18 Klotz

Pain Medicine 2020; 21: e34–e44
doi: 10.1093/pm/pny097
Original Research Article

Myofascial Findings and Psychopathological
Factors in Patients with Chronic Pelvic Pain
Syndrome
Downloaded from https://academic.oup.com/painmedicine/article/21/2/e34/4999952 by guest on 20 June 2022

Susanne G. R. Klotz, MSc,* Gesche Ketels,† with a positive diagnosis of CPPS were included.
Bernd Löwe, MD,* and Christian A. Brünahl, MD* Descriptive statistics were used to characterize and
analyze the sample. Bivariate correlations were cal-
*Department of Psychosomatic Medicine and culated for the association between myofascial find-
Psychotherapy, University Medical Centre Hamburg- ings and psychopathological symptoms.
Eppendorf and Schön Klinik Hamburg Eilbek,
Results. A total of 187 patients (56.7% female, mean
Hamburg, Germany; †Department of Physiotherapy,
age 6 SD 5 49.06 6 17.05 years) were included.
University Medical Centre Hamburg-Eppendorf,
Women had significantly higher numbers of tender
Hamburg, Germany (mean 6 SD 5 17.53 6 9.58 vs 13.40 6 8.79,
Correspondence to: Susanne G. R. Klotz, MSc, P 5 0.003) and trigger points (mean 6 SD 5
Department of Psychosomatic Medicine and 6.23 6 6.64 vs 4.09 6 7.15, P 5 0.036). They had also
Psychotherapy, University Medical Centre Hamburg- significantly higher values in the PHQ-15
Eppendorf, Martinistr. 52, 20246 Hamburg, Germany. (mean 6 SD 5 11.51 6 5.24 vs 9.28 6 5.49, P 5 0.009)
and the SF-MPQ (mean 6 SD 5 17.84 6 8.95 vs
Tel: 49-40-7410-54174; Fax: 49-40-7410-40167;
15.11 6 7.97, P 5 0.041). Several significant correla-
E-mail: s.klotz@uke.de.
tions between myofascial findings and psychoso-
Funding sources: PRANA Foundation in the cial factors exist.
Stifterverband für die Deutsche Wissenschaft e.V.
Conclusions. There might be a link between psy-
Conflicts of interest: The authors have no conflicts to chosomatic and myofascial aspects in CPPS; thus
report. further studies are needed. Nevertheless, the
results stress the urgent need of a multimodal treat-
ment including physiotherapy and psychotherapy
Abstract in these patients.
Objective. Chronic pelvic pain syndrome (CPPS) is Key Words. Chronic Pelvic Pain Syndrome; Trigger
a common pain condition with psychosocial and Points; Psychosocial Factors; Physical Therapy;
somatic symptoms. Myofascial findings and psychi- Psychosomatic Medicine; Interdisciplinary Care
atric comorbidities are frequent. Therefore, the aim
of the study was to analyze myofascial and psycho-
social aspects. Furthermore, the study focuses on Introduction
correlations between these aspects and gender
Worldwide, 5.7% to 26.6% of women [1] and 2.2% to
differences in this topic.
9.7% of men [2] are suffering from chronic pelvic pain
Design. Cross-sectional study. syndrome (CPPS), a chronic pain condition perceived in
pelvis-related structures and organs without an appar-
Setting. Interdisciplinary outpatient clinic for ent pathology or infection [3]. The pain can be perceived
patients with CPPS at the University Medical Centre in numerous locations associated with the pelvis [3];
Hamburg-Eppendorf, Germany. however, the perceived location may not be the location
of pain generation due to the multifactorial etiology and
Methods. Participants underwent a multimodal di- potential multisystem effects of chronic pain conditions.
agnostic algorithm including physiotherapeutic as- Therefore, the term CPPS should be used even if
sessment and psychotherapeutic evaluation. Those the symptoms may be perceived in a specific region
C 2018 American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com
V e34
Myofascial and Psychosocial Factors in CPPS
but without a clear association between pain and Methods

region [3,4].
Sample
Myofascial symptoms like tenderness and pain in the
muscles associated with the pelvis are frequent among Cross-sectional data were collected from an interdisci-
patients with CPPS [5–7]. Tender points can be defined plinary outpatient clinic for patients with CPPS at the
as areas of muscles that are painful to palpation without University Medical Center Hamburg-Eppendorf,
a palpable nodule [8]. In contrast, trigger points do have Germany, from October 2012 to March 2017. After
a palpable nodule located in a taut band and can gen- signing informed consent, each patient underwent a di-
erate local and/or referred pain [9]. Myofascial symp- agnostic algorithm including examinations from a uro-
toms should be acknowledged in the diagnostic and logic, a psychotherapeutic, a physiotherapeutic, and, in
treatment process of patients with CPPS as they might the case of female patients, also a gynecologic per-

result in effective treatment options, which are nonphar- spective. After completion of the assessments, all health
macological and nonsurgical [10,11]. The European care professionals discussed the findings and the diag-
Association of Urology (EAU) guidelines recommend nosis. All patients received a report with diagnosis and
physiotherapy as firstline treatment [3]. However, little is treatment recommendations [14].
known about the affected muscles in women and men
with CPPS. Inclusion criteria were a diagnosis of CPPS according to
the guidelines of the EAU [3], age at least 18 years, and
In addition to the myofascial symptoms, CPPS is con- sufficient German language skills. Patients were ex-
nected with psychosocial factors and psychiatric cluded if they suffered from severe medical conditions,
comorbidities [12–14]. Psychosocial factors like pain suicidality, or if they had a pain duration of less than six
catastrophizing and stress and high prevalence of de- months. Sociodemographic data were collected from all
pression and general anxiety can be found [14]. Higher participants. The study was approved by the institutional
prevalence also exists for somatoform disorders, mood review board of the Medical Association of Hamburg,
disorders, and anxiety disorders [12,14]. Germany (PV4220).
One approach to explain the connection between psy- Physiotherapeutic Examination

chosocial factors and myofascial symptoms in chronic
pain conditions is indicated in the fear avoidance model, All patients underwent physiotherapeutic examination by
which was first introduced in patients with chronic low a trained physiotherapist to identify tender and trigger
back pain [15]. Riegel et al. [16] modified this model points in the muscles. The examination consisted of
specifically for CPPS. The origin of the vicious circle is manual palpation of external and internal muscles. The
an acute phase with pain, which can lead to fear of ag- muscles of the abdominal wall, the back, the gluteal re-
gravation due to activity. The activities were avoided, gion, and the thighs were palpated with the patients ly-
leading to maintenance of the pain and ultimately to ing supine and on their side. Then, the internal palpation
anxiety, stress, and depressive symptoms [16]. Thus, was performed rectally with the patient lying prone, and
the model supports the biopsychosocial approach in in women also vaginally in supine position. For internal
multimodal management advocated in the EAU guide- palpation, the clock scheme was used as orientation,
lines [3]. with the symphysis at 12 o’clock and the coccyges at 6
o’clock. These two points were not palpated but were
Multimodal therapy approaches to chronic pain condi- used as reference points for localization of the muscles
tions should also be tailored to gender differences, palpated between them.
which occur due to multiple contributing factors like
genetics, hormonal effects, and anatomical and physio- Assessment of Psychosocial Factors
logical conditions [17]. The existing literature suggests
that gender differences are also present in patients with Self-report questionnaires were part of the psychothera-
CPPS, for example, various prevalence rates [1,2] or peutic assessment. Pain perception and experience
differences in the rates of mental comorbidities [12]. were measured with the Short-Form McGill Pain
However, the literature is scarce about myofascial Questionnaire (SF-MPQ) [18]. Pain catastrophization
findings in both women and men, as well as in gender was assessed with the Pain Catastrophizing Scale
differences in these findings and associations with psy- (PCS) [19]. Furthermore, the German version [20] of the
chosocial variables. Chronic Prostatitis Symptom Index of the National
Institutes of Health (NIH-CPSI) [21] was applied to mea-
The aims of this study were first to describe myofascial sure symptom severity. In female patients, a modified
and psychosocial findings in patients with CPPS, sec- version was used [22].
ond to correlate those myofascial and psychosocial find-
ings, and third to explore gender differences in the Stress was measured with the stress module (PHQ-
results. These insights might be useful in further under- stress) of the German version of the Patient Health
standing of the development and maintenance of CPPS Questionnaire (PHQ) [23]. For measurement of depres-
and also in management strategies for CPPS. sive symptoms, the PHQ-9 [24] was used, and anxiety
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Klotz et al.
Table 1 Sample characteristics
Total Sample Women Men Women vs

(N ¼ 187) (N ¼ 106, 56.7%) (N ¼ 81, 43.3%) Men P Value
Age, M (SD), range, y 49.06 (17.05), 18–84 49.62 (18.33), 18–84 48.33 (15.28), 20–80 0.610
Marital status, % (No.) 0.355 (X2 ¼ 5.53)
Single 29.9 (56) 31.1 (33) 28.4 (23)
Married 45.5 (85) 39.6 (42) 53.1 (43)
Divorced 13.4 (25) 17.0 (18) 8.6 (7)
Other 11.2 (21) 12.3 (13) 9.9 (8)
0.051 (X2 ¼ 9.42)

Education, % (No.)
Vocational training 38.0 (71) 39.6 (42) 35.8 (29)
Study 32.6 (61) 24.5 (26) 43.2 (35)
Other 29.4 (55) 35.9 (38) 21.0 (17)
Pain duration, M (SD), 5.71 (6.85), 0.5–47 5.40 (5.16), 0.5–30 6.13 (8.69), 0.5–47 0.486
range, y
was assessed with the Generalized Anxiety Disorder had to be excluded because they did not met the inclu-
Screener (GAD-7) [25]. The severity of somatic symp- sion criteria. Another group of 43 patients (15.0%) had
toms was measured using the PHQ-15 [26]. The 12- to be excluded due to missing physiotherapeutic exami-
Item Short Form Health Survey (SF-12) [27] was applied nations, which was mainly because physiotherapy was
to measure health-related quality of life. not integrated in the outpatient clinic until August 2013.
Thus, a final sample of 187 participants were included
All instruments, with exception of the SF-12, could be in the analysis. Table 1 depicts for the total sample and
interpreted as following: the higher the score, the higher separately for women and men. The mean age of
the severity of the measured construct. For the SF-12, the total sample was 49.06 years (SD ¼ 17.05 years,
the higher the score, the higher the quality of life. range ¼ 18–84 years), 56.7% (N ¼ 106) were female,
and the mean duration of years experiencing pain was
Statistical Analyses 5.71 years (SD ¼ 6.85 years, range ¼ 0.5–47 years).
All data were pseudonymized. Descriptive statistics with Table 2 and Figure 1 show the results of the physiother-
point measures, parameters of variability, and frequen- apeutic examinations. There was a significant difference
cies were used to characterize the sample, whereas cal- in the mean number of tender and trigger points when
culations were done for the sample as a whole and for comparing women and men, with higher numbers in
both sexes separately. For the comparisons of the fre- women. The differences remain significant for the sepa-
quencies, Pearson’s chi-square test was applied, and rate analysis of external tender and trigger points, but
for the comparisons of the means, the t test for inde- not for the internal ones. The most frequent referred
pendent samples was used. Frequencies were also pain site of trigger points in the total sample was the
used to describe patterns of positive muscle findings urethral orifice (N ¼ 194, 19.4%), followed by the lower
and referred pain sites for the whole sample and for abdomen (N ¼ 192, 19.2%) and the gluteal region
each sex. (N ¼ 125, 12.5%). In women, the most common pain
sites, in descending order, were the lower abdomen
Self-report questionnaires were included in the analysis (N ¼ 142, 20.0%), the urethral orifice (N ¼ 106, 15.0%),
only when at least 75% of the questionnaire was com- and the gluteal region (N ¼ 101, 14.2%), whereas in
pleted, or they were excluded. Missing items in the men they were the urethral orifice (N ¼ 88, 30.3%), the
remaining questionnaires were estimated using the lower abdomen (N ¼ 50, 17.2%), and the testicles
expectation-maximization algorithm. Associations be- (N ¼ 31, 10.7%).
tween physiotherapeutic findings (tender and trigger
points) and the questionnaires were analyzed with the aid The results from the psychosocial assessment are dis-
of bivariate correlations. The significance level for compar- played in Table 3. There were significant differences in
isons and correlations was set at P < 0.05. All statistics the mean value of the PHQ-15 and the SF-MPQ among
were calculated using IBM SPSS statistics, version 23. women and men, with higher scores in women.
Results Tables 4–9 show the correlations between the myofas-

cial findings and the psychosocial factors. For the whole
From October 2012 to March 2017, 286 patients were sample, significant correlations existed between tender
seen in the specialized outpatient clinic. Fifty-six (19.6%) points and the urological subscale of the NIH-CPSI and
e36
Table 2 Point estimates of tender and trigger points in the total sample and in women and men
separately
Total Sample Women Men Women vs

(N ¼ 187) (N ¼ 106, 56.7%) (N ¼ 81, 43.3%) Men P Value
No. of tender points, M (SD), range 15.74 (9.44), 0–46 17.53 (9.58), 0–46 13.40 (8.79), 0–34 0.003
External tender points, M (SD), range 8.94 (6.12), 0–27 10.80 (6.17), 0–27 6.51 (5.14), 0–22 0.001
Internal tender points, M (SD), range 6.8 (6.23), 0–25 6.73 (5.81), 0–25 6.89 (6.78), 0–22 0.860
No. of trigger points, M (SD), range 5.3 (6.93), 0–40 6.23 (6.64), 0–33 4.09 (7.15), 0–40 0.036
External trigger points, M (SD), range 2.72 (3.45), 0–24 3.17 (3.44), 0–15 2.12 (3.39), 0–24 0.040

Internal trigger points, M (SD), range 2.58 (4.53), 0–24 3.06 (4.48), 0–21 1.96 (4.55), 0–24 0.102
Figure 1 Myofascial findings (tender and trigger points) in both men and women with chronic pelvic pain syndrome.
A) External tender and trigger points in men (left) and women (right). B) Internal tender and trigger points in men (left)
and women (right).
between external tender points and the physical compo- significantly correlated with the PHQ-9. For women, cor-
nent score of the SF-12 and the PHQ-15, as well as relations between external tender points and the pain
both subscales and the total score of the SF-MPQ and subscale and the total score of the NIH-CPSI, the sen-
PHQ-15. Both groups of trigger points, external and in- sory subscale and the total score of the SF-MPQ, and
ternal, as well as all trigger points, were significantly cor- the PHQ-15 were significant for women, whereas there
related with the PHQ-15, the physical component score was no significant correlation with internal tender points.
of the SF-12, both subscales and the total score of the For men, associations were not significant with external
SF-MPQ, and with the urological subscale, the pain or internal tender points (Tables 4–6). Correlations be-
subscale, and the total score of the NIH-CPSI. Trigger tween external trigger points were significant for the
points as a whole and external trigger points were also pain subscale and the total score of the NIH-CPSI, for
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Klotz et al.
Table 3 Point estimates of psychosocial factors in the total sample and in women and men separately
Total Sample Women Men Women vs Men

(N ¼ 187) (N ¼ 106, 56.7%) (N ¼ 81, 43.3%) P Value
GAD-7, M (SD), range 7.50 (5.16), 0–21 7.34 (4.84), 0–21 7.71 (5.56), 0–21 0.643
NIH-CPSI, M (SD), range 24.68 (7.22), 2–40 24.45 (7.05), 2–40 24.97 (7.47), 8–40 0.636
Pain 11.78 (3.93), 0–21 11.58 (3.95), 0–19 12.02 (3.92), 0–21 0.461
Urologic symptoms 3.98 (2.90), 0–10 3.87 (2.79), 0–10 4.11 (3.04), 0–10 0.594
Quality of life 8.93 (2.57), 1–12 9.00 (2.51), 1–12 8.84 (2.66), 3–12 0.691
PCS, M (SD), range 24.59 (12.49), 2–52 25.49 (12.14), 2–52 23.44 (12.93), 4–52 0.283

PHQ-9, M (SD), range 8.33 (5.59), 0–27 8.61 (5.41), 0–27 7.96 (5.82), 0–26 0.454
PHQ-15, M (SD), range 10.56 (5.44), 0–28 11.51 (5.24), 0–28 9.28 (5.49), 2–27 0.009
PHQ-stress, M (SD), range 7.03 (3.87), 0–21 7.00 (3.77), 1–16 7.07 (4.02), 0–21 0.911
SF-12, M (SD), range
Physical health 40.91 (9.82), 19–59 40.11 (10.19), 19–59 41.97 (9.28), 23–58 0.235
Mental health 39.85 (11.07), 15–61 38.70 (9.99), 15–61 41.38 (12.28), 18–60 0.128
SF-MPQ, M (SD), range 16.70 (8.63), 1–43 17.84 (8.95), 2–43 15.11 (7.97), 1–40 0.041
Sensory subscale 12.51 (6.52), 0–31 13.14 (6.71), 2–31 11.64 (6.19), 0–31 0.137
Affective subscale 4.19 (3.14), 0–12 4.70 (3.14), 0–12 3.48 (3.03), 0–11 0.011
GAD-7 ¼ Generalized Anxiety Disorder Screener; NIH-CPSI ¼ Chronic Prostatitis Symptom Index of the National Institutes of
Health; PCS ¼ Pain Catastrophizing Scale; PHQ-9 ¼ Patient Health Questionnaire 9 (depressive symptoms); PHQ-15 ¼ Patient
Health Questionnaire 15 (severity of somatic symptoms); PHQ-stress ¼ stress module of the Patient Health Questionnaire; SF-
MPQ ¼Short Form McGill Pain Questionnaire; SF-12 ¼ 12-Item Short Form Health Survey.
Table 4 Correlations between number of tender points and the mean values in the self-report
questionnaires
Total Sample Women Men

No. r P No. r P No. r P
GAD-7 173 0.051 0.502 97 0.012 0.906 76 0.112 0.336

NIH-CPSI 177 99 78
Total 0.103 0.171 0.193 0.056 0.011 0.921
Pain 0.067 0.377 0.213 0.035 0.102 0.372
Urologic symptoms 0.151 0.044 0.103 0.309 0.242 0.033
Quality of life 0.018 0.815 0.092 0.366 0.093 0.419
PCS 176 0.006 0.934 99 0.030 0.765 77 0.068 0.557
PHQ-9 171 0.017 0.825 97 0.023 0.825 74 0.109 0.356
PHQ-15 166 0.143 0.066 95 0.129 0.213 71 0.021 0.860
PHQ-stress 172 0.072 0.346 96 0.055 0.593 76 0.103 0.375
SF-12 164 92 69
Physical health 0.078 0.327 0.164 0.119 0.115 0.345
Mental health 0.038 0.629 0.108 0.304 0.286 0.017
SF-MPQ 172 100 72
Total 0.142 0.062 0.185 0.066 0.002 0.985
Sensory subscale 0.131 0.086 0.168 0.094 0.020 0.870
Affective subscale 0.119 0.121 0.167 0.097 0.046 0.700
MPQ ¼Short Form McGill Pain Questionnaire; SF-12 ¼ 12-Item Short Form Health Survey.
e38
Table 5 Correlations between number of external tender points and the mean values in the self-report
questionnaires

GAD-7 173 0.013 0.862 97 0.062 0.545 76 0.014 0.904

NIH-CPSI 177 99 78
Total 0.126 0.095 0.229 0.023 0.034 0.768
Pain 0.099 0.190 0.265 0.008 0.083 0.470

Quality of life 0.071 0.348 0.119 0.239 0.013 0.909
PCS 176 0.021 0.783 99 0.065 0.525 77 0.113 0.328
PHQ-9 171 0.043 0.579 97 0.061 0.555 74 0.031 0.793
PHQ-15 166 0.224 0.004 95 0.231 0.024 71 0.039 0.744
PHQ-stress 172 0.122 0.110 96 0.182 0.076 76 0.066 0.572
SF-12 164 92 69
Physical health 0.174 0.027 0.208 0.047 0.056 0.646
Mental health 0.034 0.665 0.147 0.162 0.203 0.094
SF-MPQ 172 100 72
Total 0.172 0.024 0.208 0.038 0.015 0.901
MPQ ¼ Short Form McGill Pain Questionnaire; SF-12 ¼ 12-Item Short Form Health Survey.
Table 6 Correlations between number of internal tender points and the mean values in the self-report
questionnaires

GAD-7 173 0.092 0.226 97 0.046 0.652 76 0.134 0.248

NIH-CPSI 177 99 78
Total 0.034 0.653 0.077 0.446 0.011 0.925
Pain 0.005 0.950 0.072 0.477 0.070 0.542
Quality of life 0.043 0.574 0.026 0.801 0.110 0.336
PCS 176 0.011 0.885 99 0.018 0.858 77 0.002 0.986
PHQ-9 171 0.069 0.372 97 0.027 0.795 74 0.117 0.321
PHQ-15 166 0.005 0.946 95 0.032 0.760 71 0.003 0.981
PHQ-stress 172 0.008 0.912 96 0.101 0.326 76 0.086 0.460
SF-12 164 92 69
Physical health 0.053 0.501 0.056 0.593 0.195 0.108
Mental health 0.094 0.234 0.027 0.796 0.213 0.079
SF-MPQ 172 100 72
Total 0.044 0.569 0.081 0.422 0.009 0.941
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Klotz et al.
Table 7 Correlations between number of trigger points and the mean values in the self-report
questionnaires

GAD-7 173 0.099 0.194 97 0.054 0.597 76 0.265 0.021

NIH-CPSI 177 99 78
Total 0.278 0.001 0.275 0.006 0.309 0.006
Pain 0.270 0.001 0.274 0.006 0.302 0.007

Quality of life 0.122 0.105 0.073 0.474 0.173 0.130
PCS 176 0.088 0.246 99 0.032 0.755 77 0.125 0.280
PHQ-9 171 0.173 0.024 97 0.114 0.266 74 0.223 0.056
PHQ-15 166 0.263 0.001 95 0.180 0.081 71 0.306 0.009
PHQ-stress 172 0.095 0.216 96 0.002 0.983 76 0.212 0.066
SF-12 164 92 69
Physical health 0.201 0.011 0.101 0.338 0.309 0.010
Mental health 0.147 0.063 0.029 0.785 0.289 0.016
SF-MPQ 172 100 72
Total 0.305 0.001 0.178 0.077 0.451 0.001
Table 8 Correlations between number of external trigger points and the mean values in the self-report
questionnaires

GAD-7 173 0.064 0.406 97 0.047 0.648 76 0.204 0.077

NIH-CPSI 177 99 78
Total 0.237 0.001 0.176 0.082 0.334 0.003
Pain 0.244 0.001 0.167 0.099 0.377 0.001
Quality of life 0.057 0.451 0.015 0.886 0.136 0.235
PCS 176 0.041 0.593 99 0.042 0.677 77 0.114 0.324
PHQ-9 171 0.182 0.017 97 0.164 0.108 74 0.188 0.108
PHQ-15 166 0.256 0.001 95 0.200 0.052 71 0.263 0.027
PHQ-stress 172 0.076 0.322 96 0.037 0.719 76 0.130 0.264
SF-12 164 92 69
Physical health 0.225 0.004 0.133 0.207 0.331 0.005
Mental health 0.074 0.348 0.106 0.314 0.231 0.056
SF-MPQ 172 100 72
Total 0.257 0.001 0.117 0.246 0.433 0.001
e40
Table 9 Correlations between number of internal trigger points and the mean values in the self-report
questionnaires

GAD-7 173 0.105 0.167 97 0.045 0.660 76 0.267 0.020

NIH-CPSI 177 99 78
Total 0.245 0.001 0.270 0.007 0.235 0.038
Pain 0.227 0.002 0.276 0.006 0.188 0.100

Quality of life 0.145 0.054 0.119 0.242 0.174 0.127
PCS 176 0.105 0.167 99 0.079 0.435 77 0.112 0.330
PHQ-9 171 0.128 0.095 97 0.041 0.690 74 0.213 0.069
PHQ-15 166 0.212 0.006 95 0.114 0.271 71 0.290 0.014
PHQ-stress 172 0.089 0.246 96 0.035 0.738 76 0.244 0.034
SF-12 164 92 69
Physical health 0.135 0.088 0.047 0.659 0.242 0.045
Mental health 0.170 0.032 0.039 0.716 0.293 0.015
SF-MPQ 172 100 72
Total 0.275 0.001 0.174 0.084 0.397 0.001
the physical component score of the SF-12, for both the muscles of the trunk and the lower limbs emphasize
subscales and the total score of the SF-MPQ, and for the importance of not only treating the pelvic floor
the PHQ-15 in men. Internal trigger points were signifi- muscles; rather, all muscles with connection to the pel-
cantly correlated in men with the GAD-7, the total score vis should be integrated into therapy.
of the NIH-CPSI, the PHQ-15, the PHQ-stress, both
subscales and the total score of the SF-MPQ, and both To the best of our knowledge, no comparable data
component scores of the SF-12. In women, only the about myofascial symptoms in both women and men
correlations between the internal trigger points and the with CPPS exist. Comparisons could be made for trig-
pain subscale and the total score of the NIH-CPSI were ger points in male patients with CPPS with a sample
significant (Tables 7–9). from Anderson et al. [10]. The most frequently affected
internal muscle was, in both samples, the levator ani, lo-
Discussion cated at 1 and 11 o’clock, respectively. No accordance
could be found in the external muscle group. Anderson
This study explored myofascial findings in the muscles
et al. [10] had higher rates of positive muscular findings
connected with the pelvis, with emphasis on tender and
in both external and internal muscles, up to 55.6% and
trigger points and self-reported psychosocial factors in
90.3%, respectively, compared with 29.1% and 14.5%
both women and men with CPPS. Moreover, it investi-
gated correlations between painful muscle points and in this sample.
psychosocial factors. The study revealed gender differ-
ences in myofascial findings and also in significant Psychosocial Symptoms
correlations.
Compared with normative data of the general population
Physiotherapeutic Findings [25,27–29], our results demonstrated high psychosocial
burden in patients with CPPS, which is in line with pre-
Our results showed that internal tender and trigger vious findings [12–14,16]. High rates of mental disorders
points in pelvic floor muscles are highly present in both and psychopathologies could be connected to lower
women and men with CPPS, highlighting the need for quality of life [13]. Patients feel somatically burdened, in-
physiotherapeutic treatment. Moreover, the equally high dicating a linkage between psychopathologic and so-
prevalence rates of external trigger and tender points in matic symptoms [12,13].
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Klotz et al.
Correlations Between Myofascial and Psychosocial the myofascial symptoms of both women and men with
Symptoms CPPS but also in their association with psychosocial
factors.
CPPS, like other chronic pain syndromes, could be
seen as a biopsychosocial condition in which life events, Despite these strengths, the study has some potential
personal history, coping strategies, and behavior pat- weaknesses. First, the study took place in a specialized
terns, but also social situations and communities, influ- tertiary care center setting, which might result in a sam-
ence pain sensations and emotional reactions. This ple not representative of the whole population with
complex interaction between physiological and psycho- CPPS. Second, tender and trigger points were exam-
social factors stresses the importance of holistic diag- ined via manual myofascial tissue palpation performed
nostic and therapeutic management of patients with by physiotherapists specially trained in management of
patients with pelvic floor dysfunctions. This method has

CPPS, rather than an isolated treatment approach of
treating psychosocial or somatic symptoms [3,15,16]. mediocre reliability [36], but it is considered essential in
For other chronic pain conditions, the linkage between detecting painful spots in the muscles in patients with
pain, stress, anxiety, and depression has already been chronic pelvic pain, especially when performed by physi-
demonstrated [30]. Furthermore, Healy et al. [31] otherapists [37]. Finally, due to the cross-sectional na-
showed in a sample of 71 patients with myofascial pain ture of our study, we were able to detect associations
that physiotherapeutic treatment effects might be influ- between factors but no causal pathways. Other factors
enced by psychosocial factors. To the best of our that act as confounding variables might be present.
knowledge, the linkage between myofascial and psy-
chosocial factors in CPPS has not been shown empiri- Conclusions
cally before. Thus, our results help to close this gap and
support the biopsychosocial approach. Nevertheless, Women and men with CPPS in this study suffer from a
further studies are needed to explore the relationship high burden of myofascial and psychosocial symptoms.
between myofascial and psychosocial aspects in the eti- The physiotherapeutic findings indicated that gender dif-
ology, maintenance, and treatment of CPPS. ferences might exist and that a link between psycho-
pathological and myofascial symptoms, at least for men
Gender Differences with CPPS, might be present. Hence, our results sup-
port physiotherapeutic and psychotherapeutic manage-
Our results revealed several differences in myofascial ment as an integral part in multimodal treatment for
and psychosocial factors across women and men. patients with CPPS.
Women had significantly more tender and trigger points
than men. These differences might be a clue for
Acknowledgments
different phenotypes in women and men, as suggested
for other myofascial pain syndromes [32], though it
The authors would like to acknowledge the PRANA
could also be due to gender differences in pain percep-
Foundation in the Stifterverband für die Deutsche
tion, which might exist [33]. The significantly higher
Wissenschaft e.V., which funded the Interdisciplinary
amount of external tender and trigger points in women
Research Platform “Chronic Pelvic Pain Syndrome” at the
might also be attributed to pelvic girdle pain after child
University Medical Center Hamburg-Eppendorf. This
birth, which leads to high levels of muscle tenderness
study is a result of this interdisciplinary research project.
[34,35]. Women showed significantly higher scores in The PRANA Foundation had no involvement in any part of
PHQ-15 and SF-MPQ. Both results might also be attrib- the study.
uted to the possible gender differences in pain percep-
tion [33]. Several significant correlations between the
myofascial findings and psychosocial factors exist, pro-
viding some hints of the validity of the fear avoidance References
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Pain Medicine 2020; 21: e34–e44

Original Research Article

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but without a clear association between pain and Methods

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One approach to explain the connection between psy- Physiotherapeutic Examination

Table 1 Sample characteristics

Total Sample Women Men Women vs

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Results Tables 4–9 show the correlations between the myofas-

Total Sample Women Men Women vs

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Total Sample Women Men Women vs Men

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Total Sample Women Men

GAD-7 173 0.051 0.502 97 0.012 0.906 76 0.112 0.336

Total Sample Women Men

GAD-7 173 0.013 0.862 97 0.062 0.545 76 0.014 0.904

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Total Sample Women Men

GAD-7 173 0.092 0.226 97 0.046 0.652 76 0.134 0.248

Total Sample Women Men

GAD-7 173 0.099 0.194 97 0.054 0.597 76 0.265 0.021

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Total Sample Women Men

GAD-7 173 0.064 0.406 97 0.047 0.648 76 0.204 0.077

Total Sample Women Men

GAD-7 173 0.105 0.167 97 0.045 0.660 76 0.267 0.020

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€hler E, Ludwig M, et al. Two-year

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