• How should we treat pelvic floor dysfunction? 
  • Should everyone get physical therapy? 
  • What if they don’t respond well to physical therapy? 
  • What other treatment options are available. 

New clinical guidelines for the treatment of pelvic floor dysfunction were released in the Spring of 2024. Developed by eleven women’s health specialists, this first of its kind document provides a three step treatment plan for patients struggling with high-tone pelvic floor muscles. This is a fabulous new resource to share with their practitioners that validates the need for pelvic floor therapy, the importance of finding properly trained pelvic physiotherapists and options to explore when “hands-on” muscle work is ineffective. From trigger point therapy to vaginal valium suppositories, there are a number of therapies for patients to explore!

First Line Treatment – Physical Therapy

They unanimously agreed that physical therapy should be the first-line therapy and that it should be used for at least 8 to 12 weeks. Patients with a longer symptom history may require even more sessions. The goal of physical therapy is to relax the muscles, rather than strengthen them, using myofascial release. Women who respond to therapy should continue until their symptoms resolve. After four to six months of stable, controlled symptoms, they can be discharged to use techniques at home. 

Patients should be encouraged to better manage bowel and/or bladder symptoms. Yoga and stretching could also be utilized as recommended by their physical therapist. 

Second Line Treatment – Vaginal Suppositories & Trigger Point Injection 

Diazepam (aka valium) can be prescribed as a vaginal suppository to relax pelvic floor muscles. Other oral medications may also be considered including: baclofen, cyclobenzaprine (Flexeril) and tizanidine. The experts agreed that vaginal suppositories were preferable to oral medication. 

Patients with painful trigger points (tight muscle knots) can be treated with a local anesthetic (.25-.5% bupivicane) without steroids (aka trigger point injections) to further relax muscle by down-regulating the guarding reflex. This could be helpful to patients who can’t tolerate physical therapy due to pain or who have stopped responding to PT. If a patient doesn’t respond to the first injection, additional injections are not suggested. 

Cognitive behavioral therapy could also be explored to reduce anxiety, stress and calm the central nervous system. 

Third Line Treatment – BotoxA & Neuromodulation

OnabotulinumtoxinA is FDA approved for calming muscle spasm. Though not specifically approved for PFD, its use has become common as clinicians inject the medication into tight, painful pelvic floor muscles. Bilateral injections are preferred over doing a single side. Repeat injections are not recommended if the first injection is not helpful. 

Sacral neuromodulation has some evidence showing that it can be helpful for urinary symptoms, though pain improvement may not occur.  How does it work? They hypothesized that it may revive brainstem autoregulation and reset pelvic floor muscle function. Its use in pelvic floor dysfunction is off label and the experts suggest that it should only be used in patients also struggling with urinary symptoms, who have not responded to other therapies.

Conclusion

Pelvic floor therapy is remarkably successful in reducing pelvic pain and discomfort with research showing that it helps well over 60% of the patients who try it.  These guidelines validate the importance of physical therapy as a treatment for pelvic pain and will improve pelvic pain care across the USA. The biggest barriers, though, are getting a referral for PT and then finding a skilled physical therapist. There is a fabulous searchable database on-line of therapists (http://www.pelvicrehab.com) who have been trained in pelvic floor work. Look for therapists who are fully certified in pelvic floor work.

Cost, discomfort and hesitation having internal pelvic floor work can be challenging for some patients. Patients with a history of sexual abuse may be reluctant to have internal work performed. They should share their history with the physical therapist who will then work around their fears. The goal is to build trust over time and show that muscle therapy can reduce painful symptoms.

If a physical therapist suggests kegel exercises, they have not been trained properly. Both the IC/BPS and these pelvic pain guidelines clearly state that tightening muscles will exacerbate pelvic floor dysfunction and pelvic pain. Rather, the goal is always to relax and release muscles and then, if necessary, work on strengthening.

It’s also worth noting the wise words of Dr. Jerome Weiss in his book, Breaking Through Chronic Pelvic Pain. He suggested that if muscles didn’t respond to therapy and/or always returned to tension despite therapy, a thorough review of the hips, SI joint, knees and feet should be performed to identify any underlying skeletal issues. Muscles can remain tight if bones (i.e. coccyx, SI joint, hips, knees and feet) are out of position. If present, these should also be treated.

Source: 

Torosis M, et al. A Treatment Algorithm for High-Tone Pelvic Floor Dysfunction. Obstet Gynecol. 2024 Apr; 143(4):595-602 – https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10953682/