When I first discussed sharing Tyler’s story on this blog, we talked about why men are not aware of pelvic floor PT. We talked about how most websites list “chronic prostatitis” or “male pelvic pain syndrome” to define his symptoms. He shared with me what men are most likely typing into Google when looking for treatment for symptoms similar to his. He said, “I would have searched ‘why does the area between my balls and my butt hurt?’” Hence the title of this blog! This is the story of my patient, Tyler (the name has been changed for patient anonymity), including a brief Q&A.
The History of Tyler’s Pain and How He Found PHRC
Tyler is a 30 year old male who first came to PHRC with sharp pain in his tailbone, perineum, shaft of the penis and scrotum that started three to four years ago. He would feel this pain with anything that caused tension in his pelvis including erections, bowel movements and moving from a sitting to a standing position. Six to twelve months prior to his first appointment, he also started experiencing erectile dysfunction, urinary frequency, and waking up at night to pee (aka nocturia). At that time, Tyler was urinating every 1-1.5 hours during the day (normal is 3-4 hours) and waking 1 time at night and at times he would feel pain into the left side of his penis and left testicle. He was pushing and straining to have a 1 bowel movement during the day that was often painful and did not feel complete. In addition to these symptoms, he was experiencing left hip and leg shooting pain that coincided with his tailbone pain.
What was the first thing you thought when these symptoms started?
I did not notice my symptoms at first as they slowly happened. I’ve suffered minor lower back pain for a significant portion of my life and then one day my tailbone started to hurt but I attributed it to getting older. While not old at the time, late 20’s, I knew my body would start going down hill with age, so I just thought it was part of the process. Then I start getting short but sharp cramps in my perineum when I would urinate; this was a sign that something was wrong. At first I thought it was an STI and spoke to a friend, and mentioned offhand some of the other pains I was having and he immediately said that pain is not normal. This is when I decided to bring up the issues with my primary physician in my early 30’s.
Who did you first go to for this problem? Can you give a brief history of the next few steps that took place before you learned about pelvic floor PT?
I went to my primary physician and laid out the issues I was having. Immediately he questioned why I had not brought up these pains earlier, but I responded saying I thought it was something that came with age. He came up with a plan:
- Test for STI – negative
- Go to a urologist to see if there is a prostate problem – No issues
- See a specialist on tail bones – got an mri, nothing wrong
- See a pelvic floor PT – kind of a last thought by my PCP, but worth pursuing if nothing else worked. I had never heard of this and my doctor said that most patients are women typically during or after pregnancy. It is not a path he has recommended for male patients.
After being referred to a urologist and orthopedist, Tyler finally considered pelvic floor physical therapy. His doctor was coincidentally located next door to an endometriosis specialist who frequently referred to pelvic floor physical therapy. His doctor retold the story [to me] at a pelvic health event about how the light bulb finally went off when he realized that men too can have pelvic floor dysfunction. He encouraged Tyler to seek an evaluation with Pelvic Health and Rehabilitation Center.
What was your first thought when your doctor recommended pelvic floor PT?
I hope it works. At this point I had been living with constant pain (manageable but very annoying) and I would pursue anything to resolve the issues and pain. I did no research and went in blind.
Physical Exam and Assessment
After a complete evaluation including an external and internal exam, I understood why Tyler was experiencing these symptoms. Tyler had a very hypertonic pelvic floor. I could hardly complete an internal exam that first day. His hypertonic pelvic floor was the cause of his tailbone pain. His muscles seemed to be in a complete spasm. This makes sense when you think about the things that made his symptoms worse. The pelvic floor contracts when men attain an erection and when we exert ourselves like moving from a sitting to a standing position. The pelvic floor muscles also attach to the tip of the coccyx (tailbone) and pull the coccyx into flexion; think of a dog with a tail between his legs. This flexion of the coccyx can prevent a person from having a normal, healthy, pain-free bowel movement. Because his pelvic floor was severely hypertonic, I included in my plan that he would likely need pharmacological assistance (muscle relaxants) to alleviate his pelvic floor muscle tension. In addition to his pelvic floor hypertone, Tyler had significant connective tissue restrictions surrounding his pelvis and myofascial restrictions with increased muscle tension involving his quadratus lumborum, gluteal, and hip rotator muscles. All of which were contributing to his pelvic floor dysfunction. Tyler had been traveling internationally for nearly 10 years and I believe poor diet, frequent change in time zones and schedules contrubuted to constipation, long bouts of sitting, and poor bladder habits including urinary frequency caused his hypertonic pelvic floor. He also had a history of lower back pain which had improved in the last 5 years with exercise, and while he did not have back pain at the time of his visit a history of low back pain can be an underlying cause of his hypertonic pelvic floor.
In retrospect, are there things in your life or lifestyle at the time your pain started that you now think are related to why you had this pain to begin with?
I now put priority in taking my health seriously with nutrition and fitness. When pain initially started I was not taking the best care of myself and I believe it compounded the pain. It may not have directly made it worse but keeping your body in check will only improve results. I wish I had started addressing pain and taking care of myself earlier. The longer you wait, the harder it gets.
What did you think after that first appointment? What motivated you to return for future appointments?
It was not until I arrived at the PT office that I was informed there is internal work. This is something my primary care should have informed me of. At first, I was a bit put off on the idea of this but my attitude was if it will help make me better physically then it is worth a try.
The first couple of appointments were painful and not in the way you are thinking. It was painful, because my pelvic muscles were contracted…constantly. So work on this part of my body would be similar to when you get treatment for back pain or a sore neck. Just like those types of treatment, improvement is not immediate. It was after the fourth session where I felt minor improvement. I am now four months into treatment and I can see the end in sight. I feel much better now, and it is hard to remember what the pain was like. My back and tailbone pain is almost non existent, and I no longer get shooting pain in the lower half of my body.
My Plan and Goals for Tyler
It was clear to me that the cause of Tyler’s symptoms was musculoskeletal. My plan was physical therapy one time a week for eight weeks. With every patient, we are closely monitoring their progress in every visit to make sure they are progressing as expected. This is why we set short and long-term goals for our patients.
My short-term goals were:
- Reduce PF hypertone to moderate to reduce pain and improve function.
- Patient tolerates internal manual therapy.
- Patient has one BM per day without pushing and straining.
- Patient voids every two to three hours during the day without pain.
My long-term goals were:
- Normalize PFM tone to eliminate coccyx pain and improve sexual function.
- Patient urinates every three to four hours during the day and wakes zero times most nights.
- Patient has pain-free bowel movements.
When I saw Tyler for the second appointment, I encountered the same issue when attempting to work transrectally on his pelvic floor muscles; they were so tight that he could hardly tolerate insertion or palpation. I quickly realized that I was going to need some reinforcement and contacted his doctor. I asked if he would be able to prescribe a 10mg valium suppository which he quickly did since he was looking for any way to help Tyler in his situation. I advised that he use these suppositories at times when he was having significant pain or discomfort (a day when he had a difficult bowel movement, sex, or was sitting more) and the night before coming into PT.
In addition to pelvic floor PT and valium suppositories, I recommended some lifestyle changes for Tyler. I instructed him how to properly use a foam roller on his inner thigh and buttock area. I taught him how to perform a pelvic floor muscle drop, proper bowel and bladder habits, and advised he start stretching exercises like certain yoga poses (child’s pose, downward dog, happy baby, etc.). For more information on exercises for pelvic pain, click here. He was having trouble explaining his bladder symptoms, so I also had Tyler complete a bladder diary to get a better idea of his regular habits.
The Turning Point in Tyler’s Recovery
After six visits, I noticed the external findings were improving significantly and Tyler was reporting improvements in his urinary urgency, voiding, and nocturia; yet, his pelvic floor hypertone persisted and his biggest complaint continued to be tailbone pain. At this time, I suggested we try 30 minute appointments twice a week instead of a 60 minute appointment once a week. In each 30 minute session, I would focus solely on his internal pelvic floor tone and coccyx mobility. After the first week, he noticed a 10% reduction in the intensity of his tailbone pain. After two weeks, I noticed a significant improvement in his PF tone and he reported the pain had reduced from sharp to a dull ache but was still very consistent. After five weeks of appointments twice a week, Tyler came in after driving in the car for a few hours without any tailbone pain the day prior. This was a huge achievement! Ultimately, increasing the appointment frequency was a major turning point in his plan of care. After the sixth week of bi-weekly appointments, I recommended we return to weekly to start decreasing his PT frequency and improve his independent management of his pain. This is where we currently are in his plan. At this point, we have eliminated his sharp, shooting pain, nocturia, pain during bowel movements, and tailbone pain.
Was there anything that you were given in PT or by your doctor or other providers that you think significantly helped with your recovery?
Reassurance that treatment will help. Confronting any physical therapy can be tough physically and mentally but the ends justify the means. I wish I could have done this earlier because my life has significantly improved. My mobility is better and I do not have the constant weight of pain bringing me down.
In closing, I will share Tyler’s final comments and advice:
– For males, the internal work may be a non-starter due to personal reasons or what friends and family may think. I have been dealing with this, and whenever I am teased about getting internal work I always flip the situation on them. For example, I would say “if you had constant pain and there was a slightly uncomfortable way to fix it, would you?” The answer is always yes.
– If you think you may suffer from pelvic dysfunction, I would suggest researching symptoms. I had no idea and had to visit a lot of specialists before I found out I had pelvic dysfunction. I wish this was addressed for me more, but I believe most professionals think any issues in that region usually involve the prostate. So if there are no issues with your prostate, you may be out of luck unless the specialist knows about male pelvic floor dysfunction.
I hope that those reading this find a glimmer of hope in their current pain or symptoms. Symptoms of bladder, bowel, and sexual dysfunction are very real, physical problems and they can be treated. Tyler’s case is a clear example of this. To read a little more about male pelvic pain, check out our book Pelvic Pain Explained. If you are suffering from similar symptoms, do not hesitate to seek help directly from your doctor, healthcare provider, or physical therapist. In many states, a doctor’s referral is not necessary to seek an evaluation with a physical therapist so I suggest calling the PT directly to discuss if this treatment is right for you.
Additional reading, resources, podcasts, and videos: