肌筋膜症候群誘發單側外陰疼痛的案例報告

Unilateral Vulvodynia Caused by Myofascial Pain Syndrome of Adductors- A Case Report

多種因素可能與生殖器部位出現異常疼痛與觸痛相闕，但較少見內收肌群肌筋膜引發筋膜疼痛症候群併發外陰郁轉移痛的案例。在此，我們提出一位自然產後併發單側外陰異常疼痛與觸痛的案例。一位22歲年輕女性在初次自然產後，發生單側自發性外陰異常疼痛與觸痛，部位包括右側大陰唇、小陰層、陰蒂以及陰道口。尤其性行為與坐姿時，疼痛加劇。在多次婦產科求診，口服止痛藥物十個月之後，仍無法找出切確原因，症狀也無明顯改善，經轉診到本院疼痛科求診。排除產後生殖器發生異常疼痛的常見原因，包括會陰切關修補術後、發炎、感染、慢性骨盆腔疼痛等等因素之後，肌筋膜症候群列入考量。身體理學檢查發現：內收大肌有兩處引痛點，內收長肌則有一處。內收肌群肌筋膜症候群，併發外陰轉移痛的可能原因，常由過度伸張內收大肌與內收長肌，導致肌肉傷害，誘發引痛點產生，併發外陰轉移痛。回顧此婦女自然產史時，併有肩難產，使用”McRober凶手技操作法”幫助分娩，可能為此案例的主誘發因子。第一次引痛點局部注射之後，症就改善大半，一過後給予第二次治療，症狀完全痊癒。因此，建議將引發點檢查列入骨盆與外陰疼痛的身體理學檢查項目之一。此外，引痛點注射是內收肌群肌筋膜症候群併發外陰轉移痛的有效治療方法。

Tenderness and pain over the genital region may be due to enormous causes, but few are diagnosed as myofascial pain syndromes in origin. Here we presented a case of unilateral vulvodynia diagnosed as a myofascial pain syndrome was successfully treated by trigger point injections. A 22 year-old female suffered from acute right genital pain after a spontaneous delivery whenever intercourse or some sitting position. She visited gynecologists and negative pelvic examinations were told. Meanwhile, she received multi-medical treatments about ten months but in vain. She was referred to our pain clinic for further treatment. Tracing back to her delivery history, the baby' s weight was 4100 gm and shoulder dystocia was told. Physical examination revealed tenderness and pain over the region of right adductor magnus, adductor longus with trigger points and genital region. Symptoms and signs were exacerbated while abduction of right thigh. A myofascial pain syndrome of adductors referring to genital region was highly suspected, which was related to McRoberts maneuver during a spontaneous delivery. This maneuver might overstretch these muscles and develop muscular trauma. Tenderness and pain over the genital region was improved after the first trigger point injections. The second injections were performed one week later, and then symptoms and signs were fully subsided. Therefore, we suggested that palpating trigger points should be as part of physical examinations for unusual pelvic and genital pain. Trigger point injections can provide an easy and effective method in the diagnosis and treatment of vulvodynia caused by myofascial pain of adductors.