Morrissey, D, et al. Botulism Toxin A Injections Into Pelvic floor Muscles Under Electromyographic Guidance for Women with Refractory High-tone Pelvic Floor Dysfunction: A 6-Month Prospective Pilot Study.

 

Female pelvic med and reconstruct surg 2015, March 18 Epub ahead of print
Additional article for discussion

July 8, 2015 Pelvic PT Distance Journal Club

Jane Franczak

Objective: to examine the efficacy of EMG guided botox for pain and increased QoL for high tone pelvic floor dysfunction (HTPFD).

OnabotulinumtoxinA ( botox) is a neurotoxin which inhibits the release of acetylcholine and leads to ms paralysis. May last 3-6 months. Guidance from EMG can lead to precise location of high tone or TPs to ensure accurate delivery and lead to improved QoL.

Methods: 28 patients, dx HTPFD, tried and failed at l least one other conventional mode of therapy, age 18+

Data collected at 4,8,12, and 24 weeks post injection. Data included demographics, VAS, Global Response Assessment for pelvic pain, validated questionnaires for symptoms, ,QoL, PFDI-20, FSDS and SF-12., vaginal manometry for resting and max contraction of PFMs, digital exam for PFM strength ( modified oxford scale), TPs,

Botox administered under EMG.  ( lodocaine first), 300 U of botox in a 10mL syringe and attached to 12.5 cm disposable monopolar EMG needle electrode. Under transvaginal digital guidance, needle is the inserted through the perineal skin twd spastic PFM TP identified by increased frequency and amplitude EMG oscillations and auditory feedback. then was followed by pudenal nerve block to prevent post op pain.

Results

21 completed study.

mean age 35, BMI 25,

comorbidities IC/PBS (42.9%) and vulvodynia ( 66.7%).

Global response analysis: 61.9% improvement at 4 weeks.  80.9% at 8,12 and 24 wks. Sustained improvement at all visits noted in 57.1%.

Less dyspareunia at 4,8,12 and 24 wks (58.8%, 68.8% 80% and 83.3%. )

Pain during ADLs improved signif only at 24 weeks.

PFDI improvements : POP domain at 12 and 24 wks and urinary domain at 24 weeks.

QoL improved on SF-12 at al postinjextion visits,

Vaginal Manometry: significantly decreased resting Pressures and in max contraction pressures at all f/u visits.

digital assessment: decreased strength at week 4 and 8 and decreased tenderness on all visits .

Adverse effects:

new onset of SUI, new onset constipation, and worsening of preexisting  constipation, SUI ad FI.

discussion........

conclusion

botox seems to have efficacy as measure by improved QoL scores. guided placement may ensure accurate placement of toxin into TPs with elevated resting pressure.

PFM injection = knock out muscle and nerve. do one or other. don't expect UI to happen.

Manometry only has one size - small or large vagina. so resting tone does not make sense.

POP term heaviness falls under domain of POP - but is sometimes used by patient with pelvic pain