Urologic Myofascial Pain Syndromes Ragi Doggweiler-Wiygul, MD

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Urologic Myofascial Pain Syndromes
Ragi Doggweiler-Wiygul, MD
Address
Department of Urology, University of Tennessee,
1211 Union Avenue, Suite 340, Memphis, TN 38104, USA.
E-mail: [email protected]
Current Pain and Headache Reports 2004, 8:445–451
Current Science Inc. ISSN 1531-3433
Copyright © 2004 by Current Science Inc.
Treatment of pain of urogenital origin, chronic pelvic pain
syndrome, can be frustrating for patients and physicians.
The usual approaches do not always produce the desired
results. Visceral pain from pelvic organs and myofascial pain
from muscle trigger points share common characteristics.
Referred pain from myofascial trigger points can mimic
visceral pain syndromes and visceral pain syndromes
can induce trigger point development and myofascial
pain and dysfunction. The referred pain syndrome can
long outlast the initial event, making diagnosis difficult.
Introduction
Treatment of pain of urogenital origin, chronic pelvic pain,
painful bladder syndrome/interstitial cystitis, chronic prostatitis, prostatodynia, and irritative voiding and bowel
symptoms can be frustrating for patients and physicians.
The usual approaches do not always produce the desired
results. Acute insults may develop into chronic pain states
with alterations of the central nervous system and autonomic functions [1].
In many ways, current medical practice still follows a traditional Cartesian view of a mind-body dichotomy. Symptoms are seen as being physical (real) or mental, which is
outside the understanding of many physicians. This view
implies that a person’s pain experience is proportional to the
amount of physical damage—the more damage, the more
pain. If there is no obvious illness but the patient complaints
of pain and dysfunction are intense, the search for the cause
of the pain often culminates in surgery [2]. Unfortunately,
lasting pain relief can be expected only if the surgery indeed
has alleviated an underlying physical problem and if this dysfunction actually was the main cause of the patent’s pain
complaint. Many patients who are not helped by surgery are
declared as drug-addicted and psychotic. At this point,
patients are angry and feel betrayed and humiliated. They
continue the search for a cure elsewhere.
Clinical studies including large numbers of patients show
that chronic painful states of obscure causes often depend on
feedback cycles from myofascial trigger points and their pain
reference zones [3]. Symptoms outlast initiating and precipitating events because of vicious cyclic neuroreflex patterns
and continuing mechanical stresses on the affected somatic
structures. Most tissues heal when injured, but skeletal muscles “learn;” they readily develop habits of guarding that
limit movement, impair circulation, and result in chronic
pain, stiffness, and dysfunction of muscles [4].
Myofascial pain and dysfunction has been suggested as
a cause of pain of urogenital origin [5]. The tissues overlaying the lower abdomen, pelvis, and low back are innervated by T10 (umbilicus) through T12 (pubis) anteriorly
and L1 through S5 posteriorly onto the anus and
perineum. The pudendal nerve (S2, S3, S4) provides the
main sensory innervation from the clitoris and vulva [6••].
All of the pelvic organs and pelvic floor musculature share
the same innervation and the same neurologic reflexes and
coordination. Dysfunction of one pelvic organ may affect
others through a reflex mechanism. Bladder filling and
emptying is regulated similarly by neural circuitry in the
brain and spinal cord and requires coordination of activity
in the various smooth and striated muscles of the pelvis.
The central regulation of voiding is complex because reflex
pathways that mediate vesicourethral function are under
involuntary and voluntary control. This control is dependent on learned behavior [7]. Control of the sphincters
and pelvic floor muscles is learned only with postnatal
maturation of the central nervous system. If this voiding
pattern is learned in an abnormal fashion or some event
interrupts or disturbs its normal development, voiding dysfunction ensues and is thought to result in hypersensitivity
and spasticity of the urethral sphincter mechanism and
bladder. This can culminate over time into pelvic floor
dysfunction and dyssynergic voiding patterns [5].
Painful Bladder Syndrome/Interstitial Cystitis
Interstitial cystitis is a painful bladder syndrome characterized by urinary urgency, frequency, dysuria, dyspareunia,
and chronic pelvic pain. It often is associated with a number of other conditions including irritable bowl syndrome,
endometriosis, fibromyalgia, chronic fatigue syndrome,
and upper and lower torso musculoskeletal dysfunction.
In 1914, Hunner [8] described interstitial cystitis as a
diagnosis made with cystoscopy characterized by the presence of discrete, red, bleeding areas on the bladder wall—
the pathognomonic Hunner’s ulcers [8]. Nearly 60 years
ago, Dr. T. Leon Howard educated students regarding the
stressful condition of these patients [9].
446
Myofascial Pain Syndrome
Today, painful bladder syndrome/interstitial cystitis is
still an enigma and is a frustrating condition for the treating physician and for the patient who suffers from the
disease. Its etiology and pathophysiology are incompletely
understood and thus it is without a universally successful
therapy. The resurgence of interest and research in the field
of painful bladder syndrome has brought new understanding and hope to this condition.
Table 1. The National Institutes of Health
consensus classification of prostatitis syndromes
I
II
III
IV
Acute bacterial prostatitis
Chronic bacterial prostatitis
Chronic prostatitis/chronic pelvic pain syndrome
a. Inflammatory
b. Noninflammatory
Asymptomatic inflammatory prostatitis
Chronic Prostatitis/
Chronic Pelvic Pain Syndrome
Visceral Pain and Myofascial Pain
Men with pain in the genitourinary tract, which is a common problem, generally are given a descriptive diagnosis
such as orchialgia, chronic prostatitis, prostatodynia, or
chronic pelvic pain syndrome (Table 1).
More than 90% of the symptomatic patients have typeIII chronic prostatitis/chronic pelvic pain syndrome. This
term “chronic pelvic pain syndrome” recognizes the
limited understanding of the etiology of this syndrome
and the possibility that organs and structures other than
the prostate gland may be involved in the cause. Patients
with the inflammatory subtype of chronic prostatitis/
chronic pelvic pain syndrome have leukocytes in their
expressed prostatic secretions, postprostate massage urine,
or semen. In contrast, patients with the noninflammatory
subtype have no evidence of inflammation [10•].
This definition and classification of prostatitis syndromes reflects a new interest in these disorders by researchers and hopefully will result in improved approaches to
clinical diagnosis and patient management.
Visceral pain from pelvic organs and myofascial pain from
muscle trigger points share common characteristics [13].
Visceral and myofascial pain generally are diffuse and
poorly localized. In both conditions, chronic pain sensitizes the peripheral and central nervous system, causing
lowering of nociceptive thresholds. The nociceptive dorsal
horn neuron receptive fields enlarge because of neurologic
wind-up and result in hypersensitivity and allodynia.
Referred pain can be from visceral organs to the muscles or
from myofascial trigger points to visceral organs. Referred
pain from myofascial trigger points can mimic visceral
pain syndromes, just as visceral pain syndromes can
induce trigger point development and myofascial pain and
dysfunction. Painful bladder syndrome/interstitial cystitis,
chronic prostatitis, and IBS often are associated with
abdominal wall and pelvic floor muscle trigger point syndromes (Fig. 1). In both cases, the referred pain syndrome
can long outlast the initiating event, making diagnosis
more difficult [14•].
Irritable Bowel Syndrome
Etiology of Urologic
Myofascial Pain Syndromes
Irritable bowel syndrome (IBS) is a functional disorder
characterized by abdominal pain and altered bowel
habits. This syndrome may begin in young adulthood and
can be associated with significant disability. IBS is characterized by chronic relapsing patterns of bloating and
cramping pain with alterations in stool frequency or constitution. Pain often is relieved by defecation and it is
present in 50% to 80% of these patients with any form of
chronic pelvic pain [11]. IBS may present with a range and
overlay of symptoms. However, abdominal pain and
altered bowel habits remain the primary features. Abdominal discomfort often is described as cramping in nature
and located in the left lower quadrant, although the severity and location can differ greatly. Patients may report
diarrhea, constipation, or alternating episodes of diarrhea
and constipation. Diarrheal symptoms typically are
described as small-volume, loose stools, and stools that
sometimes are accompanied by mucus discharge. Patients
also may report bloating, fecal urgency, incomplete evacuation, and abdominal distention. Upper gastrointestinal
symptoms, such as gastroesophageal reflux, dyspepsia, or
nausea, also may be present [12].
Development of active trigger points can be associated
with mechanical, physical, systemic, and psychologic stressors (Fig. 1). Mechanical and physical stressors such as
traumatic overstretching and direct insult as in injury (eg,
motor vehicle accident) are of sudden onset. Gradual onset
follows overuse, repetitive strains, motion injury, or abnormal assumed postures [4] (Table 2).
Activation of trigger points can result from a fall, automobile accident, or surgery in the pelvic region. However,
very often, no injury can be identified. Sitting in a slumped
or slouched posture for prolonged periods also can be
responsible. Dysfunction of the sacroiliac joints and sacrococcygeal articulation may be aggravating sources of trigger
points. Discrepancy in length of the legs as little as 0.5 cm
can cause back pain, trigger points, and pelvic distortion. A
head-forward kyphotic posture may perpetuate trigger
points in gluteus muscles. Position at the work desk (especially computer work stations), sleeping patterns, shoes,
and posture need to be evaluated [4] (Table 3).
Some physicians have implicated voiding dysfunction in
the pediatric population as the beginning of a long process
Urologic Myofascial Pain Syndromes • Doggweiler-Wiygul
447
Figure 1. Trigger point (TrP) and chronic pelvic pain syndrome development.
Table 2. Referred myofascial pain sources
Referred pain
Abdominal pain
Buttock pain
Iliosacral pain
Lumbar pain
Pelvic pain
Muscle source
Rectus abdominis, obliquus externus
abdominis, iliocostalis thoracis,
multifidi, quadratus lumbarum,
pyramidalis
Gluteus medius, gluteus maximus,
quadratus lumbarum, iliocostalis
lumbarum, longissimus thoracis,
semitendinosus, semimembranosus,
piriformis, gluteus minimus, rectus
abdominus, soleus
Levator ani, coccygeus, gluteus medius,
quadratus lumbarum, gluteus maximus,
multifidi, soleus, rectus abdominis
Gluteus medius, multifidi, iliopsoas,
longissimus thoracis, rectus abdominis,
iliocostalis thoracis, iliocostalis
lumbarum
Coccygeus, levator ani, obturator
internus, abductor magnus, piriformis,
obliquus internus abdominis
that results in pelvic floor dysfunction in adults [5]. It has
been suggested and observed that chronic pelvic floor and
voiding dysfunction leads to bladder irritation and inflam-
Table 3. Pelvic anatomy and function
Anatomy
Bony pelvis: ischium, ilium (innominate), pubis
These three bones are fused, but have mobile
articulations: the sacroiliac joints, the pubic symphysis,
and the sacrococcygeal articulation
Additional articulations: acetabulum-femoral head, fifth
lumbar-sacrum articulation
Function
Transfer weight-bearing between trunk and
lower extremities (weight-bearing: hips/sacroiliac
joint/lumbar spine)
Support and protect pelvic viscera
Provide muscular and ligamentous attachments
Reproductive functions (birth canal, support fetus)
matory changes damaging the bladder and causing a chronic
pelvic pain complex (Fig. 1). In our experience, we have seen
that more than 50% of patients with interstitial cystitis report
voiding dysfunction in childhood (eg, enuresis, urgency/
frequency syndrome, or recurrent urinary tract infections). A
significant number of these patients referenced previously in
our experience also report a history of sexual or physical
abuse at a young age, which also may be a contributing factor
to their pelvic floor disorder (unpublished data).
448
Myofascial Pain Syndrome
All of the pelvic organs and pelvic floor musculature
share the same innervation and the same neurologic
reflexes and their coordination. Dysfunction of one pelvic
organ may affect others through the reflex mechanism.
Pelvic anatomy and function are presented in Table 3.
A particularly deceptive feature of trigger points is that
their presence may not be known until a series of muscle
stresses exceeds the limit of trauma for that muscle. A spine
or hip problem, poor posture, or abnormal holding
patterns may weaken the pelvic floor muscles. At a much
later time, bladder or vaginal infections, trauma, or surgery
may add to the already stressed muscle and cause acute
pain or abnormal functioning. In other words, a trigger
point may become active as a result of a seemingly
inconsequential event [4].
Visceral diseases tend to increase activity of myofascial
trigger points. Examples are herpes viruses and urinary
tract infections. Chronic allergies and impaired sleep also
can make muscles more painful [4]. Yoshimura [15]
demonstrated that chronic bladder inflammation induces
C-fiber bladder afferent hyperexcitability. Injury to nerves
in the distal urethra and pelvic floor also can induce hyperexcitability of C-fiber afferent neurons. Similar changes in
bladder and urethral afferent pathways may contribute to
painful symptoms in interstitial cystitis.
Subclinical hypothyroidism [16] and nutritional inadequacies can be causative and perpetuating factors in hyperirritable muscles and myofascial pain syndrome. Proper
nutrition needs to be discussed with the patient if lasting
relief from pain is to be achieved.
Psychologic factors contribute to perpetuating myofascial trigger points. Physicians must be careful not to
assume that psychologic factors are primary. This wrong
assumption can be, and often is, frightfully devastating to
the patient [4]. Depression and chronic pain are closely
associated, especially if patients are not obtaining understanding or relief from their symptoms.
Diagnosis
An in-depth history and physical examination are the
most important aspects of the diagnostic work-up. This
includes questions regarding potty training, sexual habits
and eventually abuse, and bowel habits. Detailed review
of systems is essential, including prior surgeries (hysterectomies, laparoscopies, cystoscopies with possible urethral
dilations, or even urethrotomies) and the events leading
to the interventions.
Urinary urgency, frequency, nocturia, dyspareunia,
constipation or diarrhea, and pelvic pain are cardinal
symptoms of these crippling disorders. Patients often
report urinary or bowel frequency as their attempt to
relieve pelvic or lower abdominal pain, not just because
of fear of incontinence.
The location of the pain, type of pain, precipitation
factors, and alleviating factors need to be investigated.
To better evaluate bladder function, a voiding diary is a
necessity. Patients with interstitial cystitis typically void
more frequently than those with overactive bladder. Some
patients report urinating up to 50 times daily. A diary also
provides useful information regarding voiding patterns
and maximal functional bladder capacity [17•].
A urinalysis is recommended to rule out urinary tract
infection. Patients with interstitial cystitis commonly have
sterile pyuria and, in some cases, microscopic hematuria.
Every patient with hematuria should be evaluated further
with cystoscopy and renal radiographs to exclude other
genitourinary pathologies. Urine cytology may be useful in
select patients.
A pelvic pain and urgency/frequency questionnaire
(PUF) has been developed recently to help diagnose
patients with chronic pelvic pain syndrome [18] (Fig. 2).
The PUF score evaluates the severity of the patient's
frequency, urgency and pain, and incidence in reduction of
quality of life. A score higher than 10 is highly suggestive of
a diagnosis of painful bladder syndrome/interstitial cystitis
or chronic prostatitis and may help physicians screen
patients for the disorder.
Examination of the Patient
The patient needs to be evaluated for posture, gait, pattern
of sitting, and pelvic alignment. Patients with pelvic pain
often walk slowly and sit on one side and put the leg under
the buttock to avoid pressure on the pelvic floor muscles
by correction of pelvic asymmetry.
During physical examination, patients with interstitial
cystitis typically demonstrate abdominal and pelvic floor tenderness in the absence of other local pathology. Inability to
isolate and contract their pelvic floor musculature is common
because the muscles already are chronically in spasm [17•].
Patients need to be evaluated for myofascial pain syndromes.
Myofascial pain syndrome is a neuromuscular condition resulting from mechanical failure associated with
causative and perpetuating factors. Repetitive motion
injury, trauma, and illness cause trigger points, which can
occur in any and every muscle of the body. It affects as
many men as it does women. The pain is in specific spots
rather than generalized as with fibromyalgia; it is not just a
central nervous system disorder.
Myofascial trigger points are identifiable by physical
examination and specifically by palpation.
During examination, objective and subjective signs are
investigated. Various palpation techniques were used to
isolate active myofascial trigger points in the muscles of
four patients. Physical evaluation included musculoskeletal and posture assessment and analysis of gate and active
range of motion and strength. Overall muscle tone, tissue
sensation location of tenderness and trigger points, and
perineal movement were evaluated. Vaginal or rectal pelvic
examination assessed tenderness, contraction, strength,
and coordination of the pelvic floor muscles [19].
Urologic Myofascial Pain Syndromes • Doggweiler-Wiygul
449
Figure 2. Pelvic Pain and Urgency/Frequency Patient Symptom Scale.
No specific laboratory test or imaging technique has
been established to diagnose myofascial pain syndrome.
However, surface electromyography and ultrasonography
have potential for clinical application in the diagnosis
and treatment of myofascial pain syndrome. Certain
blood tests can be helpful in looking for predisposing
conditions, such as hypothyroidism, hypoglycemia, and
vitamin insufficiency. Specific tests that may be helpful
include complete blood count, chemistry profile, erythrocyte sedimentation rate, and levels of vitamins C, B-1, B6, B-12, and folic acid. A complete thyroid assay may be
helpful even if subclinical features of thyroid disease are
present [4].
Treatment
Effective treatment needs to be directed to the visceral and
myofascial component. The treatment of myofascial trigger
points consists of myofascial release that may be achieved
by compression or by injection of minimal amounts of
local anesthetics (never use steroids or adrenaline),
followed by lengthening (stretching) and strengthening
(physical therapy) of the involved muscles [4].
Therapy is based on lengthening and strengthening of
the dysfunctioning muscle unit. Dry needling and injection of active trigger points with local anesthetics using a
25-G 1-1/2-inch needle or dry needling with a 30-G dry
needle (50 mm; Seirin, Weymouth, MA). A 25-G 3-1/2-
450
Myofascial Pain Syndrome
inch spinal needle is used to reach trigger points in the
deepest muscles, such as gluteus minimus and quadratum
lumbarum. For every type of trigger point therapy, the goal
is to restore normal resting muscle length and a full range
of motion, which is achieved first by passive stretching and
then by active effort under a light load. Visual twitch
responses at the skin surface and in the muscles are used to
verify successful needle piercing of a trigger point.
The trigger point is identified by palpation as a spot of
exquisite tenderness in the palpable band. Because some
patients are very afraid of the skin pain caused by needle
penetration, a distracting stimulus of stretching or pinching the skin or the use of cold spray as the needle is
inserted may be helpful [4]. When the active trigger point
is pierced by the needle, the patient usually can describe
the exact distribution of the referred pain. Therefore, the
patient is warned that successful needle contact with a trigger point may produce a flash of distant pain and may
cause the muscle to twitch. Multiple trigger points frequently are present in more than one region of the muscle.
All of the tender spots in one region should be eliminated.
After each probing movement, the needle must be withdrawn to subcutaneous tissue and redirected before the
next movement. In each trigger point, a very small amount
(0.1 mL) of local anesthetic is injected. Using a dry
needling technique or injection, the twitch response is
observed. Dry needling is very helpful in a region that presents with several trigger points. After injection of local
anesthetics, the dry needle is used to eliminate the remaining tender spots.
Stretching after the trigger point injection is the most
integral part of the treatment. Not stretching after injection
or needling is the same as receiving no treatment at all. Relief
usually is long-lasting, but only when mechanical and
systemic perpetuating factors are corrected [20]. Intravaginal
or intrarectal trigger points are treated with biofeedback as
described by Doggweiler-Wiygul and Sellhorn [21].
All of the patients are counseled regarding nutrition;
they should avoid foods that favor interstitial cystitis symptoms and should add supplements such as minerals, vitamins, and essential fatty acids.
Conclusions
More than 50 years ago, Travell reported the phenomenon
of referred pain and referred motor activity caused by trigger points in skeletal muscles, now known as myofascial
pain and dysfunction. These substantiate the need for myofascial evaluation before considering more invasive treatments for chronic pelvic pain syndrome. Myofascial
evaluation can be aided by showing patients with symptoms pictures of referred pain patterns to localize the trigger points. Patients frequently point to one or more
pictures stating “this is my pain.” This approach may help
physicians and patients focus on underlining problems of
these chronic pain syndromes.
The activation of a trigger point usually is associated
with some degree of mechanical abuse of the muscle in the
form of overload, which may be acute, sustained, or repetitive. Leaving the muscle in a shortened position can convert a latent trigger point to an active trigger point; this
process is greatly aggravated if the muscle is contracted
while in a shortened position. The patient often is aware of
pain caused by an active trigger point, but may not be
aware of the underlying muscle dysfunction. The intensity
and extent of the referred pain pattern depends on the
degree of irritability of the trigger point, not on the size of
the muscle. Myofascial trigger points in small muscles can
be as troublesome to the patient as trigger points in large
muscles. Trigger point injection and dry needling have
been shown to be the most effective treatment modalities
to inactivate trigger points and provide prompt relief of
symptoms [4]. If trigger points are found, treatment is
directed toward their inactivation, correcting underlying
perpetuating factors, and restoring the normal relationships among the affected muscles.
This report must not be construed as saying that painful bladder syndrome/interstitial cystitis, chronic prostatitis, and IBS are always caused by myofascial trigger points,
but the possibility needs to be considered before planning
more invasive approaches. Referred motor activity to the
pelvic floor muscles (sphincters) and to the pelvic organs
as a result of trigger points can be the sole or concomitant
cause of these debilitating pain syndromes and certainly
needs further investigation.
References and Recommended Reading
Papers of particular interest, published recently,
have been highlighted as:
•
Of importance
•• Of major importance
1.
Pain of Urogenital Origin (PUGO): a special interest group
of the International Association for the Study of Pain.
Statement 1998 (www.uab.edu/PUGO/).
2. Rosenthal RH: Psychology of chronic pelvic pain.
Obstet Gynecol Clin North Am 1993, 20:627–641.
3. Travell J: Myofascial trigger point: clinical view. In Advances
in Pain Research and Therapy, vol 1. Edited by Bonica JJ,
Albe-Fessard D. New York: Raven Press; 1976:919–926.
4. Simons DG, Travell JG, Simons LS: Travell & Simons' Myofascial
Pain and Dysfunction: The Trigger Point Manual, vol.1, edn 2.
Baltimore: Williams & Wilkins; 1999.
5. Schmidt RA: Pelvic floor behavior and interstitial cystitis.
Semin Urol 1991, 9:154–159.
6.•• FitzGerald MP: Chronic pelvic pain. Curr Womens Health Rep
2003, 3:327–333.
Excellent review on chronic pelvic pain considering visceral and
somatic pain and central nervous system sensitization.
7. DeGroat WC: Anatomy and physiology of the lower urinary
tract. Urol Clin North Am 1993, 20:383–402.
8. Hunner GL: A rare type of bladder ulcer in women:
report of cases. Trans South Surg Gynecol Assoc 1914, 27:257.
9. Mac Corquodale DW: And the poor get children. BMJ
2003, 3:230.
Urologic Myofascial Pain Syndromes • Doggweiler-Wiygul
10.• Krieger JN, Ross SO, Deutsch L, Riley DE: The NIH Consensus
concept of chronic prostatitis/chronic pelvic pain syndrome
compared with traditional concepts of nonbacterial prostatitis and prostatodynia. Curr Urol Rep 2002, 3:301–306.
Beginning of considering chronic prostatitis and interstitial cystitis
as diseases that have common denominators.
11. Bodemar G, Ragnarsson G: Irritable bowel syndrome: survey
of definitions, differential diagnosis, and pathogenesis.
Lakartidningen 2001, 98:666–671.
12. Howard FM: Irritable bowel disease. In Pelvic Pain: Diagnosis
and Management. Edited by Howard FM, Perry CP, Carter JE.
Philadelphia: Lippincott Williams & Wilkins; 2000:238–245.
13. Gerwin RD: Interstitial cystitis and related pain syndromes.
Presented at Research Insights into Interstitial Cystitis: A Basic and
Clinical Science Symposium (ICA & NIDDK cosponsored meeting).
Washington DC: October 30–November 1, 2003.
14.• Doggweiler-Wiygul R, Wiygul JP: Interstitial cystitis, pelvic
pain, and the relationship to myofascial pain and dysfunction: a report on four patients. World J Urol 2002, 20:310–314.
First report of patients affected by interstitial cystitis and diagnosed with
myofascial pain and treated successfully with trigger point treatment.
15.
451
Yoshimura N: Interstitial cystitis and related pain syndromes.
Presented at Research Insights into Interstitial Cystitis: A Basic and
Clinical Science Symposium (ICA & NIDDK cosponsored meeting).
Washington DC: October 30–November 1, 2003.
16. Travell JG: Subclinical hypothyroidisms. JAMA 1987,
258:246–247.
17.• Doggweiler-Wiygul R, MacDiarmid SA: Interstitial cystitis.
Female Patient 2004, 29:14–22.
This is a general review on interstitial cystitis/painful bladder syndrome
and discusses possible pathogenetic factors and treatment options.
18. Parsons CL, Dell J, Stanford EJ, et al.: Increased prevalence
of interstitial cystitis: previously unrecognized urologic
and gynecologic cases identified using a new symptom
questionnaire and intravesical potassium sensitivity.
Urology 2002, 60:573–578.
19. Zermann DH, Ishigooka M, Doggweiler R, Schmidt RA:
Chronic prostatitis: a myofascial pain syndrome?
Infect Urol 1999, 12:84–88, 92.
20. Simons DG, Travell JG: Myofascial origins of low back
pain. 1: principles of diagnosis and treatment. Postgrad
Med 1983, 73:66, 68–70.
21. Doggweiler-Wiygul R, Sellhorn E: Role of behavioral changes
and biofeedback in urology. World J Urol 2002, 20:302–305.

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