The Role of Pelvic Floor Therapies in Chronic Pelvic Pain Syndromes Rodney U. Anderson, MD
Corresponding author Rodney U. Anderson, MD Department of Urology, S287, Stanford University School of Medicine, Stanford, CA 94305, USA. E-mail: rua@stanford.edu Current Prostate Reports 2008, 6:139 –144 Current Medicine Group LLC ISSN 1544-1865 Copyright © 2008 by Current Medicine Group LLC
Pain syndromes are managed with multimodal therapy due to a lack of specific pathogenesis for chronic pelvic pain. This report defines urologic chronic pelvic pain syndrome and examines pelvic muscular tension with associated myofascial trigger point pain. We describe a proposed alternative treatment approach to promote physiotherapy and cognitive-behavioral modification as the foundation of treatment. Options of invasive needleapplied neurologic manipulation are also recounted.
Introduction It is frustrating when nearly 25% of one’s urologic practice consists of patient complaints of chronic pelvic pain. Several diagnoses are classically assigned to such consultations, including chronic prostatitis in men and interstitial cystitis/painful bladder syndrome in men and women. Other typical diagnoses include orchialgia, sterile epididymitis, vulvodynia, penile pain, pudendal nerve entrapment, and levator ani syndrome, all of which can be categorized as chronic pelvic pain syndromes. The National Institutes of Health (NIH) has proposed to refer to these conditions as urologic chronic pelvic pain syndromes (UCPPS). At a consensus meeting in 1995, the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) offered the term chronic prostatitis/ chronic pelvic pain syndrome (CP/CPPS) to redefi ne the most common form of nonbacterial chronic prostatitis. These terms de-emphasize the prostatocentric approach and focus more on pain elements. A recent study showed that men in whom CP/CPPS has been diagnosed typically have more tender fibromyalgia points and external painful areas outside the prostate than within it [1•]. A poor understanding of these uncharacterized conditions often leads to empirical, unsatisfactory treatment that may cause
anxiety and depression in patients. Urologists should eliminate the prostate organ approach to these disorders. Only 5%–7% of any chronic prostatitis complaint yields positive pathogenic bacterial localization. Further, the concept of inflammatory conditions of the prostate being related to chronic pain should be seriously questioned based on results of a recent national cohort study [2]. UCPPS evolve in otherwise healthy men and women with no pathogenic evidence of etiology or objective biologic markers of disease. UCPPS have received diagnostic monikers primarily based on focal points of pain and discomfort. As disease entities, these syndromes languished for several decades in the US health care system due to the lack of solid epidemiologic patterns, specific phenotyping, and scientific biologic etiology. Therefore, these disorders have no specific, effective diagnostic and management tools, particularly on a tissue or molecular basis. They are frustrating and difficult conditions to treat. Physicians rely on symptom complex diagnosis and empirical treatment for symptom relief while remaining ignorant of causation. It is believed that the UCPPS share similar systemic abnormalities with painful disease states, such as fibromyalgia, migraine headache, and irritable bowel syndrome. They are undoubtedly not homogeneous discrete diseases but heterogeneous even within their own subclassifications, with manifestations of overlapping similarities in pathogenetic mechanisms. A prevalence of 8% CP/CPPS is estimated in the US male population. The economic cost of this condition is estimated at a mean annual individual rate of $4500, with prescription drugs (highly nonspecific) making up 31% of the cost. In contrast to benign prostatic hyperplasia (BPH) and urinary calculus disease, these economic costs for urologic pain are identical throughout all geographic areas. The burden of these diseases is borne by those in their most productive years of life reducing the gross national product from work time loss and disability. Traditional therapy to treat these conditions has failed. This includes antibiotics, antiandrogens, antiinflammatories, α -blockers, thermal or surgical therapies, and virtually all phytoceutical approaches [3]. A series of monotherapies used to treat hundreds of men resulted in only 19% reporting any relief of symptoms [4]. Therefore, this review focuses on the development, outcome, and
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introduction into common practice of directed pelvic floor therapies for treating UCPPS. It is important to consider alternate therapies because urologists have developed an unsatisfactory reputation in terms of failing to diagnose and manage UCPPS in a compassionate manner.
Concepts of Pelvic Floor Muscle Pain In 1937, Thiele [5], a colorectal surgeon, referred to the association of spasm of the levator ani and coccygeus muscles. Gradually, the term levator syndrome accounted for unexplained rectal and pelvic pain. Another early publication in the medical literature concerning chronic pelvic pain came from the Mayo Clinic in 1977 [6]. Although this report was developed from the Department of Physical Medicine and Rehabilitation, urologists became aware of the concept and new approaches to treatment when Segura et al. [7 ] published “Prostatosis, Prostatitis, or Pelvic Tension Myalgia” in the Mayo Clinic Proceedings. Few adults make it through life without experiencing musculoskeletal pain. Much of that pain arises from myofascial trigger points. Clinically, trigger points are hyperirritable nodules of local tenderness within a taut band of skeletal muscle. Electromyography (EMG) measurement of trigger-point tenderness shows bursts of motor unit action potentials that worsen under psychological stress [8]. The prevalence of myofascial trigger points among patients complaining of pain anywhere in the body ranges from 30%–90% as described in a randomly selected Danish population of 1504 people [9]. Trigger points may remain in muscles in a latent form for many years after an injury or infection. Pain may recur on an intermittent basis and is often associated with stressful mental or physical conditions as discussed below. Insignificant events may initiate a flare of symptoms; even cold and damp weather activates these muscle discomforts [10]. Repetitive muscular activity or microtrauma and muscle overload contributes to recurrence of pain. The presence of perpetuating factors assures persistence of an active trigger point and sets the stage for chronicity and associated anxiety and depression. Hubbard [11] injected phentolamine, either intramuscularly into the site of active loci or intravenously, and found that the amplitudes and the number of spikes recorded from a trigger point region were significantly reduced after injection. Diagnosis and assessment of these pain disorders and associated exacerbating factors require a compassionate, trained individual to take the time and energy to isolate all variables. No laboratory testing or imaging technique has yet helped. In more accessible areas of the body, needle EMG confi rms the presence of spontaneous low-voltage motor endplate “noise” and is related to extrafusal adrenergic neural activity—the fright and fl ight activators. There is a dull and diffuse nature of pelvic pain and it must be understood as a response of intermingling of afferent (sensory) fibers and individual variations
of anatomy and neurophysiology. The human perception of and physiologic and psychologic response to pain is a complex process. Unconscious and conscious processing of nerve signals to the spinal cord, midbrain, and cortex occurs from visceral and somatic sensory afferents. The perception of pain also depends on the strength of the nociceptive stimulus, the spreading of electric action potentials by crosstalk, and the number of posterior horn nerves stimulated by incoming signaling directly from the site of the stimulus. Simons et al. [12] organized the science of fibromuscular pain into a volume entitled Myofascial Pain and Dysfunction: The Trigger Point Manual (1983), with a second edition published in 1999. Muscles of the pelvic floor create a figure-eight sling position around the opening of the urethra and anus. The superficial layer of the urogenital diaphragm rarely causes a problem, although sphincter ani may be notably contracted. Similarly, the external urethral striated sphincter may be in a high state of tension in some individuals. The pelvic diaphragm consists of levator ani and coccygeus muscles commonly involved with pelvic pain disorders. We should emphasize the concept of referred pain emanating from tender trigger points. Specific muscles project to areas such as the perineum and adjacent urogenital structures. The levator ani and coccygeus muscles, for example, refer pain and tenderness to the sacral area. The myriad of myofascial tender points and trigger points require careful intrapelvic muscle examination in a systematic way. A treating physician should study the description of pelvic anatomy as described in chapter six of Simons et al. [12] and become intimately familiar with the proper way to examine the pelvic floor muscles (Fig. 1).
Diagnostic criteria Many of the UCPPS are caused by overuse of the pelvic muscles—a tendency in predisposed individuals that over time results in pelvic pain and urinary, bowel, and sexual dysfunction [13•]. The diagnosis of myofascial trigger points causing chronic pelvic pain requires a careful history and detailed physical examination. The process once again involves the art of medicine without the customary support of high-technology and laboratory analysis. The precise pattern of the pain is a valuable clue to suggesting trigger point problems. Localization of pain helps identify the culprit muscles involved. Spot tenderness within a pelvic muscle (internal or external) that worsens with contraction is an essential condition of the diagnosis. The patient will often give a jump sign or cry out even with minimal pressure (< 4 kg/cm). Such a response indicates an active trigger point. It is quite possible to develop pressure–pain thresholds within the pelvis using pressure algometers as similarly performed for patients with fibromyalgia [14•]. Psychosocial factors should not be forgotten in the diagnostic work-up of chronic pelvic pain. Many reports associate chronic pelvic pain with personality, mood dis-
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Figure 1. Anterior levator ani, superior portion (or puborectalis), is one of the most important muscle groups for examining potential painful trigger points. Palpating high enough and firmly enough is critical in proper treatment. Frequently, this area is the site of trigger points that are responsible for pain in the tip and/or shaft of the penis. Furthermore, trigger points in this area can refer to the bladder, urethra, pressure, and fullness in the prostate.
turbances, and childhood events including sexual abuse and difficulties in sexual relationships. Clinicians have anecdotally documented that stress exacerbates symptoms and certain inherent personality traits (perhaps genetic and developmental) modulate reactivity to stress. Operant behavioral and cognitive-behavioral approaches to chronic pain were introduced many years ago and form a vital segment of the multidisciplinary treatment along with muscular therapy. There are several mind–body therapeutic interventions, including yoga (body-based), cognitive-behavioral therapy, relaxation therapy, meditation, and imagery. In 1929, Edmund Jacobson introduced a method of “progressive relaxation” and it has been used in various forms of Western medicine for many years. A modification of progressive relaxation is introduced here for treatment.
Options for Focused Pelvic Floor Therapy Our understanding of these enigmatic myofascial trigger points and brain–body interactions should lead to more effective treatment. Sadly, few basic science and controlled clinical research studies document the pathogenic mechanisms by which they elicit pain. Consequently, a multidisciplinary approach has been used with a combina-
tion of interventions, including pharmacologic, physical, and psychological therapy. Interventions recommended to date include nerve blocks (ilioinguinal, iliohypogastric, genitofemoral, hypogastric, presacral, pudendal), trigger point injections, botulinum A toxin (BTX-A) injection of muscle groups, radiofrequency, ultrasound and cold laser therapy, spinal cord stimulation, sacral root stimulation, sacral magnetic stimulation, and tibial nerve neuromodulation. Ultimately, pelvic floor treatment, using the least invasive therapy and cognitive-behavioral therapy, should form the foundation of management.
Myofascial release and progressive relaxation The Stanford Urology Department evaluates and manages chronic CPPS using an alternative approach of local prostate/pelvic floor therapy, thus avoiding pharmacologic or surgical intervention. A therapeutic team of urologist, psychologist, and physical therapist carries out the work. Without considering the presence or absence of prostate inflammatory localization, patients are treated with internal and external pelvic myofascial release of painful prostate/pelvic tender and trigger points. The psychologist provides emotional support and teaches a form of cognitive-behavioral therapy known as “paradoxical relaxation,” a method to quiet the mind and relieve the pelvic
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floor. This cognitive-behavioral skill arises from learning to profoundly relax the muscles of the pelvis, modifying the habit of focusing tension in the pelvic floor under stress, and regularly reducing the level of anxiety and nervous system arousal. The skill is developed by repetitive practice of the proper technique. One of the key elements of this relaxation technique starts with relaxation of the eyes and speech muscles. When done correctly, the other muscles of the body can relax profoundly, akin to nonrapid eye movement sleep. “Peace of mind” literally means “no thinking,” which enables muscles to relax. Paradoxical relaxation implies that one acknowledges and accepts tension in the body. As one “lets go” of the intention to relax, one paradoxically begins to achieve that state [13•]. Patients should be well informed of the treatment method, with anxiety defused as much as possible. It is helpful if a spouse or significant other is taught to administer therapy. If necessary, a relaxant such as 5–10 mg of oral diazepam taken an hour or two before may facilitate the fi rst treatment. The process begins by checking the sphincter ani. If they are in spasm it makes the rest of the treatment difficult and the patient is coached into relaxing the anus. The patient is instructed to gently exert an expulsive pressure. Women are best examined in a prone position with pillows under the pelvic girdle and hips flexed about 30 degrees. This position is often considered less threatening to them. If the internal examination is initially too painful, the external muscles (gluteals, piriformis, hamstrings, adductors, abdominals, quadrates lumborum, and paraspinals) can be worked on, which often promotes relaxation of the internal pelvic muscles. In men and women, the dorsal lithotomy position is helpful to check abdominal muscle trigger points and examine the prostate. Then, with the patient lying on his or her side and the upper leg slightly adducted and extended with a small towel under the waist, the myofascial release can be undertaken. It typically requires about 45 minutes of manipulating the trigger points, creating pressure for 60 to 90 seconds at each painful point and releasing the tension in the muscle.
Retrospective, in-depth analysis of case study series We conducted a retrospective, in-depth analysis of 138 men with CP/CPPS who were treated with the Stanford Protocol. Responses were evaluated with the Stanford Pelvic Pain Symptom Survey (PPSS) and the NIH Chronic Prostatitis Symptom Index (NIH-CPSI), with patientreported quality-of-life evaluation and Global Response Assessment (GRA) of treatment outcomes [15]. Fifty-nine percent of men reported a ≥ 25% reduction in their symptoms and 40% had ≥ 50% improvement in pain (reduced 69%) and urinary symptoms scores (reduced 80%). Median pain score improvements were fi rst observed after a median of five treatments with myofascial release and paradoxical relaxation exercises. A majority of men had pain scores that exceeded a ≥ 50% improvement after a
median of 3.4 months of therapy. Overall, 72% of men had GRA scores of marked (46%) or moderate (26%) improvement after therapy and were considered clinical successes. These responses were reflected in total NIHCPSI scores, the national validated instrument of chronic prostatitis symptomatology, that significantly decreased (P < 0.01) by 10.5 points and 6.5 points, respectively. The NIH-CPSI pain domain scores were reduced 35% and 27% (P < 0.05) for those with marked or moderate GRA responses. Although duration of responses is unknown, many patients continued with home relaxation therapy and intermittent pelvic floor physiotherapy. Pelvic floor muscle physiotherapy combined with psychological intervention using relaxation therapy was useful in ameliorating CPPS symptoms. This therapy lacks high levels of evidence because it lacks a controlled study. Results are pending of a recently completed, randomized, sham-controlled study by the NIDDH that compared internal pelvic myofascial release with routine back massage therapy.
Impact of CPPS on sexual function in men We quantified sexual dysfunction (ejaculatory pain, decreased libido, erectile dysfunction, and ejaculatory difficulties) in 146 men with refractory CPPS and assessed the effects of pelvic muscle trigger point release concomitant with paradoxical relaxation training [16]. Symptoms were documented before and after treatment with the NIH-CPSI and PPSS. GRA recorded patient perceptions of overall therapeutic effects at an average 5-month follow-up. At baseline, 133 men (92%) had sexual dysfunction, including ejaculatory pain in 56%, decreased libido in 66%, and erectile and ejaculatory dysfunction in 31%. Sexual dysfunction is common in men with refractory CPPS, but it is unexpected in the middle of the fi fth decade of life. After trigger-point release/paradoxical relaxation training, specific PPSS sexual symptoms improved an average of 77%–87% in responders (> 50% improvement). Overall, a markedly or moderately improved GRA, indicating clinical success, was reported by 70% of patients who had a significant decrease of 9 (35%) and 7 points (26%) on the NIH-CPSI (P < 0.001). PPSS sexual scores improved 43% with a markedly improved GRA (P < 0.001) but only 10% with moderate improvement (P < 0.96). Application of the trigger-point release/paradoxical relaxation training protocol was associated with significant improvement in pelvic pain, urinary symptoms, libido, ejaculatory pain, and erectile and ejaculatory dysfunction.
Biofeedback Biofeedback therapy for pelvic disorders is most commonly used for stress urinary incontinence. It is also valuable for chronic pelvic pain. This management technique is simple and relies on surface vaginal or rectal electrodes to transduce muscle potentials into visual or auditory signals to help the patient control the pelvic floor tension. One example of successful EMG biofeedback of
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the pelvic floor musculature reported results of patients with vulvar vestibulitis syndrome, a subset of vulvodynia [17 ]. Patients with vulvar vestibulitis usually have hyperirritability of the pelvic floor muscles but they also have weakness and hypocontractility of pelvic muscles. Glazer et al. [17 ] enrolled patients with vulvar vestibulitis, average duration of 3.5 years in a biofeedback program; most had abstained from sexual intercourse for an average of 1 year. Patients used a portable EMG biofeedback device and were trained in pelvic floor rehabilitation exercises practiced twice daily at home. Monthly evaluations followed during clinic visits. In the fi rst study of 33 women, symptoms ranged from only introital dyspareunia to chronic, intense pain provocation. After 16 weeks of practice, pelvic floor contraction increased 95%, resting tension levels decreased 68%, muscle instability at rest decreased 62%, and pain decreased by an average maximum of 83%. Many patients (22 of 28) resumed intercourse. Half of the women were free of pain after 6 months of follow-up.
Acupuncture treatment A treatment from the traditional Chinese system of medicine represents one of the oldest standardized neuromodulatory therapies available. An NIH consensus conference was conducted in 1998 [18]. The conclusion was that there was potential usefulness, but studies provide equivocal results because of design flaws and lack of appropriate controls. One pilot study published in the urologic literature by Chen and Nickel [19] showed the efficacy of acupuncture given twice weekly for 20 minutes using electrical stimulation. After 6 weeks of therapy, 11 of 12 patients had a more than 50% decrease in NIHCPSI total scores. Symptom improvement was sustained for an average of 33 weeks of follow-up. Further controlled studies are required.
BTX-A therapy BTX-A has been used for a variety of urologic conditions [20]. Zermann et al. [21] performed transurethral perisphincteric injections of BTX-A (200 units) in 11 patients with CPPS, achieving relaxation of the pelvic floor and relief of pelvic pain and urethral hypersensitivity. Most of the other trials with BTX-A therapy have focused on interstitial cystitis involving direct detrusor muscle injection.
Electrical stimulation Peripheral and sacral root electrical nerve stimulation has been used in an attempt to achieve neuromodulation that alleviates CPPS. Most of the experience has been with interstitial cystitis and bladder pain syndrome [22 , 23]. Sixteen of 17 patients who had qualified for a permanent sacral nerve implant were continually improved after 14 months of follow-up. A majority of the patients relying
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on narcotics for pain were able to reduce drug requirements. Both remote nerve stimulation and epicenter electrical stimulation has been tried to relieve chronic pain. A recent preliminary study of intermittent percutaneous posterior tibial nerve stimulation was carried out in men and women with chronic pelvic pain [24]. An open trial of 15 patients had 12 weekly outpatient treatment sessions for 30 minutes that resulted in more than 50% pain improvement in 60% of women and 30% of men. Another electrical stimulation trial was reported by Kothari [25], who suggested implanting an electrode in the epicenter of the painful locus. This enables subcutaneous electrode placement and the use of new, small, self-contained rechargeable battery electrodes. Such an approach is particularly appealing when local peripheral nerve blocks demonstrate a temporary relief of pain.
Trigger point injections Diagnostic and therapeutic trigger point injections can be extremely helpful in managing chronic pelvic pain. This is particularly true when myofascial release and relaxation techniques inadequately achieve the desired remission from pain. Surprisingly, rectus abdominis muscle trigger points can be amenable to injections when discoveredâ&#x20AC;&#x201D; much referred pain will disappear [26]. Levator ani trigger-point injections for chronic pain in women have recently been shown to be effective [27â&#x20AC;˘]. The technique used was transvaginal. A mixture of 10 mL of 0.25% bupivacaine, 10 mL of 2% lidocaine, and 1 mL (40 mg) of triamcinolone was injected in 5-mL increments into trigger points using a 23-gauge spinal needle through a 5.5-inch Iowa trumpet pudendal needle guide. The needle was placed deep within the muscle about 2 cm, aspirated, and then 5 mL of the solution was slowly injected while withdrawing the needle. I have used the same technique in men using a suprapubic approach with a longer needle infi ltrating the anterior levator insertions and the painful endopelvic fascia areas. One can also inject the pudendal nerves in men using a pararectal approach. Further, I fi nd that injections of the pudendal nerve and sacral roots can be comfortably performed from a posterior approach using electrical stimulation for localization of the nerves.
Conclusions The scientific establishment of pathogenesis for chronic pelvic pain is only recently unfolding as wider interest emerges across the country. Until specific neurobiochemical profi les and tissue or molecular pathways can be identified, management approaches focused on relieving symptoms must suffice. Physiotherapy targeting painful trigger points in the pelvis, coupled with appropriate muscle relaxation training, should form the foundation of therapy. Other complementary psychophysical strategies may also augment this approach.
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Disclosure Dr. Anderson is a principal investigator for Advanced Bionics and on the speakers’ bureau for Astellas and GlaxoSmithKline.
References and Recommended Reading Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance 1.•
Berger RE, Ciol MA, Rothman I, Turner JA: Pelvic tenderness is not limited to the prostate in chronic prostatitis/chronic pelvic pain syndrome (CPPS) type IIIA and IIIB: comparison of men with and without CP/CPPS. BMC Urol 2007, 7:17. This is an important new paper which proves that chronic pelvic pain is located in more areas than the prostate and pelvis. 2. Nickel JC, Alexander RB, Schaeffer AJ, et al.: Leukocytes and bacteria in men with chronic prostatitis/chronic pelvic pain syndrome compared to asymptomatic controls. J Urol 2003, 170:818– 822. 3. Anderson RU: Traditional therapy does not work for chronic pelvic pain: what do we do now? Nat Clin Prac Urol 2006, 3:145–156. 4. Shoskes DA, Katz E: Multimodal therapy for chronic prostatitis/chronic pelvic pain syndrome. Curr Urol Rep 2005, 6: 296–299. 5. Thiele GH: Coccygodynia and pain in the superior gluteal region and down the back of the thigh; causation by tonic spasm of the levator ani, coccygeus and piriformis muscles and relief by massage of these muscles. JAMA 1937, 109:1271–1275. 6. Sinaki M, Merritt JL, Stillwell GK: Tension myalgia of the pelvic floor. Mayo Clin Proc 1977, 52:717–722. 7. Segura JW, Opitz JL, Greene LF: Prostatosis, prostatitis, or pelvic tension myalgia. J Urol 1979, 122:168–169. 8. McNulty WH, Gevirtz RN, Hubbard DR, Berkoff GM: Needle electromyographic evaluation of trigger point response to a psychological stressor. Psychophys 1994, 31:313– 316. 9. Drewes AM, Jennum P: Epidemiology of myofascial pain, low back pain, morning stiffness and sleep-related complaints in the general population [abstract]. J Musculoskel Pain 1995, 3: 68. 10. Hedelin H, Jonsson K: Chronic abacterial prostatitis and cold exposure. Scand J Urol Nephrol 2007, 9:1– 6. 11. Hubbard DR: Chronic and recurrent muscle pain: pathophysiology and treatment, and review of pharmacologic studies. J Musculoskel Pain 1996, 4:123–143. 12. Simons DG, Travell JG, Simons LS, eds: Travell & Simons’ Myofascial Pain and Dysfunction: The Trigger Point Manual, vol 1, edn 2. Baltimore, MD: Williams & Wilkins; 1999.
13.•
Wise D, Anderson RU: A Headache in the Pelvis. Sebastopol, CA: National Center for Pelvic Pain Research; 2006. This valuable lay book reduces the anxiety of patients suffering from chronic pelvic pain. 14.• Tu FF, Fitzgerald CM, Kuiken T, et al.: Vaginal pressurepain thresholds: initial validation and reliability assessment in healthy women. Clin J Pain 2008, 24:45–50. This pilot objective study shows promise of future developments that measure trigger point pressure pain. 15. Anderson RU, Wise D, Sawyer T, et al.: Integration of myofascial trigger point release and paradoxical relaxation training for treatment of chronic pelvic pain in men. J Urol 2005, 174:155–159. 16. Anderson RU, Wise D, Sawyer T, et al.: Sexual dysfunction in men with chronic prostatitis/chronic pelvic pain syndrome: improvement after trigger point release and paradoxical relaxation training. J Urol 2006, 176:1534– 1538; discussion 1538–1539. 17. Glazer HI, Rodke G, Swencionis C: Treatment of vulvar vestibulitis syndrome with electromyographic biofeedback of pelvic floor musculature. J Reprod Med 1995, 40:283–290. 18. NIH Consensus Conference. Acupuncture. JAMA 1998, 280:1518–1524. 19. Chen R, Nickel JC: Acupuncture ameliorates symptoms in men with chronic prostatitis/chronic pelvic pain syndrome. Urology 2003, 61:1156–1159. 20. Maan Z, Al-Singary W, Shergill I, et al.: Alternative use of botulinum toxin in urology. Expert Opin Pharmacother 2004, 5:1015–1021. 21. Zermann D, Ishigooka M, Schubert J, Schmidt RA: Perisphincteric injection of botulinum toxin-A: a treatment option for patients with chronic prostatic pain? Eur Urol 2000, 8:393– 399. 22. Comiter CV: Sacral neuromodulation for the symptomatic treatment of refractory interstitial cystitis: a prospective study. J Urol 2003, 169, 1369–1373. 23. Peters KM, Konstandt D: Sacral neuromodulation decreases narcotic requirements in refractory interstitial cystitis. BJU Int 2004, 93:777–779. 24. Kim SW: Percutaneous posterior tibial nerve stimulation in patients with chronic pelvic pain: a preliminary study. Urol Int 2007, 78:58– 62. 25. Kothari S: Neuromodulatory approaches to chronic pelvic pain and coccygodynia. Acta Neurochir Suppl 2007, 97:365– 371. 26. Socumb JC: Chronic somatic, myofascial, and neurogenic abdominal pelvic pain. J Clin Obst Gyn 1990, 33:145–153. 27.• Langford CF, Nagy SU, Ghoniem GM: Levator ani trigger point injections: an underutilized treatment for chronic pelvic pain. Neurourol Urodyn 2007, 26:59– 62. Another report that effectively demonstrates the value of nerve block diagnostic–therapeutic attempts.