Utility of trigger point injection as an adjunct to physical therapy in men with chronic prostatitis/chronic pelvic pain syndrome

Abstract

BackgroundChronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is often associated with pelvic floor muscle spasm. While pelvic floor physical therapy (PFPT) is effective, some men are unable to resolve their symptoms and have residual trigger points (TPs). TP injection has been used for treatment in several neuromuscular pain syndromes. The objective of this study was to examine the efficacy and side effects of TP injection in men with CP/CPPS and pelvic floor spasm refractory to PT.MethodsUsing an IRB approved Men’s Health Registry we reviewed the records of all men with a diagnosis of CP/CPPS who received at least 1 TP injection. Patients were phenotyped with UPOINT (all had the “T” domain for tenderness of muscle) and symptoms measured with the NIH Chronic Prostatitis Symptom Index (CPSI). Response was measured by a 5-point Global Response Assessment (GRA) and change in CPSI (paired t-test). For pelvic TPs, a pudendal block was done in lithotomy position and then each TP was identified transrectally by palpation. A nerve block needle was passed through the perineum into the TP confirmed by palpation. Between 0.5–1 cc was injected into each TP of a local anesthetic mixture (30:70 of 2% lidocaine and 0.25% bupivacaine). For anterior TPs, an ultrasound guided ilioinguinal block was done first and then each TP injected by direct palpation through the abdominal skin. Men were offered up to three sets of injections separated by 6 weeks each.ResultsWe identified 37 patients who had a total of 68 procedures. Three men had no follow-up after their first injection and were included for side effects but not included for outcome. The indication was failure to progress on PT in 33, recurrent symptoms in 1 and refusal to do PT in 3. Mean age was 43.7 years (range 21–70 years) and median UPOINT domains was 3 (range 1–5). Initial CPSI was pain 13.7±3.4, urinary 5.3±2.2, quality of life 9.8±2.1 and total 28.8±6.0. 16 men had 1 injection, 11 had 2 and 10 had 3. All had pelvic TPs injected and 9 also had anterior TPs. By GRA, 12 had significant improvement (35.3%), 10 had some improvement (29.4%), 11 had no change (32.3%) and 1 was worse (2.9%). Mean CPSI dropped from 28.8±6.0 to 21.8±7.2 (P<0.0001). 18 men had a drop of 6 or more points in CPSI (53%). Of note, none of 3 men who were noncompliant with PT had benefit. 3 men had temporary numbness in the lateral thigh after the injection (4.4%) and 1 had difficulty weight bearing on 1 leg for about 30 minutes.ConclusionsTP injection in CP/CPPS patients as an adjunct to PT is well tolerated and leads to symptom improvement in about half. Durability and long term results are yet to be determined.

A novel, nonopiod‐based treatment approach to men with urologic chronic pelvic pain syndrome using ultrasound‐guided nerve hydrodissection and pelvic floor musculature trigger point injections

“…This indicates improvement in pain, urinary symptoms, and quality of life. 10 Another study targeting levator ani trigger point injections in 18 women with chronic pelvic pain yielded a mean preinjection VAS of 88% with a 3-month postinjection VAS of 36%. Six of the 18 patients reported being completely pain free.…”

“…9 Trigger point injections in women with chronic pelvic pain have been shown to have positive results. 10 Moreover, trigger point injections to the pelvic floor musculature, consisting of iliococcygeus, pubococcygeus, and puborectalis muscles, can potentially treat myofascial dysfunction in the pelvic floor. (Figure 1)…”

Promise and the Pharmacological Mechanism of Botulinum Toxin A in Chronic Prostatitis Syndrome

“…In these kinds of patients, neuroleptic medications can be used to relieve symptoms. In the domain of “tenderness”, trigger points may be noted in the abdomen or pelvic floor, and treatments may include muscle relaxants use, pelvic floor physical therapy (PFPT), low-intensity shock wave, or PFPT in combination with adjuvant trigger point injection [47,48]. BoNT-A injection targeting at the pelvic muscle or trigger point might ameliorate the symptom of tenderness.…”

Current best practice management of interstitial cystitis/bladder pain syndrome

“…101 Several studies have demonstrated the efficacy of trigger point injections in improving pelvic pain. [101][102][103][104] Langford and colleagues reported that in women with pelvic pain, both with and without a diagnosis of IC/ BPS, trigger point injections with a combination of bupivacaine, lidocaine, and triamcinolone caused immediate pain relief after injection. 101 Mean VAS score decreased from 88.8% (100% scale) to 36% at 3-month follow up, with 33% of patients completely pain free.…”