By Amanda Stuart, DPT, PHRC Los Angeles
Did you know that September is Chronic Pelvic Pain Awareness Month? Whether you have pelvic pain or need to treat pelvic pain, this blog will be following the success of one our patients and their time in pelvic floor physical therapy.
Fact:
Research shows that up to 16% of men suffer from Chronic Pelvic Pain Syndrome (CPPS) at some point in their life. Pelvic floor physical therapy can be an integral part of treating pelvic pain.
Background
Tony is a 45 year old male presenting to pelvic floor physical therapy for pelvic pain and urinary frequency. He reports symptom onset began about one year ago when he made a drastic change to his diet and started working out excessively which consisted of heavy weight training and Peloton riding. For about four to five months, Tony had been very consistent with this regimen of approximately one hour of strength training and ending with 45 minutes on the Peloton six to seven days per week. Around this same time period, Tony began sensing a dull ache in the perineum and urinating more frequently. Soon, the ache in the perineum began to radiate to the right inner groin and testicle.
Tony saw a urologist who diagnosed him with epididymitis and prescribed him 10 days of antibiotics which didn’t help at all.
He sought a second opinion with another urologist who prescribed him Naproxen and performed a manual exam on his prostate with nothing to note. Tony had had various imaging tests done in the abdomen, pelvic region and scrotum – none of which came back with any significant findings. He additionally reports that the right inner groin pain has since subsided and now he just feels a dull ache in the perineum and right buttock. The pain seems to worsen when sitting.
Tony has since discontinued riding the Peloton but continues to weight train at a lower intensity, surf and just started playing pickle-ball.
Physical Exam
External Exam:
- Moderate connective tissue dysfunction in his bony pelvis and inner thighs.
- Severe connective tissue dysfunction in his abdomen.
- Tenderness upon palpation of the suprapubic region on the left side.
- Myofascial trigger points in the psoas and iliacus.
- Decreased deep core (Transverse Abdominis) strength.
- Decreased gluteus medius and maximus strength (~⅗)
Internal Exam:
- Severe myalgia throughout the deeper pelvic floor, to include both the obturator internus and levator ani muscles.
- Moderate muscular restrictions throughout the urogenital diaphragm to include the bulbospongiosus, ischiocavernosus, and transverse perineal muscles.
- Poor muscle-length tension relationship meaning that the range of motion within the pelvic floor was largely reduced with subsequent difficulty attempting to lengthen or relax the pelvic floor muscles voluntarily, indicating that the pelvic floor is stuck in a more contracted state.
- Indiscernible pelvic floor contraction upon testing (~0/5), which was likely due to the level of restriction present and reduced range of motion.
Assessment
Tony presents with Chronic Pelvic Pain Syndrome (CPPS) likely secondary to months of excessive cycling on the Peloton and heavy weight training using improper mechanics. When discussing Tony’s weight lifting, he admitted he often does not breathe fluidly and will hold his breath when lifting heavy weight. Breath holding is common in weight training and tends to increase abdominal pressure and place excessive strain on the pelvic floor, causing it to contract and tighten over time. Additionally, bicycle riding can cause myalgia within the pelvic floor because the muscles are being compressed for an extended period of time.
It is common that once the pelvic floor muscles become tight, connective tissue surrounding the pelvic girdle itself will become restricted too – which is likely what caused the referring pain down to the right inner thigh. Tight muscles and restricted connective tissue within the pelvic floor and surrounding pelvic girdle can cause pain within the pelvic floor and surrounding hip musculature in addition to urinary dysfunction. In Tony’s case, it was the urinary frequency that was impeding his daily activities. It is common for urinary frequency and urgency to occur following pelvic floor dysfunction as the pelvic floor muscles are stuck in a contracted state and tend to become more irritable to the bladder filling with urine.
Additionally, Tony had reported issues with incomplete bladder emptying. This is also a common symptom associated with pelvic floor muscle tightness because the pelvic floor muscles are supposed to relax around the bladder neck to allow for complete evacuation of urine. If the muscles are stuck in a contracted state, they will not allow all the urine to come out and an individual will end up feeling as though they did not completely empty after using the restroom.
The last piece to this puzzle was addressing hip and low back stability as Tony was a very active individual and though he chose to give up the Peloton riding, he wanted to continue with strength training, surfing and playing pickle-ball. Though it tends to be forgotten all too often, the Obturator Internus muscle is crucial to supporting the pelvic floor.
Strength in the gluteal muscles will offset tight hip rotators that make up the side wall of the pelvic floor. This same concept of utilizing correct gluteal firing patterns will also prevent the low back from being over active. Oftentimes, low back and pelvic floor can refer pain from one to the other and appropriate assessment between the core, hip and pelvic floor need to be addressed.
Goals
Tony’s Goals were split between six and 12 week intervals:
Short Term: six weeks
- Tony will demonstrate 50% reduction in PF ms myalgia and restriction.
- Tony will demonstrate 50% reduction in CTR surrounding the pelvic girdle.
- Tony will demonstrate the ability to lengthen the pelvic floor through diaphragmatic breathing.
- Tony will improve motor control from a poor to fair score.
Long Term: 12 weeks
- Tony will urinate no more than six to eight times in a 24 hour period.
- Tony will initiate and complete his urinary stream without difficulty.
- Tony will return to his preferred recreational activities without perineal or pelvic pain.
- Tony will demonstrate adherence to HEP & symptom management.
Plan
The plan for Tony’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 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 pelvic floor control, he will receive hip strengthening and core stabilization exercises.
The Recovery
Within the first four weeks..
Tony noticed a significant reduction in his urinary frequency and pain. He would go almost the entire week following our session with normal urination intervals and wouldn’t notice any internal pelvic pain. Tony did find that if he did not do his flexibility and stretching regimen at home a few times per week, the frequency would be more elevated so he was careful about adherence.
About six weeks in..
Tony experienced a bout of severe constipation when switching his diet resulting in hemorrhoids and an increase in urinary frequency and pelvic floor discomfort after that had mostly subsided. I explained to Tony that constipation places mechanical strain on the pelvic floor which can lead to pelvic floor pain and dysfunction. Stool in the rectum causes a reflexive pelvic floor contraction to help keep us continent, which in the short term is beneficial; however, in the case of constipation – the constant state of pelvic floor contraction causes the pelvic floor to become tight and place pressure on the bladder, urethra or prostate. In the case of Tony, since he already had pelvic floor tightness – the constipation only exacerbated his symptoms until he completely evacuated the stool. Once he incorporated the right amount of foods into his diet, the constipation went away and both the level of pain and urinary frequency continued to improve again.
About eight weeks in..
Tony started to prioritize playing pickle-ball of all his recreational activities. He began to notice low back pain that seemed to radiate to the upper glute and he wasn’t sure if this was being caused by the pelvic floor or the low back. After assessment of posture while playing pickle-ball, it was noted that Tony tended to lean forward at his spine for hours. He had also reported that sitting exacerbated this low back and gluteal pain which seemed to correlate more with a true low back issue rather than referral from the pelvic floor. We went over how to hip hinge rather than to bend from the low back while playing pickle-ball and worked on glute isolation exercises to diminish the need for the low back to become overactive.
Soon, the low back and gluteal pain went away. This also assisted in the pelvic floor being able to maintain a more relaxed state since it was no longer over compensating for weak hip stabilizing muscles. As Tony became busy with travel, he was seen less frequently but carried over his strength and flexibility routine at home. By around the fifth month Tony had reported back that he no longer had urinary frequency or pelvic floor pain and was able to engage in his preferred recreational activities, specifically pickle-ball. Occasionally, he would feel the low back if he did not utilize proper mechanics but was easily able to adjust and confident that as he continued to work on his strengthening this would entirely go away. Tony was pleased with his progress and ability to engage in what he loves doing again.
If you are experiencing chronic pelvic pain, you may consider physical therapy. Pelvic pain can be tricky to navigate if you do not know where to start. Help is out there! Get your pelvic pain treated today with pelvic floor physical therapy.
Frequently Asked Questions
Q: Where could I learn more about pelvic pain therapy? Do you have other resources to learn about pelvic pain, the pelvic muscles/pelvic organs?
A: Check out our service page about pelvic floor physical therapy. It will review a variety of symptoms of pelvic pain and why one might seek physical therapy for it. You can search key terms in the blog search bar to find specific topics. We also recommend checking out our Youtube page for more information!
Q: I think I need physical therapy, but I am nervous as I have never been before. Any recommendations? Please help me relieve pelvic pain!
A: If you would like to know what to expect, we have a blog about what a good pelvic floor physical therapy session should be like. We recommend checking it out so you know what to expect and can be more prepared before you enter the treatment room.
Q: I need my pelvic pain treated, but you are unfortunately too far away from me. Can you help me find a provider to manage my pelvic pain?
A: If you scroll to the bottom of this page, there a handful of directories that will help you find a provider in your area. The blog is also a resource list for chronic pelvic pain, so you may find a few more resources in there!
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