Download PDF
Semin Reprod Med 2017; 35(01): 088-097
DOI: 10.1055/s-0036-1597123
Review Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Relating Chronic Pelvic Pain and Endometriosis to Signs of Sensitization and Myofascial Pain and Dysfunction

Jacqueline V. Aredo
1   National Institute of Neurological Disorders and Stroke, Clinical Center, Intramural Research Program NIH, Bethesda, Maryland
,
Katrina J. Heyrana
2   Department of Obstetrics and Gynecology, University of Rochester Medical Center, Rochester, New York
,
Barbara I. Karp
1   National Institute of Neurological Disorders and Stroke, Clinical Center, Intramural Research Program NIH, Bethesda, Maryland
,
Jay P. Shah
3   Rehabilitation Medicine Department, Clinical Center, Intramural Research Program NIH, Bethesda, Maryland
,
Pamela Stratton
1   National Institute of Neurological Disorders and Stroke, Clinical Center, Intramural Research Program NIH, Bethesda, Maryland
› Author Affiliations
Further Information

Publication History

Publication Date:
03 January 2017 (online)

    Permissions and Reprints

Abstract

Chronic pelvic pain is a frustrating symptom for patients with endometriosis and is frequently refractory to hormonal and surgical management. While these therapies target ectopic endometrial lesions, they do not directly address pain due to central sensitization of the nervous system and myofascial dysfunction, which can continue to generate pain from myofascial trigger points even after traditional treatments are optimized. This article provides a background for understanding how endometriosis facilitates remodeling of neural networks, contributing to sensitization and generation of myofascial trigger points. A framework for evaluating such sensitization and myofascial trigger points in a clinical setting is presented. Treatments that specifically address myofascial pain secondary to spontaneously painful myofascial trigger points and their putative mechanisms of action are also reviewed, including physical therapy, dry needling, anesthetic injections, and botulinum toxin injections.

Keywords

endometriosis - chronic pelvic pain - sensitization - myofascial trigger points - botulinum toxin
 

  • References

  • 1 Practice bulletin no. 114: management of endometriosis. Obstet Gynecol 2010; 116 (1) 223-236
    CrossrefPubMedGoogle Scholar
  • 2 Vercellini P, Fedele L, Aimi G, Pietropaolo G, Consonni D, Crosignani PG. Association between endometriosis stage, lesion type, patient characteristics and severity of pelvic pain symptoms: a multivariate analysis of over 1000 patients. Hum Reprod 2007; 22 (1) 266-271
    CrossrefPubMedGoogle Scholar
  • 3 Hsu AL, Sinaii N, Segars J, Nieman LK, Stratton P. Relating pelvic pain location to surgical findings of endometriosis. Obstet Gynecol 2011; 118 (2, Pt 1) 223-230
    CrossrefPubMedGoogle Scholar
  • 4 Institute of Medicine (US) Committee on Pain D, and Chronic Illness Behavior. The Anatomy and Physiology of Pain. In: Osterweis M, Kleinman A, Mechanic D, , eds. Pain and Disability: Clinical, Behavioral, and Public Policy Perspectives. Washington, DC: National Academy Press; 1987: 123-145
    Google Scholar
  • 5 Latremoliere A, Woolf CJ. Central sensitization: a generator of pain hypersensitivity by central neural plasticity. J Pain 2009; 10 (9) 895-926
    CrossrefPubMedGoogle Scholar
  • 6 Stratton P, Berkley KJ. Chronic pelvic pain and endometriosis: translational evidence of the relationship and implications. Hum Reprod Update 2011; 17 (3) 327-346
    CrossrefPubMedGoogle Scholar
  • 7 Burnstock G. Autonomic neurotransmission: 60 years since sir Henry Dale. Annu Rev Pharmacol Toxicol 2009; 49: 1-30
    CrossrefPubMedGoogle Scholar
  • 8 May K, Becker CM. Endometriosis and angiogenesis. Minerva Ginecol 2008; 60 (3) 245-254
    PubMedGoogle Scholar
  • 9 Raab S, Plate KH. Different networks, common growth factors: shared growth factors and receptors of the vascular and the nervous system. Acta Neuropathol 2007; 113 (6) 607-626
    CrossrefPubMedGoogle Scholar
  • 10 Pezet S, McMahon SB. Neurotrophins: mediators and modulators of pain. Annu Rev Neurosci 2006; 29: 507-538
    CrossrefPubMedGoogle Scholar
  • 11 Anaf V, Simon P, El Nakadi I , et al. Hyperalgesia, nerve infiltration and nerve growth factor expression in deep adenomyotic nodules, peritoneal and ovarian endometriosis. Hum Reprod 2002; 17 (7) 1895-1900
    CrossrefPubMedGoogle Scholar
  • 12 Tokushige N, Markham R, Russell P, Fraser IS. Nerve fibres in peritoneal endometriosis. Hum Reprod 2006; 21 (11) 3001-3007
    CrossrefPubMedGoogle Scholar
  • 13 Berkley KJ, Dmitrieva N, Curtis KS, Papka RE. Innervation of ectopic endometrium in a rat model of endometriosis. Proc Natl Acad Sci U S A 2004; 101 (30) 11094-11098
    CrossrefPubMedGoogle Scholar
  • 14 Berkley KJ, Rapkin AJ, Papka RE. The pains of endometriosis. Science 2005; 308 (5728) 1587-1589
    CrossrefPubMedGoogle Scholar
  • 15 Mechsner S, Kaiser A, Kopf A, Gericke C, Ebert A, Bartley J. A pilot study to evaluate the clinical relevance of endometriosis-associated nerve fibers in peritoneal endometriotic lesions. Fertil Steril 2009; 92 (6) 1856-1861
    Google Scholar
  • 16 Snider WD, McMahon SB. Tackling pain at the source: new ideas about nociceptors. Neuron 1998; 20 (4) 629-632
    CrossrefPubMedGoogle Scholar
  • 17 Beste MT, Pfäffle-Doyle N, Prentice EA , et al. Molecular network analysis of endometriosis reveals a role for c-Jun-regulated macrophage activation. Sci Transl Med 2014; 6 (222) 222ra16
    Google Scholar
  • 18 Anaf V, Chapron C, El Nakadi I, De Moor V, Simonart T, Noël JC. Pain, mast cells, and nerves in peritoneal, ovarian, and deep infiltrating endometriosis. Fertil Steril 2006; 86 (5) 1336-1343
    CrossrefPubMedGoogle Scholar
  • 19 Willard F., Basic Mechanisms of Pain. In: Audette JF, Bailey A. , eds. Integrative Pain Medicine: The Science and Practice of Complementary and Alternative Medicine in Pain Management. Totowa, NJ: Humana Press; 2008: 19-61
    Google Scholar
  • 20 Sauer SK, Reeh PW, Bove GM. Noxious heat-induced CGRP release from rat sciatic nerve axons in vitro. Eur J Neurosci 2001; 14 (8) 1203-1208
    CrossrefPubMedGoogle Scholar
  • 21 Saria A. Substance P in sensory nerve fibres contributes to the development of oedema in the rat hind paw after thermal injury. Br J Pharmacol 1984; 82 (1) 217-222
    CrossrefPubMedGoogle Scholar
  • 22 Chiu IM, von Hehn CA, Woolf CJ. Neurogenic inflammation and the peripheral nervous system in host defense and immunopathology. Nat Neurosci 2012; 15 (8) 1063-1067
    CrossrefPubMedGoogle Scholar
  • 23 Gebhart GF. J.J. Bonica Lecture--2000: physiology, pathophysiology, and pharmacology of visceral pain. Reg Anesth Pain Med 2000; 25 (6) 632-638
    PubMedGoogle Scholar
  • 24 Cervero F, Tattersall JE. Somatic and visceral sensory integration in the thoracic spinal cord. Prog Brain Res 1986; 67: 189-205
    PubMedGoogle Scholar
  • 25 Jänig W, Morrison JF. Functional properties of spinal visceral afferents supplying abdominal and pelvic organs, with special emphasis on visceral nociception. Prog Brain Res 1986; 67: 87-114
    PubMedGoogle Scholar
  • 26 Schwartz ES, Gebhart GF. Visceral pain. Curr Top Behav Neurosci 2014; 20: 171-197
    PubMedGoogle Scholar
  • 27 Rogers JR. Basic pelvic neuroanatomy. In: Steege JF, Metzger DA, Levy BS, , eds. Chronic Pelvic Pain: An Integrated Approach. Philadelphia: W.B. Saunders Company; 1998: 31-58
    Google Scholar
  • 28 Sugiura Y, Tonosaki Y. Spinal organization of unmyelinated visceral afferent fibers in comparison with somatic afferent fibers. In: Gebhart GF, , ed. Visceral Pain: Progress in Pain Research and Management Series. Vol 5. Seattle, WA: IASP Press; 1995: 41-59
    Google Scholar
  • 29 Nagabukuro H, Berkley KJ. Influence of endometriosis on visceromotor and cardiovascular responses induced by vaginal distention in the rat. Pain 2007; 132 (Suppl. 01) S96-S103
    CrossrefPubMedGoogle Scholar
  • 30 Jarrell J. Myofascial dysfunction in the pelvis. Curr Pain Headache Rep 2004; 8 (6) 452-456
    CrossrefPubMedGoogle Scholar
  • 31 Willard FH. Nociception, the neuroendocrine immune system, and osteopathic medicine. In: Ward RC, Hruby RJ, Jerome JA, , eds. Foundations for Osteopathic Medicine. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2003: 137-156
    Google Scholar
  • 32 Patterson MM, Wurster RD. Neurophysiologic mechanisms of integration and disintegration. In: Ward RC, Hruby RJ, Jerome JA, , eds. Foundations for Osteopathic Medicine. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2003: 1370-1156
    Google Scholar
  • 33 Butrick CW. Discordant urination and defecation as symptoms of pelvic floor dysfunction. In: Howard FM, , ed. Pelvic Pain: Diagnosis and Management. Philadelphia, PA: Lippincott Williams & Wilkins; 2000: 280-299
    Google Scholar
  • 34 Simons DG. Clinical and etiological update of myofascial pain from trigger points. J Musculoskeletal Pain 1996; 4 (1–2) 93-122
    CrossrefPubMedGoogle Scholar
  • 35 Simons DG, Travell JG, Simons LS. Myofascial Pain and Dysfunction: The Trigger Point Manual. Vol 1. 2nd ed. Baltimore, MD: Williams & Wilkins; 1999
    Google Scholar
  • 36 Simons DG, Travell JG, Simons LS. Myofascial Pain and Dysfunction: The Trigger Point Manual. Vol 2. Baltimore, MD: Williams & Wilkins; 1992
    Google Scholar
  • 37 Pastore EA, Katzman WB. Recognizing myofascial pelvic pain in the female patient with chronic pelvic pain. J Obstet Gynecol Neonatal Nurs 2012; 41 (5) 680-691
    CrossrefPubMedGoogle Scholar
  • 38 Stratton P, Khachikyan I, Sinaii N, Ortiz R, Shah J. Association of chronic pelvic pain and endometriosis with signs of sensitization and myofascial pain. Obstet Gynecol 2015; 125 (3) 719-728
    CrossrefPubMedGoogle Scholar
  • 39 Moldwin RM, Fariello JY. Myofascial trigger points of the pelvic floor: associations with urological pain syndromes and treatment strategies including injection therapy. Curr Urol Rep 2013; 14 (5) 409-417
    CrossrefPubMedGoogle Scholar
  • 40 Gerwin RD. Myofascial and visceral pain syndromes: visceral-somatic pain representations. J Musculoskeletal Pain 2002; 10 (1–2) 165-175
    CrossrefPubMedGoogle Scholar
  • 41 Woolf CJ. Central sensitization: implications for the diagnosis and treatment of pain. Pain 2011; 152 , (3 Suppl): S2-S15
    Google Scholar
  • 42 Shah JP, Thaker N, Heimur J, Aredo JV, Sikdar S, Gerber L. Myofascial trigger points then and now: a historical and scientific perspective. PM R 2015; 7 (7) 746-761
    CrossrefPubMedGoogle Scholar
  • 43 Carter JE. Abdominal wall and pelvic myofascial trigger points. In: Howard FM, , ed. Pelvic Pain: Diagnosis & Management. Philadelphia, PA: Lippincott Williams & Wilkins; 2000: 314-358
    Google Scholar
  • 44 Desai MJ, Saini V, Saini S. Myofascial pain syndrome: a treatment review. Pain Ther 2013; 2 (1) 21-36
    CrossrefPubMedGoogle Scholar
  • 45 Bedaiwy MA, Patterson B, Mahajan S. Prevalence of myofascial chronic pelvic pain and the effectiveness of pelvic floor physical therapy. J Reprod Med 2013; 58 (11-12) 504-510
    PubMedGoogle Scholar
  • 46 Ay S, Evcik D, Tur BS. Comparison of injection methods in myofascial pain syndrome: a randomized controlled trial. Clin Rheumatol 2010; 29 (1) 19-23
    CrossrefPubMedGoogle Scholar
  • 47 Montenegro ML, Braz CA, Rosa-e-Silva JC, Candido-dos-Reis FJ, Nogueira AA, Poli-Neto OB. Anaesthetic injection versus ischemic compression for the pain relief of abdominal wall trigger points in women with chronic pelvic pain. BMC Anesthesiol 2015; 15: 175
    CrossrefPubMedGoogle Scholar
  • 48 Langford CF, Udvari Nagy S, Ghoniem GM. Levator ani trigger point injections: An underutilized treatment for chronic pelvic pain. Neurourol Urodyn 2007; 26 (1) 59-62
    CrossrefPubMedGoogle Scholar
  • 49 Kim DS, Jeong TY, Kim YK, Chang WH, Yoon JG, Lee SC. Usefulness of a myofascial trigger point injection for groin pain in patients with chronic prostatitis/chronic pelvic pain syndrome: a pilot study. Arch Phys Med Rehabil 2013; 94 (5) 930-936
    CrossrefPubMedGoogle Scholar
  • 50 Karp BI. Botulinum toxin treatment of occupational and focal hand dystonia. Mov Disord 2004; 19 (Suppl. 08) S116-S119
    CrossrefPubMedGoogle Scholar
  • 51 Münchau A, Bhatia KP. Uses of botulinum toxin injection in medicine today. BMJ 2000; 320 (7228) 161-165
    CrossrefPubMedGoogle Scholar
  • 52 Göbel H, Heinze A, Reichel G, Hefter H, Benecke R ; Dysport myofascial pain study group. Efficacy and safety of a single botulinum type A toxin complex treatment (Dysport) for the relief of upper back myofascial pain syndrome: results from a randomized double-blind placebo-controlled multicentre study. Pain 2006; 125 (1-2) 82-88
    CrossrefPubMedGoogle Scholar
  • 53 Harden RN, Cottrill J, Gagnon CM , et al. Botulinum toxin a in the treatment of chronic tension-type headache with cervical myofascial trigger points: a randomized, double-blind, placebo-controlled pilot study. Headache 2009; 49 (5) 732-743
    CrossrefPubMedGoogle Scholar
  • 54 Kwanchuay P, Petchnumsin T, Yiemsiri P, Pasuk N, Srikanok W, Hathaiareerug C. Efficacy and safety of single botulinum toxin type A (Botox®) injection for relief of upper trapezius myofascial trigger point: a randomized, double-blind, placebo-controlled study. J Med Assoc Thai 2015; 98 (12) 1231-1236
    PubMedGoogle Scholar
  • 55 Montal M. Botulinum neurotoxin: a marvel of protein design. Annu Rev Biochem 2010; 79: 591-617
    CrossrefPubMedGoogle Scholar
  • 56 Abbott JA, Jarvis SK, Lyons SD, Thomson A, Vancaille TG. Botulinum toxin type A for chronic pain and pelvic floor spasm in women: a randomized controlled trial. Obstet Gynecol 2006; 108 (4) 915-923
    CrossrefPubMedGoogle Scholar
  • 57 Petersen CD, Giraldi A, Lundvall L, Kristensen E. Botulinum toxin type A-a novel treatment for provoked vestibulodynia? Results from a randomized, placebo controlled, double blinded study. J Sex Med 2009; 6 (9) 2523-2537
    CrossrefPubMedGoogle Scholar
  • 58 Ghazizadeh S, Nikzad M. Botulinum toxin in the treatment of refractory vaginismus. Obstet Gynecol 2004; 104 (5, Pt 1) 922-925
    CrossrefPubMedGoogle Scholar
  • 59 Jarvis SK, Abbott JA, Lenart MB, Steensma A, Vancaillie TG. Pilot study of botulinum toxin type A in the treatment of chronic pelvic pain associated with spasm of the levator ani muscles. Aust N Z J Obstet Gynaecol 2004; 44 (1) 46-50
    CrossrefPubMedGoogle Scholar
  • 60 Bertolasi L, Frasson E, Cappelletti JY, Vicentini S, Bordignon M, Graziottin A. Botulinum neurotoxin type A injections for vaginismus secondary to vulvar vestibulitis syndrome. Obstet Gynecol 2009; 114 (5) 1008-1016
    CrossrefPubMedGoogle Scholar
  • 61 Nesbitt-Hawes EM, Won H, Jarvis SK, Lyons SD, Vancaillie TG, Abbott JA. Improvement in pelvic pain with botulinum toxin type A—single vs. repeat injections. Toxicon 2013; 63: 83-87
    CrossrefPubMedGoogle Scholar
  • 62 Morrissey D, El-Khawand D, Ginzburg N, Wehbe S, O'Hare III P, Whitmore K. Botulinum 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 Reconstr Surg 2015; 21 (5) 277-282
    CrossrefPubMedGoogle Scholar
  • 63 Adelowo A, Hacker MR, Shapiro A, Modest AM, Elkadry E. Botulinum toxin type A (BOTOX) for refractory myofascial pelvic pain. Female Pelvic Med Reconstr Surg 2013; 19 (5) 288-292
    CrossrefPubMedGoogle Scholar
  • 64 Romito S, Bottanelli M, Pellegrini M, Vicentini S, Rizzuto N, Bertolasi L. Botulinum toxin for the treatment of genital pain syndromes. Gynecol Obstet Invest 2004; 58 (3) 164-167
    CrossrefPubMedGoogle Scholar
  • 65 Brin MF, Vapnek JM. Treatment of vaginismus with botulinum toxin injections. Lancet 1997; 349 (9047) 252-253
    PubMedGoogle Scholar
  • 66 Thomson AJ, Jarvis SK, Lenart M, Abbott JA, Vancaillie TG. The use of botulinum toxin type A (BOTOX) as treatment for intractable chronic pelvic pain associated with spasm of the levator ani muscles. BJOG 2005; 112 (2) 247-249
    CrossrefPubMedGoogle Scholar
  • 67 Park AJ, Paraiso MF. Successful use of botulinum toxin type a in the treatment of refractory postoperative dyspareunia. Obstet Gynecol 2009; 114 (2, Pt 2) 484-487
    CrossrefPubMedGoogle Scholar
  • 68 Pellett S, Yaksh TL, Ramachandran R. Current status and future directions of botulinum neurotoxins for targeting pain processing. Toxins (Basel) 2015; 7 (11) 4519-4563
    CrossrefPubMedGoogle Scholar
  • 69 Shah JP, Phillips TM, Danoff JV, Gerber LH. An in vivo microanalytical technique for measuring the local biochemical milieu of human skeletal muscle. J Appl Physiol (1985) 2005; 99 (5) 1977-1984
    CrossrefPubMedGoogle Scholar
  • 70 Shah JP, Danoff JV, Desai MJ , et al. Biochemicals associated with pain and inflammation are elevated in sites near to and remote from active myofascial trigger points. Arch Phys Med Rehabil 2008; 89 (1) 16-23
    CrossrefPubMedGoogle Scholar
  • 71 Shah JP, Gilliams EA. Uncovering the biochemical milieu of myofascial trigger points using in vivo microdialysis: an application of muscle pain concepts to myofascial pain syndrome. J Bodyw Mov Ther 2008; 12 (4) 371-384
    CrossrefPubMedGoogle Scholar