Dry needling of trigger points under ultrasound guidance effective to treat chronic pelvic pain and pelvic prolapse

Bubnov R1, Kalika L2

Research Type


Abstract Category


Abstract 494
ePoster 7
Scientific Open Discussion Session 32
Pelvic Organ Prolapse Pelvic Floor Pain, Pelvic/Perineal Neuropathies: Peripheral Imaging
1. Clinical hospital ‘Pheophania’ of State Affairs Department, Kyiv, Ukraine, 2. New York Dynamic Neuromuscular Rehabilitation & Physical Therapy https://nydnrehab.com/, New York, USA

Rostyslav Bubnov



Hypothesis / aims of study
Pelvic ultrasound (US) is effective to assess pelvic health, has a strong potential for diagnosis pelvic floor disorders [1]. Pelvic floor ultrasound performed via transabdominal approach cen effectively detect movement of bladder neck associated with LUTS and symptoms of incontinence; is feasible and reliable method for assessment bladder neck motility in women [1] and men.
Myofascial pelvic pain evoked by myofascial trigger points (MTrPs) is detected in large number of gynecological and urological patients, pelvic prolapse and pelvic pain can depend on postural imbalance and associated with generalized pelvic pain and pelvic floor dysfunction. 
Ultrasound (US) revolutionized physical therapy and  myofascial pain treatment, precise muscle dry needling (DN) under US guidance (US-DN) can multiply clinical effect [2,3]. Bladder neck mobility is a manifestation of posture imbalance and myofascial disorders.
We assume that treatment of MTrPs via precise US-DN and inegrative correcting posture decrease pelvic pain, is beneficial for LUTS and improve bladder neck motility as assessed via transabdominal ultrasound.
Study design, materials and methods
We included 28 patients (8 males, aged 34–68 y.o.) suffering from extensive pelvic pain with different patterns, location,  from low back pain and LUTS. Inclusuion criteria: pelvic pain of different pattern inguinal, pubic, vulvodynia, rectal pain, LUTS. Any relevant urological gynecological disease excluded. Healthy 20 individuals (18–53, 10 males) were controls. 
All patients underwent general examination, MRI, precise physical tests, extensive functional multilevel multiparameter neuromuscular US [3] using 4-8 MHz/5-12 MHz probes in shoulder, sacroiliac junction (SIJ), intervetrebral spaces, foot, ankle, gluteus region and pelvis, abdominal wall, diaphragm and pelvic floor motility. We did M-mode, transient elastography and shear wave elastography (SWE) of nerves and muscles, evaluated structure, CSA, detecting compressions, contact to scars, muscle TrPs, spasticity and evaluated nerve motion and SWE during overstraining neurodynamic tests. 
All patients underwent transabdominal pelvic ultrasound for evaluation bladder neck motility. Transabdominal US measurements of bladder neck rotation in a postero-inferior direction at rest and on maximal Valsalva was performed to all patients. Measurements were taken at rest and on maximal Valsalva, and the difference yields a numerical value for bladder neck descent. 
We evaluated bladder motion, deformation, determined side of deviating bladder (according to the position/tone of psoas muscle) before and after intervention. 
Then patients received DN of detected MTrP under US guidance. 
Approches for needling. The treatment approach by [Evidence-based pain management: is the concept of integrative medicine applicable? EPMA Journal 3, 13 (2012). https://doi.org/10.1186/1878-5085-3-13] was applied, that included ultrasound identification of MTrPs with following dry needling under US guidance using steel acupuncture needles (28 gage) to elicit the LTR effect. Retention of needles depended of muscle twitch response duration. Visual analogue scale data (0 to 10) were measured before, immediately after and 24 hours after the intervention.
Seventeen patients were effectively treated via DN of paravertebral muscles muscles (multifidus musckes at lumbar, thoracic levels), correcting posture. 1-2 sessions were needed, in one session 3-4 needles were inserted.
In rest of patients after insufficient efficacy of treatment after paravertebral muscles MTrPs inactivation, trigger points were detected  in deep pelvic muscles: in 8 female and 1 male patients we needed to use deep pelvic muscles DN. In 6 patients active trigger points were diagnosed in deep pelvic muscles, that caused compression of n.pudendus in Alcock’s canal. 
We distinguished patients who demonstrated patterns as follows:
•	Inguinal pain;
•	Genital pain, vulvodynia (pudendal nerve involvement);
•	Coccygodynia;
•	Rectalgia;
•	Sacral pain.
Specifically adapted protocols for diagnosis and DN to restore muscle function, motion restriction and overall postural imbalance were applied in every case
•	Obturator muscles – transmembrane approach was used for DN of obturator int. muscle;
•	Anterior approach (mm. pectineus, iliocapsularis);
•	SIJ dysfunction, fascia and muscles at upper and lower portions;
•	Thoracolumbar fascia (TLF);
•	Local applications. 
The bladder neck hypermotility (over 45 mm) was detected in 14 patients and was restored after treatment in 13 cases. Pelvic pain and LUTS intensity correlated with bladder neck hypermotility.
After treatment completed pain relief was obtained in all patients (VAS levels  improved from 7.3 to 1.4), long term effect remained in all patients.
Interpretation of results
Among patients with pelvic pain locations of dysfunctions / hypomobility at lower thoracic, lumbar multifidus muscles were the leading triggers of pelvic pain and pelvieac floor weakness and bladder neck hypermobility. 
The pelvic pain and dysfunction associated with SIJ and TFL dysfunction, shoulder impingement and headache (involving cervical muscles) and often involved thoracic dysfunction (restricted movement in functional unit in mid-thorax (e.g., Th5-7 vertebraes and Th5-7 ribs).
Whole body neuromuscular ultrasound helped to detect and effectively inactivate all relevant MTrPs considering complexity of posture and muscle chains. 
This holistic approach addresses: movement control, pain generators, fascias and trigger points at the same time at epaxial (spine), hypaxial (abdomen), and appendicular (the 4 extremities) myofascial systems.
Concluding message
US-DN is accessible and effective method for myo-fascial pelvic pain treatment providing significant mechanical benefits to the posture. US-DN of central (core, spinal) MTrPs evokes significant decreasing of pelvic pain. 
US imaging is effective techniques for assessment overall posture, interaction of internal genitalia with pelvic floor muscles, resulting bladder neck hypermotility, urogenital symptoms and pain and for monitoring treatment.
Further studies to establish causality in regards to MTrPs and other conditions are required including development validated questionnaires conjoined with specific background analysis essential for personalized management of pelvic floor dysfunction.
  1. Bubnov R, Goncharenko V. The use of transabdominal vs translabial ultrasound for diagnosis and screening of bladder neck mobility: comparative study https://www.ics.org/2019/abstract/362
  2. Bubnov R. Unremovable idiopathic pelvic pain treatment by a novel ultrasound guided technique. European Journal of Neurology. 2012, 19 (Suppl. 1), 586.
  3. Bubnov R, Kalika L, Babenko L. Dynamic ultrasound for multilevel evaluation of motion and posture in lower extremity and spine. Annals of the Rheumatic Diseases 2018;77:1699. http://dx.doi.org/10.1136/annrheumdis-2018-eular.3949
Funding Self-supporting Clinical Trial No Subjects Human Ethics Committee NY Dynamic Neuromuscular Rehabilitation & Physical Therapy Helsinki Yes Informed Consent Yes
18/07/2024 08:52:41