The hypothesis was that treatment of MTrPs via precise US-DN and integrative correcting posture decrease pelvic pain, is beneficial for LUTS and improves bladder neck motility as assessed via transabdominal ultrasound. Bladder neck hypermobility (BNH) associated with intrinsic sphincteric deficiency (ISD) is used for the clinical evaluation and management of stress urinary incontinence. Pelvic floor muscles play a crucial role in postural balance in the pelvis and beyond. Ultrasound is effective in assessing muscle activation, but physio and exercise can have limited effectiveness. However, after DN inactivation of MTrPs can increase efficacy of physiotherapy of affected muscles. 
This study is a follow-up to a previous study [1] that aimed to investigate the effect of precise muscle dry needling (DN) under ultrasound (US) guidance on pelvic pain and bladder neck motility in patients suffering from myofascial pelvic pain and bladder neck hypermobility.

The study design included 30 patients suffering from extensive pelvic pain and different patterns of location, as well as low back pain and LUTS. Inclusion criteria were pelvic pain of different patterns, inguinal, pubic, vulvodynia, rectal pain, and LUTS, and any relevant urological or gynecological disease was excluded. Healthy 30 individuals were included as controls. All patients underwent general examination, MRI, precise physical tests, and extensive functional multilevel multiparameter neuromuscular US using 4-8 MHz/5-12 MHz probes in the shoulder, sacroiliac junction (SIJ), intervertebral spaces, foot, ankle, gluteus region and pelvis, abdominal wall, diaphragm, and pelvic floor motility. The researchers also did M-mode, transient elastography, and shear wave elastography (SWE) of nerves and muscles, evaluated structure, CSA, detected compressions, contact to scars, muscle TrPs, spasticity, and evaluated nerve motion and SWE during overstraining neurodynamic tests. All patients underwent transabdominal pelvic ultrasound for the evaluation of bladder neck motility. Transabdominal US measurements of bladder neck rotation in a postero-inferior direction at rest and on maximal Valsalva were performed, and measurements were taken before and after intervention. The researchers evaluated bladder motion, deformation, and determined the side of deviating bladder (according to the position/tone of the psoas muscle) before and after intervention. Then patients received DN of detected MTrP under US guidance [1-3]. The researchers applied the treatment approach that included ultrasound identification of MTrPs with following dry needling under US guidance using steel acupuncture needles (28 gauge) to elicit the LTR effect. The retention of needles depended on muscle twitch response and `needle grasp` duration. Visual analogue scale data (0 to 10) was used. 
Additionally, our focus was on the intrinsic and extrinsic factors associated with pelvic floor hypermobility and pelvic pain. In terms of intrinsic factors, we examined the levator ani and obturator internus muscles using functional ultrasound as they play a crucial role in postural balance in the pelvis and beyond. We found that muscle activation physiotherapy and exercise can be limited in effectiveness, but deactivation of trigger points in the deep pelvic muscles after the inactivation of paravertebral muscles' trigger points can increase efficacy.
We also looked at extrinsic factors, which included shoulder impingement, multiple trigger points in the lumbar and thoracic multifidus muscles, dysfunction of the sacroiliac joint, fascia and muscles at upper and lower portions, obturator muscles, gluteus medius, anterior approach (pectineus and iliacus muscles), thoracolumbar fascia, local applications, psoas muscle, abdominal wall, diaphragm, and lower extremities' health (walking and amputees).

After treating the patients, we found that pain relief was obtained in all patients, and the long-term effect remained. We observed that the pelvic pain and dysfunction associated with sacroiliac joint and thoracolumbar fascia dysfunction, shoulder impingement, headache, and thoracic dysfunction restricted movement in functional units in mid-thorax.
The study also found a strong correlation between BNH and pelvic pain and lower urinary tract symptoms (LUTS) intensity. We detected BNH in all patients and restored it after treatment in 28 cases. After completing the treatment, all patients reported pain relief, with visual analog scale (VAS) levels improving from 7.5 to 1.3. The long-term effect of treatment remained in all patients.
We identified lower thoracic and lumbar multifidus muscles as the leading triggers of pelvic pain and pelvic floor weakness and BNH. Dysfunction associated with the sacroiliac joint (SIJ), thoracolumbar fascia (TLF), shoulder impingement, and cervical muscles was also found to contribute to pelvic pain and dysfunction. We identified five distinct patterns of pelvic pain based on previous research, including inguinal pain, genital pain, coccygodynia, rectalgia, and sacral pain. In each case, the we used a combination of local and whole-body neuromuscular ultrasound to detect and effectively inactivate all relevant myofascial trigger points. We detected increasing of activation affected muscles after DN treatment of MTrPs. 
The study identified BNH and intrinsic sphincteric deficiency (ISD) in patients, both phenomena were visualized on US as dilating internal part of urethra. US tests for BNH correlated with symptoms and ISD, and bladder neck deviation decreased when muscles were activated. The activation of pelvic muscles was found to depend highly on extrinsic factors such as SIJ and gluteus medius, lumbar multifidus, thoracic multifidus muscles, and shoulders.

The study aimed to investigate the triggers of pelvic pain and dysfunction, particularly focusing on myofascial pain syndrome and associated muscle trigger points in various parts of the body. The researchers applied specifically adapted protocols for diagnosis and dry needling (DN) to restore muscle function, motion restriction, and overall postural imbalance in each case.
Restoring motion at the epaxial (spine) system was found to lead to beneficial modifications in the hypaxial (abdomen) and appendicular (the four extremities) systems.  The study's findings emphasized the importance of taking a holistic approach that addresses movement control, pain generators, fascias, and trigger points at the same time, with consideration of the complexity of posture and muscle chains.
At the thoracic level, dysfunction resulting from COPD and asthma, long coughing, and pathological diaphragm movement was also found to involve myofascial systems. Evaluating spine, abdominal wall, diaphragm, and pelvic floor motion could provide insights into the underlying triggers of pelvic pain and dysfunction.
Overall, the study highlights the importance of a comprehensive approach that considers the interconnectedness of various parts of the body and the potential triggers of pain and dysfunction.

The study's holistic approach involved examining ribs, spine, abdominal wall, diaphragm, and pelvic floor motion to address movement control, pain generators, fascias, and trigger points. Restoring motion at the epaxial (spine) system was found to lead to beneficial modifications in the hypaxial and appendicular systems.
Study suggested that correcting other points of dysfunction in the body is important to maintain the effect of treatment. The study's findings highlight the importance of taking a holistic approach that considers the complex interplay between different parts of the body and potential triggers of pain and dysfunction.
In summary, the study confirms that US-DN is an accessible and effective treatment for myofascial pelvic pain, and can provide significant mechanical benefits to posture. By targeting central MTrPs, it can lead to a significant decrease in pelvic pain. The use of US imaging is also an effective technique for assessing the interaction between internal genitalia and pelvic floor muscles, which can cause bladder neck hypermotility, urogenital symptoms, and pain. However, further studies are needed to establish causality between MTrPs and other conditions, and to develop validated questionnaires and personalized management plans for pelvic floor dysfunction.

Bubnov R, Kalika L Dry needling of trigger points under ultrasound guidance effective to treat chronic pelvic pain and pelvic prolapse.  ICS 2020 https://www.ics.org/2020/abstract/494
Bubnov RV. Evidence-based pain management: is the concept of integrative medicine applicable? EPMA J 2012, 3(1):13.
Bubnov RV: Unremovable idiopathic pelvic pain treatment by a novel ultrasound guided technique. European Journal of Neurology. 2012, 19 (Suppl. 1), 586.

Continence 7S1 (2023) 100813
DOI: 10.1016/j.cont.2023.100813