The Clinical Use Of Botulinum Toxin In The Management Of Pelvic Pain
06/05/2013 // Concord, CA, USA // Vaginal Mesh Website // Greg Vigna, M.D., J.D. // (press release)
The FDA in 1989 approved the use of Botulinum Toxin Type A (Botox) in the treatment in hemifacial spasm, blepharospasm, and strabismus. In 1997, Brin reported the effectiveness relieving painful vaginal spasms (vaginismus) with Botox. It currently is not approved for the use in myofascial pelvic pain syndrome (MPPS) despite being shown to be safe and effective in several studies. Botox’s effect on the muscle is to decrease the muscle tension by blocking the release of neurotransmitters from the nerve to the muscle that is responsible for contraction. This causes a relative decrease in contraction of the muscle and a relative increase in relaxation. Botox has advantages for myofascial pain syndrome because of a prolonged duration of action with sustained effects on relaxation.
Dr. Michael Hibner, Director of the Arizona Center for Chronic Pelvic Pain at St. Joseph’s Hospital in Phoenix, in an interview stated that “a lot of women with chronic pelvic pain develop muscle spasm in their pelvic floor and Botox is very, very good in relaxing those muscles”. Dr. Hibner’s experience is extensive in the use of Botox; he uses this medication in patients who do not respond to physical therapy. He generally uses 200 units of Botox into the pelvic floor muscles.
In a study that Dr. Hibner conducted, he found the Botox was most beneficial in those patients with pain from muscle spasms rather than pain due to nerve injury. The benefit appears to be similar in patients who, following the injection, participated in physical therapy and patients who do not participate in physical therapy. Further, the study revealed that in patients who received multiple injection sessions, 88% had improvement after each injection with an average duration between injections between 84-190 days. Complications were rare.
Patients will generally begin to experience pain relief within 7-14 days following the injection. Repeat injections may be necessary if pain relief was effective after three months and if there weren’t any significant side effects.
A significant limitation in the use of Botox is cost. Two hundred units of the medication will generally cost around $1000 dollars and some commercial and public insurance plans do not cover the cost for Botox for myofascial pelvic pain syndrome.
Life Care Planning Perspective:
It is a life care planner’s role to provide a road map for the care of these patients to maximize function, reduce or eliminate complications, and improve the individual’s quality of life going forward. All recommendations must be medically necessary, appropriate and should not be affected by cost and source of payment. In the case of a transvaginal mesh patient with chronic pelvic pain, a life care planner will provide a comprehensive plan based on the recommendations of the patient’s medical providers and the needs and desires of the patient. Historically it is common practice in the medical community to practice ‘off label’ uses of medications and medical devices. If Botox has provided the patient with a therapeutic benefit, and the treating physician recommends future injections for pain relief, Botox would clearly be a necessary and appropriate management option in the future and should be included in the patient’s life care plan.
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