Methodological approaches to botulinum toxin for the treatment of chronic pelvic pain, vaginismus, and vulvar pain disorders

  • Barbara Illowsky KarpEmail author
  • Hannah Tandon
  • Deionna Vigil
  • Pamela Stratton
Review Article


Introduction and hypothesis

Botulinum toxin (BoNT) is increasingly used for pain, especially with muscle spasm. We describe our methodology for BoNT treatment of chronic pelvic pain (CPP) in women and place it in the context of the literature on techniques for this use.


Databases were searched using terms “botulinum toxin,” “pelvic pain,” and “vaginismus.” Reports on vaginismus/vulvodynia/vestibulodynia (included if pelvic floor muscles were injected) were grouped as “vaginismus/vulvar pain disorders” (V/VPD). We analyzed the type of report, condition, toxin serotype/brand, dose/dilution, muscle selection, guidance technique, and anesthesia. Publications from the same authors without unique information were combined for specific analyses.


Thirty-eight reports had analyzable information; many lacked complete information. Most were open-label prospective reports; there were four technical reports, one randomized comparison of doses and one placebo-controlled study of efficacy. Pelvic floor muscles were approached transvaginally, transperineally or transgluteally. BoNT brand/dose/dilution varied widely. Muscle localization techniques included anatomical landmarks only, electromyography, electrical stimulation with/without ultrasound, and fluoroscopy/CT scanning. Papers discussing analgesia utilized general anesthesia, conscious sedation with/without topical/local anesthesia, topical/local agent alone or pudendal block before or after injection. Cumulatively, 58–100% of patients with CPP and 71–100% of those with V/VPD improved. Serious adverse events (transient fecal incontinence/constipation, urinary incontinence/retention) were more frequent with higher doses.


BoNT can be safely and tolerably injected into pelvic floor muscles in women as an out-patient procedure. This study identifies methodological factors to be considered in future studies and the critical need for high-quality clinical trials for this emerging treatment.


Botulinum toxin Chemodenervation Chronic pelvic pain Pelvic floor spasm Pelvic pain Vaginismus 


Source of funding

This research was supported by the Intramural Research Program of the National Institutes of Health.

Compliance with ethical standards

Conflicts of interest

The authors declare that they have no conflicts of interest related to this article.


Dr Karp, Dr Stratton are investigators and Ms Tandon was a research assistant on a different study for which the National Institutes of Health received a grant from Allergan, Inc, the manufacturer of onabotulinumtoxinA (Botox). Dr Karp is also an associate investigator on one study for which the Icahn School of Medicine at Mt Sinai received a grant from Allergan, Inc, and another study for which the National Institutes of Health received a grant from Merz, Inc, the manufacturer of incobotulinumtoxinA (Xeomin). Ms Vigil has no disclosures.


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Copyright information

© This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply 2019

Authors and Affiliations

  1. 1.National Institute of Neurological Disorders and StrokeNational Institutes of HealthBethesdaUSA
  2. 2.Department of Rehabilitation MedicineNational Institutes of HealthBethesdaUSA
  3. 3.CarmelUSA

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