Disclosures: Patricia Orme, MD: No financial relationships or conflicts of interest

Case Description: A patient with refractory chronic pelvic floor pain presented for evaluation. She underwent selective diagnostic motor nerve blocks of the nerves innervating the levator ani bilaterally. These were efficacious in controlling her pain, therefore, confirming a diagnosis of focal dystonia. She then underwent chemodenervation with botulinum toxin, which provided sustained relief.

Setting: The patient presented to the Center for Tone Management, a private practice, for her chronic pelvic floor pain.

Patient: Patient is a 40 year old female who has suffered from chronic pelvic pain with associated dyspaurenia for decades. She has failed multiple therapies, including pelvic floor therapy, vaginal dilators, hormonal therapy, oral and topical pain medications, pudendal nerve block, and exploratory laparotomy. Assessment/

Results: To determine dystonia as the source of the patient’s pain, she underwent diagnostic selective motor nerve blocks to the nerves innervating the levator ani bilaterally. She was placed in lithotomy position and the perineal region exposed. Skin was prepped in sterile fashion and 1% lidocaine was used for local anesthesia. Using a transcutaneous nerve stimulator, motor nerve branches of the levator ani were identified bilaterally. A total of 6 motor nerve branches were identified, followed by precise localization with a transdermal needle electrode. Once this was achieved with less than 0.3 milliamps of current, 1cc of 0.25 bupivicaine was injected onto each nerve. The patient had pain relief following the procedure, deeming her an appropriate candidate for chemodenervation. Upon followup, under EMG guidance, the aforementioned muscles were injected with a total of 500U abobotulinumtoxin over 3 sites bilaterally. The patient reported 50% relief in her pain.

Discussion: Pelvic floor pain may be attributed to focal dystonia of the levator ani, confirmed by performing diagnostic selective motor nerve blocks and subsequent chemodenervation.

Conclusion: Pelvic floor pain due to dystonia of the levator ani muscles may be alleviated by chemodenervation with neurotoxin.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/chemodenervation-for-chronic-pelvic-floor-pain-due-to-focal-dystonia-of-the-levator-ani/