By Elizabeth Akincilar, MPT, Cofounder, PHRC Lexington
In the past, when most folks in the medical community thought about pelvic pain, the assumption often was that it was due to pregnancy or labor and delivery, or something related to a woman’s menstrual cycle or reproductive organs. Thankfully, the medical community has come a long way. Within the community of medical providers who treat pelvic pain, it is common knowledge that all people can suffer from pelvic pain.
The medical literature estimates that 8-12% of men will suffer with pelvic pain at some point in their lives. Pelvic pain in men was typically thought to be due to prostatitis, or inflammation of the prostate due to infection. Interestingly, prostatitis is the most common urologic diagnosis in men under 50 years old. Prostatitis can indeed cause pelvic pain, but, we now know that in many cases of pelvic pain in men, it is not due to dysfunction or pathology of the prostate. Pelvic pain in men is often due to causes other than the prostate, such as neuromuscular impairments (muscles, nerves, tissue). The National Institutes of Health classified Chronic Pelvic Pain Syndrome (CPPS) in men as follows:
- Chronic Pelvic Pain Syndrome I: formerly known as Acute Bacterial Prostatitis, defined as acute sudden pelvic pain, typically associated with fevers and other signs of infection as well as bacteria identified in urine or prostate secretions
- Chronic Pelvic Pain Syndrome II: formerly known as Chronic Bacterial Prostatitis, defined as recurrent or chronic pelvic pain, associated with bacteria identified in urine or prostate secretions, usually in the absence of fevers or other signs of infection
- Chronic Pelvic Pain Syndrome III: formerly known as Non-Bacterial Prostatitis or Prostatodynia, defined as recurrent or chronic pelvic pain that is not associated with bacteria identified in urine or prostate secretions. CPPS III may be subdivided into type A, when inflammatory cells are found in urine or prostate secretions and type B, when inflammatory cells are NOT found in urine or prostate secretions
- Chronic Pelvic Pain Syndrome IV: presence of inflammatory cells in urine or prostate secretions in the absence of any symptoms
CPPS III is by far the most common found in clinical practice. Yet, men are still over prescribed antibiotic therapy in the absence of infection.
Those with CPPS III, particularly type B, are the most appropriate to see a pelvic floor physical therapist.
Common symptoms of CPPS include
- Pelvic pain: can be burning, shooting, aching, and/or itching in nature in the lower abdomen, groin, buttocks, and/or inner thighs
- Genital pain: can include scrotal, testicular, and/or penile pain
- Perineal and/or anal/rectal pain
- Urinary dysfunction: can include urinary frequency, urgency, hesitancy, incomplete emptying, pain, and/or dribbling
- Bowel dysfunction: can include pain with bowel movements, constipation, incomplete emptying, gastrointestinal distress, and/or bloating
- Sexual dysfunction: can include erectile dysfunction and/or pain before, during and/or after ejaculation
- Pain with sitting, particularly in the perineum and/or “sit bones”
- Pain with exercise, particularly with squatting or heavy lifting
Common causes of CPPS
- Excessive sitting, such as with cycling, horseback riding, or long periods of required sitting
- Surgical trauma: inguinal hernia repairs, vasectomy, benign prostatic hyperplasia (BPH) interventions
- For further explanation on how inguinal hernia repairs can contribute to pelvic pain, check out this blog!
- Orthopedic injuries or trauma: spine, knee, ankle and/or other orthopedic pathologies
- Biomechanical or structural dysfunction: hip dysfunction, leg length discrepancy, sacroiliac dysfunction
- Excessive exercise or change to exercise routine
- Excessive and aggressive sexual activity and/or aggressive lengthening of the penis, also known as jelqing
- Chronic constipation or straining with bowel movements
- Chronic infections, such as bacterial prostatitis or sexually transmitted infections
How to manage CPPS
- It’s important to consult with your urologist to rule out a prostate infection and/or any other pathology that should be treated medically
- Check out this interview with urologist Dr. Joshua Gonzalez for more information!
- Schedule an evaluation with a pelvic floor physical therapist
- If you have discomfort sitting and your occupation requires a lot of computer time, consider using a standing desk
- If you have discomfort with sitting, consider using a pressure relieving cushion to minimize compression of the pelvic floor structures
- If you have increased discomfort with exercise, talk to your physical therapist about how to modify your exercise program
- Incorporate a daily mindfulness meditation practice
Whether you recently developed symptoms consistent with CPPS or you have persistent symptoms and haven’t yet found relief, there is hope. There are treatment interventions available to alleviate your symptoms. Often successful treatment is achieved through a combination of therapies initiated at the right time. Working with a team of providers who are well versed in treating pelvic pain is paramount. That team of providers typically includes a urologist, a pain management specialist, a mental health specialist, and, most importantly, a pelvic floor physical therapist. It’s important to find a pelvic floor physical therapist who is comfortable treating men with pelvic pain, as not all are.
Check out these success stories for inspiration!
- Penile pain success story
- Clyde’s success story
- Michael’s success story
- Joseph’s success story
- Tyler’s success story
- Scott’s success story
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Are you unable to come see us in person in the Bay Area, Southern California or New England? We offer virtual physical therapy appointments too!
Virtual sessions are available with PHRC pelvic floor physical therapists via our video platform, Zoom, or via phone. For more information and to schedule, please visit our digital healthcare page.
In addition to virtual consultation with our physical therapists, we also offer integrative health services with Jandra Mueller, DPT, MS. Jandra is a pelvic floor physical therapist who also has her Master’s degree in Integrative Health and Nutrition. She offers services such as hormone testing via the DUTCH test, comprehensive stool testing for gastrointestinal health concerns, and integrative health coaching and meal planning. For more information about her services and to schedule, please visit our Integrative Health website page.
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FAQ
What are pelvic floor muscles?
The pelvic floor muscles are a group of muscles that run from the coccyx to the pubic bone. They are part of the core, helping to support our entire body as well as providing support for the bowel, bladder and uterus. These muscles help us maintain bowel and bladder control and are involved in sexual pleasure and orgasm. The technical name of the pelvic floor muscles is the Levator Ani muscle group. The pudendal nerve, the levator ani nerve, and branches from the S2 – S4 nerve roots innervate the pelvic floor muscles. They are under voluntary and autonomic control, which is a unique feature only they possess compared to other muscle groups.
What is pelvic floor physical therapy?
Pelvic floor physical therapy is a specialized area of physical therapy. Currently, physical therapists need advanced post-graduate education to be able to help people with pelvic floor dysfunction because pelvic floor disorders are not yet being taught in standard physical therapy curricula. The Pelvic Health and Rehabilitation Center provides extensive training for our staff because we recognize the limitations of physical therapy education in this unique area.
What happens at pelvic floor therapy?
During an evaluation for pelvic floor dysfunction the physical therapist will take a detailed history. Following the history the physical therapist will leave the room to allow the patient to change and drape themselves. The physical therapist will return to the room and using gloved hands will perform an external and internal manual assessment of the pelvic floor and girdle muscles. The physical therapist will once again leave the room and allow the patient to dress. Following the manual examination there may also be an examination of strength, motor control, and overall biomechanics and neuromuscular control. The physical therapist will then communicate the findings to the patient and together with their patient they establish an assessment, short term and long term goals and a treatment plan. Typically people with pelvic floor dysfunction are seen one time per week for one hour for varying amounts of time based on the severity and chronicity of the disease. A home exercise program will be established and the physical therapist will help coordinate other providers on the treatment team. Typically patients are seen for 3 months to a year.
What is pudendal neuralgia and how is it treated?
Pudendal Neuralgia is a clinical diagnosis that means pain in the sensory distribution of the pudendal nerve. The pudendal nerve is a mixed nerve that exits the S2 – S4 sacral nerve roots, we have a right and left pudendal nerve and each side has three main trunks: the dorsal branch, the perineal branch, and the inferior rectal branch. The branches supply sensation to the clitoris/penis, labia/scrotum, perineum, anus, the distal ⅓ of the urethra and rectum, and the vulva and vestibule. The nerve branches also control the pelvic floor muscles. The pudendal nerve follows a tortuous path through the pelvic floor and girdle, leaving it vulnerable to compression and tension injuries at various points along its path.
Pudendal Neuralgia occurs when the nerve is unable to slide, glide and move normally and as a result, people experience pain in some or all of the above-mentioned areas. Pelvic floor physical therapy plays a crucial role in identifying the mechanical impairments that are affecting the nerve. The physical therapy treatment plan is designed to restore normal neural function. Patients with pudendal neuralgia require pelvic floor physical therapy and may also benefit from medical management that includes pharmaceuticals and procedures such as pudendal nerve blocks or botox injections.
What is interstitial cystitis and how is it treated?
Interstitial Cystitis is a clinical diagnosis characterized by irritative bladder symptoms such as urinary urgency, frequency, and hesitancy in the absence of infection. Research has shown the majority of patients who meet the clinical definition have pelvic floor dysfunction and myalgia. Therefore, the American Urologic Association recommends pelvic floor physical therapy as first-line treatment for Interstitial Cystitis. Patients will benefit from pelvic floor physical therapy and may also benefit from pharmacologic management or medical procedures such as bladder instillations.
Who is the Pelvic Health and Rehabilitation Team?
The Pelvic Health and Rehabilitation Center was founded by Elizabeth Akincilar and Stephanie Prendergast in 2006, they have been treating people with pelvic floor disorders since 2001. They were trained and mentored by a medical doctor and quickly became experts in treating pelvic floor disorders. They began creating courses and sharing their knowledge around the world. They expanded to 11 locations in the United States and developed a residency style training program for their employees with ongoing weekly mentoring. The physical therapists who work at PHRC have undergone more training than the majority of pelvic floor physical therapists and as a result offer efficient and high quality care.
How many years of experience do we have?
Stephanie and Liz have 24 years of experience and help each and every team member become an expert in the field through their training and mentoring program.
Why PHRC versus anyone else?
PHRC is unique because of the specific focus on pelvic floor disorders and the leadership at our company. We are constantly lecturing, teaching, and staying ahead of the curve with our connections to medical experts and emerging experts. As a result, we are able to efficiently and effectively help our patients restore their pelvic health.
Do we treat men for pelvic floor therapy?
The Pelvic Health and Rehabilitation Center is unique in that the Cofounders have always treated people of all genders and therefore have trained the team members and staff the same way. Many pelvic floor physical therapists focus solely on people with vulvas, this is not the case here.
Do I need pelvic floor therapy forever?
The majority of people with pelvic floor dysfunction will undergo pelvic floor physical therapy for a set amount of time based on their goals. Every 6 -8 weeks goals will be re-established based on the physical improvements and remaining physical impairments. Most patients will achieve their goals in 3 – 6 months. If there are complicating medical or untreated comorbidities some patients will be in therapy longer.