Success Story: Exploring the Clinical Presentation of CPPS

By Lauren Rogne, PT, DPT, PHRC San Francisco

The case of the mysterious pelvic pain – Exploring the clinical presentation of Chronic Pelvic Pain Syndrome (CPPS)

Background

Ben is a 35 year old with sudden onset of urinary tract-like infection symptoms, including urinary frequency, urgency, pain and burning. He visited his doctor, and his urinalysis came back negative for infection… but what could it be? About six months ago, Ben had transitioned from being a long distance runner to using a stationary bike at home more often for exercise. He also was sitting more for his job since COVID prevented him from going into the office as much. While working from home, he admits he is much more sedentary and there no longer is as much need to get up and go for a walk such as for a coffee break, or a walk with a coworker. Additionally, Ben reports he had COVID a few weeks prior to his symptoms beginning, and he was coughing quite a bit. Traveling also seems to aggravate symptoms. After discussing this more with his doctor, he was diagnosed with pelvic floor dysfunction, also known as chronic pelvic pain syndrome and was referred to pelvic floor physical therapy. His doctor also prescribed him an alpha blocker for the pain, which Ben reports was helpful. Unfortunately, this medication has resulted in a few fainting spells and difficulty orgasming. Ben’s goals for physical therapy are as follows:

Treat pelvic floor dysfunction and return to a painless, normal function of my pelvic floor muscles
Return to normal sexual activity
Get off alpha blockers ASAP
Learn how to improve my posture, exercise routine, and behaviors to prevent symptoms like this in the future

Objective findings

Moderate connective tissue restrictions in the bony pelvis
Moderate increased tightness in urogenital triangle muscles (ischiocavernosus, bulbospongiosus, deep transverse perineal muscle)
Severe increased tightness at superficial transverse perineal muscle
Moderate increased tightness at levator ani muscles
Severe increased tightness of obturator internus muscles
Limited ability to “drop” and lengthen pelvic floor muscles
Poor ability to correctly demonstrate diaphragmatic breathing, primarily demonstrating chest breathing
Moderate to severe myalgia at urogenital triangle
Mild to moderate myalgia at levator ani muscles

Assessment, Plan, and Goals

Based on these findings, Ben would benefit greatly from pelvic floor PT to reduce myalgia and increased tightness of pelvic floor muscles, as well as improve connective tissue restrictions of his bony pelvis. He also would benefit from improving his motor control with diaphragmatic breathing and ability to lengthen his pelvic floor. His physical therapy plan of care consisted of patient education, manual therapy, neuromuscular re-education, and therapeutic exercise. He had a total of 17 physical therapy visits. We started with a frequency of once every two weeks, and then after six treatment sessions reduced frequency to once per month.

My goals for Ben were as follows:

Pt will be independent with HEP in two weeks for better self management of symptoms.
In four weeks, pt will demonstrate 10 diaphragmatic breaths without compensation to improve relaxation of pelvic floor.
In six weeks, pt will present with 50% improvement in ROM with PF drops to improve relaxation of pelvic floor.
In eight weeks, pt will report being able to sleep on his side without pain.
In 10 weeks, pt will present with mild to no hypertonicity or myalgia of pelvic floor muscles to reduce pain with daily activities.
In 10 weeks, pt will be able to safely discontinue the alpha blocker medication without increase in pelvic floor symptoms to meet his goals of not relying on this medication for pelvic floor pain management.
In 16 weeks, pt will be able to tolerate sexual activity without provocation of symptoms.

Follow-up Sessions

Manual therapy

First, we needed to address the hypertonicity and myalgia in Ben’s pelvic floor muscles. He responded well to manual techniques including internal stretching of urogenital triangle, levator ani, and obturator internus muscles bilaterally, and we saw consistent improvements visit to visit. We also addressed his connective tissue restrictions in his abdomen, bony pelvis, and inner thighs using a technique called skin rolling. It was important to improve the mobility of these tissues to ensure adequate blood flow not only to these tissues, but also to the surrounding muscles and nerves.

Neuromuscular Re-education

Addressing deficits in motor control of pelvic floor lengthening and proper diaphragmatic breathing was crucial to improving the tightness and pain found in Ben’s pelvic floor muscles. Re-learning to breathe properly sounds like something we would never have to do, but it’s so common! We see this a lot in our patients. We have several accessory breathing muscles like our scalenes, sternocleidomastoid, and trapezius muscles, which all help lift up our chest when we’re breathing heavy. We do not need to use these muscles when we are breathing quietly throughout the day, but many of us get in the habit of using these all the time. The diaphragm is our biggest breathing muscle, so we should use it! When used properly, it works like a piston with the pelvic floor. As we inhale and our diaphragm descends, our pelvic floors descend and lengthen. Diaphragmatic breathing is a great way to bring movement and length to the pelvic floor muscles.

Patient education

Ben was waking at night with pelvic pain, solely when sleeping on his side. A simple tip of putting a pillow between his knees when laying on his side seemed to do the trick. We also discussed healthy sitting habits, best ergonomics when sitting, and the importance of getting up once every hour. We talked about the importance of proper breathing and the relationship of the diaphragm to the pelvic floor. This really helped Ben understand why we did so much breathing during our sessions and as part of his home program.

Therapeutic Exercise

We initially started with an emphasis in breathing and stretching to help improve the muscle pain and tightness found in the pelvic floor. I also had Ben use foam rolling as a way to address the connective tissue restrictions in his legs and bony pelvis. He responded great to these. Once symptoms had improved about 75%, we began progressing to more global strengthening to provide support for the pelvic floor muscles including gluteus muscles and abdominal muscles. This also would help us meet Ben’s goals of learning how to improve his exercise routine.

Outcomes

-normal tone of pelvic floor with mild increased tightness of urogenital triangle

-mild to no connective tissue restrictions of bony pelvis

-good execution of diaphragmatic breathing

-good pelvic floor drop during diaphragmatic breathing

-no longer taking alpha blockers

-sexual function returned to normal and no pain

-able to run three to four miles a few days per week without symptom aggravation

Discussion and Conclusion

There are many reasons why Ben could have developed his pelvic floor symptoms initially. We usually see the “perfect storm” with an onset of pelvic floor pain. Ben recently took up cycling, he was sitting more at work, and he was coughing a lot when he had COVID. Cycling can put a lot of compression on the pelvic floor and the pudendal nerve, the main nerve that controls the pelvic floor muscles. Sitting more for work or traveling can put more strain and compression on the pelvic floor as well; and coughing certainly puts more strain through the pelvic floor. All of these things likely had a compounding effect on one another, resulting in pelvic floor pain for Ben.

Ben had made significant progress after just six follow up sessions, but during re-examination, we continued to find increased tightness of his pelvic floor muscles. That is why we decided to continue with once monthly sessions to continue addressing pelvic floor impairments, but encourage more independence for Ben. Throughout this time, Ben experienced a couple of flare-ups. One was due to traveling to Europe, which involved a long flight and lots of sitting. Another involved more stress at work and prolonged sitting. Having monthly visits allowed us to work through these flare ups and give him more tools to self manage his symptoms in these times, as well as address tension that developed in the muscles and keep his pelvic floor healthy. We also were able to progress him as he was able to return to more difficult exercises like running three to four miles a few days per week!

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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.