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A Clinical Consensus Treatment Algorithm for Patients with High-tone Pelvic Floor Dysfunction: a Multidisciplinary Delphi Study

BACKGROUND High-tone pelvic floor dysfunction (HTPFD) is a neuromuscular disorder of the pelvic floor characterized by non-relaxing pelvic floor muscles, resulting in lower urinary tract and defecatory symptoms, sexual dysfunction, and pelvic pain. Despite affecting 80% of women with chronic pelvic pain, there are no uniformly accepted guidelines to direct the management of these patients. We sought to develop evidence-and consensus-based clinical practice guidelines for management of HTPFD.

METHODS AND FINDINGS A Delphi method of consensus development was used, comprising three survey rounds administered anonymously via web-based platform (Qualtrics® XM) to national experts in the field of HTPFD recruited through targeted invitation between September and December 2021. Twelve experts participated with backgrounds in urology, urogynecology, minimally invasive gynecology, and pelvic floor physical therapy (PFPT) participated. Panelists were asked to rate their agreement with rated evidence-based statements regarding HTPFD treatment. Statements reaching consensus were used to generate a consensus treatment algorithm. A total of 31 statements were reviewed by group members at the first Delphi round with 10 statements reaching consensus. 28 statements were reposed in the second round with 17 reaching consensus. The putative algorithm met clinical consensus in the third round. There was universal agreement for PFPT as first-line treatment for HTPFD. If satisfactory symptom improvement is reached with PFPT, the patient can be discharged with a home exercise program. If no improvement after PFPT, second line options include trigger or tender point injections, vaginal muscle relaxants, and cognitive behavioral therapy, all of which can also be used in conjunction with PFPT. Onabotulinumtoxin A injections should be used as third line with symptom assessment after 2-4two to four weeks. There was universal agreement that sacral neuromodulation is fourth line intervention. The largest identified barrier to care for these patients is access to PFPT. For patients who cannot access PFPT, experts recommend at-home, guided pelvic floor relaxation, self-massage with vaginal wands, and virtual PFPT visits.

CONCLUSIONS A stepwise approach to the treatment of HTPFD is recommended, with patients often necessitating multiple lines of treatment either sequentially or in conjunction. However, PFPT should be offered first line.

Michele Torosis,1 Erin Carey,2 Kristin Christensen,3 Melissa R. Kaufman,4 Kimberly Kenton,5 Rhonda Kotarinos,6 H. Henry Lai,7 Una Lee,8 Jerry L. Lowder,9 Melanie Meister,10 Theresa Spitznagle,11 Kelly Wright,3 A. Lenore Ackerman12

  1. Department of Obstetrics and Gynecology, UCLA, Los Angeles, CA
  2. Department of Obstetrics and Gynecology, UNC, Chapel Hill, NC
  3. Cedars-Sinai Medical Center, Los Angeles, CA
  4. Department of Urology, Vanderbilt, Nashville, TN
  5. Department of Obstetrics and Gynecology, University of Chicago, Chicago, IL
  6. Kotarinos Physical Therapy, Lake Zurich, IL
  7. Division of Urologic Surgery, Departments of Surgery and Anesthesiology, Washington University, Saint Louis, MO
  8. Department of Urology, Virginia Mason, Seattle, WA
  9. Department of Obstetrics and Gynecology, Washington University, Saint Louis, MO
  10. Obstetrics and Gynecology, University of Kansas, Kansas City, KS
  11. Washington University, Saint Louis, MO
  12. Department of Urology, UCLA, Los Angeles, CA
Source: Torosis M, Carey E, Christensen K et al. A Clinical Consensus Treatment Algorithm for Patients with High-tone Pelvic Floor Dysfunction: a Multidisciplinary Delphi Study. medRxiv. 2023. https://doi.org/10.1101/2023.08.11.23293953.