MyofascialPelvicPain:BestOrientationandClinicalPractice.PositionoftheEuropeanAssociationofUrologyGuidelinesPanelonChronicPelvicPain

Chronic pelvic pain (CPP) is a debilitating condition that affects millions of people, yet one of its most common components remains frequently overlooked: myofascial pain originating from trigger points in the pelvic floor muscles and adjacent skeletal muscles. Myofascial pelvic pain syndrome refers to pain arising from hyperirritable areas called myofascial trigger points (MTrPs), which can develop in the pelvic floor muscles themselves or in nearby muscles such as the iliopsoas, abdominal wall, and piriformis. These trigger points can be active—constantly tender and causing symptoms—or latent, only becoming painful when pressed or activated by stress, infection, or trauma. Despite research dating back to 1991 showing connections between pelvic floor muscle dysfunction and chronic pelvic pain, awareness among healthcare providers remains surprisingly low.

Studies have found that myofascial pain components are present in the vast majority of patients with chronic pelvic pain syndromes, including 92.2% of men visiting tertiary care centers for pelvic pain and approximately 85% of women with bladder pain syndrome. The consequences of this oversight are significant: when myofascial pain is not identified and treated, patients may undergo unnecessary investigations and receive incomplete treatment, leading to persistent suffering and reduced quality of life.

This paper represents a narrative review conducted by the European Association of Urology (EAU) Guidelines Panel on Chronic Pelvic Pain, combining three sources of information. First, the authors drew from the existing EAU guidelines on chronic pelvic pain, which are updated annually and developed by a multidisciplinary panel including urologists, gynecologists, physiotherapists, anesthesiologists, gastroenterologists, and psychologists, with input from patients. Second, they performed a narrative review of literature published between January 2017 and June 2021, using search terms related to myofascial pain, trigger points, pelvic pain, and physical therapy. After screening 375 papers, they included 12 additional papers that provided new evidence beyond what was already in the guidelines.

These included six systematic reviews and meta-analyses, two prospective studies, two retrospective studies, and two narrative reviews. Third, they incorporated expert opinion from panel members with specialized experience in myofascial pelvic pain management. The review followed PRISMA reporting guidelines for study selection, and two reviewers evaluated papers with a third available for arbitration when needed. Given the limited availability of high-quality randomized controlled trials in this field, the authors included all types of studies and explicitly noted that much of the evidence base remains weak.

The review confirmed that myofascial pain components are highly prevalent across chronic pelvic pain syndromes. In men with chronic prostatitis/chronic pelvic pain syndrome, 51% had tenderness in muscles or other locations compared to only 7% of controls, with pelvic floor muscle tenderness found exclusively in the chronic pelvic pain group. In a cohort study of 72 men with chronic pelvic pain, 90% showed tenderness in the puborectalis muscle and 55% in abdominal wall muscles; notably, 93% of those with puborectalis trigger points reported referred pain to the penis. For women with bladder pain syndrome/interstitial cystitis, approximately 85% had myofascial pain and hypertonic pelvic floor.

A case series found that 88% of patients presenting with pelvic pain had poor to absent pelvic floor function.

Regarding treatment, the evidence remains limited but suggestive of benefit. In one RCT, Mensendieck somatocognitive therapy achieved 64% pain reduction maintained at 1-year follow-up. A pilot trial of 21 women with bladder pain syndrome found that transvaginal manual therapy (Thiele massage) significantly improved pain and symptom scores in both short and long term. A multicenter RCT comparing pelvic floor myofascial physical therapy with global therapeutic massage found global response assessment rates of 59% versus 26%, respectively, though pain, urgency, and frequency ratings improved in both groups without significant between-group differences.

Trigger point injections with bupivacaine, lidocaine, and triamcinolone improved symptoms in 72% of women, with 33% completely pain-free at three months. Botulinum toxin-A showed pain-reducing effects in refractory cases, particularly at doses of 100 units or more, with secondary improvements in dysmenorrhea, dyspareunia, bladder and bowel symptoms, and quality of life. However, systematic reviews concluded that while manual therapy and needling show some effect on pain, it is neither supported nor refuted that this effect exceeds placebo. A 2012 systematic review of six RCTs found only three with low risk of bias, concluding that recommendations for physiotherapy remain uncertain due to study heterogeneity.

This review carries important implications for both patients and clinicians. For patients with chronic pelvic pain, it means that a thorough evaluation of pelvic floor muscle function should be standard care, not an afterthought. The high prevalence of myofascial components means that many people currently receiving incomplete treatment could potentially benefit from targeted physical therapy. Patients should be aware that various treatment options exist, including manual therapy, trigger point release, needling, and in refractory cases, botulinum toxin injections, though they should also understand that the evidence base for these treatments, while promising, remains limited in quality.

For clinicians, the key message is that myofascial pain must be systematically assessed in all patients with chronic primary pelvic pain syndromes. This requires training in pelvic floor examination techniques, following standardized protocols such as those from the International Continence Society, or referral to specialized pelvic floor physiotherapists. The review emphasizes that a multidisciplinary approach is most effective, combining expertise from urologists, gynecologists, physiotherapists, pain specialists, and psychologists. Clinicians should also recognize the bidirectional relationship between visceral and somatic dysfunction: pelvic organ problems can cause pelvic floor muscle hypertonus, and pelvic floor dysfunction can perpetuate organ-related symptoms through central sensitization mechanisms.

The authors explicitly call for better quality research, particularly randomized, double-blind, placebo- or sham-controlled studies with standardized diagnostic criteria, adequate power calculations, and sufficient follow-up periods. Until such studies are available, treatment decisions must be individualized based on the patient's specific presentation and preferences, with realistic discussion of the current uncertainty in the evidence base.