— When Frequent Urination Comes from the Pelvis, Not the Bladder —
Today, I’d like to share a case that could easily appear in a medical textbook on myofascial pelvic pain syndrome (MPPS).
Patient profile:
A woman in her late 30s
Main complaint: frequent urination
History: She had been experiencing urinary frequency for over 10 years, and recently, she needed to use the bathroom every 15 minutes.
Detailed urological examinations showed:
Normal cystoscopy (no bladder wall abnormalities, no tumors) Voiding diary showed she could hold 360 ml of urine without leakage
At first glance, it seemed like there was no issue with the bladder itself.
Key findings on physical examination:
Severe tenderness in both obturator internus muscles; the pain was so intense that she recoiled when touched Complete lack of pelvic floor muscle movement Uroflowmetry showed a voiding time of over one minute, and she was voiding with abdominal straining (abdominal voiding)
Understanding the condition
In this case, long-term stress and overload on the obturator internus muscles likely led to:
① Bladder sensory symptoms (sensory abnormalities) via fascial connections
② Disruption of levator ani (pelvic floor) muscle function originating from the obturator internus (motor abnormalities)
MPPS is a condition in which local muscle pain can cause:
Referred pain to other areas Radiating pain Sensory and motor disturbances in distant body parts
In other words, even though the bladder itself was healthy, sensory and motor disturbances triggered by pelvic muscle dysfunction caused the urinary frequency.
Treatment strategy
The key to improving urinary frequency here is treating the obturator internus muscles.
Specifically:
Physical therapy (muscle release and training by a specialist) High-Tesla magnetic stimulation therapy Extracorporeal shock wave therapy Hydrorelease injections to loosen fascial adhesions Oral medications (for pain or bladder overactivity)
Among these, physical therapy to create a pain-free body is the foundation of treatment. Magnetic stimulation, shock wave therapy, injections, and medications can help, but they are mostly supportive or symptomatic treatments.
Summary
For patients with long-standing urinary frequency, sometimes the problem isn’t the bladder but the pelvic muscles—especially the obturator internus.
When bladder exams show no abnormalities, evaluating the pelvic floor muscles can hold the key to diagnosis and treatment.
If you or someone you know is struggling with persistent urinary frequency despite “normal tests,” it may be worth seeking an assessment focused on the pelvic floor.
Many people suffer from pelvic pain, urinary problems, or discomfort in the lower body, yet never receive a clear diagnosis. One possible cause that is often overlooked is Myofascial Pelvic Pain Syndrome (MPPS), a type of pain that originates from tight or irritated muscles in the pelvic floor.
But how did we come to understand this condition? Let’s take a quick look at the history behind the diagnosis of MPPS.
1. The Early Days – Understanding Myofascial Pain
The concept of Myofascial Pain Syndrome (MPS) dates back to the early 20th century. Doctors began to notice that certain tight areas in muscles—called “trigger points”—could cause both local and referred pain. At first, this was mostly studied in areas like the shoulders or back, but over time, it became clear that the same thing could happen in the pelvic muscles as well.
2. Recognizing Pelvic Muscles as a Source of Pain
It wasn’t until the second half of the 20th century that researchers began to seriously consider muscles and fascia (the connective tissue around muscles) as potential causes of chronic pelvic pain. In the 1990s, studies started to highlight how some patients with pelvic pain actually had myofascial pain, not infections or inflammation.
3. Defining MPPS as a Distinct Condition
By the early 2000s, the term Myofascial Pelvic Pain Syndrome started gaining ground. Doctors began to look for key features such as:
• Ongoing or recurring pelvic pain
• Tender spots in certain muscles (like the obturator internus or iliococcygeus)
• Pain that spreads from those spots to other parts of the body (called referred pain)
4. New Tools for Diagnosis
Today, imaging tools like ultrasound and MRI are being used to support the diagnosis of MPPS. Still, one of the most important tools remains a skilled physical examination—often done by physiotherapists or doctors trained in pelvic floor care.
5. A Team-Based Approach
MPPS treatment works best when multiple types of care are combined. This might include physical therapy, acupuncture, medication, and even psychological support. This holistic approach offers the best chance for lasting relief.
Why MPPS Is Often Missed
One reason MPPS has gone unrecognized for so long is that the pelvic floor muscles are deep and can’t be felt from the outside. This makes the diagnosis more difficult—especially when symptoms mimic other conditions.
If you or someone you know has been told “your bladder infection won’t go away,” or you’re struggling with unexplained symptoms like urinary urgency, anal or genital discomfort, lower abdominal pain, or even back pain—it may be time to consider whether the pelvic floor muscles are playing a role.
Understanding referred pain from the pelvic floor may be the key to healing and preventing long-term suffering.
A woman in her 30s came to our clinic with a long-standing history—10 years of frequent urination and a persistent feeling of incomplete emptying.
She had already tried almost all available medications for overactive bladder, antidepressants, and even underwent bladder hydrodistension. Unfortunately, none of these provided relief.
During the evaluation at our clinic, we discovered tenderness in her obturator internus muscle, a deep pelvic muscle that’s not commonly recognized as a source of urinary symptoms.
We started pelvic floor rehabilitation and performed a hydrorelease (injecting saline, local anesthetic, and neurotropic agents into the muscle fascia). Remarkably, she experienced immediate relief from her symptoms right after the procedure.
Of course, much of this relief comes from the temporary effects of the local anesthetic, but the fact that her symptoms disappeared helped her clearly recognize that the pelvic muscle itself was the key contributor.
We explained that symptoms may return as the anesthetic wears off, but the saline helps soften muscle fibers, and neurotropin may help reduce inflammation. She is continuing pelvic floor rehab to learn self-care techniques.
She told us that she’s “feeling a bit better than before”—a small but meaningful step forward.
We’ve also started Storz Magnetic Stimulation (StarFormer), which seems promising. The neuromuscular stimulation it provides might help release chronic muscle tension even further.
Being part of a patient’s journey to find answers after many years of suffering is deeply rewarding. We hope our work can offer hope to others who have been told “nothing is wrong” despite very real symptoms.
“I suddenly feel the urge to urinate and can’t hold it…”
“I’ve tried all the medications for overactive bladder, but nothing works…”
A woman in her late 60s had been struggling with this issue for over 10 years.
Despite trying every available medication for overactive bladder (OAB), she saw little improvement. There were times when her symptoms settled down, but they never truly went away.
So, was her bladder really the problem?
A closer examination revealed some surprising findings.
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