Pelvic Floor Muscle Spasm and Myalgia

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
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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
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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

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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!