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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., Competing Interests: 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., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.)

Importance: Although pelvic floor physical therapy (PFPT) is effective in treating high-tone pelvic floor dysfunction (HTPFD), data on the mechanism of improvement are limited., Objectives: This study aimed to compare squeeze intravaginal closure force after 6 weeks of PFPT in women affected by HTPFD and, secondarily, to describe changes in levator dimensions and short-term effects of PFPT on bladder, bowel, and pain symptoms., Methods: We conducted a prospective cohort study of patients undergoing 6 sessions of PFPT for the diagnosis of HTPFD. At baseline, we measured intravaginal closure force using an instrumented speculum, levator hiatal dimension using a 3-dimensional endovaginal ultrasonography, and symptom severity using 3 validated questionnaires. Intravaginal closure force and symptoms were reevaluated after the second, fourth, and sixth PFPT sessions, and levator hiatus was reevaluated at the sixth session., Results: Twenty-six women were enrolled and 22 completed 6 sessions and are included in the analysis. Contrary to our hypothesis, mean ± SD vaginal closure force (N) did not demonstrate a significant change (3.27 ± 2.34 vs 3.67 ± 2.02 N, P = 0.18). However, mean levator hiatal area (cm2) increased between visit 1 (13.71 ± 1.77 cm2) and visit 6 (14.43 ± 2.17 cm2, P = 0.05), as did the transverse diameter (3.83 ± 0.03 vs 3.95 ± 0.03 cm, P = 0.04). Survey responses demonstrated significant improvements across all measures of genitourinary symptoms, pain, lower gastrointestinal symptoms and quality-of-life measures after 6 sessions of PFPT., Conclusion: Although the levator hiatal area increased after 6 sessions of PFPT (suggesting muscle lengthening), we were unable to demonstrate that this changed the force generated by pelvic floor muscles as measured by a speculum., Competing Interests: The authors have declared they have no conflicts of interest., (Copyright © 2023 American Urogynecologic Society. All rights reserved.)

Objectives: This study aimed to assist practitioners in performing an accurate assessment of the external and internal pelvic musculoskeletal (MSK) systems to improve appropriate diagnosis and referral of patients with pelvic floor disorders or pelvic pain and to improve understanding of physical therapy (PT) treatment principles, thereby improving communication between practitioners and encouraging a multidisciplinary approach., Methods: A referenced review of the anatomy of the pelvic floor muscles, pelvis, and surrounding structures, followed by a detailed assessment of anatomy, posture, and gait, is presented. A thorough description of PT assessment and treatment is included with clinical relevance., Results: When proper assessments are routinely performed, MSK conditions can be recognized, allowing for prompt and appropriate referrals to PT. Assessment and treatment by qualified physical therapists are integral to pelvic health care. After efficient medical assessment, MSK dysfunction can be addressed expeditiously, thereby avoiding further decline. Left unaddressed, pelvic dysfunction may become chronic., Conclusions: We propose a guide for MSK assessment of the pelvis and associated structures that can be used for both clinical and research purposes. This guide is designed for health care providers caring for women with pelvic floor disorders, including physicians, advanced practice providers, and nurses. This guide serves to improve communication among multidisciplinary practitioners to refine MSK assessment and treatment approaches and thereby advance clinical care and research., Competing Interests: The authors have declared they have no conflicts of interest., (Copyright © 2021 American Urogynecologic Society. All rights reserved.)

Purpose: We determined the feasibility of conducting a randomized clinical trial designed to compare 2 methods of manual therapy (myofascial physical therapy and global therapeutic massage) in patients with urological chronic pelvic pain syndromes., Materials and Methods: We recruited 48 subjects with chronic prostatitis/chronic pelvic pain syndrome or interstitial cystitis/painful bladder syndrome at 6 clinical centers. Eligible patients were randomized to myofascial physical therapy or global therapeutic massage and were scheduled to receive up to 10 weekly treatments of 1 hour each. Criteria to assess feasibility included adherence of therapists to prescribed therapeutic protocol as determined by records of treatment, adverse events during study treatment and rate of response to therapy as assessed by the patient global response assessment. Primary outcome analysis compared response rates between treatment arms using Mantel-Haenszel methods., Results: There were 23 (49%) men and 24 (51%) women randomized during a 6-month period. Of the patients 24 (51%) were randomized to global therapeutic massage, 23 (49%) to myofascial physical therapy and 44 (94%) completed the study. Therapist adherence to the treatment protocols was excellent. The global response assessment response rate of 57% in the myofascial physical therapy group was significantly higher than the rate of 21% in the global therapeutic massage treatment group (p = 0.03)., Conclusions: We judged the feasibility of conducting a full-scale trial of physical therapy methods and the preliminary findings of a beneficial effect of myofascial physical therapy warrants further study., (Copyright © 2013 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Myofascial pelvic pain is fraught with many unknowns. Is it the organs of the pelvis, is it the muscles of the pelvis, or is the origin of the pelvic pain from an extrapelvic muscle? Is there a single source or multiple? In this state of confusion what is the best way to manage the many symptoms that can be associated with myofascial pelvic pain. This article reviews current studies that attempt to answer some of these questions. More questions seem to develop as each study presents its findings.

Purpose: We determined the feasibility of conducting a randomized clinical trial designed to compare 2 methods of manual therapy (myofascial physical therapy and global therapeutic massage) in patients with urological chronic pelvic pain syndromes., Materials and Methods: We recruited 48 subjects with chronic prostatitis/chronic pelvic pain syndrome or interstitial cystitis/painful bladder syndrome at 6 clinical centers. Eligible patients were randomized to myofascial physical therapy or global therapeutic massage and were scheduled to receive up to 10 weekly treatments of 1 hour each. Criteria to assess feasibility included adherence of therapists to prescribed therapeutic protocol as determined by records of treatment, adverse events during study treatment and rate of response to therapy as assessed by the patient global response assessment. Primary outcome analysis compared response rates between treatment arms using Mantel-Haenszel methods., Results: There were 23 (49%) men and 24 (51%) women randomized during a 6-month period. Of the patients 24 (51%) were randomized to global therapeutic massage, 23 (49%) to myofascial physical therapy and 44 (94%) completed the study. Therapist adherence to the treatment protocols was excellent. The global response assessment response rate of 57% in the myofascial physical therapy group was significantly higher than the rate of 21% in the global therapeutic massage treatment group (p = 0.03)., Conclusions: We judged the feasibility of conducting a full-scale trial of physical therapy methods and the preliminary findings of a beneficial effect of myofascial physical therapy warrants further study.

Pelvic floor muscle training has long been recognized as a beneficial treatment for urinary incontinence. This paper discusses the concepts of muscle grading facilitation and training. Individually designed programs, suitable for the patient's current status, are critical to success. It may be tempting to operate, but it takes a dedicated health care provider to manage incontinence nonsurgically.