Physical Therapy for Male Pelvic Pain: Don’t Let the Penis Come Between Us

In Male Interstitial Cystitis / Nonbacterial Chronic Prostatitis / Chronic Pelvic Pain Syndrome, Male Pelvic Pain by Stephanie Prendergast23 Comments

 

By Stephanie Prendergast

The Situation Room: Why do men have to see Women’s Health Physical Therapists?

 

The facts:

 

15% of adult men worldwide suffer from pelvic pain. 1

 

8.2% of men will experience prostatitis-like symptoms at some point in their lives, and greater than 90% of those men will have symptoms consistent with chronic pelvic pain syndrome (CPPS).2,3  

 

Symptoms of CPPS can include

  • Penile/scrotal/perineal pain
  • Urinary urgency/frequency
  • Erectile dysfunction
  • Post-ejaculatory pain
  • Painful bowel movements or delayed genital/bladder pain after bowel movements

 

The situation:

 

CPPS symptoms drive men to the urologist. Tests come back normal. Men turn to Google University and usually self-diagnose themselves with pudendal neuralgia, nonbacterial chronic prostatitis, or CPPS. They discover they need pelvic floor physical therapy. They look for one…and discover that they need to see a “Woman’s Health” physical therapist?!? As if this isn’t bad enough, men then find out that many of these physical therapists do not treat men.

 

Aw, NUTS!!

 

When it comes to physical therapy training in male pelvic floor dysfunction, we are facing a multifactorial problem. Course instructors are frustrated. Pelvic floor physical therapists do not feel qualified based on the training. Suffering men do not know where to go for treatment, creating one more hurdle in the obstacle course of recovering from pelvic pain.

 

Pelvic floor muscle evaluations and treatment are STILL not yet part of the regular medical and physical therapy school curricula. Liz and I were trained on the job; we learned how to do examinations on male and female patients, starting on day 1 of our careers. This situation is not common. Instead, many physical therapists gain pelvic floor training through continuing education courses. These courses are typically  2-3 days in length, or roughly 16 -24 hours of training. A typical course costs about $600-800 and likely involve a weekend in a bad hotel, airline ticket, and meal expenses. Physical therapists may receive a continuing education allowance for such courses of roughly $500 – $1000 per year. So, physical therapists may be able to take about one course per year for their training.

 

I was horrified at my first course to learn that in these courses there are no models; we are instructed to drop our drawers and practice on each other.

 

The majority of pelvic floor physical therapists are women and as a result, there are often no men in these courses. The obvious problem with this is that in the course on male pelvic health, the physical therapists are practicing on women, not men. This does not necessarily foster confidence in the student about how to transition their new knowledge to a clinical setting. We understand this.

 

Several years ago, Liz and I wanted to solve this problem by hosting a course on male pelvic pain with male models. Imagine trying to hire ten models that will allow twenty women to practice pelvic floor techniques on them, for four hours a day. It was an administrative nightmare for us and raised the cost of the course to an unaffordable number for potential students.

 

Sandy Hilton, PT, DPT, MS, co-owner of Entropy Physical Therapy in Chicago, and Tracy Sher, MPT, CSCS, owner of Sher Pelvic Health in Orlando and founder of Pelvic Guru, shared similar frustrations.

 

Sandy brought up an interesting double standard:

 

“Most “Men’s Health” physio courses do not require that there be male models for the assessments. I think this is unhelpful and misses an opportunity to teach comfort and confidence to the participants. If a woman comes to a pelvic health course but can’t participate in labs, she is to provide a model, if a guy goes to a pelvic health course he is to bring a female for the labs… but in the men’s health courses the females are not required to bring a male for the labs… and the courses are done anyway, leaving participants not fully prepared for their first real male patient!”

 

This is an excellent point. Out of curiosity I asked my partner last night if he would attend a weekend course with me and allow me to practice on his perineum for a few hours in a room full of people. He laughed right in my face and the thought of this made me laugh as well. However, this is a noted fair and practical point.

 

Sandy goes on to say:

 

“Not every pelvic health therapist wants to treat men.  And they should not treat men if they are not interested or comfortable with male pelvic health challenges.  And they should rapidly refer to those of us who ARE!

 

Around the country there are different attitudes about women treating men, and men treating women. I think this is probably part of why some female pelvic health therapists chose to not treat men. I don’t think they are comfortable, or they work in settings that are so “pink” that a man wouldn’t be comfortable there.”

 

Tracy adds:

 

“ Some female therapists simply don’t feel comfortable treating men when it comes to the pelvic region; and thus, they do not seek out additional training for this. Some would say, “oh, just get over it,” it’s more complex than that. Just as patients may have anxieties and fears about coming in for care for the pelvic region, practitioners also have their own anxieties and concerns. This can reflect personal, cultural, religious or other factors. Though it is all professional in a medical setting, this type of therapy does involve touching the pelvic region and talking about very intimate topics.

 

When there’s a female therapist/male patient dynamic, some therapists would only feel comfortable treating if an assistant or another person was in the room. In some practices this is not always an available option”.

 

Troubleshooting the situation

 

Knowing our own challenges trying to host a course, I asked Tracy and Sandy how they are helping to improve male pelvic health physical therapy training.

 

From Sandy:

 

Sarah Haag and I have an Introduction to Men’s Health course which utilizes Male Standardized Patients for the lab portion. There is no pre-requisite for this course, other than having a license that allows you to do internal pelvic assessments and treatment.  We welcome women and men to the course and the standardized patients provide valuable feedback. I credit Karen Liberi for this, her and I taught a men’s health course in Portland Maine some years ago based on this format.  

 

A standardized patient (SP) (or a patient model) is the reference for those people who are paid as professional patients. Major teaching hospitals have them – that’s who the MDs and RNs train on – as opposed to PTs who volunteer as lab models!

We hire them – and they know how many internal pelvic exams they are able to do in a set amount of time. Depending on the class size, you would do some simple math to know how many ‘patients’ you would need to run the course.

 

This way there is no pretending that your lab partner is a guy! Plus they are exceptionally knowledgeable and provide invaluable feedback.

 

The cost is variable depending on the area. $50 per hour may be average?

 

Lab hours: for the internal exam that depends on the number of participants, but figure at least one hour for internal assessment.

 

Treatment is a separate lab, not using the standardized patient (SP), then the participants would be lab partners as in most courses.

There’s additional labs for manual therapy and some neurodynamics, although in depth I do that as a separate course. (And it has internal components)

 

Costs are not significantly higher here in Chicago but we have exceptional access. The logistics are the thing – the course has to be well crafted and the standardized patients need to be available and the schedule needs to be followed.

 

We pay them directly – there is a contract.

 

From Tracy:

 

I’m already making a shift now with my educational courses I teach to Pelvic PTs and other healthcare professionals. I teach a pudendal neuralgia course and a clinical competency pelvic PT “bootcamp” course. In both of those classes, I make a big effort to try to have a male model or a male class participant available and willing to allow me to do a live demonstration on all sorts of anatomy, clinical pearls, positioning strategies, etc. Each time I do this, someone comes up and says “this was worth the price of admission” because many therapists want to learn this, but just haven’t seen the practical clinical skills to feel comfortable.

 

One of the big challenges I still see is that even if a PT receives some training in it, they may not see males right away after training and then seem to lose confidence again.

 

Next, Can you tell us about how the Section on Women’s Health is working to incorporate male pelvic health as part of the section?

 

From Sandy:

 

“The board of the SOWH is supportive of the Men’s Health Special Interest Group (SIG), which is in process of creating the structure needed to be an active SIG and is extremely supportive of the Men’s Health programming at Combined Sections Meeting.

Part of the current process of the Name Change is to address the treatment of men in pelvic health.  See the update on where the SOWH is in this process and please make your voice heard:  http://www.womenshealthapta.org/the-sowh-name-change-task-force-the-journey/

 

I am happy to have met with some of the men in the SOWH and the DPT Students (men) who are passionate about being a voice in moving forward to have more trained therapists working with Male Pelvic Health as having more male therapists involved in care. “

 

The professionals who teach courses through Herman and Wallace and the American Physical Therapy association are forced to work within a model that is severely flawed. I hope that these organizations, with deeper pockets than solo providers trying to run a course, will take this into consideration and modify their courses to better meet the needs of their students and men with pelvic floor disorders.

 

Closing thoughts

 

Given these circumstances, we can understand that many physical therapists do not feel qualified to treat men. Most of the physical therapists working at PHRC had no prior experience with male or female pelvic floor disorders, so we trained them through reading materials, our course DVD with instructional videos, and practice on patients that we accept pro-bono: in exchange for allowing our newer therapist to practice with one of us and then we do not charge them for treatment. We know this is a luxury not available to most newer therapists, particularly the solo provider.

 

So what are PTs to do?

 

  1. Seek out individual preceptorships with practices that may be able to help. It cannot hurt to ask.
  2. Ask an experienced therapist to mentor you with one of your own male patients. In my first year of practice my mentor, Rhonda Kotarinos, came to California and treated 8 of my active patients while I observed, took notes, and asked questions. Many of those patients were men and this absolutely was the most useful learning experience in my first five years of practice.

 

As for the courses…

  1. Considering Sandy’s comments, would it be reasonable to ask male pelvic health course instructors if it is ok to bring a man to lab for practice? During lab, people are undressed but draped. With careful planning ahead this could be a reasonable solution.
  2. Larger organizations such as hospitals have larger budgets than solo providers like Sandy, Tracy, and ourselves, who also teach.  Organizations that teach courses such as Herman and Wallace and the APTA could better support their course instructors by hiring male models.
  3. Given the expense of courses in terms of time, money, and energy, consider eliminating pre-requisites. To quote Sandy, one ‘shouldn’t have to go through the vagina’ to take a Men’s Health course.

 

As men, students, and professionals, what are your thoughts and suggestions on this situation?

 

Resources

 

Entropy Continuing Education Courses: http://entropy-physio.com/professional-courses

Pelvic Guru Courses: http://www.eventbrite.com/o/pelvic-guru-academy-and-sher-pelvic-health-and-healing-llc-4356240713

Pelvic Health and Rehabilitation Center Instructional DVD (for professionals only): https://pelvicpainrehab.com/instructional-video/

 

References

 

  1. Systematic Review of Acupuncture for Chronic Prostatitis/Chronic Pelvic Pain Syndrome. Qin Z, Wu J, Zhou J, Liu Z. Medicine (Baltimore). 2016 Mar;95(11):e3095.
  2. J.N. Krieger, S.W. Lee, J. Jeon, P.Y. Cheah, M.L. Liong, D.E. Riley. Epidemiology of prostatitis. Int J Antimicrob Agents, 31 (Suppl 1) (2008), pp. S85–S90
  3. Eur Urol. 2016 Feb;69(2):286-97. doi: 10.1016/j.eururo.2015.08.061. Epub 2015 Sep 26. Contemporary Management of Chronic Prostatitis/Chronic Pelvic Pain Syndrome. Magistro G1, Wagenlehner FM2, Grabe M3, Weidner W2, Stief CG4, Nickel JC5.

 

Comments

  1. Hi Stephanie, what a great post! I am just entering into the world of pelvic floor physical therapy. I took PF 1 and care of the pregnant patient through Herman and Wallace. As a new practitioner I completely agree with what you said – I would be apprehensive about treating men without ever having practiced on one. I believe we absolutely need to improve the curriculum of DPT programs to include pelvic floor anatomy, function, and at the very least how to screen for PF dysfunction and when to refer out. It’s ridiculous to ignore an entire musculoskeletal body region which is so integral to our daily lives. While I do not advocate forcing anyone to pursue this speciality, it should not be hidden or ignored because it may make people uncomfortable. Wound care makes plenty of people uncomfortable yet that is taught!

  2. I opened a pelvic health clinic and purposely kept the word “women” out of it. My colleague and I do a lot of visiting doctors offices to provide education- we talk about the pelvis – everyone’s pelvis-. We are located in a college town filled with men and women 18-35. So there is a need. Men are so thankful we exist- there is no awkwardness. We are health professionals. It is our ethic responsibility to make this happen- thanks for all the great suggestions and references! You continue to raise the professional bar- love it!!

  3. I am a male patient receiving pelvic PT services from 2 very skilled and compassionate female physical therapists. I had to search dilligently to find them after encountering many options that only treat women. I am thankful for their willingness to treat men with pelvic pain issues. Please continue to advocate for the training and the treatment of male patients. I am a triathlete that was told I should never ride a bike again by my physician. With the help of PT for my pelvic pain, I have been able to train and compete. I am very grateful!

    1. Hi, I am glad to hear that PT is helping gou get through your pelvic pain issues! I live in the UK and I was wondering if your physios practise here at all as I have been struggling to find someone knowledgeable enough or willing to treat men properly( i.e internally and externally)

    2. Been struggling 3 months constant pain. 41 years old. Father of 2. Healthy. I feel like my life is now a bad dream. Do u have any referrals in chicago? Sincerest most thankful feelings for any suggestion

  4. I personally did not find it difficult to treat men without classroom training. I kept an anatomy book handy and and lucked out with some great feedback from my first few male clients. Good communication skills are essential. I don’t think that lack of male models in courses should a such a barrier, especially for a more experienced therapist.

  5. I am a 36 year old male who is suffering from these symptoms. I started having them after a dirt bike race and brushed it off as something that would go away, I was wrong. I seen a NP which prescribed me with antibiotics and diclofanac. I took some time off work (5days) symptoms seemed better until my wife and I had intercourse, it was painful like my muscles were in a knot/knife like pain between anus and scrotom. Went to a urologist (6weeks after injury) he prescribed 800mg ibuprofen and flomax, I was hopeful until intercourse again, same problem. My job requires lifting 50+ lbs and a lot of climbing and traveling, I can’t do my job due to this and that is frightening to me as I just got a great job with excellent benefits and could not stand to lose it. I need help and I do not know where to turn. I live 2hrs from Orlando and hear there is a great place near by, any help will be much appreciated.

    Thank you
    Charlie

  6. I am also a male PT patient diagnosed recently with interstitial cystitis. When searching, I did notice that 70% or more of the pelvic floor physical therapists seemed to treat only women. People like me are in so much pain and discomfort, I don’t really think you will see that many men who won’t see female therapists. I actually prefer it, simply because I have a harder time opening up and being emotional when it is a male doctor, because I don’t expect them to have empathy or understand my complaints. There is a lot of stress and such a mental aspect to this that I am thankful to have someone to be able to talk to openly about my problems without feeling judged. If that make sense

  7. Stephanie,

    I am a PT that works on the pelvis for both semester. I have a question for you. Do you have a good resource for a chronic pain pyschologist or group to help with cns quieting and the mental challenges?

    1. Author Stephanie Prendergast says:

      “We recommend the Pain Psychology Center in LA – they see people from all over the country via Skype.”

  8. I have pelvic floor dyfuction. I’ve been in PT for two months. I had sever referd pain in the outer part of my thigh and lower back by my hip from my pelvic floor I could not sleep because of the pain I also was getting up every night to urinate 3 to 5 times a night for years. Thanks to my female therapist I have no more pain in my leg and I sleep through the night. I still have a ways to go but thanks to all the therapist who are willing to work on male pelvic floor it changed my life.

  9. Thanks for this post and all of the others. I’m a 45yr old male who has been dealing with a variety of pelvic floor pain and dysfunction issues for 5 years now. Although I see many MD’s for my issues, my PT’s (all female’s) have been the only consistent medical practitioners to actually help and be engaged in my case for all these years. After becoming somewhat self educated in my issues and having many long discussions with my PT’s, I realize the issues PT’s face when it comes to training and becoming comfortable with the male pelvis. Has anyone considered asking male PT patients (who are comfortable with and really understand the benefit of pelvic floor PT work) to volunteer to be training models? I know and appreciate that without my PT’s, my pain and dysfunction would never have improved and I’d be happy to “give back” by serving as a model. I would bet other men who have been helped would feel the same.

  10. Does Sports Hernia or Athletic Pubalgia fall into your article of pelvic pain in men? I have been seen by numerous therapist for over 8 months now 3 times a week, seen doctors, had PRP therapy to my Pubic Symphysis, seen a world famous doctor that said experimental surgery was my only choice (not covered by insurance), rested, and still no relief. I have contacted numerous doctors and PT’s all of whom say “not my area of experience” and push me into therapy with a PT that is inexperienced with chronic pelvic pain and my diagnoses. I am looking for help but cannot seem to find any. Can you offer me any suggestions?

    Any help would be greatly appreciated.

  11. really depressing. had inquinal mesh surgery surgery and ongoing pain.
    -surgeon: “5% of patients have ongoing pain, sorry”: no p/t recommended
    -urologist to double check: “nothing in the testicles”, no p/t recommend
    -3x different pysiatrists over 4 years for injections, no improvement, no p/t recommended
    -p/t working on my post -shoulder surgery scar tissue tells me “we don’t go there” when I ask if p/t can work with hernia surgery scars,,,,
    -by complete accident I get referred to a woman’s health p/t clinic get some, but not complete, relief. she says, “boy, I wish you’d come to me earlier….”
    -is it lack of male models? if so, my rates are cheap.
    -is it being afraid of the “penis”? well, let’s all get over it
    -is it the potential to encounter creepy men? well, you can weed them out with medical records
    -lack of awareness? well wikipedia doesn’t even mention p/t as a treatment option. https://en.wikipedia.org/wiki/Post_herniorraphy_pain_syndrome#Nonsurgical_management

    -whatever it is, this is a real issue….. thanks for addressing it. maybe you can edit that wikipedia page, had it mentoned p/t, maybe I’d have thought to google something like “male pelvic floor p/t” years ago…

  12. Thank you for promoting pelvic health for men. I am a 56 yr old man receiving treatment for chronic constipation, OAB and pelvic pain. I am so thankful for my therapist who is retraining my pelvic muscles.
    I want to say from a male perspective having someone touching me anywhere down there can cause me to have an unwanted and embarrassing arousal. Communicating with her beforehand cleared the way for progress..My fear was that i was disrespecting my therapist and i felt shameful. I am very lucky to have a therapist that is very professional and understanding. She keeps me draped as much as possible and teaches breathing exercises to keep me calm. When it does happen she simply gives me a few moments to regain my calm.
    My pelvic issues have greatly improved and this would not be possible if not for the skill and understanding of my therapist.

  13. I’m a male and live in the Bronx, nyc my psa is below 1, seamen culture was fine ruin fine, I’m trying to find a dr to diagnose me and can’t seem to find one, thanks

  14. I had a radical prostatectomy to remove cancer at age 46. I missed am two years cancer free but have frequent leaking and wetting at night.. Also climax is virtually non existent. Can this therapy help? Thank you in advance for providing an answer.

  15. Thank you so much for all of this info. I suffer from an old sports hernia injury, labral tear of the hip, and it all added up to a misdiagnosis as prostatitis. Fortunately I went to a forward thinking urologist who re-diagnosed it as pelvic floor disorders. I have been seeing a compassionate female PT who has done a world of good. So often a good PT can do so much more than drug dispensers.

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