A Standard terminology in chronic pelvic pain syndromes: a report from the chronic pelvic pain working group of the international continence society. Doggweiler R, et al. Neurourol and Urodynam 2016 DOI 10.1002/nau.23072.

Pelvic PT Distance Journal Club Oct 5, 2016

Beth Shelly

The following text in black is the exact text in the document.  Red comments added for discussion.  This is only a portion of the entire document. The recording starts with a discussion of the taxonomy at the beginning of the document and the question of what nociceptive, inflammatory and neuropathic types of pain are only listed under visceral pain and not also listed under somatic pain.  The group also discussed the confusion of the terms "centrally generated pain", "hypersensitivity", and "central sensitization". 

 

Signs

Female genital

·         C. Pelvic Floor Muscle (See Domain V Musculoskeletal Pain)

o   Urinary/defecatory dysfunction.

o   Dyspareunia (see also VIII sexual aspects).

o   Pain with sitting.

o   Bulging sensation. ? for pain

Gastro-intestinal

·         2. Levator Ani Syndrome (the term may refer to the same syndrome as ‘‘pelvic floor muscle pain syndrome’’/‘‘tension myalgia of the PFM’’—see Domain V).

o   Pain with sitting. where is the pain and how is it different from PFM pain

o   Pain with defecation.

TABLE V. Musculoskeletal Domain

Common complaints: abdominal/pelvic pain, pain with sitting or with movement or with change of posture, with sexual activity, unilateral or bilateral pain. Possible pain with voiding or bowel evacuation.

A. Pelvic Muscle Pain10,46 (See also Domain IV)

·         Pelvic Floor Muscle Pain (Pelvic Floor Myalgia)FN26 many terms suggested for the same symptoms, which is suggested in current literature?

o   Pain in the muscles of the pelvic floor (perineal or levator ani). ?EAS

·         Intra-pelvic Muscle Pain

o   Pain in the pelvic side wall muscles (obturator internus, piriformis, coccygeus).

·         Anterior Pelvic/Lower Abdominal Muscle Pain

o   Pain in the rectus abdominus, oblique or transverse abdominus muscles, described below the umbilicus.

·         Posterior Pelvic/Buttock Muscle Pain

o   Pain in the gluteal muscles.

 

B. Coccyx Pain Syndrome very unclear what this is

·         Complaint of chronic or recurrent pain in the coccyx or sacro-coccygeal joint.

C. Pelvic Joint, Ligament, or Bony Pain

·         Joint pain

o   Sacroiliac or pubic symphysis joint.

·         Ligament pain

o   Sacro-spinous or Sacro-tuberous ligament.

·         Bony pain

o   Pain described in or along the margins of the pubic ramus, ilium, ischial spine or ischial tuberosity.

 

Signs - no signs related to coccyx or joint pain

C. Pelvic Floor Muscle (See Domain V)

·         Perineal scarring, neuroma, dermal cutaneous allodynia.

·         Tenderness (local and/or referred to another pelvic location).

·         Vaginal discharge, mesh extrusion.53

·         Bulging.

·         Mass, radiation changes.

Levator Ani Syndrome—Identification of tenderness during posterior traction on the puborectalis.

 

V. Musculoskeletal

The musculoskeletal structures are examined for signs of tenderness and altered tension or abnormal movement.73–76 FN31

·         FN31Varying reliability has been found from pelvic floor muscle (PFM) studies assessing pain and tension using digital palpation scales.73–76 Patients who present with alteration in the musculoskeletal structure need to be referred to a Physical Therapist well trained in the treatment of CPPS.

 

1. Muscle tone: State of the muscle, usually defined by its resting tension, clinically determined by resistance to passive movement. Muscle tone has two components:

(i) the contractile component, created by a low-frequency activation of a small number of motor

units;

(ii) the viscoelastic component, which is independent of neural activity and reflects the passive physical properties of the elastic tension of the muscle fiber elements and the osmotic pressure of cells.46

In normally innervated skeletal muscle, tone is comprised of both ‘‘active’’ (contractile) and ‘‘passive’’ (viscoelastic) components.46,77,78 FN32

·         FN32Muscle tone is evaluated clinically as the resistance provided by a muscle when a pressure/deformation or a stretch is applied to it46,77,78Muscle tone may be altered in the presence or absence of pain. There is no single accepted or standardized way of measuring muscle tone, and there are no normative values.

a. Hypertonicity is a general increase in muscle tone that can be associated with either elevated contractile activity and/or passive stiffness in the muscle.5,77–79 FN33

·         FN33As ‘‘hypertonicity’’ can also be used to describe increased muscle tone of neurogenic origin, the term ‘‘increased tone’’ is preferred when the cause is non-neurogenic. which term is suggested? increased tone, hypertonicity, or overactive PFM

b. Hypotonicity is a general decrease in muscle tone that can be associated with either reduced contractile activity and/or passive stiffness in the muscle.FN34 As the cause is often unknown, the terms neurogenic hypotonicity and non-neurogenic hypotonicity are recommended.

·         FN34As ‘‘hypotonicity’’ can also be used to describe decreased muscle tone of neurogenic origin, the term ‘‘decreased tone’’ is preferred when the cause is nonneurogenic. many terms hear, not clear which one is being suggested, what about underactive PFM

2. Stiffness: Stiffness is the resistance to deformation.80,81 FN35

·         FN35 Passive elastic stiffness is defined as the ratio of the change in the passive resistance or passive force (DF) what does DF stand for? passive force?  and is it a abbreviation used in the literature?  to the change in the length displacement (DL) or DF/ DL.81 The term should only be used if stiffness is measured quantitatively such as with instruments like dynamometry or myotonometry.

3. Compliance: Passive compliance is defined as the reciprocal of muscle stiffness.80,81 FN36

·         FN36 It represents the compressibility of a muscle, clinically assessed by pressing a finger into it (palpation) to determine how easily it is indented and how ‘‘springy’’ it is.

4. Tension: may have a similar meaning to tone and stiffness.FN37 when do we use this term?

·         FN37Muscle tension can be increased or decreased due to exogenous factors such as the amount of pressure applied and endogenous factors such as thickness/ cross sectional area of the muscle itself, fluid present within the muscle (swelling, inflammation), position (e.g., standing vs. sitting) or increased neural activity.

5. Spasm: persistent contraction of striated muscle that cannot be released voluntarily.82 FN38

·         FN38 Occurs at irregular intervals with variable frequency and extent. Spasm over days or weeks may lead to a contracture. is this neurologically driven

a. Contracture: is an involuntary shortening tightening of a muscle. Clinically, a muscle cramp and contracture may appear similar, however contractures are electrically silent.83

6. Cramp: a muscle cramp is a painful involuntary muscle contraction that occurs suddenly and can be temporarily debilitating.83,84 FN39

·         FN39 Pain is intense and localized. It tends to occur when the muscle is in the shortened position and contracting, is generated by the motor unit, and displays a high firing rate (20–150 Hz).83 Muscle cramp either during or immediately after exercise is commonly referred to as ‘‘exercise- associated muscle cramping.’’84 However, cramps are not specific to exercise.

7. Fasciculation: A fasciculation is a single, spontaneous, involuntary discharge of an individual motor unit.83 FN40

·         FN40The source generator is the motor unit or its axon, prior to its terminal branches. Fasciculations display an irregular firing pattern of low frequency (0.1–10 Hz).83 Clinically, fasciculations are recognized as individual brief twitches. They may occur at rest or after muscle contraction and may last several minutes.

8. Tender point: tenderness to palpation at soft tissue body sites.46

9. Trigger point (TrP): a tender, taut band of muscle that can be painful spontaneously or when stimulated.85 The taut band is electrically silent. Local or referred pain may be reproduced.86 FN41

·         FN41An active TrP is said to have a characteristic ‘‘twitch’’ response when stimulated; however, the twitch response to palpation has been shown to be unreliable. The most reliable sign of a TrP is sensitivity to applied pressure.86

Examination

C. Pelvic Floor Muscle

·         1. Questionnaires.

o   Visual Analog Scale for pain.86

o   Pelvic Floor Distress Inventory (PFDI).110

o   Prolapse and Incontinence Sexual Questionnaire (PISQ).111 ? for pain?

·         2. Laboratory Testing - for what?

o   Wet Mount, Culture.

o   Biopsy.

·         3. Imaging References

o   Ultrasound (4D if available for visualization of mesh, where applicable).

o   MRI (with or without defecography).

o   Defecography.

V Musculoskeletal 117

·         1. Questionnaires

o   McGill Pain Questionnaire.118

o   Pelvic Floor Distress Inventory (PFDI).110

o   Female Sexual Function Index (FSFI).61

o   Female Sexual Distress Scale (FSDS).107

·         2. Pain Location Drawing (Pain Mapping)

o   Pain Chart body map.87

·         3. Evaluation of Muscle Tension There is no single tool which is able to measure all components of muscle tone. Some tools may be able to measure aspects of tone such as contractility, stiffness or elasticity. Instrumented methods may have a role in the valid and reliable evaluation of muscle tone, for example, surface electromyography, dynamometry, real-time ultrasound, elastometry, myotonometry.

o   Pressure manometry is the measurement of resting pressure or pressure rise generated during contraction of the pelvic floor muscles using a pressure device (a manometer) inserted into the urethra, vagina or anus.119,120 FN58

§  FN58The tool has been used as an outcome measure in intervention studies of pelvic floor pain.119,120 However, the tool has not been tested for reliability in this population. ? in the vaginal canal?

o   Surface electromyography (sEMG) refers to the bioelectrical activity generated by muscle fibres.121,122 FN59

§  FN59 Pelvic floor muscle surface electrodes use either flat interface perineal electrodes or intra-vaginal/intra-anal probes to record sEMG either at rest or during a PFM contraction. Surface EMG is considered to be non-specific to the PFM. Because of the large surface area covered by the electrode, cross-talk from adjacent muscles often occurs.121,122 It is therefore not considered reliable as a measure.

o   Dynamometry is the measurement of pelvic floor muscle resting and contractile forces using strain gauges mounted on a speculum (a dynamometer), which is inserted into the vagina.123

o   Real-time ultrasound measures pelvic floor muscle morphology and function via a non-invasive (trans-abdominal or trans-perineal) probe.124 FN60

§  FN60 Trans-perineal measures of ano-rectal angle and levator plate angle have been tested for reliability in a male pelvic pain population.124Therefore, this tool shows promise as an instrumented method to evaluate pelvic floor muscle changes in pelvic pain.

o   Elastometry measures the elasticity of a tissue.125 FN61

§  FN61 It has recently been applied to measure the passive stiffness of puborectalis in asymptomatic women and shown to be reliable in this pilot study125However, it requires testing to establish application in a pelvic pain cohort.

·         4. Trigger point injection or needling has been used as a diagnostic test to identify pain generators.125 FN62

o   FN62The taut band(s) of sarcomeres within the TrP can be identified by ultrasonography.126 and magnetic resonance elastography.127 A tissue compliance meter which measures stiffness in the taut band has been shown to confirm the hardness of the discrete band of muscle that harbors the tender region in peripheral skeletal muscle.128

·         5. Imaging

o   X-Ray.

o   Ultrasound.

o   MRI.