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August 2009 - Trigger Point Therapy for Pelvic Pain
If you suffer from pain in the area of your pelvis — the large ring-like structure of bones between the hips — the pain may be coming from one or more trigger points.
A trigger point is a sensitive area in a muscle or connective tissue that becomes painful when compressed. The pain may radiate throughout the muscle and connective tissue. Pressing on a trigger point can also cause referred pain that is felt elsewhere in the body.
| The pelvic floor consists of layers of muscle and other tissues that stretch from the tail bone at the back to the pubic bone in front. The pelvic floor muscles control the bladder and the bowels. Trigger points can be a source of pain in any part of the pelvic floor and cause the affected muscle(s) not to function properly. |
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Trigger points are generally caused by a muscle being “overloaded” following an acute, prolonged or repetitive incident.
“Trigger points may form in pelvic floor muscles for a variety of reasons,” said Margarita Kressin, MD, Medical College of Wisconsin urologist in the Women’s Incontinence and Sexual Health (WISH) Program. These include:
- Obesity
- Trauma (injury or previous surgery in the pelvic region)
- Joint problems
- Stress (tension held in pelvis)
- Misuse of pelvic muscles, such as a change in walking or performing Kegel exercises incorrectly (an exercise used by women to strengthen pelvic floor muscles)
- Pregnancy/injury during childbirth
“Pelvic muscle trigger points occur in both men and women,” Dr. Kressin said. “They may experience persistent pain resulting in a decreased range of motion in the affected muscles. In some cases, the pain can limit a person’s ability to walk, work, enjoy intimacy and perform the activities of daily life.”
Among men, one of the most common symptoms of a trigger point is testicular pain. Other symptoms include difficulty voiding, prostate pain or urinary symptoms. Urologists need to rule out common causes such as infection or prostate growth (BPH) first before assuming the cause is pelvic pain.
Among women, common symptoms include pain during or after intercourse, difficulty voiding, pain during exercise and urinary symptoms. As in men, common sources of pain such as a urinary tract infection or other gynecologic conditions (cysts, fibroids, endometriosis) need to be rules out before assuming pelvic floor dysfunction.
Physical Therapy The first step in treating pain caused by pelvic trigger points is physical therapy. Beth Malak, MPT, BCIA-PMDB, a physical therapist at Froedtert Hospital, specializes in therapy that targets sensitive sites of the pelvis to relieve muscle pain.
“Physical therapy starts with patient education,” Malak said. “Patients learn about the pelvic muscles, how they work and where they are attached.”
Before therapy begins, Malak conducts a physical assessment of a patient’s pelvic muscles. The first stage of therapy involves muscle stretching and relaxation exercises.
“We use a technique called biofeedback to test the pelvic floor muscles,” Malak said. Biofeedback helps a person gain awareness and control of the pelvic muscles to help relax the muscles when there is pain in that region.
Electrodes (small pads placed on the skin) or patient-inserted internal sensors are used to “feed back” information about the activity in the pelvic muscles at rest and during exercise. The sensor or electrodes are attached to a device that shows information about pelvic muscle activity on a screen, so the patient and physical therapist can see how the muscles are actually working. This information can then be used to promote easier relaxation of the muscles.
“If biofeedback and stretching don’t succeed in resolving pain after three to five sessions, I look more specifically at where the pain is,” Malak said. “There are many muscles in the pelvic floor that interact with the hips and lower back. I assess the patient’s hips and back as they move to determine the exact site of the pain.”
The next step in treatment is called soft tissue mobilization, a type of internal massage of the affected muscle. If this proves helpful, Malak will continue to provide this therapy. If the pain doesn’t improve after about five visits, however, the next step is trigger point injections.
Trigger Point Injections“If physical therapy doesn’t effectively reduce pain, trigger point injections may offer effective pain relief,” Dr. Kressin said. “A mixture of a numbing medication (anesthetic) and an anti-inflammatory (steroid) medication is injected in the tender muscles in the pelvic floor. A total of four injections are given over four weeks.”
These injections are given by Dr. Kressin and Medical College of Wisconsin urogynecologist Sumana Koduri, MD. During the procedure, Malak helps to guide the physician to the site of the trigger point. Patients may receive mild sedation before receiving the injection.
After each injection, when the muscle is numb, Malak is able provide more intense manipulation of the tender muscle. The anesthetic makes it possible to stretch the sore muscle or group of muscles more without hurting the patient.
In most cases, trigger point injections reduce the pain. The amount of relief obtained from the injections varies from person to person and may last from a few weeks to a few months.
ResourcesSmall Stones, a health resource center of Froedtert & The Medical College of Wisconsin, offers the following resources on pelvic pain and trigger points:
The Trigger Point Therapy Workbook by Clair Davies, NCTMB, with Amber Davies, NCTMB
The Vulvodynia Survival Guide by Howard I. Glazer, PhD, and Gae Rodke, MD, FACOG
The V Book, A Doctor’s Guide to Complete Vulvovaginal Health by Elizabeth G. Stewart, MD, with Paula Spencer
Author: Marla Fraunfelder | Medical Reviewer: | Margarita Kressin | | Medical College of Wisconsin urologist |
Last Review Date: Aug. 1, 2009 Online Editor(s): Christopher Sadler
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