Patient Information > Muscle and Joint

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.What is musculoskeletal pain?

Women and their gynecologists are often frustrated when the cause of their pain is still unclear, after endoscopic surgery reveals a more or less normal pelvis, and a trial of birth control pills to suppress circulating estrogen is unsuccessful. In fact many of these women may be suffering from unidentified musculoskeletal pain disorders, which we find frequently in women who have no clear cause for their pain. This may be due to the fact that many physicians regardless of specialty receive little training in how to identify or treat problems of the muscles, fascia, and connective tissue. In studies we performed in an academic medical center, up to one in five women seen with complex pain problems reported pain in the pelvic floor muscles on exam, for example. This pain can also include tissues such as the sacroiliac joint (in the back between the back and buttocks), the symphysis pubis (which joins the 2 parts of the pelvis together), and deeper muscles often ignored by clinicians but that are very important in posture (the pelvic floor, obturator, and iliopsoas muscles).

How are these problems diagnosed?

Perhaps the most important test that needs to be done to find musculoskeletal problems is a thorough history, following by a physical exam looking at the pelvic muscles and joints. These simple assessments, done carefully, can turn up restriction of normal range of motion in joint, tightness or tenderness in regions of certain muscles, or weakness in muscles that normally compensate for other related muscles. Only rarely do imaging studies (CT scans, ultrasounds, or MRI’s) or blood work turn up additional problems, unless the ordering doctor strongly suspects a specific condition.
We emphasize that obvious causes of pelvic pain, such as pregnancy, endometriosis, acute pelvic infection, large ovarian cysts, or degenerating fibroids should not be ignored when looking for a musculoskeletal pain problems, but occasionally both can present at the same time. This is especially true in pregnant women, who should not be told that pain in pregnancy is just “part of being pregnant.”
Severe trauma, such as motor vehicle collisions or athletic injuries, or less obvious stresses, such as pregnancies, can disrupt the normal balance of these musculoskeletal elements, and eventually put excessive strain on parts of the pelvis. Questioning about these sorts of problems is critical to do for all patients who appear to have mostly somatic location of their pain (no organ-related symptoms such as pain with menstrual flow, urination or bowel movements).

How are these problems treated?

The keys to treatment are to address any potential muscle imbalance, as the pelvis functions as an integrated “kinetic chain” along with the torso and the lower extremities. Although the majority of testing needs further validation, research has shown manual and injection therapies to be frequently successful in the treatment of pelvic muscle tension. Effective manual therapies may consist of home exercises, vaginal/rectal massage, electrical stimulation, and muscle relaxants, while injection therapy involves local anesthetics, steroids, or even botulinum toxin (in selected situations) for chronic muscle spasm.
Over-the-counter anti-inflammatories can be helpful in many cases, but clinicians should not hesitate to treat pain even as functional issues are being addressed. Some of our recent work has found that experimental pain thresholds (the amount of pressure that is needed to elicit pain on exam of muscles) are lower in women with chronic pelvic pain, suggesting that neurological therapies used in chronic nerve pain conditions may be very helpful. Some women will also find benefit from use of opioid medications, but the possibility of dependence and tolerance developing, and the risk of abuse, requires a clear line of communication between the patient and prescribing clinician.
In rare circumstances where compression of pelvic nerves has occurred, surgery is a last resort option to relieve pain. It is crucial to find a center that is doing research into pudendal nerve injury and sees a high volume of such patients.
While many studies have attempted to identify the causes of chronic pelvic pain, most lack efficient information. Musculoskeletal dysfunction should be taken into account upon evaluating central pelvic pain, but appropriately designed randomized, controlled trials are desperately needed to provide reliable evidence for proper diagnosis and treatment.

References

1. Tu, F., et al., Pelvic floor pressure-pain thresholds: A pilot study. Journal of Pain, 2006. 7(4): p. S30.
2. Tu, F.F., S. As-Sanie, and J.F. Steege, Prevalence of pelvic musculoskeletal disorders in a female chronic pelvic pain clinic. J Reprod Med, 2006. 51(3): p. 185-9.
3. Tu, F.F., S. As-Sanie, and J.F. Steege, Musculoskeletal causes of chronic pelvic pain: a systematic review of existing therapies: part II. Obstet Gynecol Surv, 2005. 60(7): p. 474-83.
4. Tu, F.F., S. As-Sanie, and J.F. Steege, Musculoskeletal causes of chronic pelvic pain: a systematic review of diagnosis: part I. Obstet Gynecol Surv, 2005. 60(6): p. 379-85.
5. Oyama, I.A., et al., Modified Thiele massage as therapeutic intervention for female patients with interstitial cystitis and high-tone pelvic floor dysfunction. Urology, 2004. 64(5): p. 862-5.
6. Cornel, E.B., et al., The effect of biofeedback physical therapy in men with Chronic Pelvic Pain Syndrome Type III. Eur Urol, 2005. 47(5): p. 607-11.

Frank Tu, MD, MPH
Division Director, Gynecological Pain and Minimally Invasive Surgery
Feinberg School of Medicine at Northwestern University