By Elizabeth Akincilar-Rummer
I am happy to say that in March we celebrated our one year anniversary in our Boston area office!! In February 2016 we were excited to welcome our new staff, Melissa Hines, DPT, staff physical therapist and Erika Toronto, Administrative Assistant. It has been a crazy year, but I’ve truly enjoyed getting to know new colleagues and being another resource for the many people suffering from pelvic pain in New England.
During the past year there has been one glaring difference between my practice in San Francisco and here in the Boston area. Men! I have a larger percentage of male patients in this office than I ever had in San Francisco. So, I thought it would only be fitting to share a recent success story about one of my male patients, Steve (his name has been changed for anonymity). His journey with pelvic pain is unfortunately not an uncommon one, but fortunately has a happy ending!
“I suffered with great pain and restricted activities for more than five years, and no doctor ever mentioned the possibility of physical therapy. I found out about it online. What the doctors and specialists said was incurable was entirely curable! Before consenting to surgeries (I had two) and all sorts of pills, you really owe it to yourself check out physical therapy.” Steve, age 40
Steve is a 40 year old man that drove 1 ½ hours in desperation of finding some help for his 6 year history of pelvic pain. Here’s his story: In 2007 he noticed blood when he ejaculated. He was prescribed antibiotics and his symptoms resolved. In 2009 the same thing happened, noticeable blood when he ejaculated, but in addition, this time he also experienced pelvic pain. Again, he was prescribed antibiotics and the blood in his ejaculate resolved, but the the pain did not. Since 2009, his pain has been consistently sharp pain in his right lower abdomen, and radiating pain to the right side of his penis and perineum. He noted that any friction to the right side of his lower abdomen (i.e. when wearing a belt) would increase his pain. He reported that his pain was the most severe after ejaculating, lasting up to 36 hours. He had basically given up on even trying to ejaculate because the resulting pain was so intense and debilitating. He also noted that he was unable to walk fast because the friction caused by swinging his arms would flare up his pain.
During these 6 years he attempted several treatment interventions. He saw several urologists and pain management specialists. At no point did any medical provider recommend physical therapy. In 2012 he was diagnosed with a right inguinal hernia which was surgically corrected. He reported one month of relief and then the pain returned as before. In 2013 he underwent a partial orchiectomy during which his right spermatic cord and right testicle were surgically removed. Again, he reported one month of relief only. Later in 2013 he had a series of 3 right ilioinguinal nerve blocks. He reported the first nerve block gave him approximately 20% pain relief, but the latter two had no effect. Virtually coming to the conclusion that this was just something he was going to have to live with, he found PHRC during extensive online research.
When I evaluated him in early 2015 he reported the same pain symptoms: sharp right lower abdominal pain and hypersensitivity, radiating sharp pain to his perineum and right side of his penis, inability to ejaculate without 1-2 days of severe pain, and an inability to walk fast without causing an increase in pain. He reported urinary frequency only if his pain was very severe and denied any bowel dysfunction. He was currently taking 3600 mg/day of gabapentin (neurontin) which he thought was helpful. He was able to work from home as a musician and composer.
During his initial evaluation I noted the following:
- moderate connective tissue dysfunction in his abdomen, lower abdomen and along his bony pelvis on the right side
- Hypertonus (tightness) in his right psoas, adductors, and abdominal musculature
- inguinal hernia scar restriction
- right bulbospongiosus, ischiocavernosus, and transverse perineum hypertonus
My assessment was that the infection in 2009 caused changes in the surrounding somatic tissues via the visceral-somatic reflex. In other words, the infection initiated dysfunction in the muscles, nerves and connective tissue in the pelvis. The initial infection in 2007 likely caused some of these same changes, but at that time the changes in the muscles, tissue, and nerves weren’t significant enough to cause pain. When the second infection occurred, the dysfunctional changes were then enough to cause symptoms of pain. Another possible factor was that the inguinal hernia that was later diagnosed was also contributing by irritating the ilioinguinal nerve, which would be consistent with his symptoms of lower abdominal and penile pain. The partial relief of pain with the ilioinguinal nerve block also supports this theory.
Steve’s goals were the following:
- No pain during or after sexual activity
- Able to walk at desired speed
- Stop taking gabapentin
I recommended treatment 1x/week for 8 visits. My treatment plan included scar mobilization, connective tissue manipulation, myofascial release, myofascial trigger point release, pain physiology education, and home exercise program development. During his initial evaluation, we began discussing pain physiology and the impact chronic pain can have on one’s nervous system. I gave him the book, Explain Pain, to read prior to his next appointment.
At his first follow-up visit he reported that he thought many of the concepts in Explain Pain applied to him and his history of chronic pelvic pain. We continued our discussion about these concepts and how he could apply them in his life. I continued the manual therapy on the myofascial impairments, including the inguinal scar, the abdominal and adductor trigger points, connective tissue restrictions and the pelvic floor hypertonus.
At his second visit, he reported that clothes were now less irritating and he had less pain with walking. He was now able to walk slightly faster and swing his arms more without aggravating his pain. At this point he also started to decrease his gabapentin. Upon exam, I noted that the scar mobility was improved, he had less skin hypersensitivity, and the connective tissue mobility was improved. He continued to have urogenital diaphragm hypertonus.
At his third visit, he reported that he was now able to wear a belt without pain. During the last week he ejaculated one time and had minimal discomfort, but then tried to ejaculate a second time that week and had significant pain afterward. He also decreased his gabapentin again. I noted the connective tissue restrictions continued to decrease and the urogenital diaphragm muscles had less hypertonus. I taught him self myofascial release techniques to utilize after ejaculation.
At his fourth visit, he reported that he was able to walk even faster without pain and was able to ejaculate without any pain or limitations in activity the following day. I noted minimal connective tissue restrictions and minimal scar restrictions. The primary remaining impairments were hypertonus in his right ischiocavernosus, bulbospongiosus, proximal adductors, and right lower abdominal muscles.
By his sixth visit, he reported he had no limitations in walking and was able to have sex in the evening multiple times during the week without pain or any limitations the following day. He had also completely stopped taking gabapentin by this point. I noted minimal hypertonus in his ischiocavernosus, bulbospongiosus, and lower abdominals. I decreased the frequency of treatments to 1x/2 weeks.
By his eighth visit, he reported that he felt 90% better. I noted minimal myofascial impairments. At this point I recommended we decrease the frequency of treatment to 1x/month.
After 2 additional visits, once per month, he reported no restrictions or pain with exercise/walking or sexual activity. After a total of 11 visits over 5 months, I discharged him with his home exercise program of self myofascial release as needed.
As you can see, with the correct treatment interventions, Steve’s symptoms resolved relatively quickly given the amount of time he had been suffering. He underwent at least one major surgical procedure that was completely unnecessary and possibly two. This is an excellent example of the importance to educate the medical community about pelvic pain and the role physical therapy can play in recovery. Had his medical providers been better educated about treatment options for pelvic pain, Steve’s pain could have been resolved years earlier. Those of us who treat pelvic pain need to take on the challenge of educating our colleagues to prevent situations like Steve’s from happening.
All my best,
Elizabeth Akincilar-Rummer, MSPT