Modified Delphi Consensus Guidelines for Pelvic Floor Botulinum Toxin Injection

Myofascial pelvic pain (MPP) is an under-treated etiology of pelvic pain, presenting with pelvic floor tender points and/or increased tension. While limited data support off-label use of pelvic floor botulinum toxin (BTA) injections for refractory MPP, clinical guidance on its utilization is lacking.

We sought to develop consensus-based guidelines for pelvic floor BTA injection.

We identified 46 potential experts in the use of pelvic floor BTA injection based on research, clinical volume, and publication of patient-facing materials, 18 of whom agreed to participate. Consensus, defined as at least 70% agreement or disagreement, was determined through 3 rounds of electronic surveys using a modified Delphi method between September 2023 and July 2024.

A total of 15 practitioners completed the first survey, with most based in the United States (93%), working in academic settings, with Obstetrics and Gynecology training (85%). Expert consensus supports that BTA injection is a third-line therapy for high-tone pelvic floor dysfunction and myofascial pelvic pain. Its use may also be considered for involuntary vaginismus, vestibulodynia, and anismus/dyssynergic defecation. Preprocedural examination is sufficient to localize sites and should palpate the puborectalis, pubococcygeus, iliococcygeus, and obturator internus. Injections of 100-200 units total should focus on areas of increased tenderness/hypertonicity; however, for global symptoms or inability to tolerate examination, templated injections may be used. Experts did not support performing local anesthetic injections to predict responses. Injection is performed transvaginally with each muscle group receiving 20-50 units BTA in divided 1-2 mL injections. Injections are performed bilaterally. Patients should be followed by quantitative pain assessments with repeat injections as needed.

Using a modified Delphi method, we describe expert consensus-based guidelines for pelvic floor BTA injection to provide practical guidance for its use.