Department of Obstetrics & Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Washington University in St. Louis, St. Louis, Missouri.
Department of Surgery, Division of Public Health Sciences, Washington University in St. Louis, St. Louis, Missouri.
Am J Obstet Gynecol. 2019 Sep;221(3):235.e1-235.e15. doi: 10.1016/j.ajog.2019.07.020. Epub 2019 Jul 15.
Pelvic floor myofascial pain, which is predominantly identified in the muscles of the levator ani and obturator internus, has been observed in women with chronic pelvic pain and other pelvic floor disorder symptoms, and is hypothesized to contribute to their symptoms.
To describe the prevalence of pelvic floor myofascial pain in patients presenting with pelvic floor disorder symptoms and to investigate whether severity of pelvic floor myofascial pain on examination correlates with degree of pelvic floor disorder symptom bother.
All new patients seen at 1 tertiary referral center between 2014 and 2016 were included in this retrospectively assembled cross-sectional study. Pelvic floor myofascial pain was determined by transvaginal palpation of the bilateral obturator internus and levator ani muscles and scored as a discrete number on an 11-point verbal pain rating scale (range, 0-10) at each site. Scores were categorized as none (0), mild (1-3), moderate (4-6), and severe (7-10) for each site. Pelvic floor disorder symptom bother was assessed by the Pelvic Floor Distress Inventory short form scores. The correlation between these 2 measures was calculated using Spearman rank and partial rank correlation coefficients.
A total of 912 new patients were evaluated. After exclusion of 79 with an acute urinary tract infection, 833 patients were included in the final analysis. Pelvic floor myofascial pain (pain rated >0 in any muscle group) was identified in 85.0% of patients: 50.4% rated as severe, 25.0% moderate, and 9.6% mild. In unadjusted analyses and those adjusted for postmenopausal status, severity of pelvic floor myofascial pain was significantly correlated with subjective prolapse symptoms such as pelvic pressure and heaviness but not with objective prolapse symptoms (seeing or feeling a vaginal bulge or having to push up on a bulge to start or complete urination) or leading edge. Severity of myofascial pain at several individual pelvic floor sites was also independently correlated with lower urinary tract symptoms, including pain in the lower abdomen (myofascial pain at all sites) and difficulty emptying the bladder (right obturator internus and left levator ani); and with defecatory dysfunction, including sensation of incomplete rectal emptying (pain at all sites combined and the right obturator internus), anal incontinence to flatus (pain at all sites combined), and pain with defecation (pain at all sites combined, and the right obturator internus and left levator ani).
Pelvic floor myofascial pain was common in patients seeking evaluation for pelvic floor disorder symptoms. Location and severity of pelvic floor myofascial pain was significantly correlated with degree of symptom bother, even after controlling for postmenopausal status. Given the high prevalence of pelvic floor myofascial pain in these patients and correlation between pain severity and degree of symptom bother, a routine assessment for pelvic floor myofascial pain should be considered for all patients presenting for evaluation of pelvic floor symptoms.
盆底肌肉筋膜疼痛主要发生在提肛肌和闭孔内肌，在患有慢性盆腔疼痛和其他盆底功能障碍症状的女性中观察到，并且被假设为导致其症状的原因。
描述患有盆底功能障碍症状的患者中盆底肌肉筋膜疼痛的患病率，并探讨检查时盆底肌肉筋膜疼痛的严重程度是否与盆底功能障碍症状的困扰程度相关。
本回顾性横断面研究纳入了 2014 年至 2016 年间在一家三级转诊中心就诊的所有新患者。通过阴道触诊双侧闭孔内肌和提肛肌来确定盆底肌肉筋膜疼痛，并在每个部位使用 11 点言语疼痛评分量表（范围 0-10）对疼痛进行离散评分。每个部位的评分分为无（0）、轻度（1-3）、中度（4-6）和重度（7-10）。通过盆底窘迫症清单短表评分评估盆底功能障碍症状的困扰程度。使用 Spearman 秩和偏秩相关系数计算这两个指标之间的相关性。
共评估了 912 名新患者。排除 79 例急性尿路感染后，833 名患者纳入最终分析。85.0%的患者存在盆底肌肉筋膜疼痛（任何肌肉群疼痛评分>0）：50.4%为重度，25.0%为中度，9.6%为轻度。在未调整分析和调整绝经后状态后，盆底肌肉筋膜疼痛的严重程度与主观脱垂症状（如盆腔压迫感和沉重感）显著相关，但与客观脱垂症状（看到或感觉到阴道膨出或必须向上推膨出物才能开始或完成排尿）或前缘无关。几个单独的盆底部位的肌肉筋膜疼痛严重程度也与下尿路症状独立相关，包括下腹痛（所有部位的肌肉筋膜疼痛）和排空膀胱困难（右侧闭孔内肌和左侧提肛肌）；以及排便功能障碍，包括直肠排空不完全感（所有部位结合右闭孔内肌）、肛门排气失禁（所有部位结合）和排便时疼痛（所有部位结合，右闭孔内肌和左提肛肌）。
在寻求盆底功能障碍症状评估的患者中，盆底肌肉筋膜疼痛很常见。即使控制绝经后状态，盆底肌肉筋膜疼痛的位置和严重程度与症状困扰程度显著相关。鉴于这些患者中盆底肌肉筋膜疼痛的高患病率以及疼痛严重程度与症状困扰程度之间的相关性，对于所有因盆底症状就诊的患者，应常规评估盆底肌肉筋膜疼痛。
