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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