INTRODUCTION — Myofascial pelvic pain syndrome (MPPS) is a source of chronic pelvic pain in women and men that is defined by short, tight, tender pelvic floor muscles that include palpable nodules or trigger points that cause referred pain. The pain can be continuous or episodic. MPPS can impact urinary, bowel, and sexual function. As pelvic pain is a common reason for women to seek health care and many women with chronic pelvic pain have some degree of MPPS, clinicians need to include this syndrome in the differential when evaluating women with pelvic pain.

Clinical manifestations and diagnosis of MPPS in women are reviewed here. Treatment of this condition and other causes of pelvic pain in women are reviewed separately.

●(See "Myofascial pelvic pain syndrome in females: Treatment".)

●(See "Myofascial pelvic pain syndrome in females: Pelvic floor physical therapy for management".)

●(See "Evaluation of acute pelvic pain in nonpregnant adult women".)

●(See "Evaluation of acute pelvic pain in the adolescent female".)

●(See "Chronic pelvic pain in adult females: Evaluation".)

●(See "Chronic pelvic pain in nonpregnant adult females: Causes".)

DEFINITIONS

Myofascial pelvic pain syndrome — MPPS is a non-articular musculoskeletal pain disorder characterized by contracted bands of skeletal muscle that contain discrete, painful nodules, also called trigger points [1,2]. MPPS is thought to originate at the trigger point [3].

Trigger points — Trigger points, the hallmark of myofascial pain, are hyperirritable, palpable nodules that are painful to compression and produce sensory, motor, and, rarely, autonomic symptoms (eg, coldness, sweating, tachycardia, coryza, lacrimation, and erythema) [1,4]. Trigger points can be active (ie, spontaneously painful) or latent (ie, painful only with stimulation) [5]. A local twitch response occurs when firm pressure is applied (strummed) across the point [6,7]. However, the twitch response is not always palpable, especially in the pelvic floor. Trigger points in the pelvic floor often refer pain to the vagina, vulva, perineum, rectum, and bladder, as well as to more distant areas such as the thighs, buttocks, or lower abdomen [8,9]. At distant sites, irritative symptoms can be more prominent than pain. Irritative symptoms include urinary urgency, frequency, vulvar or vaginal burning, itching, or dysuria, alone or in combination. When these symptoms occur in the absence of objective findings (eg, positive cultures), myofascial pain should be added to the differential diagnosis.

EPIDEMIOLOGY — The prevalence of MPPS in the general population is not known. Chronic pelvic pain syndrome, of which MPPS is one cause, affects 14 to 25 percent of women [10,11]. In one retrospective study of over 1100 women referred for evaluation of chronic pelvic pain, 13 percent were diagnosed with MPPS [12]. (See "Chronic pelvic pain in nonpregnant adult females: Causes".)

PATHOGENESIS

Myofascial pain — The pathogenesis of MPPS is unclear [3,13,14]. Theories for the etiology of myofascial pain include neuromuscular microtrauma [15-17], metabolic imbalance in the peripheral tissue [13,18], and centralization of pain [19,20]. These processes likely work in combination. Acute trauma or repetitive microtraumas can cause high-intensity stimulation of the motor end plates of the pelvic floor muscles, which in turn may result in chronic muscle contraction (hypertonus) and formation of trigger points [6]. Metabolic imbalance, consisting of elevated levels of pain-producing compounds, has been demonstrated in the vicinity of active trigger points [13,18]. Centralization of pain occurs when the sensory pain information is abnormally processed in the central nervous system (ie, central sensitization) and appears to result in pain that is then perpetuated by the central nervous system, also known as a dysfunctional pain syndrome [19,21,22].

The pelvic floor is believed to be at risk of developing hypertonus, myofascial trigger points, and pain because pelvic floor muscles (1) are involved in several different kinds of activities, including musculoskeletal support of the upper body and lower extremities, and control of bladder, bowel, and sexual function; (2) must elongate and contract eccentrically; and (3) are affected by physiologic and psychologic stress [23-25]. Over time, muscles with trigger points become weak, tender, and shortened [26]. Dysfunction of one muscle can then cause surrounding muscle groups, including muscles of the buttocks, thighs, and abdomen, to contract and develop trigger points, thereby worsening myofascial pain and related symptoms [23,27].

Relation to other pelvic pain syndromes — Pelvic floor muscle hypertonus and MPPS have been associated with other pain processes including painful bladder syndrome/interstitial cystitis, provoked vestibulodynia, generalized vulvodynia, endometriosis, dysmenorrhea, and dyspareunia [21,27]. Central sensitization of pain has been demonstrated in all these syndromes and therefore provides one possible explanation for the coexistence of multiple pain syndromes in the same woman [21,26,28,29].

Additionally, there is a correlation between visceral inflammation and myofascial abnormalities in tissues that share the same innervation [8]. Because of the proximity in the spinal cord between the afferent nerve endings of deep muscles of the pelvic floor and the parasympathetic nerves of the bladder, the bladder can be negatively impacted by pelvic floor contraction and trigger points [24]. This nerve proximity could explain why women with painful bladder syndrome often have a high tone, or contracted, pelvic floor [30,31]. (See "Interstitial cystitis/bladder pain syndrome: Clinical features and diagnosis".)

CLINICAL PRESENTATION — Women with MPPS generally present with pain in the pelvis, vagina, vulva, rectum, or bladder, or in more distant referral areas such as the thighs, buttocks, hips, or lower abdomen. Commonly associated symptoms include a sense of aching, heaviness, or burning in these areas and/or symptoms of overactive bladder, constipation, or dyspareunia [32,33]. Symptoms can be continuous or episodic and acute or chronic [7]. The pain is often worsened with specific positions/activities and improved by others [2].

DIAGNOSTIC EVALUATION

History — The evaluation of women with MPPS starts by taking a complete history that includes urinary, gastrointestinal, gynecologic, sexual, and psychosocial symptoms [2]. One purpose of the history is to identify other possible pain etiologies, such as endometriosis. Deep muscular pain and visceral pain can be difficult, if not impossible, for most patients to differentiate [9]. The International Pelvic Pain Society has developed a detailed history and physical examination form for evaluation of women with chronic pelvic pain of any etiology. The general approach to evaluation of women with pelvic pain is described in detail in a separate topic review. (See "Chronic pelvic pain in adult females: Evaluation".)

As part of the history, we specifically inquire about the following:

●Symptoms suggestive of MPPS [8,26]:

•Pelvic/abdominal pain (location, duration, and referral patterns)

•Urinary tract symptoms (eg, frequency, urgency, incontinence, nocturia, dysuria, sensation of incomplete emptying, bladder pain)

•Vulvovaginal discomfort, including dyspareunia

•A feeling of abdominal fullness or bloating

•Rectal fullness or constipation, dyschezia

•Rectal, vaginal, or bladder spasms

•Low back and hip pain

●Impact of position on pain – Pain that results from MPPS and trigger points is often aggravated by specific movements and alleviated by certain positions [2]. We ask women which positions and/or activities (including prolonged sitting, intercourse, and exercise) worsen or improve their symptoms.

●History of pelvic infection – We ask whether the patient has had laboratory-proven urinary tract, vaginal, or pelvic infections. MPPS can be a sequelae of infection and inflammation, as demonstrated in patients with herpes zoster infections and men with prostatitis [34,35]. Additionally, women can report the sensation of a urinary tract infection or vaginitis after MPPS flares, but tests are consistently negative. Because these symptoms can be erroneously diagnosed as an infectious etiology, we ask women if they have previously been diagnosed with pelvic infections (urine, vagina, or cervix) that were not confirmed upon testing.

●Impact of menstrual cycle – MPPS symptoms do not generally change during menses, although, in some women, menses can either exacerbate or improve the pain due to monthly hormonal fluctuations that impact sensory pain perception.

●Referred pain – MPPS often mimics visceral pain in that it can be poorly localized and referred to a distant cutaneous site, which can also be tender. Conversely, the woman can note that skin compression, such as by clothing or position, causes deep visceral discomfort [9].

●History of pain at other locations – Women with MPPS frequently have pain in other muscles of the pelvic girdle, including back and hips (figure 1). In our experience, when directly asked about pain in other locations, many women acknowledge pain that they previously had not thought pertinent. Additionally, MPPS is associated with other pelvic pain syndromes, including painful bladder syndrome/interstitial cystitis and vulvodynia [21,27]. (See 'Relation to other pelvic pain syndromes' above.)

●History of interventions for pain – Myofascial pelvic pain that begins as a local process can become widespread or more severe, sometimes as a result of diagnostic interventions or surgical attempts to resolve pain [23,36]. As an example, a woman who undergoes laparoscopic evaluation for chronic pelvic pain can have postoperative worsening of her myofascial symptoms. The cause is unknown.

●History of trauma – MPPS can result from pelvic trauma such as pelvic surgery, injuries or surgery to the back or hip, or childbirth. We specifically inquire about recent falls or injuries as women often do not equate musculoskeletal issues with their pelvic floor symptoms.

Physical examination — Physical examination for MPPS includes an external examination of the trunk muscles and connective tissue, a pelvic examination with assessment of the pelvic floor musculature, and assessment of the patient's gait and motor strength. There is little correlation between any single presenting symptom and physical findings in women with MPPS [37]. Having the patient indicate the site of pain helps to direct the examination; this area is examined last to minimize the effects of voluntary guarding.

Palpation is the main method for clinical assessment of pelvic floor hypertonus and trigger points [38]. Skeletal muscles are palpated for a tight band of tissue (hypertonus) or nodule (trigger point) that produces local pain, a twitch response, and/or referred pain to the pelvic organs or surrounding tissues [39]. Studies support that palpation is reliable when performed by a skilled examiner [40-42]. Most women with MPPS have pelvic floor trigger points that are exquisitely tender [43]. In a series of 49 women with MPPS, 92 percent had trigger points in the levator ani muscles. Other commonly affected muscle groups included the rectus (65 percent), iliopsoas (43 percent), obturator internus (45 percent), and piriformis (8 percent) [8]. The variation in trigger point location may account for the diversity of presenting symptoms among women with MPPS.

We take the following approach to the physical examination in women suspected of having MPPS:

External examination — We perform an external examination that includes visual inspection and palpation of the abdomen, hips, low back, buttocks, and thighs. We also examine any other areas of concern to the patient. We assess for areas of tenderness, referred pain, and trigger points. (See 'Trigger points' above.)

●Examine the rectus abdominis for tenderness, trigger points, referred pain, and diastasis recti. Women with MPPS often have diffuse tenderness in the abdomen, particularly over the rectus abdominis and external oblique muscle groups.

●Assess the connective tissues by rolling the skin lightly between two fingers (not pinching); tender areas often feel thickened or tight and will elicit sharp pain or a deep "bruise-like" pain [8].

●Apply pressure over the suprapubic area to see if pain is elicited, especially as the bladder is compressed.

●Manipulate any surgical scars. Scars should move easily and without restrictions; scars that are puckered, have limited movement, or are tender could be a source of MPPS or exacerbate symptoms.

Pelvic examination — We perform a standard pelvic examination that also includes assessment of pelvic floor motion. (See "The gynecologic history and pelvic examination", section on 'Pelvic examination'.)

●Observe the external genitalia as the woman bears down and also as she contracts the pelvic floor. Women with MPPS often have weak pelvic floor muscles that have limited mobility, move paradoxically, and relax slowly or incompletely. If the woman has difficulty contracting her pelvic floor, ask her to squeeze the vaginal muscles around the examiner's single digit or try to "pick up a dime" with the vaginal muscles. As the pelvic floor contracts and relaxes, look for asymmetry, incomplete contraction or relaxation, limited mobility, and paradoxical contraction.

●Provoke an anal wink reflex by gently stroking the skin immediately surrounding the anus; this results in a reflexive contraction of the external anal sphincter. For women with MPPS, the reflex can be absent because the pelvic floor muscles are already contracted. However, the absence of this reflex can also be due to nerve damage and interruption of the spinal arc. Thus, an absent anal wink contributes to the diagnosis but is not definitive. In addition, many asymptomatic women have an absent anal wink.

●Perform a speculum examination and assess for signs of hypoestrogenism or infection. Both hypoestrogenism and vaginal infections can cause pain as well as trigger or exacerbate MPPS. Pain from MPPS will not resolve after treatment for vaginal atrophy or infection. (See "Genitourinary syndrome of menopause (vulvovaginal atrophy): Clinical manifestations and diagnosis" and "Genitourinary syndrome of menopause (vulvovaginal atrophy): Treatment" and "Approach to females with symptoms of vaginitis".)

●Perform a bimanual examination. The uterus, bladder, and adnexa are palpated to determine if other pathology, such as fibroids or ovarian cysts, are present. MPPS and other pelvic pathology may coexist. However, identifying another possible cause for the pelvic symptoms does not exclude MPPS. (See "The gynecologic history and pelvic examination", section on 'Bimanual examination'.)

Pelvic floor musculature examination — We perform a detailed assessment of the pelvic floor musculature with focus on identifying areas of hypertonic muscle bands and/or trigger points. Trigger points can often be localized in areas of tight or bandy muscles, which can feel like violin strings; these areas can be exquisitely tender with even light palpation. Pain is usually associated with involuntary spasm of the pelvic floor muscles (eg, bulbospongiosus, ischiocavernosus, transversus perineum, sphincter ani, piriformis, levator ani, or obturator internus, alone or in any combination) (figure 2 and figure 3 and figure 4) [26]. Prior to examination, we inform women that some patients report worsened pain following the muscle examination. We counsel women that persistent or worsened pain confirms their diagnosis, can last for several hours, and typically resolves with time. In the examination, we do the following:

●Apply pressure to the woman's thigh as a baseline reference of how much pressure to expect during the examination (enough pressure to blanch the examiner's fingernail). For the rest of the examination, proceed slowly and gently and ask the woman to indicate if she has discomfort at any point. We ask her to rate her pain on a scale of zero (feels pressure, but no pain) to 10 (worst pain imaginable).

●Perform a vaginal examination and apply pressure to the obturator internus, located laterally and deep to the vaginal opening. Asking the patient to abduct the knee against resistance while the hip is flexed will make this area easier to palpate. Next we sweep the fingers medially to locate the iliococcygeus, noting any areas of tenderness, tension, or banding.

●Assess the deep pelvic muscles on vaginal examination. In particular, the levator ani muscle group can develop hypertonus, myalgia, overuse, and fatigue (figure 3 and figure 4). We do not examine all deep pelvic muscles but instead assess one or two groups on each side. If there is severe pain elicited on palpation of one muscle group, we do not continue the examination on the painful side. Instead, we examine the same muscle group on the other side of the pelvis, to assess symmetry of pain.

●Assess the urethral sphincter and pubococcygeus in the vagina by gently compressing these areas between your finger and the pubic symphysis (figure 3 and figure 4). If this area is involved, the patient will often note a feeling of urinary urgency or tenderness.

●Assess the puborectalis (medial portion of pubococcygeus) with either the vaginal or rectal examination (figure 4). A rectal examination is necessary to assess the anal sphincter and coccyx.

Assessment of posture, gait, and range of motion — Because trigger points prevent muscle lengthening and restrict range of movement [2], the woman can develop muscle asymmetry and resultant weakness. Muscles with trigger points are already in a state of contraction or spasm and therefore do not have full range of motion. Muscle strength is compromised due to inability to fully contract. We refer all patients with symptoms and findings of short, tender muscles to a physical therapist specialized in treating disorders of the pelvic floor. The referral is not urgent unless pain is severe. The therapist assesses the patient for posture, gait, range of motion of the trunk and hips, pelvic instability, and lower extremity strength, mobility, and length as well as assessing the pelvic muscles. [25]. While waiting for the physical therapy evaluation, we offer patients comfort measures consisting of stretching, self-massage, heat or ice (whichever feels better), and oral analgesics. (See "Musculoskeletal examination of the hip and groin", section on 'Physical examination'.)

Additionally, a physical therapist or physiatrist can diagnose problems such as scoliosis, leg-length discrepancy, or other spinal abnormalities can contribute to MPPS. Women with confounding issues usually require a longer course of treatment. (See "Myofascial pelvic pain syndrome in females: Pelvic floor physical therapy for management".)

Laboratory tests — MPPS does not cause laboratory abnormalities. Laboratory evaluation is done to exclude other causes for the patient's symptoms. For example, women with pelvic pain often have a urine culture and cervical tests for gonorrhea, chlamydia, and trichomonas performed as indicated to exclude infection.

Imaging — Imaging techniques are not used to diagnose myofascial pain syndromes but can be useful to identify visceral causes of pain, such as uterine fibroids or ovarian cysts. Thus, most women with pelvic pain undergo transvaginal ultrasound to assess for visceral pathology. More data are needed on the role of modalities such as ultrasound and magnetic resonance imaging in the diagnosis of MPPS [44-48]. As with physical examination, identifying an abnormality on imaging does not exclude the diagnosis of MPPS. Often, it is useful to exclude other pathology or pain sources, especially if the pelvic examination is difficult to perform or an abnormality is suspected. As women with MPPS often have a wait time for pelvic floor physical therapy and then require time for treatment before we reevaluate them, it is important that other etiologies of pain are either excluded or identified and addressed.

DIAGNOSIS — MPPS is a clinical diagnosis based on physical examination demonstrating significant muscle and connective tissue tenderness in the region of pain as well as trigger points that evoke referred pain [14,49]. The diagnosis of MPPS is supported by a history of prior trauma or test-confirmed infection, as well as by a history of infection-like symptoms despite negative laboratory tests.

A clinician does not need to feel the actual trigger point or muscle quivering to make a diagnosis of MPPS. The finding of tender muscles and hypersensitive tissues confirms this diagnosis. The presence of other pelvic abnormalities (eg, fibroids or ovarian cyst) at the time of physical examination does not exclude the diagnosis of MPPS.

DIFFERENTIAL DIAGNOSIS — The differential diagnosis of MPPS includes many potential causes of acute and chronic pelvic pain (table 1 and table 2). The pelvic organs, bladder, and bowel are evaluated for underlying pathology. Additionally, MPPS is included in the differential diagnosis for any woman presenting for the evaluation of pelvic pain, particularly when no other cause has been identified. For women with suspected or surgically confirmed endometriosis, it can be difficult to ascertain whether the pain relates to endometriosis or to pelvic floor hypertonicity, which often coexists. We recommend addressing any pelvic floor findings either concurrently or sequentially, as MPPS can be a significant contributing factor to patient symptoms. Endometriosis is addressed below.

●(See "Evaluation of acute pelvic pain in nonpregnant adult women".)

●(See "Evaluation of acute pelvic pain in the adolescent female".)

●(See "Chronic pelvic pain in adult females: Evaluation".)

For women suspected of having MPPS, we specifically exclude:

●Abdominal myofascial pain – Trigger points in the rectus abdominis muscles can cause pain or burning in the abdomen or a sense of bloating or fullness. Similar to the pain of MPPS, abdominal myofascial pain is easily confused with pain of a visceral origin. Abdominal myofascial pain can usually be identified by having the patient Valsalva (by performing a half sit-up from the supine position), which tightens the rectus muscles. If tenderness is worsened with palpation of the abdominal wall during Valsalva, the patient's pain is likely originating from the abdominal musculature. If the abdominal wall contraction lessens the pain, the pain is more likely visceral in origin. (See "Anterior cutaneous nerve entrapment syndrome", section on 'Diagnostic approach'.)

●Other myofascial pain syndromes – Other muscle groups can also refer pain to the pelvis [26]. Coccygodynia, pelvic floor tension myalgia, piriformis syndrome, levator ani spasm syndrome, and proctalgia fugax share hypertonicity of regions of the pelvic musculature as an underlying problem, and may represent various manifestations of the same disease state. These syndromes are differentiated from MPPS by their specific anatomic location. However, it can be impossible to attribute specific symptoms to distinct muscle groups. Typically, the same muscle groups are involved in differing degrees in women presenting with other myofascial pelvic pain syndromes.

●Fibromyalgia – Fibromyalgia is a collection of symptoms including widespread pain (figure 5), accompanied by tactile allodynia, fatigue, sleep disturbance, and psychological distress [50]. Fibromyalgia differs from MPPS in that patients with fibromyalgia have pain throughout their bodies, have other somatic symptoms, have symptoms for at least three months duration, and generally do not have trigger points. (See "Clinical manifestations and diagnosis of fibromyalgia in adults".)

●Cutaneous allodynia – Allodynia is pain in response to a non-nociceptive (ie, non-painful) stimulus [51,52]. Cutaneous allodynia is relatively common among women with chronic pelvic pain. In a study of 81 women with chronic pelvic pain, over half had cutaneous allodynia [53]. Cutaneous allodynia is differentiated from MPPS by its restriction to the abdominal wall and, in most cases, identification of a trigger point located at the junction of the rectus abdominus and external oblique muscles and consistent with the location of the anterior cutaneous nerve [54,55]. (See "Anterior cutaneous nerve entrapment syndrome".)

●Endometriosis – Endometriosis is a common cause of pelvic pain. It is differentiated from MPPS by symptoms that are usually related to the menstrual cycle and possibly by findings suggestive of endometriosis on imaging, such as complex ovarian cysts. Endometriosis is definitively diagnosed by tissue biopsy. Endometriosis often co-occurs with MPPS. Women with endometriosis-related pelvic pain have also been shown to have signs of sensitization and myofascial dysfunction, particularly in the abdomino-pelvic regions [56]. It is not known if the two disorders share a common pain mechanism or if endometriosis leads to MPPS. (See "Endometriosis: Pathogenesis, clinical features, and diagnosis".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Female pelvic pain".)

SUMMARY AND RECOMMENDATIONS

●Myofascial pelvic pain syndrome (MPPS) describes a disorder in which pelvic pain is attributed to short, tight, tender pelvic floor muscles that usually contain hypersensitive trigger points. (See 'Myofascial pelvic pain syndrome' above.)

●Trigger points are hyperirritable, palpable nodules that are painful to compression and produce sensory, motor, and autonomic symptoms (eg, coldness, sweating, tachycardia, coryza, lacrimation, and erythema). Trigger points can be active (ie, spontaneously painful) or latent (ie, painful only with stimulation). Pelvic trigger points often refer pain to the vagina, vulva, perineum, rectum, and bladder, as well as to more distant areas such as the thighs, buttocks, or lower abdomen. (See 'Trigger points' above.)

●MPPS is considered in any woman presenting for the evaluation of pelvic pain, particularly when no other cause has been identified. If a potential source of chronic pelvic pain is identified, such as endometriosis or ovarian cysts, the diagnosis of MPPS is not excluded. (See 'Diagnosis' above.)

●Women with MPPS generally present with pain in the pelvis, vagina, vulva, rectum, or bladder, or in more distant referral areas such as the thighs, buttocks, hips, or lower abdomen. Commonly associated symptoms include a sense of aching, heaviness, or burning in these areas and/or symptoms of overactive bladder, constipation, or dyspareunia. Symptoms can be continuous or episodic. (See 'Clinical presentation' above.)

●A complete diagnostic evaluation assesses urinary, gastrointestinal, gynecologic, sexual, and psychosocial symptoms. One purpose of the evaluation is to exclude other possible causes of pelvic pain (table 1 and table 2). The International Pelvic Pain Society has developed a detailed history and physical examination form for evaluation of women with chronic pelvic pain of any etiology. (See 'Diagnostic evaluation' above.)

•Symptoms suggestive of MPPS include (see 'History' above):

-Pelvic and/or abdominal pain

-Urinary tract symptoms (eg, frequency, urgency, incontinence, nocturia, dysuria, sensation of incomplete emptying, bladder pain)

-Vulvovaginal discomfort, including dyspareunia

-A feeling of abdominal fullness or bloating

-Rectal fullness or constipation, dyschezia

-Rectal, vaginal, or bladder spasms

-Culture negative recurrent infections

•Manual palpation identifies pelvic muscle hypertonus and pain as well as trigger points. Skeletal muscles are examined for a tight band of tissue or painful nodule (trigger point) that produces a twitch response, as well as local and/or referred pain to the pelvic organs or surrounding tissues. Studies support that palpation is reliable when performed by a skilled examiner. The examination includes the abdomen, back, and hips in addition to detailed internal and external pelvic evaluations (figure 1 and figure 3 and figure 4). (See 'Physical examination' above.)

•Laboratory and imaging studies are not helpful in making the diagnosis of MPPS, but can be useful in excluding other etiologies of pelvic pain. (See 'Laboratory tests' above and 'Imaging' above.)

●The diagnosis of MPPS is based on a physical examination demonstrating significant muscle and connective tissue tenderness in the region of pain as well as trigger points that evoke referred pain. A clinician does not need to feel the actual trigger point or muscle quivering to make a diagnosis of MPPS. Supporting information comes from the history, which can include information on prior pelvic trauma or infection. The symptoms can be acute or chronic.

●The differential diagnosis of MPPS includes many potential causes of acute and chronic pelvic pain (table 1 and table 2). The pelvic organs, bladder, and bowel are evaluated for underlying pathology. For women suspected of having MPPS, we also exclude abdominal myofascial pain syndromes, other myofascial pain syndromes, fibromyalgia, cutaneous allodynia, and endometriosis. (See 'Differential diagnosis' above.)