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Modified Delphi Consensus Guidelines for Pelvic Floor Botulinum Toxin Injection.

Demetra H Hufnagel1, Michele Torosis1, A Lenore Ackerman1,2

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Urogynecology (Philadelphia, Pa.)
|March 19, 2026
PubMed
Summary
This summary is machine-generated.

Botulinum toxin (BTA) injections are recommended as a third-line therapy for myofascial pelvic pain and high-tone pelvic floor dysfunction. These expert-guided protocols offer practical insights for BTA utilization in treating pelvic pain conditions.

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Area of Science:

  • Pelvic pain management
  • Neuromodulation therapies
  • Musculoskeletal disorders

Background:

  • Myofascial pelvic pain (MPP) is a common cause of pelvic pain, often characterized by pelvic floor muscle hypertonicity.
  • Current treatment options for refractory MPP are limited, with a lack of established clinical guidelines for off-label therapies like botulinum toxin (BTA) injections.

Purpose of the Study:

  • To establish consensus-based guidelines for the utilization of pelvic floor botulinum toxin (BTA) injections.
  • To provide practical guidance for clinicians managing patients with refractory myofascial pelvic pain and related conditions.

Main Methods:

  • A modified Delphi method was employed, involving three rounds of electronic surveys.
  • Expert consensus was achieved among 18 specialists in pelvic floor BTA injection, identified through research, clinical volume, and patient-facing materials.
  • Surveys were conducted between September 2023 and July 2024 to determine agreement on BTA injection protocols.

Main Results:

  • Botulinum toxin (BTA) injection is supported as a third-line therapy for high-tone pelvic floor dysfunction and myofascial pelvic pain.
  • Consideration for BTA use in vaginismus, vestibulodynia, and anismus/dyssynergic defecation was agreed upon.
  • Guidelines detail preprocedural examination, injection sites (puborectalis, pubococcygeus, iliococcygeus, obturator internus), total dosage (100-200 units), and bilateral transvaginal administration (20-50 units per muscle group).

Conclusions:

  • Consensus-based guidelines for pelvic floor BTA injection were developed using a modified Delphi method.
  • These guidelines offer practical recommendations for the effective use of BTA in managing myofascial pelvic pain and related conditions.
  • The study provides much-needed clinical guidance for this under-treated etiology of pelvic pain.