ICS 1999, Denver
Informally discussed posters
Pelvic floor
Botulinum toxin type A - a treatment option for chronic pelvic pain?

D.-H. Zermann, M. Ishigooka, R. Doggweiler, J. Schubert, R.A. Schmidt
Neuro-Urology Unit, University of Colorado Health Science Center, Denver, CO, USA
Department of Urology, University Hospital, Friedrich-Schiller-University, Jena, F.R.G.

Aim of the Study: Pelvic floor muscle dysfunction is an integral component of most Chronic Pelvic Pain Syndromes. As muscle spasticity reflects a disturbance in central nervous system regulatory pathways, it was postulated that treatment of pelvic floor muscular dysfunction, may also help reverse or stabilize the CNS disturbance causing pain.

Methods: A neuro-urological work-up of 27 patients (20 women, 7 men) with chronic pelvic pain, was completed. This included a visual and digital evaluation of pelvic floor movement dynamics, urodynamic investigation of bladder and urethra function and a cystoscopy to exclude morphological aberrations. 200 units Botulinum Toxin Type A [BTX] were then injected into the external urethral sphincter transurethrally. Pain symptoms and pelvic floor dynamics were re-evaluated two to four weeks later.

Results: All pelvic pain patients suffered from a pathological pelvic floor tenderness, an inability to consciously regulate their pelvic floor muscles, urethral hypersensitivity/ hyperalgesia and urethral muscle hyperactivity. The basic parameters of bladder function (capacity, sensitivity, compliance) were normal. The BTX-injection was followed by a lowering of external sphincter tone, from an abnormally high to normal ranges. There was a parallel lessening of pelvic pain and urethral hypersensitivity/ hyperalgesia of a varying degree (moderate to complete) in all patients. A BTX-related decrease of the peak urethral pressure, the post-void residual volume and an increase of the peak and average uroflow were urodynamically recorded.

Conclusions: Myofascial tenderness and behavioral dysfunction of the pelvic floor and urethral sphincter are physical manifestations of chronic pelvic pain. Management of pelvic pain should therefore include management of sphincter muscle spasticity and voiding dysfunction. BTX-injection is a safe, effective, and technically feasible therapy to achieve this goal.