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Botulinum Toxin Type A (BOTOX) for Refractory Myofascial Pelvic Pain

Adelowo, Amos MD, MPH*†; Hacker, Michele R. ScD, MSPH†‡; Shapiro, Alex MD*†; Modest, Anna Merport MPH†‡; Elkadry, Eman MD*†

Female Pelvic Medicine & Reconstructive Surgery: September/October 2013 - Volume 19 - Issue 5 - p 288–292
doi: 10.1097/SPV.0b013e3182989fd8
Original Articles

Objective To assess intralevator botulinum toxin type A (Botox) injections for refractory myofascial pelvic pain with short tight pelvic floor.

Methods Retrospective cohort study of all women with intralevator Botox injection (100–300 Units) from 2005 through 2010 for refractory myofascial pelvic pain. Primary outcomes were self-reported pain on palpation and symptom improvement. Secondary outcomes included postinjection complications and a second injection. Pain was assessed during digital palpation of the pelvic floor muscles using a scale of 0 to 10, with 10 being the worst possible pain. Follow-up occurred at less than 6 weeks after injection and again at 6 weeks or more. Data are presented as median (interquartile range) or proportion.

Results Thirty-one patients met eligibility criteria; 2 patients were lostto follow-up and excluded. The median age was 55.0 years (38.0–62.0 years). Before Botox injection, the median pain score was 9.5 (8.0–10.0). Twenty-nine patients (93.5%) returned for the first follow-up visit; 79.3% reported improvement in pain, whereas 20.7% reported no improvement. The median pain with levator palpation was significantly lower than before injection (P<0.0001). Eighteen women (58.0%) had a second follow-up visit with a median pain score that remained lower than before injection (P<0.0001). Fifteen (51.7%) women elected to have a second Botox injection; the median time to the second injection was 4.0 months (3.0–7.0 months). Three (10.3%) women developed de novo urinary retention, 2 patients (6.9%) reported fecal incontinence, and 3 patients (10.3%) reported constipation and/or rectal pain; all adverse effects resolved spontaneously.

Conclusions Intralevator injection of Botox demonstrates effectiveness in women with refractory myofascial pelvic pain with few self-limiting adverse effects.

Intralevator injection of Botox in women with chronic myofascial pelvic pain refractory to other treatment modalities results in effective decrease in pain symptoms with minimal and reversible adverse effects.

From the *Division of Urogynecology, Mount Auburn Hospital, Cambridge, MA; †Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Boston, MA; and ‡Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA.

Reprints: Amos Adelowo, MD, MPH, Boston Urogynecology Associates, Mount Auburn Hospital, 725 Concord Ave, Suite 1200, Cambridge, MA 02138. E-mail:

The authors have declared they have no conflicts of interest.

This work was conducted with support from Harvard Catalyst | The Harvard Clinical and Translational Science Center (National Center for Research Resources and the National Center for Advancing Translational Sciences, National Institutes of Health Award 8UL1TR000170-05, and financial contributions from Harvard University and its affiliated academic health care centers).

Presented at AUGS 31st Annual Scientific Meeting, Long Beach, CA, September 2010.

© 2013 by Lippincott Williams & Wilkins