Pelvic Floor Tension Myalgia (PFTM)
Chronic pelvic and rectal pain is a common and frustrating problem for many patients. It has been shown that the prevalence is almost 15% in some patient populations.1 The etiology of the pain is often unknown despite extensive work-up. In some of these patients, the cause of the pain is secondary to the pelvic floor muscles. Despite the prevalence of chronic pelvic and rectal pain, the muscles of the pelvic floor are often overlooked as a source of the discomfort. This muscular pain has been referred to by numerous names in the literature including coccygodynia, levator spasm syndrome, levator ani syndrome, spastic pelvic floor syndrome, diaphragma pelvis spastica, and pelvic floor tension myalgia.2,3,4,5,6 All of these terms refer to a similar set of symptoms and clinical findings. The authors prefer the term “pelvic floor tension myalgia” (PFTM), as it seems to most accurately describe the syndrome.
PFTM affects women more often than men, and patients are frequently in their fourth to sixth decade of life.2,3,6 In a survey of over 5,000 women aged 18-50 years, Mathias et al found that 14.7% reported chronic pelvic pain (sustained over six months) within the past three months.1 Additionally, Drossman et al reported that 6.6% of people in their survey had symptoms consistent with “levator syndrome.”7
While the etiology of PFTM is unknown, pelvic floor muscle spasm is thought to play a key role, although there is no EMG study definitely showing this. Hypotheses have included genitourinary inflammation, poor posture, rectal disorders, pudendal nerve entrapment, trauma, reaction to pelvic organ disease, post-surgical scarring, central pain sensitization, and psychological factors as contributing to PFTM.
“Symptoms are often vague and difficult to localize, but patients classically complain of pain, pressure, or discomfort in the rectum, pelvis, sacrum, or coccyx. Symptoms are typically present for months to years at the time of diagnosis.6”
Symptoms are often vague and difficult to localize, but patients classically complain of pain, pressure, or discomfort in the rectum, pelvis, sacrum, or coccyx. Symptoms are typically present for months to years at the time of diagnosis.6 Other complaints may include a feeling of heaviness in the pelvis, low back pain, thigh pain, and dyspareunia. Patients may notice that the symptoms are worse with prolonged sitting, physical activity, bowel movements, menses, or psychological or general physical tension. Some investigators have noted that the left side is more commonly affected for unknown reasons.3 On physical examination, patients have extreme muscular tenderness of one or more of the pelvic floor muscles (ileococcygeus, pubococcygeus, puborectalis, coccygeus) during digital rectal and/or vaginal examination. The examiner must attempt to palpate each of the muscles bilaterally for a complete exam. While most patients will find digital rectal exam uncomfortable, the discomfort should reproduce the patient’s pain and is often quite striking. It must be emphasized that PFTM is a diagnosis of exclusion, made only after gynecologic, urogenital, gastrointestinal, infectious, and neurologic causes have been ruled out.
A 55 year-old female presented to the emergency department with a two-week history of worsening sacrococcygeal area pain radiating into her buttocks, predominately on the left side. The pain had been getting progressively worse, and was rated as a 6 on a scale of 10 — even while taking scheduled oxycodone. The pain was worse lying supine, and improved with standing. She had a past medical history notable for stage IIB squamous cell carcinoma of the cervix, and had received radiation and chemotherapy treatment two years ago. She was admitted to the hospital and started on a fentanyl PCA and fentanyl patch for pain control, but continued to have significant pain. Diazepam was then given with moderate, although short-term, pain relief. Gynecology and gastroenterology consults were obtained, but no source of her pain was found on exam. Neurologic exam was normal. Work-up included a MRI of the pelvis, bone scan, flexible sigmoidoscopy, pap smear, urinalysis/urine culture, and transvaginal pelvic ultrasound. None of these studies identified a source for the patient’s pain. A physical medicine and rehabilitation consult was then ordered and completed by one of the authors (S.W.). The patient’s exam was notable for mild left sacroiliac joint pain on palpation, and extremely severe pain on rectal examination with palpation of the left pubococcygeal muscle. The patient stated that this reproduced her pain, and the diagnosis of pelvic floor tension myalgia was made. Physical therapy, consisting of EMG biofeedback relaxation, superficial heat, myofascial release, TENS unit trial, neuro-muscular re-education, and posture training, was initiated. During the first three days of treatment, the patient was able to discontinue the fentanyl PCA and fentanyl patch, and was discharged from the hospital with oral pain medications. She continued with outpatient physical therapy treatments with gradually increasing intervals between sessions, and has continued to have excellent relief over the course of three months.
Treatment of PFTM is often quite challenging, with numerous treatments showing moderate success. Treatment for PFTM in the literature has been quite diverse. A combined approach with multiple simultaneous forms of treatment seems to be most beneficial in these patients and may include:
- High-voltage electrogalvanic stimulation (HVGS)
- Short Wave Diathermy
- Other (relaxation therapies, cognitive behavioral therapy, ultrasound, sitz baths, posture training, hydrotherapy, strengthening exercises, and TENS units)
A discussion of each of the above modalities follows.
Thiele was first to describe muscle spasm of the levator ani and coccygeus muscles as a source of pelvic pain.2 He called this “coccygodynia” even though he noted that the coccyx was non-tender on palpation. He treated these patients with transrectal massage of the affected muscles along with proper sitting posture. Massage was performed daily for five or six days, then every other day for a week or ten days, then with a gradual weaning. The massage consisted of applying as much pressure as the patient could tolerate along the fibers of the pelvic floor muscles. Each side of the pelvis was massaged 10 to 15 times during one session. In a study of 324 patients, he reported 62% had a successful outcome with massage only. Individual studies on massage are lacking. In a retrospective study by Sinaki, “Thiele’s massage” resulted in at least mild improvement in symptoms in 76 out of 83 patients, although numerous other treatments were used in these patients as well.6