Success Story: How André Recovered from Groin Pain

In Male Pelvic Pain by Emily Tran1 Comment

By Jennifer Guan, PT, DPT  PHRC  Los Gatos

 

André Fenri* is a 28 year old male who was referred to PHRC by his urologist. André reports that three months prior to his initial evaluation, he developed pressure and pain on the left side in his groin region. He reports that he had gone skateboarding prior and his MD suspected a hernia or a pulled muscle. However, test results were inconclusive. He reports that the pain had become so significant that he was bedridden. He was using some groin compression wraps to help the pain but stopped using them as he was worried they were going to make his muscles weaker. He tried to work on some stretching exercises, but worries that he may have overdone it. He reports overall the symptoms are worse at the end of the day. He reports that he feels that walking and movement cause him more strain. It is hard to sleep on his left side as well. After sexual intercourse he feels pain in the left side, but the pain is in his groin and he denies pain in his penis, scrotum, or testicles. 

 

He also reports that for a few weeks, he has had a sensation of urine dribbling which prompted him to seek an appointment with a urologist. He reports that although it was only drops, he was fearful that it would be a full leakage. A urine sample was obtained, and was positive for a UTI. He also received a CT scan to rule out kidney stones. He was prescribed some antibiotics but reports continued groin pain and dribbling. He was provided some gentle stretching exercises by his urologist as well as a referral for pelvic floor physical therapy. When he had his active UTI, he reported using the restroom about three times every two hours. Currently he reports that his urination symptoms have gone back to more normal, other than the dribbling. He does not urinate at night and goes at a more normal interval. He reports that his urine stream is a bit slower when his bladder is full vs prior to these symptoms starting. He was also recommended to perform double voiding to avoid dribbling.

 

 

Physical Exam:

 

Current objective findings:

 

  • External Exam:
    • Moderate connective tissue dysfunction in his bony pelvis and inner thighs. Severe connective tissue dysfunction in his abdomen.
    • Sensitivity upon palpation of the suprapubic region on the left side.
    • Myofascial trigger points in the psoas and iliacus.
    • Decreased abdominal deep core (Transverse Abdomnius muscle) and hip stability and strength
  • Internal Exam:
    • Severe hypertonicity (tightness) throughout the urogenital diaphragm (bulbospongiosus, ischiocavernosus, and transverse perineal muscles) and moderate hypertonicity in the obturator internus, coccygeus and levator ani muscles.
    • Poor muscle-length tension relationship of the pelvic floor muscles, with poor ability to lengthen and relax the pelvic floor muscles voluntarily

 

 

Assessment:

Overuse, injury, and stress can lead muscles into tightness. Additionally, when an injury occurs, muscles can also tighten as a protective mechanism. Even if the injury is to one specific muscle, the muscles in the surrounding region will be impacted as they will react to the injury. In Andre’s case, it is likely that the injury caused by skateboarding was to his hip flexor muscle group. Inconclusive imaging does not always rule out injury. Following the injury, the connective tissue and muscles in the surrounding abdomen, pelvis, and thigh regions were also affected.

 

The tight muscles then in turn lead to his reports of dribbling urine. Tight muscles in the pelvic floor can lead to urinary dribbling because when the muscles are so tight, the muscle-length tension relationship changes. This leads to a decreased ability for the muscle to activate as the available length of the muscle has changed. Imagine trying to do a bicep curl, when your elbow is already bent- you are not going to be able to do a full curl. I had a very difficult time inserting my finger during the rectal exam. For Andre, this was exacerbated by his UTI which caused him more pain and urinary function disruptions.

 

Fortunately in Andre’s case because he had the additional symptom of dribbling, he was working with a urologist and ended up at PHRC to have his pelvic floor evaluated. It is all too common for us to meet patients who report groin pain, and after months or even years of orthopedic treatments, do not feel 100% symptom resolution because there was an important piece of the puzzle missing. The pelvic floor has a very important role to play in pelvic stability as well as spine, hip, and pelvic function. Furthermore, the obturator internus muscle, while a part of the hip, originates quite deep in the pelvis and the majority of the muscle cannot be accessed externally.

 

Plan:

The plan for André’s treatment sessions include connective tissue manipulation, myofascial release, and myofascial trigger point release to address the dysfunction in the muscles and fascia. His plan also included neuromuscular reeducation, therapeutic exercise and activity, and home exercise program prescription and management to improve his ability to voluntarily lengthen the pelvic floor muscles. After he masters the ability to lengthen his muscles and has improved neuromotor control, he will receive hip and core strengthening and stabilization exercises. These exercises will help him to return to some more high impact activities and prevent future injury to the region. 

 

Goals:

Andre shared with me that his goal is that he is “hoping to get an understanding of what is wrong with my body and get closer to getting back to normal life. Walking/hiking without having to lay down to recover, comfortably at my desk,  and sexual intercourse without feeling strain.”

 

My long term goals for Andre were:

  • Patient will normalize pelvic floor tissue tension and connective tissue mobility in order to support proper pelvic floor function in 12 weeks.
  • Patient will report 0% pain in his groin for at least one hour during the day in 12 weeks. 
  • Patient will report no urinary leaking with standing, walking, or transitional activities in 12 weeks. 

 

 

The Recovery:

 

Andre’s progression has been slow and steady. He has been conscious about not rushing himself. We began with addressing the pain and providing him with techniques and manual treatments targeted at pain management. Pelvic pain can be challenging as certain triggering activities such as walking, standing, and sitting cannot be 100% avoided. This makes it all the more important for patients to remember to not over-do it and to introduce activity modifications.  Andre needed to bring all of his tight muscles into a better resting position and to learn how to voluntarily relax his pelvic floor muscles. After this was achieved, we began strengthening his core and hips to provide him with stability and strength in this new and improved muscular resting state. Andre started with weekly appointments, but after seven appointments, he was showing improvements in his tissue and muscles and he was subsequently able to be seen every two weeks, and then every three weeks. 

 

Two and a half months into his treatments, he was able to attend a music festival which included a significant amount of walking and standing. He reported that he walked on average 20,000 steps per day. He reports that he knows he still needs to be mindful of his groin and not overdo it, but was glad to be able to spend time with his family and friends and not decline social invitations anymore like he had been earlier in the year. 

 

At this time, Andre is able to complete hikes with elevation and has been jogging as well. Last weekend, he went on three hikes and also went kayaking. His dribbling symptoms are not affecting him anymore and he does not need to consciously think about it as he knows he is not going to have an accident. 

 

Andre says “If I could share thoughts to myself in the past or to someone just starting their journey, I’d say: listen to your body. Don’t forget to do your stretches and exercises.  Most of all, be patient and stay positive. Healing takes time”.

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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

Melissa Patrick is a certified yoga instructor and meditation teacher and is also available virtually to help, for more information please visit our therapeutic yoga page

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