Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2024 Apr 1;143(4):595-602.
doi: 10.1097/AOG.0000000000005536. Epub 2024 Feb 22.

A Treatment Algorithm for High-Tone Pelvic Floor Dysfunction

Michele Torosis  1 , Erin Carey, Kristin Christensen, Melissa R Kaufman, Kimberly Kenton, Rhonda Kotarinos, H Henry Lai, Una Lee, Jerry L Lowder, Melanie Meister, Theresa Spitznagle, Kelly Wright, A Lenore Ackerman
Affiliations

A Treatment Algorithm for High-Tone Pelvic Floor Dysfunction

Michele Torosis et al. Obstet Gynecol. .

Abstract

Objective: To develop evidence- and consensus-based clinical practice guidelines for management of high-tone pelvic floor dysfunction (HTPFD). High-tone pelvic floor dysfunction is a neuromuscular disorder of the pelvic floor characterized by non-relaxing pelvic floor muscles, resulting in lower urinary tract and defecatory symptoms, sexual dysfunction, and pelvic pain. Despite affecting 80% of women with chronic pelvic pain, there are no uniformly accepted guidelines to direct the management of these patients.

Methods: A Delphi method of consensus development was used, comprising three survey rounds administered anonymously via web-based platform (Qualtrics XM) to national experts in the field of HTPFD recruited through targeted invitation between September and December 2021. Eleven experts participated with backgrounds in urology, urogynecology, minimally invasive gynecology, and pelvic floor physical therapy (PFPT) participated. Panelists were asked to rate their agreement with rated evidence-based statements regarding HTPFD treatment. Statements reaching consensus were used to generate a consensus treatment algorithm.

Results: A total of 31 statements were reviewed by group members at the first Delphi round with 10 statements reaching consensus. 28 statements were reposed in the second round with 17 reaching consensus. The putative algorithm met clinical consensus in the third round. There was universal agreement for PFPT as first-line treatment for HTPFD. If satisfactory symptom improvement is reached with PFPT, the patient can be discharged with a home exercise program. If no improvement after PFPT, second-line options include trigger or tender point injections, vaginal muscle relaxants, and cognitive behavioral therapy, all of which can also be used in conjunction with PFPT. Onabotulinumtoxin A injections should be used as third line with symptom assessment after 2-4 weeks. There was universal agreement that sacral neuromodulation is fourth-line intervention. The largest identified barrier to care for these patients is access to PFPT. For patients who cannot access PFPT, experts recommend at-home, guided pelvic floor relaxation, self-massage with vaginal wands, and virtual PFPT visits.

Conclusion: A stepwise approach to the treatment of HTPFD is recommended, with patients often necessitating multiple lines of treatment either sequentially or in conjunction. However, PFPT should be offered first line.

PubMed Disclaimer

Conflict of interest statement

Financial Disclosure Michele Torosis is an advisor for Iota Bioscience and Exploramed Development. Kimberly Kenton reports receiving payment from Ethicon for expert witness testimony. Rhonda Kotarinos is a contributor to UpToDate. Erin Carey reports providing expert witness testimony unrelated to this work for McEwan, Martinez, Dukes & Hall, P.A.; BeytinMcLaughlin; Massy & Associates; Wallach; McBrideHall; and Davis Wright Tremaine, LLP. She received payments from Med IQ for providing education on endometriosis. She holds two patents held by UNC remote from commercialization. Neither is licensed and neither is evaluated or considered in this Delphi review. No payment, royalties, or honoraria were received or planned from them in the next 12 months: 1) PCT International PCT/US20/55816, a drug delivery system for vulvodynia symptoms in women; and 2) PCT/US2023/016013, a device for pelvic floor dysfunction in women. She received honoraria for Grand Rounds from LSU (5/2023) and USF (4/2023). She is an International Pelvic Pain Society Immediate past president. H. Henry Lai disclosed money was paid to his institution from the NIH and Metronic. He received payment from Neuspera. He has relationships with Astella, IronWood, BioHaven, Aquinox, Teva, and MicroGenDx. Jerry Lowder reports money was paid to their institution from the NIH-NIDDK. They also received payment as an expert witness. Melanie Meister reports receiving payment from AbbVie, Inc. A. Lenore Ackerman receives grant funding from Medtronic, Inc. and MicrogenDx. Dr. Ackerman is an advisor for AbbVie and Watershed Medical. The other authors did not report any potential conflicts of interest.

Figures

Fig. 1.
Fig. 1.. Treatment algorithm for high tone pelvic floor dysfunction. The consensus statements regarding treatment approaches for high tone pelvic floor dysfunction were organized into an algorithm with levels of treatment ranging from least invasive and most evidence-based to more invasive approaches with weaker supporting evidence. Treatment approaches that did not reach expert consensus were not included in the final treatment algorithm. Behavioral interventions include timed voiding, urge suppression, and dietary modifications for bowel and bladder symptoms. GI, gastrointestinal; PMR, physical medicine and rehabilitation; PT, physical therapy; PFPT, pelvic floor physical therapy; Dx, diagnosis; HTPF, high-tone pelvic floor.
Figure
Figure
No available caption
See this image and copyright information in PMC

References

    1. Chronic pelvic pain: ACOG practice bulletin, number 218 2020. 135(3):e98-e09. doi: 10.1097/AOG.0000000000003716 - DOI - PubMed
    1. Mathias SD, Kuppermann M, Liberman RF, Lipschutz RC, Steege JF. Chronic pelvic pain: prevalence, health-related quality of life, and economic correlates. Obstet Gynecol 1996;87:321–7. doi: 10.1016/0029-7844(95)00458-0 - DOI - PubMed
    1. Ross V, Detterman C, Hallisey A. Myofascial pelvic pain: an Overlooked and treatable cause of chronic pelvic pain. J Midwifery Womens Health 2021;66:148–60. doi: 10.1111/jmwh.13224 - DOI - PubMed
    1. Westbay LC, Adams W, Kistner M, Brincat C, Bresler L, Yang LC, et al. Clinical outcomes of a Multidisciplinary Female chronic pelvic pain Program. Female Pelvic Med Reconstr Surg 2021;27:753–8. doi: 10.1097/SPV.0000000000001045 - DOI - PubMed
    1. Bedaiwy MA, Patterson B, Mahajan S. Prevalence of myofascial chronic pelvic pain and the effectiveness of pelvic floor physical therapy. J Reprod Med 2013;58:504–10. - PubMed