of self-worth  Fear of abandonment  Inability to trust authority Often we must address emotional issues first  Acknowledge how much suffering the patient is experiencing  Acknowledge stress and worry  Say early in the visit that you want to see them back  Show – don’t say – that you can be trusted Physical Exam Don’t Cause More Pain! Think about vulvar vestibulitis (vestibulodynia)  Q-tip Test—light touch just outside hymeneal ring  Pain may be elicited by stretch to examine introitus  Pain is ablated rapidly with 2% lidocaine jelly  Start with one finger, not speculum ✖ Vulvar Vestibulitis Ask patient to Kegel Palpate for pain Give patient feedback during the digital exam  If you reproduce her pain, gently show this  Let her know that the exam may make her pain worse temporarily  Do 2-3 contraction-relaxation cycles and assess     Her ability to contract the right muscles How she breathes Whether she can perceive muscle contraction Whether she can perceive muscle relaxation Contraction-Relaxation Cycles  I want you to do small Kegel squeeze, just enough that you can feel the muscle contracting  While holding that small squeeze, take a slow breath in and out  Now let the contraction go; this means letting the muscle fall downward toward the floor or the table  Use your finger to gently show her the direction the muscle should go to relax Contraction-Relaxation Cycles  On the out breath especially, think of letting the muscles soften, let your bottom sink into the table and let the table hold you  Some of my patients visualize butter melting during this part of the exercise  Do 2 cycles with your finger lightly on the muscle  Do 1 cycle with no finger – the way the patient will do this at home; watch the perineum for movement Contraction-Relaxation Cycles  Don’t say – RELAX!!  Don’t say – If only you could relax, this wouldn’t hurt do much  Don’t say – You need counseling!  Note that learning to relax the muscles is much harder than learning to contract  The muscle is “stuck in the on position” and we are trying to turn it off, little by little Helpful Analogies  Tension Headache of the Pelvic Floor  Demonstrate Muscle Tension using your own bicep  Learning to relax the pelvic floor muscles can be like learning to ride a bike; at first it seems impossible, but someone runs along beside you to hold you up until something “clicks” and you learn how to do it  PFM pain is best treated by “TLC—tender, loving care,” not “Tough Love” How to refer  There are many ways to treat PFM pain  I work with a team -- WE will help you learn about all your options and then WE choose the ways that work best for you  Our team has created a class where you can learn about the options to get started  The pain has been there for some time, it may take several weeks to get you back to health  I want to see you back to monitor your progress Coding Summary  Feel more confident in diagnosing and treating Pelvic Floor Muscle Spasm and Myalgia  Know about resources to help you and your patients  Recognize that PFM spasm and myalgia mimic pelvic organ prolapse symptoms  Please don’t repair a minor prolapse when PFM spasm is the cause of symptoms!