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ABSTRACT & COMMENTARY
By Chiara Ghetti, MD
Associate Professor, Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Washington University School of Medicine, St. Louis, MO
Dr. Ghetti reports no financial relationships relevant to this field of study.
SYNOPSIS: Levator myalgia is a prevalent condition in women presenting with pelvic floor symptoms and is associated with greater symptom bother. Fibromyalgia is associated with an increased risk of levator ani myalgia in women presenting with prolapse.
SOURCE: Adams K, et al. Does fibromyalgia influence symptom bother from pelvic organ prolapse? Int Urogynecol J 2014;25:677-682.
The objective of this study was to determine whether women with fibromyalgia experience increased bother from pelvic floor disorders compared to women without fibromyalgia. This was a retrospective cross-sectional study of 1113 women presenting for urogynecologic evaluation over a 46-month period. The main outcome of this study was to compare mean Pelvic Floor Distress Inventory (PFDI) scores in women with prolapse with and without fibromyalgia. The PFDI is a 46-item, self-reported, validated, condition-specific questionnaire that assesses presence or absence of pelvic floor disorder symptoms as well as symptom-associated bother.1 Secondary outcomes included several based on physical examination: anatomical extent of prolapse, the presence of levator ani myalgia and vulvodynia, as well as self-reported history of sexual abuse and depression. Anatomical extent of prolapse was assessed using the leading edge of prolapse or the largest anterior, posterior, or apical measurement as measured by the Pelvic Organ Prolapse Quantification examination. Levator ani myalgia and vulvodynia were routinely assessed by physical examination. For the purpose of this study, levator ani myalgia was defined as any pain with light palpation of any of the pelvic floor muscle groups.2 Vulvodynia was defined as pain with the light touch of a cotton swab at any point along the distribution of the vestibule or vulva. PFDI scores were compared between women with prolapse with and without fibromyalgia. Multiple linear regression modeling was used to investigate the effect of depression and levator ani myalgia on the relationship between fibromyalgia and symptom bother scores while adjusting for body mass index (BMI).
The study recruited 1113 women who presented for urogynecologic consultation at a community-based urogynecology practice over a 46-month time period. Four hundred seventeen (37%) reported prolapse symptoms. Of these, 43 (7%) reported a history of fibromyalgia. Participants’ mean age was 58 (standard deviation [SD] 12.7) years. BMI varied between groups, with women with fibromyalgia having higher BMI (30.5 kg/m2; SD 8.4) compared to women without fibromyalgia (27.6 kg/m2; SD 5.3; P = 0.006). Among women with prolapse symptoms, women with fibromyalgia reported about 50% more pelvic floor symptom bother as measured by validated pelvic floor questionnaires. Despite having more symptom bother, women with fibromyalgia had less severe anatomical prolapse as measured by the leading edge of prolapse. Average leading edge was 0.3 cm outside the hymen (SD 1.7) in women with fibromyalgia vs 0.9 cm outside the hymen (SD 1.8) in women without fibromyalgia (P = 0.045). Women with fibromyalgia were more likely to have levator ani myalgia (36%) compared to women without fibromyalgia (13%). Multivariable logistic regression found that pelvic floor symptom bother was significantly related to fibromyalgia, but even more so related to levator ani myalgia. In addition, levator ani myalgia was more associated with measurements of symptom bother than anatomical extent of prolapse.
Fibromyalgia is a common chronic condition characterized by widespread muscle pain and may also include fatigue, sleep disturbances, cognitive dysfunction, and mood disturbance.3 It is more common in women than men. In the United States, it affects more than 5 million individuals (2-5% of the adult population),3 and it is the most common cause of generalized musculoskeletal pain in women between 20 and 55 years.4 It has been estimated that women have an 11-19% lifetime risk for undergoing surgery for prolapse or incontinence.5,6 Levator ani myalgia is characterized by hypertonic and shortened pelvic floor muscles, often with myofascial trigger points.7 It is known to contribute to chronic pelvic pain. The authors previously reported that levator ani myalgia is a prevalent condition in urogynecology practice and is associated with an increase in pelvic floor symptom bother including urinary, defecatory, and prolapse symptoms.8
This study, alongside the previously published study by the authors, brings to light a very important relationship between pelvic floor muscular pain and women’s experience of pelvic floor symptoms including urinary, defecatory, as well as prolapse symptoms. Many studies have explored the absence of a linear relationship between anatomic prolapse and symptom bother. The authors present the important contribution of pelvic floor muscle pain in the perception of pelvic floor symptom bother. Levator ani myalgia remains under-recognized, under-treated, and under-studied.
I was fortunate to have been taught the evaluation of pelvic floor musculature as part of a systematic urogynecologic evaluation, and anecdotally and clinically I witness the relationship between pelvic floor muscle pain and pelvic floor symptoms on a daily basis. The authors’ findings highlight for clinicians the important role that pelvic floor muscle health plays in the perception of pelvic floor disorders. Evaluating the pelvic floor musculature is an essential step in the evaluation and treatment of women with pelvic floor disorders. Women with pelvic floor muscle pain experience tender trigger points in several muscle groups including the levator ani muscles, suprapubic, iliopsoas, obturator internus, and piriformis.9 Painful pelvic floor muscles can be caused by many conditions, including but not limited to, chronic constipation, chronic lifting, core muscle weakness, postural issues, and pelvic floor injury (birth-related, trauma, etc.). Painful pelvic floor muscles can cause abdominal pain, defecatory dysfunction, mimic urinary symptoms (urgency, frequency, hesitancy, dysuria), dyspareunia, and pain with sitting.10 Pelvic floor myofascial pain can limit physical activity and impact quality of life and mood.10 Painful pelvic floor muscles can be effectively treated with pelvic floor physical therapy through the use of a combination of modalities.9-12 Addressing pelvic floor muscle pain found on examination through physical therapy may have a role reducing pelvic floor symptom bother and may inform the management of pelvic floor disorders in women.