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Treatment for Chronic Pelvic Pain

There are many causes of chronic pelvic pain making a thorough review of your situation important. When the pelvic muscles become over contracted, they may cause intermittent sharp pain, pain with intercourse, or pain when using your bowels or bladder. Treatment may be similar as with other muscular pain, with physiotherapy being the first-line treatment, then in certain circumstances injections may be used to relax the muscles in the pelvis.

Treatment of chronic pelvic pain and pelvic muscle spasm

When the pelvic floor muscles are continuously contracted this may lead to abnormal pelvic floor muscle function and chronic pelvic pain. Women who suffer from chronic pelvic pain experience a decrease in their quality of life including physical activity, work productivity, sexual fulfilment and mood. Therefore, treatment that is able to decrease this pain may be beneficial. For pelvic floor muscle spasm, this may include treatments such as physiotherapy or injections to these muscles.

The injectable used acts as a selective muscle weakening and/or paralysing agent, however, its effects are reversible. It becomes effective only when it is injected into the muscles that are in spasm. This injectable is used widely to treat muscles causing spasm of the eyelids, face, ankle and neck. It has also has been used effectively with patients experiencing chronic constipation due to spasm in the pelvic floor muscles.

You can download our Patient Information Sheet on injectables here.

How can the muscle spasm be diagnosed?

A thorough medical and surgical history is taken and any symptoms and treatments that you have had are documented. You will have a pelvic and vaginal examination and sometimes a special air-filled sensor (manometer) will be used to assess your pelvic floor muscles and tone. Any areas of contraction and tenderness will be noted.

Other examinations such as an ultrasound may be performed. Because pelvic floor muscle spasm may be associated with other conditions such as endometriosis, then examination for other causes of pelvic pain is essential.

Assessment of the pelvic floor by examination is considered the best way to assess for spasm in the pelvic floor muscles and no other technique has yet been helpful in making the diagnosis.

How is it given?

It is usually injected under anaesthetic into the muscles in the pelvic floor through the vaginal skin. Because muscles that are in spasm (much like a cramp) are painful, the anaesthetic is usually general, although it may be performed under local anaesthetic in some circumstances. You will not need to stay in hospital overnight after you have had an injection alone, although this may be necessary if other surgeries are also performed.

How is the injection performed?

You will be given fasting directions according to the time of day that you are being admitted for your procedure. You will be given information on the exact nature of what is required and the timing of this when your procedure is planned.

On the day of injection you will be admitted to hospital.  After admission procedures are complete and you are ready to go to the operating theatre you will be transferred to the anaesthetic bay and preparations made for the injection.

Before the procedure you will be given medications via a drip in your arm by a doctor trained in anaesthetics. These drugs will not make you lose consciousness but will make you feel sleepy and relaxed. If you are having other procedures performed as well, you will nearly always have a general anaesthetic and not be aware of the procedure at all. If you are only having a pelvic floor muscle injection, then you may have this without a general anaesthetic. In this case you may be aware of some of the following events happening; you will have an oxygen mask on your face and a monitoring device placed on your finger to measure the amount of oxygen in your blood. Your anaesthetist will monitor you at all times.

Your doctor will then inject into the muscles of your pelvic floor via a needle. Following the procedure you will stay in the hospital for at least two hours or until you are ready to go home. There may be some discomfort and bruising at the site of the injection. The drip will be removed prior to you going home. To ensure the spread of the therapeutic agent through the pelvic floor muscles there will be a small vaginal pack (like a bandage) placed into your vagina, which will stay in place for approximately one to two hours after the procedure. You will need to pass urine and be able to tolerate food and drink before you go home. You will be unable to drive or return to work on the day of the injections and you must have someone to accompany you home.

What are the risks, benefits and side effects from injections?

From studies performed, we know that women who have high pressures in the pelvic floor muscles will almost always have relaxation of the muscles following an injection. Studies have also shown that just because there are relaxed muscles, the pain may not always be decreased. About 75% of women will have a good response to injection and good relief of pain symptoms, but not all women. The effect may take 1-2 weeks to come on and will usually last for about 6 months. Occasionally it may be shorter. Some women have had a single injection only and have had complete resolution of their pain symptoms for more than 5 years.

There are relatively few side effects associated with these injections to the pelvic floor, however, they may include local pain and bruising at the site of the injection and urinary and/or faecal incontinence (the inability to control your bladder or bowel function). During the course of the studies that our doctors have been involved with, these events are rare (<1%) and are always temporary. There have been no long-term complications known but this is always a possibility in a medication that has been used for a relatively short time.

There have been a small number of women who have had a reaction to the injection in the form of local pain, swelling and flu like symptoms. This may require admission to hospital for pain medication and other treatments, but this is rare.

The following events have been reported rarely since this injectable has been marketed: skin rash, itching and allergic reaction, malaise or tiredness, and (rarely) changes in the way the heart beats and chest pain.

Frequently Asked Questions

Are there alternatives to injections?
Yes, usually you will be recommended to have physiotherapy first, after you have been assessed and the diagnosis made. If there are other problems that are noted then it may be suggested that these be treated first. If physiotherapy is not successful (it is for 40% of women without the need for injection), then injections may be helpful.
Can I have repeat injections?
If your treatment is successful, but the effect of the injection wears off (as it often does), then you may be able to have further injections.  The usual time before re-injections are performed is 6 months, but may be a little shorter or much longer.
Will the effect always be the same?
Usually if you have responded to an initial injection, then you will respond in a similar manner to subsequent injections.   If you have had no relief in your symptoms but the muscles are relaxed by the injection, then other treatments may be required. It may be that due to development of new problems (such as endometriosis or other pelvic problems) that the injections are not as effective as previously. If this is the case, then it may be suggested that further investigations or tests are performed.
What if I have side effects?
These will usually be temporary and managed individually. You should let your Alana doctor know as soon as possible if a side effect has occurred and get advice regarding how to proceed.
Will injections affect my fertility?
No. Studies have shown that there is no adverse effect on fertility or the ability to have a normal vaginal delivery. It is not recommended that you have injections through your pregnancy and you should not try and become pregnant for 6 months after an injection.
Can injections make my pain worse?
In rare cases, yes, it is possible that the pain may be worse. Worsening of symptoms has been reported by only 2 women to date (risk <1%) both of whom had multiple surgeries in the area of the perineum (pelvic floor).  It is thought that abnormal muscle/nerve connections may be responsible for this. This is a very rare event and careful consideration should be given if you have had more than one surgical procedure to the area to be injected.
What are the costs?
The medication is not reimbursed by the PBS and the cost of between $500-650 will be your responsibility. Some health funds may cover the cost of the medication. You will need to discuss this directly with your health fund. The remainder of the costs will be estimated depending on the procedure and indication. You can contact the staff at Alana Healthcare to obtain a quote after you have had an assessment with your doctor.
Can I have physiotherapy for pelvic floor issues including urinary issues or pelvic pain?
Our specialised physiotherapy team offer services for women with problems related to pelvic floor function.  This may be issues related to bladder or bowel problems (leakage or needing to toilet frequently) and problems associated with pelvic pain.  Our team work together to formulate a plan specifically for you.
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