We know it can relax our face, but . . . the vagina?

Pelvic floor muscle dysfunction (PFM) is characterized by involuntary spasm of the pelvic floor muscles around the vagina. PFM is a relatively common sexual pain disorder, leading to impossible or extremely painful intercourse. In extreme cases, conventional treatment methods may fail. Botulinum toxin (Botox®) has emerged as an effective treatment option in cases of refractory PFM dysfunction. 

Further randomized controlled trials may be needed to determine the degree of Botox efficacy, optimal doses and injection technique. Botox is not FDA approved for the pelvic floor at this time.

What causes PFM? The exact cause remains undetermined, it is often the result of a complex interaction between gastrointestinal, urinary, gynecologic, musculoskeletal, neurologic and endocrine systems. It has been suggested that up to 85% of women with chronic pelvic pain have a dysfunction of the musculoskeletal system. It can be associated with lack of sex education, conservative and religious upbringing, history of sexual abuse, anxiety or depression and relationship factors.

How do we classify PFM dysfunction? 

  1. Primary – lifelong, when a patient has never had pain-free intercourse
  2. Secondary – acquired, when the patient experiences sexual pain after a period of non-painful intercourse

How is it diagnosed?

A vaginal examination is key to the diagnosis and taut muscles are easily felt and usually enough to make the diagnosis of pelvic floor spasm on vaginal exam.

How severe is it?

Grade 1 – symptoms relieved with reassurance

Grade 2 – patient unable to relax during pelvic examination despite reassurance

Grade 3 – patient involuntarily elevates buttocks during attempted pelvic examination

Grade 4 – patient elevates buttocks, retreats and tightly closes thighs to avoid exam

What treatment options are available?

  • Cognitive behavior therapy
  • Pelvic floor physical therapy
  • Kegel exercises
  • Vaginal dilation therapy
  • Lubricants
  • Vaginal valium
  • Recently, researchers have shown increased interest in botulinum toxin (BoNTA) as an alternative option for refractory cases of PFM dysfunction, especially those that fail first-line treatments. 

Botox for the Vagina?

Over the past 3 decades, Botox has been described in the management of other sexual pain disorders, such as dyspareunia, vestibulodynia and persistent genital arousal disorders. In 1997, Brin and Vapnek described the use of Botox for the first time in the management of severe PFM dysfunction. In this case, the patient was able to have intercourse successfully with no recurrence after 2 years.

To understand the use of Botox in pain syndromes it is important to understand the mechanism of pain with muscle spasm/myofascial trigger points and mode of action of Botox.

The main factor in pain appears to be ischemia due to compression of the muscle’s blood vessels in cases of muscle spasm. In a hyperactive muscle, nerve compression can occur which leads to pain. Botox can relax hyperactive muscle and the pain due to compressions of muscles and nerves. Release of muscle tightness (paralysis) will improve circulation and break the vicious cycle of spasm and pain. 

Where do you inject?

Most commonly the levator ani muscles

  • Puborectalis
  • Pubococcygeus
  • Iliococcygeus

Success rates?

Most studies report 62-100%

Most patients included in studies reported no recurrent symptoms for up to one year after injection.

When can we not use Botox?

  • Pregnancy
  • Breastfeeding
  • Hypersensitivity to albumin
  • Active infection at the planned injection site
  • Neuromuscular or bleeding disorder
  • If on anticoagulation therapy

What side effects might be expected?

  • Transient urinary and fecal incontinence (usually resolved spontaneously at 4 months)
  • Side effects of Botox are rare, but could include pain, hematoma, and infection at the site of injection.

Average costs: $1500-2000

Conclusion: Despite being widely used for musculoskeletal disorders in other areas, the use of Botox for pelvic pain is still limited. Further randomized controlled trials are warranted to standardize the use of Botox for PFM dysfunction, but if you have tried several treatment options and are still having debilitating pain affecting your quality of life, there is promising evidence to support the use of Botox.

We offer Botox for cases of refractory pelvic floor muscle dysfunction at Sky Women’s Health.

Call to schedule your consultation.

817-915-9803

skywomenshealth.com

Resources: 

Gari R, Alyafi M, Gadi RU, et al. Use of Botulinum Toxin (Botox ®) in Cases of Refractory Pelvic Floor Muscle Dysfunction. Sex Med Rev 2022; 10:155-161.

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