Ben is a 32-year-old male whose chief complaints are: right testicle ascension and sometimes associated pain, which started after he began using the hip adductor machine at the gym. His symptoms are worse post ejaculation or with strenuous activity, such as biking or playing tennis and remain for 20 to 30 minutes.
He has a history of constipation and anal fissures and has worn orthotics for flat feet. He takes fiber and magnesium for bowel health. His primary care doctor evaluated him with an ultrasound, but there were no findings.
Ben’s functional limitations include testicular ascension and discomfort upon ejaculation.
Patient Goals for PT
No testicular ascension with ejaculation or exertion and no testicular discomfort.
The patient’s findings include:
- Connective tissue restrictions throughout his anterior, medial, and posterior thighs, and bony pelvis;
- increased tone and trigger points in rectus abdominis, hip adductors, and pelvic floor muscles;
- and intact cremaster and anal wink reflexes.
The hypertonicity and trigger points in adductors are creating associated contraction of pelvic floor and cremaster muscle leading to testicular ascension and pain. The rectus abdominus and connective tissue restrictions are contributing to the symptoms by encouraging a high tone pelvic floor.
Short term goals: (4-6 weeks)
- Patient will be independent with his home exercise program
- Decrease connective tissue restrictions, trigger points, and hypertonus in abdomen and legs by 50%
- Decrease pelvic floor tone to < or = min
Long Term goals: (8-10 weeks)
- No testicular ascension with ejaculation or exertion
- No testicular pain
- No constipation
Initial treatment plan
Patient will be seen once a week for eight weeks at which time PT will re-evaluate.
The treatment plan will include connective tissue manipulation, pelvic floor myofascial release, trigger point release, pelvic floor down training home program and education on proper exercise techniques to prevent further injury. The patient was instructed to avoid adductor strengthening, sit-ups, and sitting for long periods of time.
Overview of treatments and changes
After patient’s fourth visit, he reported symptoms occurring less frequently and only after ejaculation. Connective tissue restrictions improved with the area of the dorsal branch remaining the most impaired.
On sixth visit, PT shifted focus to dorsal branch area, connective tissue, and ischiocavernosus and pectineus as these were the remaining objective findings.
On seventh visit, patient reported no testicular ascension or discomfort with ejaculation in past two weeks as well as no constipation during course of treatment. In addition, he is taking frequent breaks from sitting, and continuing normal workouts without adductor or rectus abdominus strengthening.
Re-assessment on seventh visit reevaluation
Connective tissue restrictions improved to WNL in thighs and decreased in suprapubic and groin region. Tone in rectus abdominus and medial thigh reduced to almost normal, with the exception of pectineus trigger point. Pelvic floor tone normalizing, but ischiocavernosus tone persists. Therefore, I believe the adductor trigger points and tone may have been what started the symptoms, but decreasing the adductor and pelvic floor tone and connective tissue around the pelvis seems to have eliminated the symptoms so far.
New plan since seventh visit reevaluation
Patient to continue current home program. Patient will be seen on an as-needed basis to eradicate pectinues trigger point, ischiocavernosus tone, and connective tissue restrictions in the area of the dorsal branch in order to keep symptoms away.