By Malinda Wright
Chronic Prostatitis! It’s not something discussed at a baseball game or at a family gathering. However, it is estimated that between 2-14% of men worldwide are diagnosed with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS)1. But what exactly is CP/CPPS? According to the National Institutes of Health, CP/CPPS, also known as category III prostatitis, is characterized by pain in the pelvic area for 3 of the last 6 months without any signs of infection, malignancy, or structural abnormalities 2. In fact, it is the number one reason why men under the age of 50 visit a urologist. 95% of men with a “prostatitis” diagnosis actually have CPPS and in fact have NOTHING wrong with the prostate itself. Instead, there are almost always problems with the musculoskeletal system, including the pelvic floor muscles.
Men with CP/CPPS report genital and urinary symptoms including the following:
- Urinary frequency
- Urinary urgency
- Burning sensation with urination
- Hesitancy with starting stream
- Incomplete emptying of the bladder
- Pain in the perineum – region between the testicles and anus
- Pain in the genital region
- Pain in the lower abdomen and/or low back
- Pain with ejaculation
- Pain with bowel movements
- Erectile dysfunction
How is CP/CPPS Diagnosed?
Medical doctors will conduct a systemic workup to exclude other possible diagnoses, such as cancer, painful bladder syndrome, or bowel pathologies. An extensive workup may consist of a urinalysis and culture, PSA study, cystoscopy, different types of imaging, such as a transrectal ultrasound, and any other studies a doctor may deem necessary. He/she will also conduct a thorough history exam asking questions regarding symptoms, past medical history, psychosocial history, family history, and medication. It is best to report all of your medical history to your doctor, even the things you might not find significant, such as cardiovascular disease or irritable bowel syndrome (IBS). Researcher are finding a correlation between CP/CPPS and other systems in the body, such as the gut and cardiovascular system. It is necessary to address and treat all impairments found when treating a patient with CP/CPPS.
Men with CP/CPPS have varying causes of their symptoms and therefore one standard treatment protocol, such as antibiotics, does not work for everyone. Repeated courses of antibiotics without a positive infection is NOT acceptable treatment. Research shows CP/CPPS is multifaceted with varying presentations. It is important to acknowledge and treat all possible causes of the symptoms.
The UPOINT classification system was created to help guide multimodal therapy for CP/CPPS. UPOINT is an acronym for urinary, psychosocial, organ-specific, infection, neurologic/systemic, and tenderness of muscles. These are all areas that can contribute towards CP/CPPS symptoms and need to be addressed. Research has shown that pelvic floor physical therapy is the FIRST line of treatment for the musculoskeletal impairments commonly found with CP/CPPS.
A physical therapist’s evaluation consists initially of a subjective exam. A PT will ask questions similar to the doctor’s history exam. We will want to know more about the behavior of the urinary, sexual, and pain symptoms, such as the quality, location, frequency, and severity of the pain, history of the symptoms, such as when they began, past medical history including surgeries and/or other injuries, psychosocial history, and questions regarding medication.
Next, a physical exam is conducted, which consists of an observation of the body looking for any abnormalities from the head down to the feet, an assessment of the pelvic girdle alignment (checking to see if the hips are in alignment), an assessment of the range of motion of the hips and low back, as well as palpation of the muscles in the abdomen, low back, hips, buttocks, thighs, and pelvic floor. When we palpate muscles, we are looking for tenderness, tightness, and myofascial trigger points in the muscles. Here at PHRC, we also assess for connective tissue restrictions throughout the abdomen, thighs, buttocks, low back, and bony pelvis. Please see our blog The Role of Connective Tissue Manipulation to learn more.
During the physical exam, an intrarectal exam is also performed to assess the pelvic floor muscles. We once again are looking for tightness, tenderness, and myofascial trigger points as well as pudendal nerve hypersensitivity. It is also important to assess motor control of the pelvic floor. Can our patient contract, relax, and lengthen the pelvic floor muscles when we ask him to? A primary goal of physical therapy is to teach our patients how to regain control of their muscles in order to reduce their symptoms and improve muscle function.
What is physical therapy treatment?
Physical therapy treatment focuses on the neuromuscular impairments. It is very common for men experiencing CP/CPPS to present with increased muscle tone and myofascial trigger points, connective tissue restrictions, and altered peripheral nerve function throughout the pelvic girdle area, abdomen, pelvic floor muscles, and thighs. Manual therapy, especially intrarectal manual therapy, is often necessary to normalize these impairments. Training patients to voluntarily relax and lengthen the pelvic floor is also a must. It is common for patients experiencing pain to guard, which contributes towards pelvic floor tightness and trigger points. Men suffering from CP/CPPS benefit from learning to relax their pelvic floor muscles since these muscles play such a large role in their pain. We call this exercise “Pelvic Floor Dropping” and we teach our patients how to do this early on in their treatment plan. To learn how to do a pelvic floor drop please click here.
More often than not, the symptoms of CP/CPPS are associated with tight muscles rather than weak muscles. Therefore, the majority of men suffering from CP/CPPS will likely NOT need to perform Kegels as part of their treatment program.
How long is this going to take?
Typically, men with CP/CPPS have physical therapy 1 -2 times per week, usually for 3 – 6 months. The timeline will vary based on the chronicity, severity, and other contributing factors.
Men with CP/CPPS may have multiple impairments contributing towards the pain, such as inflammation, stress/anxiety, gut pathology, infection, systemic pain, for example chronic fatigue syndrome. A multidisciplinary approach is the most effective strategy when confronted with multiple causes of pain. Part of our job as a PHRC physical therapist is to coordinate the overall treatment plan with other providers that our patients are being treated by. Other treatments may include acupuncture, pharmaceutical management, procedures such as trigger point injections, botox injections, nerve blocks, and psychological services such as cognitive behavioral therapy.
Will prostatitis ever go away?
YES! Physical therapy involves developing an assessment as to how the symptoms developed and what impairments need to be treated. This open discussion between the physical therapist and the patient leads to the development of reasonable short term and long terms goals and a strategy for achieving these goals. Although improvement does not happen overnight, it does happen!
CP/CPPS may not be a common subject spoken about at the water cooler, however for millions of men around the world it is a part of their daily life. These men do not have to live with the symptoms. Treatment is available!
Readers we want to hear from you! If you have any questions regarding CP/CPPS, please do not hesitate to leave them in the comment section below.
And if you haven’t already, SUBSCRIBE to this blog (up top, to the right, under Stephanie’s photo!), so you can get weekly updates in your inbox, and follow us on Facebook and Twitter where the conversation on pelvic health is ongoing.
Malinda Wright, PT, MPT
Malinda is originally from Boise, Idaho, and currently sees patients in our Los Gatos office. Malinda received her undergraduate degree from Dominican University of California in International Management. She attended graduate school for physical therapy at Royal College of Surgeons Ireland. She has been fortunate to travel to some wonderful countries, including Scotland, Egypt, and Brazil. Malinda has always had a flair for adventure and enjoys snow skiing and hiking; however, believes that there is nothing like spending time with family in beautiful California.
- Konkle, K. and Clemens, J. New Paradigms in Understanding Chronic Pelvic Pain Syndrome. Curr Urol Rep. 2011 Aug; 12 (4): 278-83.
- Pontari, M. and Giusto, L. New Developments in the Diagnosis and Treatment of Chronic Prostatitis/Chronic Pelvic Pain Syndrome. Curr Opin Urol. 2013 Nov; 23 (6): 565-9.