By Morgan Conner, DPT
Clyde’s symptoms started about one year before he first came to physical therapy. They started suddenly after he forced an orgasm by squeezing his pelvic floor while enjoying morning sex. Later that day he started feeling pins and needles in his prostate, pain at the tip of the penis, and burning with urination. When the pain did not subside, he initially went to his primary care provider who tested his PSA levels and upon finding a slight elevation, prescribed him a 14-day course of antibiotics. However, despite a normal result after retesting his PSA a month later, his symptoms were still present.
|The Prostate-specific antigen (PSA) is a protein produced in the prostate by both cancerous and noncancerous tissues. Elevated levels can sometimes be an indication of prostate cancer, although they are usually used in conjunction with other tests such as digital rectal exam and/or biopsy to make a diagnosis of prostate cancer. They can also be elevated in people with an enlarged prostate or in the presence of inflammation or infection of the prostate. However, urine, blood, or prostate excretion tests are a better indicator of a true prostate infection than elevated PSA. You can learn more information about PSA testing and diagnostic tests for prostatitis.|
Over the next few months his pain slowly subsided. Unfortunately, about six months later it started again while he was on vacation in overseas and then a third time again when he went on a cross-country flight shortly after having sex. This last flare-up happened about two months before he started physical therapy. In that time, his pain got to the point where he was avoiding any sexual activity, solo or partnered. By this time he was having perineal and penile pain during and after ejaculation. During this time he also started having urinary symptoms as well as pain. These included pain with voiding, hesitation with initiation of stream, post-void increase in pain and urgency. Luckily his bowel function was fairly normal, though he mentioned that in the past he has had occasional instances of bloating, abdominal discomfort after eating, and constipation that sometimes flare his pain symptoms.
Turning to internet research, Clyde found the Pelvic Health and Rehabilitation website and our page on sexual dysfunction and reached out to schedule an appointment. As we progressed through his physical exam, we began to see connections between his symptoms and impairments (physical therapy terminology for abnormal physical findings) and I was looking for evidence to support my preliminary hypothesis that dysfunction in his pelvic floor musculature and surrounding tissues was irritating the pudendal nerve. In Clyde’s case, his findings did match what I had imagined I would find and supported my hypothesis. He had connective tissue restrictions in his abdomen, medial thighs, bony pelvis (the area near your sitz bones) and buttocks. One of the ways that we examine connective tissue mobility is with a technique called “skin rolling.” It helps us as PTs feel where fascia may be tight and limiting movement of the underlying muscles or blood flow to the muscles or nerves. Given his connective tissues restrictions, it was not too surprising that he also had myofascial trigger points in the adductors, abdominals, hip flexors and throughout both the superficial and deep pelvic floor muscles. In addition to the trigger points in the pelvic floor, his internal exam also revealed tension in both the urogenital diaphragm and levator ani muscles and a positive Tinel’s sign on both sides at Alcock’s Canal.
|A tinel’s test is performed to test irritation of a nerve by palpating it. It is often done by performing repeated taps at where a nerve is palpable. Other nerve that are commonly tested with Tinel’s test are the medial nerve at the inner wrist which can be irritated with carpal tunnel syndrome or the ulnar nerve at back of the elbow, you might know that spot as the “funny bone”|
Clyde’s positive result with the tinel test indicated that the pudendal nerve was irritated. The pudendal nerve is one of the major nerves of the pelvic floor and plays a role in bowel, bladder and sexual function. Clyde’s pelvic floor motor control (his ability to contract, relax, and lengthen the pelvic floor) was good and he demonstrated good movement of the pelvic floor with deep breathing, but the resting state was slightly contracted and guarded against pain. It is not uncommon that awareness and control of the pelvic floor becomes impaired in the face of long term pelvic pain so it is always good to check. In Clyde’s case, his tenderness at Alcock’s Canal along with the tension in his pelvic floor muscles and surrounding connective tissues supported my hypothesis that his pelvic floor could be aggravating his pudendal nerve and leading to his symptoms.
We then discussed Clyde’s treatment plan. He would start physical therapy once per week to focus on manual therapy to help start to relieve the muscular and connective tissue tension in the pelvic floor and surrounding tissues and we established a home program. Clyde would start adding deep breathing exercises with pelvic floor relaxation on the inhalation, also called a “pelvic floor drop.”
Pelvic floor drops are an often overlooked exercise that is just as important as its well known cousin the “Kegel.” Most people have heard of a kegel and something that new mom’s should be doing. A “kegel” is a pelvic floor contraction, the pelvic floor equivalent of flexing your biceps to “make a muscle.” A “pelvic floor drop” on the other hand is the opposite of that, it’s a pelvic floor relaxation and lengthening. Why is it important that the pelvic floor relax, you might ask? Well, there are certain, everyday, bodily activities during which it is essential that the pelvic floor relaxes. Think about the relaxing feeling you get in your pelvic floor when urinating or having a bowel movement, that’s your pelvic floor dropping! While we obviously shouldn’t be dropping our pelvic floors all the time, we also shouldn’t be contracting them all the time either. But, when someone has pelvic pain, the pelvic floor can react to that pain by contracting to try to protect or “guard” itself. It’s the same as when we contract our shoulders up to our ears when we hear a loud noise or are frightened or stressed. However, if we are tightening for too long, those muscles can “forget” how to relax and end up alway contracted and always tight. That in turn might start compressing or irritating the nerves around them which can lead to pain. So for someone like Clyde who’s been having pain for a while and whose muscles are tight, the best thing he could do was to let them relax and relieve some of that pressure on the pudendal nerve.
After three sessions, Clyde reports that his urinary symptoms were completely normalized. He was still having pain after intercourse and masturbation but it would only last about 30-60 minutes. His baseline pain was also reduced and he was generally only having pain in the penis and perineum after bowel movements, sexual activity or prolonged sitting. Because his pelvic floor tension and trigger points were improving, he still had connective tissue restrictions and trigger points in the thighs and gluteal muscles. However, the most likely explanation at this point was that his pudendal nerve was still irritated and those three activities were all putting stress on the pudendal nerve. That combined with his lingering external tension was likely the culprit of his flare-ups. We decided to add foam rolling to his home program and continued working weekly to reduce the connective tissue tension and trigger points. Over the next few sessions, he had various little flare-ups usually after sexual activity and more-so if it was two days in a row. However, overall he was making steady progress and we had been able to decrease his frequency of physical therapy visits to once every two weeks.
After his eighth session, he went on a cross-country road trip and on the way back his symptoms flared up. This was right before PHRC closed during the first Shelter in Place due to the ongoing Coronavirus pandemic and he was not able to come back in for two months. During that time, he started doing internal self massage of the pelvic floor which helped decrease but didn’t completely relieve the pain in his left perineum which was once again brought on by sexual activity.
When he returned to physical therapy about three months later, he was coming to physical therapy every other week and continuing with his home program of self massage, pelvic floor relaxation and gentle stretches for the hamstrings, quads and gluteal muscles. Over the next four months, his pain slowly subsided to the point where he was able to manage the pain at a minimal level most of the day and after sexual activity with his daily home program. By the end of those four months his urinary sxs were almost completely resolved, sitting was much less aggravating, bowel movements were usually pain free, and he was continuing to be diligent with his home program. However, he had frequent flare-ups in his penile and perineal pain after sexual activity that would not fully calm down (self massage helped somewhat) until after he came into the clinic for physical therapy. At that time, I believe that while we had managed to decrease the irritability of his pudendal nerve and as well as the tension and tightness in his pelvic floor, we were not there yet but we were making progress, especially when looking back at where he had started.
Unfortunately, flare-ups are not unusual and the key is to be able to manage them before they get too bad and ultimately eliminate them, if possible. While Clyde was steadily getting better, he had one flare-up that shook my confidence that we were on the right track. It had started after a longer session of sexual activity and more aggressive self massage with more pressure than usual. When he reported it to me the next session, I realized that while he had been making good progress, his pudendal nerve was still easily irritable and that he might benefit from the addition of an evaluation by a pain management specialist for pharmacological pain management. He was open to this and scheduled an eval. That session we focused on calming techniques and luckily by the next session he was almost back to his pre-flare baseline.
Over the next few sessions, I continued with manual therapy techniques for trigger point relief both internally and externally around the gluteal muscles and hamstrings. But, I changed my technique a little. I started using lighter pressure and mobilizing tissues in less aggressive ways. I also started using a few new techniques that I had learned in a recent continuing education class to help retrain correct activation of the pelvic floor muscles. To both his and my delight, his symptoms started to dramatically improve. And at his most recent session, he reported that he was able to sit for longer periods with less discomfort and that he was even able to masturbate two days in a row without a flare-up.
Clyde is still coming to physical therapy and we are still working on improving the fine tuning of his motor control of the pelvic floor. We are working on his awareness and control of activating certain muscles in the pelvic floor while keeping others more relaxed with the goal of reducing that guarding tightness response of the pelvic floor. We are also continuing to work on reducing his trigger points and tender spots in the pelvic floor. He has not yet seen the pain management specialist but it is still in the works as still think the addition of a pharmacological modality might allow the pudendal nerve to calm down even more and get him over this last hump.
To conclude, Clyde’s case has a few key messages in it that I think we can all learn from both as physical therapists and as patients. One, diligence and adherence with an independent home program will help you get a lot more out of physical therapy. You only see your physical therapist for a short amount of time each week or even every other week, and that leaves a lot more days and hours when you are not seeing your physical therapist. A home program bridges that gap between physical therapy sessions and ultimately gives you, as the patient, the power to heal yourself. Two, flare-ups happen, they are not the end of the world. This is the one that I really needed to remember in this case. I had to adjust my own expectations and really take a hard look at his case when that last big flare happened. I had to think through my strategy and come up with a new plan. As a patient, it’s important to remember that flare-ups will happen but you have the tools to manage them and you have your physical therapist to give you new ideas if the ones you have aren’t working. Physical therapists like to help people and we like to help people help themselves, so if you come to us asking us to help you, help yourself, you might see our eyes get all sparkly and giddy smiles stretch across our faces! Finally, when looking for progress and successes, it’s good to go back to the very beginning and remind yourself exactly where you started. Sometimes, it can be harder to feel like you are making progress day to day or week to week. But, when you compare the present moment to the start of your physical therapy journey, you see just how far you have come and that sort of reflection can help reinvigorate you when they are feeling down and feel like you aren’t making progress.
If you are experiencing sexual dysfunction or pelvic pain, please reach out to us. We are available for both in person and digital health sessions to help you take the first step towards better pelvic health!
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.
PHRC is also offering individualized movement sessions, hosted by Karah Charette, DPT. Karah is a pelvic floor physical therapist at the Berkeley and San Francisco locations. She is certified in classical mat and reformer Pilates, as well as a registered 200 hour Ashtanga Vinyasa yoga teacher. There are 30 min and 60 min sessions options where you can: (1) Consult on what type of Pilates or yoga class would be appropriate to participate in (2) Review ways to modify poses to fit your individual needs and (3) Create a synthesis of your home exercise program into a movement flow. To schedule a 1-on-1 appointment call us at (510) 922-9836
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