Uncovering the black box of pelvic pain, understanding the role of the pelvic floor. These slides cover a review for pain management of the pelvic floor and pelvic pain.

2. PHYSIATRISTS AND PELVIC PAIN
What Role Do We Play in the Pelvis?
-Muscles
-Nerves
-Joints

3. CHRONIC PELVIC PAIN
Definition: Persistant, noncyclic pain perceived to be in structures
related to the pelvis, lasting fro more than 6 months
• Poorly Understood Condition
• Difficult to treat because CPP has multiple etiologies all with
significant overlap
-Endometriosis
-Interstitial Cystitis
-Irritable Bowel Syndrome
-Proctalgia Fugax
-Pudendal Neuralgia

4. CHRONIC PELVIC PAIN (CPP)
-More than 300 million adults world-wide
-Approximately 15% of Men and Women
-Affects 1 in 6 women aged 18-50
-Prevalence women of reproductive age as
high as 25%
-20% of all gynecological referrals are for
CPP

5. FEMALE SYMPTOMS
-Vaginal Burning
-Pain with Intercourse
-Pain with Menstrual Cycle
-Pain with Sitting
-Pain with Bowel Movement
-Constipation
-Incomplete Evacuation
-Urinary Urgency/Frequency
-PGAD (Persistant Genital Arousal Disorder)
-Coccyx Pain
-Buttock Pain
-Pubic Symphysis Pain
-Abdominal/Groin Pain
-SI Joint Pain

6. WHERE IS PAIN COMING FROM?

7. CHRONIC PELVIC FLOOR MUSCLE PAIN
-Short, Contracted, Spastic, Tender and Weaker
with Trigger Points
-Pro-Inflammatory State
-Neurogenic Inflammation
-Myofascial Pain

8. THEORIES BEHIND CPP
“Global or Systemic Stress”
- HPA axis dysfunction and Adrenocortical Hormone (Endocrine)
abnormalities
“Dysregulation of the LOCAL nervous system due to past trauma, infection,
or an anxious disposition with chronic unconscious pelvic tensing”
-Neurogenic Inflammation
-Myofascial Pain Syndrome
Genitourinary tract Inflammation:
-GU tract (bladder, urethra, testicles, prostate, vulva) can become
inflamed by the action of the chronically activated pelvic nerves on the
mast cells at the end of the nerve pathways

10. NERVE PAIN RELATED TO PERIPHERAL AND
CENTRAL SENSITIZATION

11. CENTRAL SENSITIZATION
-Predisposed Anatomical Anomaly + Local Injury + General Sensitizing
Factors
-Chronic Neuropathic Pain
-Persistant Pain Signals
- “Wind Up”
-”Inflammatory Soup”

12. PERIPHERAL SENSITIZATION

13. “FIRST LINE” TREATMENT
• Pelvic Floor Physical Therapy
• Modalities: TENS UNIT, ultrasound
• Lifestyle Modifications
• Alternative Therapies
• Cushion, SI Belt
• +/- Oral Nerve Medications and Muscle
Relaxants

14. TREATMENT ALGORITHYM
Phase 1
Pelvic Floor Physical Therapy +/- Valium Supp for 8-12 weeks
Modalities: TENS Unit, Ultrasound, etc
Gel Cushion for Pudendal Nerve/Coccyx relief
SI Joint Belt
Alternative therapies: Accupuncture, Craniosacral, Yoga
Phase 2
Medications
Trigger Point Injections
Selective Peripheral Nerve Blocks
Phase 3
Botox
Alpha-2 Macrobglobluin

15. GOAL OF OUR PROGRAM
1) “Retrain” Central and Peripheral Nervous
System
2) Create Space in the Pelvis
3) Decrease Inflammation
4) Decrease Myofascial Tension and Improve
Blood Flow
5) Lengthen and Strengthen Pelvic Musculature in
combination with Neuromuscular Re-education

16. PELVIC REHAB MEDICINE PROTOCOL TO TREAT CPP
1) External Ultrasound Guided Trigger Point Injections to
Pelvic Floor Muscles
2) Ultrasound Guided Peripheral Nerve Hydrodissection
Blocks
Series of injections, once weekly for 6 weeks, individually tailored for
patient specific muscles and peripheral nerves to concomitantly
address Myofascial Pain and Neurogenic Inflammation
Followed by Pelvic Floor PT within 24H-7 days post treatment

19. INJECTIONS OPTIONS
• Lidocaine/Dexamethasone
• Lidocaine/Traumeel
• Alpha-2 Macroglobulin
• Botox

25. NEEDLE TIP

27. ALPHA-2 MACROGLOBULIN
1) Largest nonimmunoglobulin protein in plasma.
2) Protease Inhibitor- “Inactivate a variety of proteinases”
A. Inhibits Fibrinolysis (Plasmin and Kallikrein)
B. Inhibits Coagulation (thrombin)
C. Used for Chronic Pain because it decreases Inflammation
-”Carrier Protein” binds to numerous Growth Factors and
Cytokines
-PDGF, BFGF, TGF-β, insulin, and IL-1β

31. REFERENCES
Shaowei Wang , et al. Identification of Alpha 2-Macroglobulin as a Master Inhibitor of Cartilage-
Degrading Factors That Attenuates the Progression of Posttraumatic Osteoarthritis ARTHRITIS
& RHEUMATOLOGY Vol. 66, No. 7, July 2014, pp 1843–1853 DOI 10.1002/art.38576
Scuderi et al. Abstract Improving Response to treatment in patient with DDD by the use of Molecular
Markers
Scuderi et al, A2M Inhibition of Proteases and Wound fluid
Molcrani et al. HPA axis dysfunction in depression: Correlation with monoamine system
abnormalities, Psychoneuroendocrinology, Volume 22, Supplement 1, 1997, Pages S63–S68