Male Pelvic Pain and Chronic Nonbacterial Prostatitis: A Story of Hope and Determination

In Male Pelvic Pain by Shannon Pacella6 Comments

 

By Shannon Pacella, DPT, PHRC Lexington

 

Unfortunately, the majority of the men we see at PHRC have been through quite a journey with their pelvic pain, before finding pelvic floor physical therapy. I want to share a recent success story about one of my male patients, Ben (his name has been changed for anonymity). My hope by sharing his success story is to allow others dealing with pelvic pain to find a treatment path that works for them.

 

“I’d struggled for 6 years with pelvic floor pain, and even though I had determined it was a muscular and connective tissue problem, I could never find the right combinations of therapies to ease my symptoms. Then I finally discovered PHRC and knew from the beginning that they were different.”

 

Ben is a 50 year old man with a six year history of pelvic pain. Here’s his story: In 2010, Ben began having perineal and pelvic pain as well as urinary urgency/frequency, which led him to seek out a urologist. The urologist diagnosed him with prostatitis, and Ben was given antibiotics for ~three months, without any change in symptoms or decrease in pain. So for the next year or so, Ben started doing research online to try and find an answer to his pain. During this time, he saw another urologist who suggested pursuing pelvic floor physical therapy, as well as referring to a pain management physician. Ben worked with a pelvic floor physical therapist for ~six months, which helped to decrease his urinary urgency and frequency symptoms, but continued to have flares in his pelvic and perineal pain. Ben read A Headache in the Pelvis, and Heal Pelvic Pain, but was having difficulty making changes on his own. Ben was frustrated and feared his pain would never change. This stress and anxiety only further increased his pain. Fast forward three more years of struggling to find an answer to his symptoms, when he found PHRC online.

 

When I evaluated him in 2016, Ben described his symptoms as: constant deep perineal aching (four to five out of ten pain at worst, three out of ten pain on average), radiating pelvic pain to buttocks with sitting (sitting tolerance less than one hour), decreased ability to maintain an erection, and pain post ejaculation. Ben is a self proclaimed “clencher”, saying that he tends to hold tension in his buttocks and pelvis, especially when stressed or anxious. Ben avoids sitting as much as possible, and uses a standing desk at work. He also reports being an avid runner, and would very much like to be able to run and exercise without exacerbating his symptoms.

 

During his initial evaluation I noted the following:

 

  • Moderate connective tissue dysfunction at his inner thighs, inguinal creases, suprapubic region, and bony pelvis.
  • Myofascial trigger points along adductors, piriformis, and perineum.
  • Hyperactivity (tightness) at the urogenital triangle (bulbospongiosus, ischiocavernosus, and transverse perineal muscles).
  • Decreased ability to voluntarily relax pelvic floor muscles.

 

My assessment was that Ben had pudendal neuralgia secondary to pelvic floor hyperactivity. The tension in his pelvic floor muscles was putting pressure and irritating the pudendal nerve, which became exacerbated with sitting (puts even more pressure on this nerve). Due to Ben’s history of being a “clencher,” this pelvic floor muscle tension was not a result of one specific incident or injury, but built up over time, until it reached a tipping point and became symptomatic and painful.

 

Ben’s goals were the following:

 

  1. To understand his condition better.
  2. To alleviate/manage his pain, and be able to sit with less pain.
  3. Resume physical activities such as running.
  4. Feel healthier emotionally, and learn to decrease stress/anxiety.

 

I recommended treatment one time per week for eight to twelve visits. My treatment plan included connective tissue manipulation, myofascial release, myofascial trigger point release, neuromuscular reeducation, pain physiology education, home exercise program (HEP) prescription and management, therapeutic exercise and activity, activity modification, and stress relieving exercises. During his initial evaluation, we discussed how chronic pain can affect the nervous system and the relationship between heightened stress/anxiety and increasing pain. Ben was given handouts on the mind/body connection and ideas to facilitate change. We practiced pelvic floor drops/relaxations while incorporating diaphragmatic breathing, and this was given as the first part of his home exercise program.

 

“Through a combination of physical work and coaching, my therapist Shannon allowed me to understand this syndrome better than I ever had before – and gave me a wide variety of tools and techniques that I could use to help get better.”

 

If you want to learn more about what connective tissue and myofascia are, and how they can play a big role in pelvic floor dysfunction, you may find fellow PHRC PT Ciel Yogis’ blog post Sitting on painful fascia: connective tissue and pelvic pain to be a good resource.

 

At Ben’s first follow-up visit, he reported having some soreness after the initial exam in the areas where we focused the manual therapy, but felt better than he had previously. He rated his current perineal pain as two out of ten. I continued the manual therapy, which was aimed at the connective tissue and myofascial impairments, the adductor and bony pelvis trigger points, and pelvic floor hyperactivity. Ben demonstrated improvement with relaxing his pelvic floor muscles while diaphragmatic breathing with moderates cues. We discussed the use of cushions with sitting, to help to decrease symptom exacerbation. Ben found that using a cushion was helpful to increase his sitting tolerance.

 

At his second visit, Ben reported having reduced pain for four to five days after the last session, but his symptoms then started to return. Upon exam, I noted a decrease in the myofascial trigger points along his adductors. We discussed the use of a foam roller at his adductors and hamstrings in order to further reduce the myofascial restrictions at home and maintain the progress being made during the treatment sessions. He continued to have urogenital triangle hyperactivity.

 

At the third treatment visit, he reported being consistent with using a foam roller and stretching everyday, with noted tension in his lateral thighs. He was able to run three miles without pain and without exacerbating symptoms. I continued the manual myofascial and connective tissue release, including the lateral thighs, with decreased tension noted. Ben’s pelvic floor motor control was improving, and he was able to perform a pelvic floor drop/relaxation with less cueing.

 

By the fifth visit, Ben reported experiencing stretches of time that were pain-free. He reported that he was able to do some plane traveling which did not increase his pain as much as he anticipated. I continued to notice decrease in the urogenital triangle hyperactivity and myofascial and connective tissue restrictions throughout Ben’s thighs and pelvis. I taught Ben self myofascial release techniques focused at the bulbospongiosus and ischiocavernosus muscles for his home exercise program.

 

At the sixth visit, he reported having a flare in his pain, and felt pelvic tension. He stopped running due to exacerbating symptoms further. Ben was a bit frustrated with having such a good week prior, and then having a not so great week. We discussed how his pain and symptoms may fluctuate, and how that is okay and normal! The biggest take home message that I wanted Ben to understand is to not let a flare up in symptoms increase his stress/anxiety (going back to the pain science education from the initial evaluation). He reported that he did believe in how much his stress increased his symptoms and how incorporating daily relaxation was now important to him. I noted a slight increase in myofascial and connective tissue restriction at his inner and posterior thighs (which may have been linked to the increase in his pain). Ben was interested in other ways to perform at home myofascial and connective tissue release besides using his hands and the foam roller, so I discussed and demonstrated use of a myofascial roller stick. I also instructed Ben in alternative positions to perform the pelvic floor drops/relaxations (cat/cow and low and high kneeling positions).

 

At the seventh visit, Ben reported that he had been completely pain free for four days after the previous session, and that it was the best week he’d had in the past six years. He reported that he got a myofascial roller stick and was using it consistently each day, and had also found the cat/cow positions to be helpful in doing the pelvic floor drops/relaxations. I noticed a significant decrease in the myofascial and connective tissue restrictions at his inner and posterior thighs, as well as a decrease in the urogenital triangle hyperactivity. I felt bilateral hip flexor tension during this session, so I added a kneeling hip flexor stretch to his home exercise program.

 

By the ninth visit, Ben reported that his pain and symptoms were decreasing and felt a direct correlation between being consistent with his home exercise program and feeling better overall. He reported full days of having no pain or feelings of tension in his pelvis. Ben’s pelvic floor motor control had improved; he was able to perform a good pelvic floor drop/relaxation while diaphragmatic breathing independently (without any cues). I noted a continuing decrease in the urogenital hyperactivity as well. Due to Ben’s improvements in his pain and symptoms, I decided to decrease the frequency of visits from one time per week, to one time every two weeks.

 

Two weeks later, at his tenth visit, Ben reported that he had been consistent with his home exercise program and was able to incorporate more physical activities and exercising without pain. Because he noted no restrictions or pain with exercise, sitting, or sexual activity, I discharged him from pelvic floor physical therapy. Ben was instructed to continue to be consistent with his home exercise program for the next four to six weeks, and then he could decrease the frequency as needed.

 

“Two months out of therapy, my pain has subsided dramatically, and most important I am back to working out and on the road to achieving my fitness goals – which hasn’t been possible in years! I highly recommend PHRC!”

 

With the correct combinations of treatments and interventions, Ben’s pain and symptoms resolved relatively quickly (three months) given the amount of time he had been suffering (six years). A major contributing factor to Ben’s success with pelvic floor physical therapy was his willingness to incorporate changes into his daily life, in order to facilitate and maintain the changes made during the therapy sessions. Ben was able to change his life-long “clenching” tendencies with hard work and perseverance through daily relaxation, breathing techniques and bringing awareness to what his pelvic floor muscles were doing throughout the day. Change in chronic pain is possible, with the right guidance and mindset!
If you’d like to learn more about how pelvic floor physical therapy can help with male pelvic pain, click here.

 

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Are you unable to come see us in person? We offer virtual physical therapy appointments too!

Due to COVID-19, we understand people may prefer to utilize our services from their homes. We also understand that many people do not have access to pelvic floor physical therapy and we are here to help! The Pelvic Health and Rehabilitation Center is a multi-city company of highly trained and specialized pelvic floor physical therapists committed to helping people optimize their pelvic health and eliminate pelvic pain and dysfunction. We are here for you and ready to help, whether it is in-person or online. 

Virtual sessions are available with PHRC pelvic floor physical therapists via our video platform, Zoom, or via phone. The cost for this service is $75.00 per 30 minutes. 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

PHRC is also offering individualized movement sessions, hosted by Karah Charette, DPT. Karah is a pelvic floor physical therapist at the Berkeley and San Francisco locations. She is certified in classical mat and reformer Pilates, as well as a registered 200 hour Ashtanga Vinyasa yoga teacher. There are 30 min and 60 min sessions options where you can: (1) Consult on what type of Pilates or yoga class would be appropriate to participate in (2) Review ways to modify poses to fit your individual needs and (3) Create a synthesis of your home exercise program into a movement flow. To schedule a 1-on-1 appointment call us at (510) 922-9836

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.

Comments

  1. I have had pelvic pain since immediately after a TURP. On 8/13/15. I had two stricture operations (Sept & Nov.) Zi had about 60 PT sessions between 12/2016 and 12/2017. The Person giving me PT specialized in pelvic PT. In April and May I had three shots by a Dr specializing in pelvic pain. I also was treated for bacteria Prostititus. I take Gabapentin for nearly a year but still have pain. Pain Dr recommended a Ganglion Impar block. My Urologist had me try Amatryptoline for pain but had to stop as it affected my vision. Pain is largely under testicles by leg and on left side of penis and it burns a bit after I pee. Sometimes I have pain in my left testicle as well. I think I my pain is a bit less than last year as if I sit in a foam cushion I can sit for @90 minutes without creating lots of pain. I cannot sit on soft chars and watch TV or do email laying on the floor with my legs straight. (If I bend my legs laying on the floor I get level 4 pain. I am 71 and otherwise healthy. I wish you were somewhere near upper Westchester, NY.

    1. Hi James,

      We recommend Beyond Basic Physical Therapy in New York City.

      Regards,
      Admin

  2. Is the cat and the cow similar to the cat and camel? What do you mean by low kneeling? Always great to review and think about individual cases and treatment that was effective. I see a lot of men and utilize a very similar approach. Thanks for posting!

    1. Author Shannon Pacella says:

      Yes, the cat/cow exercise is similar to the cat/camel with the focus on pelvic floor relaxation. Starting on hands and knees, while inhaling: gently raising the head up, arching the back, and anteriorly tilting the pelvis. Then with the exhale: gently drop the head down, round the back, and posteriorly tilt the pelvis. The low kneeling position is a great position to practice pelvic floor drops/relaxations. Have the patient kneel on the ground (can place a pillow underneath knees for comfort) have them spread their knees to shoulder width apart, with feet together (just doing this would get them in the high kneeling position I use). To get into the low kneeling, have them sit back onto their heels. From there you can have them perform diaphragmatic breathing while focusing on pelvic floor relaxation. Thank you for reading the blog and I hope this helps you get a better idea of the various positions.

  3. Where can I find a PT in my area who understands this issue and will treat pelvic issues males?

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