Hypothesis / aims of study
The hypothesis of this study is that both ultrasound-guided dry needling (DN) and exercise intervention are effective in managing pelvic pain and improving bladder neck motility in patients with myofascial pelvic pain syndrome [1-3]. The aim is to compare the outcomes of these two interventions and evaluate their effectiveness in reducing pelvic pain severity, improving bladder neck motility, and alleviating lower urinary tract symptoms (LUTS).
Study design, materials and methods
A total of 20 female patients under 50 years old with extensive pelvic pain and LUTS, along with bladder neck hypermobility measuring 70+ mm, were recruited for this study. Patients with relevant urological or gynecological diseases were excluded. The study comprised two groups: one group (n=10) received ultrasound-guided DN, while the other group (n=10) underwent a 2-week exercise intervention. All patients underwent a comprehensive assessment including general examination, MRI, precise physical tests, and extensive functional multilevel multiparameter neuromuscular ultrasound. Transabdominal pelvic ultrasound was performed to evaluate bladder neck motility: 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. Ultrasound identification of myofascial trigger points (MTrPs) in the muscles at lumbar level, in sacroiliac junction (SIJ) was conducted, followed by DN under US guidance using steel acupuncture needles (28 gauge). Visual analog scale (VAS) scores were used to assess pelvic pain severity before and after the interventions.
Results
Both ultrasound-guided DN and exercise intervention led to significant improvements in pelvic pain severity, bladder neck motility, and LUTS. The mean VAS scores decreased from 6.3 to 1.2 in both groups, indicating a reduction in pain intensity. Additionally, bladder neck motility showed a significant decrease in both groups, with similar efficacy observed between ultrasound-guided DN and exercise intervention. After DN-US, hypermobility improved by 40-70 mm (up to 100%), while after exercises, hypermobility improved by 20-50 mm (up to 70%).
Interpretation of results
Considerations for Choosing Each Method:
• After 1-2 sessions, ultrasound-guided dry needling (DN-US) showed comparable results to 2 weeks of systemic exercise in reducing pelvic pain and improving bladder neck motility. This suggests that DN-US may offer rapid relief and could be considered as an initial treatment option for patients requiring immediate symptom management.
• Both interventions demonstrated similar efficacy in moderate levels of pelvic pain and dysfunction, particularly in younger patients. This highlights the importance of individualized treatment plans based on the severity of symptoms and patient demographics.
• In cases of severe pelvic pain or serious dysfunction, such as postoperative muscle weakness, DN-US may be more effective in providing immediate and targeted relief. The precision of DN-US in targeting myofascial trigger points may offer superior outcomes in severe cases compared to exercise intervention alone.
• Fitness of muscle: Exercise intervention may be more suitable for patients with adequate muscle strength and endurance, while DN-US could be preferred for patients with specific trigger points or areas of muscle tension that require targeted treatment.
• Gynecological Pathology: Patients with underlying gynecological conditions may benefit from a multidisciplinary approach that addresses both the gynecological pathology and associated pelvic pain. DN-US could complement gynecological treatments by targeting myofascial trigger points contributing to pelvic pain.
• Age and Delivery: Older patients may face challenges with both exercise intervention and DN-US due to factors such as reduced muscle strength, mobility limitations, and potential contraindications. Individualized treatment plans should consider the patient's age, mobility, and ability to tolerate interventions.
• Sex Differences: While the study focused on female patients, similar principles may apply to male patients experiencing pelvic pain and dysfunction. However, further research is needed to investigate the effectiveness of DN-US and exercise intervention in male populations.
• Postoperative Considerations: In patients recovering from surgery, such as pelvic floor surgery or gynecological procedures, DN-US may offer targeted relief for postoperative muscle weakness and associated pain. Exercise intervention may be introduced gradually as part of postoperative rehabilitation to improve muscle strength and function.
Concluding message
In conclusion, this study provides evidence supporting the effectiveness of both ultrasound-guided DN and exercise intervention in managing pelvic pain and improving bladder neck motility. These findings underscore the importance of individualized treatment approaches and offer insights into the management of pelvic floor dysfunction. Further research is warranted to explore the long-term effects and optimal duration of these interventions.
Future Directions:
• Future research should explore the long-term effects and optimal duration of both DN-US and exercise intervention and other modalities like US-guided neuromodulation in managing pelvic pain and improving bladder neck motility.
• Comparative studies with larger sample sizes and diverse patient populations are needed to further elucidate the effectiveness of these interventions across different age groups, sexes, and severity levels of pelvic dysfunction.
• Multidisciplinary approaches that integrate gynecological, urological, and musculoskeletal treatments may offer comprehensive care for patients with complex pelvic pain syndromes.
By considering these points, clinicians can make informed decisions regarding the selection of treatment modalities for patients with myofascial pelvic pain syndrome.