Wu YC. et al., 2026: Effects of extracorporeal shockwave therapy on pain and pelvic floor function in women with pelvic floor myofascial pain: a retrospective cohort analysis.

Wu YC, Ding DC.
BMC Womens Health. 2026 Apr 30;26(1):312. doi: anil. PMID: 42062986

Abstract

BACKGROUND: Pelvic floor myofascial pain (PFMP) is a common cause of chronic pelvic pain. We aimed to explore whether the application of extracorporeal shockwave therapy (ESWT) is associated with reductions in pain intensity and pelvic floor dysfunction scores among patients with PFMP. METHODS: We conducted a retrospective cohort study of 20 female patients with PFMP treated with ESWT between July 2022 and February 2024. All participants underwent a baseline assessment, which included a comprehensive medical history, physical examination, and symptom evaluation using the Visual Analogue Scale (VAS) and the Pelvic Floor Disability Inventory-20 (PFDI-20). ESWT was administered perineally in lithotomy position once weekly for four consecutive weeks, with 2,000 impulses delivered per session. Changes in VAS, PFDI-20, and its subscales (POPDI-6, CRADI-8, UDI-6) were analyzed using paired statistical comparisons. RESULTS: The median age of the patients was 55 years (interquartile range, IQR, 47.5–63.0). After 4 weeks of ESWT, the median VAS score decreased significantly from 7.0 to 2.0 (p < 0.01). The median PFDI-20 score decreased from 33.0 to 26.5 (p < 0.01). Subscale analysis revealed significant reductions in POPDI-6 (from 11.0 to 8.0, p < 0.01), CRADI-8 (from 13.0 to 10.0, p < 0.05), and UDI-6 (from 10.0 to 9.0, p < 0.01). Effect sizes for pre–post changes ranged from r = − 0.54 to − 0.88, with 95% bootstrap confidence intervals reported for all outcomes. CONCLUSION: ESWT is associated with decreased pain intensity and reduced pelvic floor dysfunction scores in patients with PFMP. However, short-term, within-patient change remains the dominant interpretative frame. As such, ESWT is described as associated with symptom reductions rather than implying effectiveness. These preliminary, within-patient findings warrant confirmation in larger, controlled prospective studies.

Comment Jens Rassweiler

Objective

This study examined whether extracorporeal shockwave therapy (ESWT) was associated with reduced pain and improved pelvic floor symptoms in women with pelvic floor myofascial pain.

Study design

The authors conducted a retrospective cohort study involving 20 women treated at a pelvic floor clinic between July 2022 and February 2024. All patients received ESWT using the DUOLITH SD1 T-TOP machine (STORZ MEDICAL, Tägerwilen, Switzerland). once weekly for four weeks. Each session involved 2,000 focused shockwave impulses applied perineally to bilateral upper and lower vulvar regions.

Pain was assessed using the Visual Analogue Scale, or VAS, and pelvic floor dysfunction was measured using the Pelvic Floor Disability Inventory-20, or PFDI-20, including its three subscales:

• POPDI-6: prolapse-related distress
• CRADI-8: colorectal-anal distress
• UDI-6: urinary distress
  
  

Results

After four weeks of ESWT, the median VAS pain score decreased from 7.0 to 2.0, which was statistically significant. The median PFDI-20 score also decreased from 33.0 to 26.5. All three PFDI-20 subscales showed statistically significant reductions.

Discussion

The most notable finding was the reduction in pain intensity.This is a large reduction in reported pain. The authors note that the change exceeds commonly cited minimal clinically important difference thresholds for chronic pain, which are often around 1.5–2 points on the VAS.

Concerning pelvic floor symptom improvement the overall PFDI-20 score also improved.
However, the clinical importance of this change is less certain. The authors acknowledge that commonly used clinically meaningful thresholds for the PFDI-20 were developed mainly in populations with prolapse or urinary incontinence, not specifically pelvic floor myofascial pain.

Concerning subscale changes, all three symptom domains improved statistically:

The urinary and colorectal changes were relatively small in absolute terms, especially UDI-6, which decreased by only one point.

The study suggests that ESWT may be a promising non-invasive treatment option for women with pelvic floor myofascial pain, especially for reducing pain intensity.

However, because this was a single-arm retrospective study, the findings should be interpreted as associations, not proof of treatment effectiveness. The observed improvements may have been influenced by placebo effects, expectation bias, natural symptom fluctuation, regression to the mean, or other unmeasured factors. The authors are appropriately cautious in their wording. They state that ESWT was “associated with” symptom reductions rather than claiming that ESWT “caused” improvement.

Strengths of the Study

1. Clearly defined clinical population

The authors used a standardized pelvic floor examination protocol to identify pelvic floor myofascial pain. Diagnosis required reproducible tenderness, trigger points or taut bands, reproduction of the patient’s typical pain, and exclusion of alternative structural causes.

2. Consistent treatment protocol

All patients received the same ESWT regimen: Four sessions once weekly,2,000 impulses per session with Energy level of 0.3–0.35 mJ/mm² at frequency of 4 Hz.This consistency improves internal comparability.

3. Use of validated outcome measures

The study used recognized patient-reported measures:

• VAS for pain
• PFDI-20 for pelvic floor symptoms

These are commonly used instruments in pain and pelvic floor research.

4. Complete follow-up data

All 20 patients completed both baseline and post-treatment assessments. No imputation was needed.

5. Appropriate caution in conclusions

The authors openly acknowledge the limitations of the study and do not overstate the findings.

Limitations

1. Very small sample size

Only 20 patients were included. This limits statistical power and makes the results vulnerable to random variation.

2. No control group

This is the most important limitation. Without a sham-treatment group, usual-care group, or untreated comparison group, it is impossible to know whether ESWT itself caused the improvements.

3. Retrospective design

Because the study was retrospective, the investigators relied on existing clinical data. Retrospective studies are more vulnerable to selection bias, incomplete documentation, and uncontrolled confounding.

4. Short follow-up period

Outcomes were assessed only after four weeks. The study cannot determine whether symptom improvement persisted over months or years.

Although PFDI-20 scores improved statistically, the median change was modest. It is unclear whether the observed PFDI-20 improvement was large enough to be meaningful to patients with pelvic floor myofascial pain.

.Clinical Relevance

The most clinically relevant finding is the large decrease in VAS pain scores. A reduction from 7 to 2 suggests a potentially meaningful improvement in pain burden.

However, this should not yet change clinical practice on its own. The study provides preliminary evidence that ESWT may be worth investigating further, but it does not establish ESWT as an evidence-based standard treatment for pelvic floor myofascial pain.

At present, ESWT should probably be considered an investigational or adjunctive option rather than a proven therapy for this condition.

Conclusiona

This is a useful exploratory study that contributes early evidence on ESWT for female pelvic floor myofascial pain, an area where data are limited. The findings are encouraging, especially regarding pain reduction. The study is also notable for its cautious interpretation and transparent acknowledgment of methodological weaknesses.

However, the evidence level is low because of the retrospective design, small sample, lack of control group, lack of blinding, and short-term follow-up. The results are best viewed as hypothesis-generating rather than confirmatory.

A well-designed randomized controlled trial is needed before ESWT can be recommended confidently for pelvic floor myofascial pain.

Jens Rassweiler