Recognizing myofascial pelvic pain in the female patient with chronic pelvic pain

Investigators have reported that myofascial pelvic pain syndromes can be effectively treated with a variety of physical therapy techniques including manual therapy, biofeedback, electrical stimulation and other modalities ( Chiarioni et al., 2010 ; FitzGerald et al., 2009 ; FitzGerald et al., 2012 ). Numerous uncontrolled trials and case studies report the effectiveness of myofascial trigger point release, Thiele massage, dilators or trigger point wands, biofeedback, electrical stimulation, pelvic muscle relaxation, and general relaxation training in reducing myofascial pelvic pain syndromes ( Anderson, Wise, Sawyer, & Chan, 2005 ; Anderson, Wise, Sawyer, & Nathanson, 2011 ; Fitzwater, Kuehl, & Schrier, 2003 ; Gentilcore-Saulnier et al., 2010 ; Montenegro et al., 2010 ; Oyama et al., 2004 ; Weiss, 2001 ). Many investigators combined interventions, thus making single intervention recommendations difficult, therefore, a multi-modal approach may be most effective in treating these women. Utilizing a multi-disciplinary team knowledgeable in treating the complex issues of CPP and MFPP is the best approach to take when working with this population. In addition to physical therapists, other team members may include a psychologist to help manage emotional issues, a clinical sexologist or sex therapist to assist with sexual concerns, an orthopedist, neurologist or pain specialist to treat serious orthopedic or neurological pathology such as a herniated disc or nerve entrapment. Certainly, urologists, urogynecologists, gastroenterologists, and other specialists should be utilized as appropriate. Growing evidence suggests that Traditional Chinese Medicine, such as acupuncture and herbal medicine, helps in the treatment of chronic pain, and women experiencing CPP are seeking alternative care with good results ( Suh & Lowe, 2011 ). The interdisciplinary team can be as varied as necessary, but adequate communication between members is essential. Nurses play a critical role in caring for women with CPP/MFPP and are important members of the interdisciplinary team. They understand the importance of providing holistic care to, which is vital for this population. Nurse practitioners and certified nurse-midwives are often responsible for the assessment, diagnosis, treatment, and appropriate referrals for these women. Once MFPP is identified, nurses can act as educators, patient advocates, and case managers. For example, nurses can train women in techniques such as diaphragmatic breathing, which promotes relaxation and improves parasympathetic activity, bowel health and constipation management, and bladder retraining. Education regarding pain management techniques is critical and includes: teaching appropriate resting postures for perineal or vulvar pain control, such as elevating the pelvis with pillows or supporting the legs over a chair; using ice and heat following the basic principles that ice is helpful for hot, burning pain associated with swelling, while heat is helpful for relaxing muscle spasms. Nurses can teach stress reduction techniques using guided imagery or meditation. Also, nurses who are trained in biofeedback could pursue specialized training in the treatment of pelvic floor conditions using this modality. As case manager or patient advocate, nurses can help the woman locate appropriate services and provide much needed psychosocial support, which is often missing in this era of managed care. Myofascial pelvic pain is a major component of CPP in women that is often not properly identified by health care providers. Attempting to reproduce symptoms in the woman who is experiencing CPP by performing a brief musculoskeletal screen and pelvic floor muscle assessment during the medical examination can help establish if a myofascial pain component exists. Chronic pelvic pain affects women of all ages and every socioeconomic class, and occurs amidst a myriad of physical and psychological conditions making a cure challenging. However, successfully treating the MFPP component of CPP is feasible with a comprehensive approach. In addition to addressing the medical, psychological, and sexual concerns, the women’s health practitioner should refer women to a pelvic floor physical therapist who can provide effective treatments, such as skillful manual therapy, biofeedback, and training in self-care strategies to reduce MFPP and improve associated complaints. An interdisciplinary team in which nurses play a critical role is essential for identifying and successfully treating MFPP in women with CPP.