OnabotulinumtoxinA (BOTOX®) Injection of Levator Ani Muscles with Ultrasound Correlation

Objectives: Objective of this video is to demonstrate a technique for levator ani injection with onabotulinumtoxinA that is well tolerated and essentially bloodless.

Methods: Vaginismus is characterized by involuntary levator ani spasms that can make vaginal penetrative intercourse painful or not achievable. Etiology remains largely unknown. A variety of treatments exist, including cognitive behavioral therapy, pelvic floor physical therapy, gradual vaginal dilators, vaginal valium and onabotulinumtoxinA (BOTOX®). In our practice, if a patient fails to improve after several sessions of pelvic floor physical therapy, we offer levator ani BOTOX® injections. In this video, we will go over the levator ani anatomy with aid of diagrams and 3D ultrasound, as well as a unique technique for BOTOX® injection of the levator ani muscles. First the ischial spine and the ischial tuberosity are palpated. With use of ultrasound guidance puborectalis, pubococcygeus and iliococcygeus muscles are identified and palpated. We use 100 units of BOTOX® reconstituted in 3 mL of normal saline per side. Using 1mL syringe and a 22-gauge spinal needle, we insert the needle lateral to the perineum, medial to the ischial tuberosity and angled medially to transverse the ischiorectal fat to access the levator ani muscles. We inject 0.1mL per site to ensure even distribution of the medication along the levator ani muscles. Afterwards, manual therapy under anesthesia is performed for three to five minutes to lengthen the pelvic floor muscles. After the procedure is completed, patients continue to follow with pelvic floor physical therapy to maximize the benefits of BOTOX®.

Clinical Relevance: This technique of BOTOX® injection of the levator ani muscles is well tolerated by patients, reproducible, provides great results and is essentially bloodless.