Male Pelvic Pain Explained: Steve’s Success Story

In Male Pelvic Pain by Elizabeth Akincilar8 Comments

By Elizabeth Akincilar-Rummer
I am happy to say that in March we celebrated our one year anniversary in our Boston area office!! It has been a crazy year, but I’ve truly enjoyed getting to know new colleagues and being another resource for the many people suffering from pelvic pain in New England.  

During the past year there has been one glaring difference between my practice in San Francisco and here in the Boston area. Men! I have a larger percentage of male patients in this office than I ever had in San Francisco. So, I thought it would only be fitting to share a recent success story about one of my male patients, Steve (his name has been changed for anonymity). His journey with pelvic pain is unfortunately not an uncommon one, but fortunately has a happy ending!

 
“I suffered with great pain and restricted activities for more than five years, and no doctor ever mentioned the possibility of physical therapy. I found out about it online. What the doctors and specialists said was incurable was entirely curable! Before consenting to surgeries (I had two) and all sorts of pills, you really owe it to yourself check out physical therapy.”    Steve, age 40

Steve is a 40 year old man that drove 1 ½ hours in desperation of finding some help for his 6 year history of pelvic pain. Here’s his story: In 2007 he noticed blood when he ejaculated. He was prescribed antibiotics and his symptoms resolved. In 2009 the same thing happened, noticeable blood when he ejaculated, but in addition, this time he also experienced pelvic pain. Again, he was prescribed antibiotics and the blood in his ejaculate resolved, but the the pain did not. Since 2009, his pain has been consistently sharp pain in his right lower abdomen, and radiating pain to the right side of his penis and perineum. He noted that any friction to the right side of his lower abdomen (i.e. when wearing a belt) would increase his pain. He reported that his pain was the most severe after ejaculating, lasting up to 36 hours. He had basically given up on even trying to ejaculate because the resulting pain was so intense and debilitating. He also noted that he was unable to walk fast because the friction caused by swinging his arms would flare up his pain.
During these 6 years he attempted several treatment interventions. He saw several urologists and pain management specialists. At no point did any medical provider recommend physical therapy.  In 2012 he was diagnosed with a right inguinal hernia which was surgically corrected. He reported one month of relief and then the pain returned as before. In 2013 he underwent a partial orchiectomy during which his right spermatic cord and right testicle were surgically removed. Again, he reported one month of relief only. Later in 2013 he had a series of 3 right ilioinguinal nerve blocks. He reported the first nerve block gave him approximately 20% pain relief, but the latter two had no effect. Virtually coming to the conclusion that this was just something he was going to have to live with, he found PHRC during extensive online research.

When I evaluated him in early 2015 he reported the same pain symptoms: sharp right lower abdominal pain and hypersensitivity, radiating sharp pain to his perineum and right side of his penis, inability to ejaculate without 1-2 days of severe pain, and an inability to walk fast without causing an increase in pain. He reported urinary frequency only if his pain was very severe and denied any bowel dysfunction. He was currently taking 3600 mg/day of gabapentin (neurontin) which he thought was helpful. He was able to work from home as a musician and composer.

During his initial evaluation I noted the following:

    • moderate connective tissue dysfunction in his abdomen, lower abdomen and along his bony pelvis on the right side
    • Hypertonus (tightness) in his right psoas, adductors, and abdominal musculature
    • inguinal hernia scar restriction
    • right bulbospongiosus, ischiocavernosus, and transverse perineum hypertonus

 

My assessment was that the infection in 2009 caused changes in the surrounding somatic tissues via the visceral-somatic reflex. In other words, the infection initiated dysfunction in the muscles, nerves and connective tissue in the pelvis.  The initial infection in 2007 likely caused some of these same changes, but at that time the changes in the muscles, tissue, and nerves weren’t significant enough to cause pain. When the second infection occurred, the dysfunctional changes were then enough to cause symptoms of pain. Another possible factor was that the inguinal hernia that was later diagnosed was also contributing by irritating the ilioinguinal nerve, which would be consistent with his symptoms of lower abdominal and penile pain. The partial relief of pain with the ilioinguinal nerve block also supports this theory.  

 

Steve’s goals were the following:

  1. No pain during or after sexual activity
  2. Able to walk at desired speed
  3. Stop taking gabapentin

I recommended treatment 1x/week for 8 visits. My treatment plan included scar mobilization, connective tissue manipulation, myofascial release, myofascial trigger point release, pain physiology education, and home exercise program development. During his initial evaluation, we began discussing pain physiology and the impact chronic pain can have on one’s nervous system. I gave him the book, Explain Pain, to read prior to his next appointment.

At his first follow-up visit he reported that he thought many of the concepts in Explain Pain applied to him and his history of chronic pelvic pain. We continued our discussion about these concepts and how he could apply them in his life. I continued the manual therapy on the myofascial impairments, including the inguinal scar, the abdominal and adductor trigger points, connective tissue restrictions and the pelvic floor hypertonus.

At his second visit, he reported that clothes were now less irritating and he had less pain with walking. He was now able to walk slightly faster and swing his arms more without aggravating his pain. At this point he also started to decrease his gabapentin. Upon exam, I noted that the scar mobility was improved, he had less skin hypersensitivity, and the connective tissue mobility was improved. He continued to have urogenital diaphragm hypertonus.

 

At his third visit, he reported that he was now able to wear a belt without pain. During the last week he ejaculated one time and had minimal discomfort, but then tried to ejaculate a second time that week and had significant pain afterward. He also decreased his gabapentin again. I noted the connective tissue restrictions continued to decrease and the urogenital diaphragm muscles had less hypertonus. I taught him self myofascial release techniques to utilize after ejaculation.
At his fourth visit, he reported that he was able to walk even faster without pain and was able to ejaculate without any pain or limitations in activity the following day. I noted minimal connective tissue restrictions and minimal scar restrictions. The primary remaining impairments were hypertonus in his right ischiocavernosus, bulbospongiosus, proximal adductors, and right lower abdominal muscles.

By his sixth visit, he reported he had no limitations in walking and was able to have sex in the evening multiple times during the week without pain or any limitations the following day. He had also completely stopped taking gabapentin by this point. I noted minimal hypertonus in his ischiocavernosus, bulbospongiosus, and lower abdominals. I decreased the frequency of treatments to 1x/2 weeks.

 

By his eighth visit, he reported that he felt 90% better. I noted minimal myofascial impairments. At this point I recommended we decrease the frequency of treatment to 1x/month.

 

After 2 additional visits, once per month, he reported no restrictions or pain with exercise/walking or sexual activity. After a total of 11 visits over 5 months, I discharged him with his home exercise program of self myofascial release as needed.   

As you can see, with the correct treatment interventions, Steve’s symptoms resolved relatively quickly given the amount of time he had been suffering. He underwent at least one major surgical procedure that was completely unnecessary and possibly two. This is an excellent example of the importance to educate the medical community about pelvic pain and the role physical therapy can play in recovery. Had his medical providers been better educated about treatment options for pelvic pain, Steve’s pain could have been resolved years earlier. Those of us who treat pelvic pain need to take on the challenge of educating our colleagues to prevent situations like Steve’s from happening.

 

All my best,

Elizabeth Akincilar-Rummer, MSPT

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. Great story… gives us all hope… it makes so much sense and it amazes me how urologist want nothing to do with really understanding it and then handing a patient who has this issue off to folks like you who can help…

  2. Great information. Your article should be required reading by urologists!Thanks for sharing.
    Jane Silverstein
    Soul Source Therapeutic Devices

  3. xoxo loved the care you gave me also, being one of the “MEN”………………Happy Anniversary.

  4. Hi Elizabeth, what a great story! I am wondering if you can share any specifics about the myofascial techniques you gave Steve for home after ejaculation. This is an area I have found to be a challenge with my own patients. I learned connective tissue manipulation with you and Stephanie many years ago and still use it every day.
    Thanks and Happy Anniversary!
    Catherine Veeser,PT

    1. Author Liz Akincilar says:

      Hi Catherine,

      I’m glad you have found that connective tissue manipulation has been helpful! I taught Steve how to do a self bulbospongiosus release technique by tacking the tissue at the base of the penis with one hand and then stretching the tissue towards the anus, medial to the pubic rami, with the other hand. It’s hard to explain in writing, but fairly easy to show a patient during a session. Hope that helps!!

  5. Hi Elizabeth.
    What a great success story and a happy ending for steve.
    I am Bruce, 20 and 3 years ago I started doing kegels because I read about it online and unkown of its side affects I kept doing it. I had no problem before doing kegels I was very healthy. I kept doing them for a week when one night kegeled very hard and the next morning I had urinary frequency, incomplete voiding and shrinkage. I have no pain but urinary frequency and poor urine flow. I believe my bulbospongiosus is at spasm because it involuntary kegels and I have developed ED + post mictruition dribble. There is also discomfort feeling sometimes behind pubic bone.
    Can you please give me some techniques to get rid of the spasm. PFD has completely ruined my social and academic life.

    1. Author Elizabeth Akincilar says:

      Hi Bruce,

      I’m sorry you’re experiencing these symptoms. It does sound like you have pelvic floor muscle hypertonus or hyperactivity. You should be evaluated by a pelvic floor physical therapist to be certain. He/She will be able to evaluate and treat the likely muscle impairments and give you recommendations on how to reduce the hyperactivity yourself. It’s very difficult to explain what to do in writing. However, I can recommend trying to practice diaphragmatic breathing, which is essentially belly breathing. When you breathe, put your hands on your belly and make your hands rise and fall while you breathe. I hope this helps!

  6. Hi,
    I have pain in the perenium region and only at the tip of penis(right side area on the glans). I have atleast 5 sessions of PT. She did internal relxation techniques on the pelvic floor. It helped a little but the pain at the tip of penis is persistent. Its non existent when i wake up and as the day progresses it worsens. I think the mild trauma at the tip of penis may have caused it. I used a condom after a long time and was not able to get full erection. That’s when i think i had the trauma at the tip. There is small swelling like area on the right side of the glans( penis top) and the pain continues on the right side of scrotum into the perineum.
    I am doing all the stretching, but some days are good and when i get anxious it flares up.. and i am back to having this pain.
    It has been going along for three months. The tip of penis is very sensitive and slight contact causes the flare up. Any advice. I have tried glabapentin/Amtirpetin/bloco compounds. I am hesitant to take gabapentin orally.

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