V12-07: Pelvic Floor Chemodenervation for Refractory High Tone Pelvic Floor Dysfunction
High tone pelvic floor dysfunction (HTPFD) can lead to pelvic pain, elimination dysfunction and dyspareunia. Pelvic floor physical therapy (PFPT) is a mainstay of treatment; however, there are limited additional options when PFPT fails. Thus, we aim to characterize our safe, effective pelvic floor botulinum toxin type A (BoNTA) injection technique.
A 31yo female presents with bothersome HTPFD. She attended PFPT without improvement. Options were discussed, and she elects to proceed with injection of BoNTA to the pelvic floor.
The following is an injection of 150u. Setup includes a right angle retractor, maleable retractors, gauze and lidocaine jelly. BoNTA is reconstituted to a concentration of 10u/cc. Sterile prep and surgical towels create a small field. Fifty units are distributed to the superficial transverse perineii (STP) over 5 injections. The first injection is placed mid-STP. After the needle is withdrawn, gentle massage of the injection site assists with hemostasis and drug distribution. The medial right and left STP are then injected transcutaneously (10u each). Next, the lateral right and left STP muscle bellies are injected near the ischial tuberosity insertion (10u each). Attention is then turned to the internal musculature. The maleable retractor is placed vaginally and adjusted to provide exposure. Fifty units are delivered to each levator ani complex over 5 separate 10u injections (proximal to distal) along each muscle belly. The levator ani complex is isolated between two fingers. The initial insertion of the needle is distal, near the levator complex-symphysis pubis insertion, followed by a quick transition to the left mid levator ani. Gently adjusting the needle depth from medial to lateral helps to distribute the BoNTA from the more medial puborectalis muscle belly to the more lateral iliococcygeus. Last, the more proximal insertion of the levator ani on the coccyx is injected. Other than the switch from the dominant hand, the right levator ani complex is injected in an identical fashion with palpation to identify musculature followed by injection and massage.
Pelvic floor muscle BoNTA injections for HTPFD leading to pelvic pain/dyspareunia is a safe, efficacious, minimally-invasive technique, which can be straightforward and have excellent results in properly selected patients. There is a low risk of theoretical complications, such as new-onset SUI or anal incontinence. After two years of inability to tolerate vaginal penetration, our patient was able to have intercourse and orgasms within 1 month post procedure.