By Stephanie Prendergast, MPT and Urology Expert Joshua Gonzalez, MD
Most men who develop the symptoms of Chronic Pelvic Pain Syndrome (CPPS) are given unnecessary courses of antibiotics, at least once. How do we know they were unnecessary? Most of our patients have never been properly tested for a prostate infection. Men with CPPS account for up to 97% of visits to urology offices and these men do NOT have infections, they have pelvic floor dysfunction. This has been published over and over, yet here in 2021 a disappointingly low number of general urologists and primary care physicians understand what CPPS actually is. It is therefore not unexpected that they do not know how to perform a very brief digital pelvic floor exam to identify painful muscles. This blog may surprise people, most people do not realize how cumbersome it is to accurately test for prostate infections. Many men reading this likely thought they were tested and they were not. Antibiotic use and overuse comes with consequences, including gut dysbiosis, muscle tearing and sometimes irreversible peripheral neuropathies. We see this daily and it needs to stop.
I sat down with our trusted urology colleague, Dr. Joshua Gonzalez, to help set the record straight. Here are my questions and his answers.
Q: PSA: what it means and does not mean, what does it tell us?
A: PSA stands for prostate specific antigen. It is a protein produced by the prostate gland. It is a test commonly used for the screening of prostate cancer. It is typically combined with a digital rectal examination of the prostate to assess someone’s risk of prostate cancer. An abnormally high PSA can indicate underlying prostate cancer and other non-cancerous conditions such as benign prostatic hyperplasia (BPH, or enlarged prostate) or prostatitis.
Can a high PSA signify a prostate infection? What is considered normal range?
Yes, elevated PSA can signify a prostate infection. Generally, PSA < 4 is considered normal. But what qualifies as a normal PSA depends on the person’s age and history. PSA trends are more helpful than looking at one specific value.
Take Home Message: A PSA test alone should NOT be used to diagnose a prostate infection. It may have useful information for a doctor when combined with other tests, patient history and age, and clinical examination.
Q: What can a urine sample tell us?
A: A urine sample can be analyzed for bacteria, yeast, red and white blood cells, and additional markers to determine whether an infection may be present.
Can a urine sample tell us if there is a bladder infection and/or prostate infection?
Urine samples can be helpful in determining whether an infection is present. Many clinicians often assume infection simply by checking an in-office urinalysis. These are not always accurate, so typically we recommend checking a formal urine culture, which will indicate if bacteria or yeast are present (along with quantity and antibiotic susceptibility).
Take Home Message: A urine test alone is not a reliable way to identify a true prostate infection. We are heading towards the correct way to figure out if this is a problem.
Q: What can a blood test tell us?
A: Blood may be collected if an acute or serious infection is suspected. Generally, an elevated white blood cell count may indicate infection. Blood can also be cultured if the infection is thought to have spread there.
Take Home Message: A blood test cannot determine if a prostate infection is present.
Q: What is the difference between a prostate infection and a UTI and a bladder infection?
A: I explain a prostate infection as a more serious UTI. Prostate infections are caused by the same bacteria that cause most urinary tract infections (including bladder infections). The bacteria typically ascend via the ejaculatory ducts into the prostate where they can replicate and cause a more serious infection. Prostate infections often require a longer course of antibiotics than traditional UTI.
Take Home Message: UTIs and prostate infections are not the same and they need to be treated differently.
Q: Finally, we need to talk about the 4-glass test. Most urologists empirically treat young men with CPPS symptoms with antibiotics without doing this test because basically, it’s a pain in the ass. Please explain what it is and how it is done.
A: The 4-glass test involves collection and analysis of fluid obtained pre- and post- prostate massage. The first sample is the initial 10ml of urine voided. The second sample is a midstream urine collection. After the second sample is collected a vigorous massage of the prostate is performed. The third sample is a collection of expressed prostatic excretions. The fourth sample is the first 10ml of urine voided after prostatic massage. All 4 collections are then cultured and help distinguish between acute and chronic bacterial prostatitis. If all cultures are negative, the diagnosis is more consistent with either inflammatory or non-inflammatory chronic pelvic pain syndrome (CPPS). Most urologists treat men with CPPS symptoms with antibiotics empirically because performing this test can be time-consuming and uncomfortable for the patient.
Take Home Message: Most men have definitely NOT been through this test and it is truly the only accurate way to see if there is a true prostate infection.
In Conclusion…
The majority of men with CPPS symptoms do NOT have a prostate infection, but they do have pelvic floor floor dysfunction with or without prostate inflammation. Men can develop prostate infections and we need to accurately test people to know what the proper course of treatment is. Men presenting with the signs and symptoms of CPPS should see a pelvic floor physical therapist. If the doctor is unwilling to do a 4-glass test to help you figure out if there is an infection or not we likely know a doctor who will. Say No to Cipro and avoid the consequences of unneeded antibiotics.
Dr. Gonzalez can be found here on his website and on TikTok!
For more information check out our YouTube Channel Resources:
Inguinal Hernias and Male Pelvic Pain
Male Pelvic Pain – What is it? Why Do Men Get it? And What Can They Do About it?
Penile Pain – Why it Happens and How to Fix it
Erectile Dysfunction and Your Pelvic Floor
An Explanation of Hard Flaccid
What to Expect at a Pelvic Floor Physical Therapy Appointment
An Introduction to Your Pelvic Floor
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Are you unable to come see us in person? We offer virtual physical therapy appointments too!
Due to COVID-19, we understand people may prefer to utilize our services from their homes. We also understand that many people do not have access to pelvic floor physical therapy and we are here to help! The Pelvic Health and Rehabilitation Center is a multi-city company of highly trained and specialized pelvic floor physical therapists committed to helping people optimize their pelvic health and eliminate pelvic pain and dysfunction. We are here for you and ready to help, whether it is in-person or online.
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.
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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.