This one is for the guys. While 75-80% of the patients I treat are women, I do treat quiet a few male patients. The number one reason that men come to me for treatment is for chronic pelvic pain syndrome, often diagnosed as “chronic non-bacterial prostatitis”. Now this diagnosis can be really confusing. “Prostatitis” means “inflammation of the prostate gland”, but in many cases it has nothing to do with the prostate at all. Symptoms of “prostatitis” include pain in the area of the prostate (perineal, testicular, penile, lower abdominal) and difficulty with, or painful, urination. The National Institutes of Health (in the USA) breakdown the diagnosis of prostatitis to 4 categories
- Category I: Acute bacterial prostatitis
- Category II: Chronic bacterial prostatitis
- Category III: Chronic pelvic pain syndrome (CPPS)
- A. Inflammatory
- B. Noninflammatory
- Category IV: Asymptomatic inflammatory prostatitis
The patients that I treat typically fall into the Category III, Chronic Pelvic Pain Syndrome which makes up to 90-95% of patients diagnosed with prostatitis. This category may or may not have anything to do with the prostate. NIH describes type III as:
|Irritation with urination, without indication of urinary tract infection (for over 3 months duration). The prostate may be normal or enlarged, but not tender. Chronic pelvic pain may include, perineal, lower abdominal, penile, testicular, rectal and lower back, pain and may include ejaculatory pain.|
90-95% of cases of “prostatitis” are non-bacterial (category III) Yet, surprisingly, even with only 5-10% of cases actually showing an infection in the prostate, antibiotics are still the most common treatment prescribed for all patients with prostatitis in the US. I can attest, that most of the patients that eventually come to see me have been on 4, 5 …or more courses of antibiotics, with no success. Although antibiotics are very necessary for the treatment of bacterial prostatitis , they are not effective for non-bacterial categories.
So why do doctors still prescribe antibiotics?
This may be from the notion that there may be a hidden, undetected infection that is the cause of the pain. Or it may be from lack of knowledge about other possible treatment options.
So if it is not an infection, what is it?
There have been research studies trying to determine the “one” cause of chronic pelvic pain. Is it neurological? Is it hormonal? Is musculo-skeletal? Is it psychological? While all of these have shown some relationship, none have provided us with the “smoking gun”.
The most effective model that I have seen so far for treating patients with prostatitis is the UPOINT model (J.C .Nickel, et al). Although there is plenty room for improvement, the UPOINT model is a good start and shows good improvement in dealing with this challenging condition.
The UPOINT model suggests that there may be multiple different factors that contribute to ongoing pelvic pain in men. It suggests that treatment recommendations should be individualized to the patient, based on their clinical findings. This should include a team approach including medication, physical therapy and psychology when indicated.
Pelvic physical therapy has been shown to be very effective treatment for pelvic floor muscle pain (Tenderness), with very little risk. However, what is not shown on this (medication dominant) table is that physical therapy treatment can also have a positive impact on the urinary, psychosocial and neurologic components.
Now, don’t get me wrong, I am not a psychologist and I don’t pretend to be! I do work closely with several counselors who provide amazing care. However, we do know that simply providing education, a supportive environment, and reassurance, we can significantly reduce psychological distress, and may be appropriate for those with only mild clinical findings in the psychosocial category.
We also know that appropriate exercise, breathing, mindfulness and relaxation training can have a significant effect on the nervous system , which may be better tolerated than any of the medications recommended to address these same issues. Concerning urinary symptoms, I have seen with many patients, that if they improve the function of their pelvic floor muscles, the urinary urgency, frequency, and incomplete emptying can resolve.
So, my wish list is this:
1) I would like to see more physicians using a modified UPOINT model to guide care for men with prostatitis. ( please consider non-mediation options before medication options, when appropriate)
2) I would like to see more physicians assessing the pelvic floor for tenderness to help know when to refer to physical therapy.
2a) And for those physicians that don’t feel competent in assessing the pelvic floor muscles, I would like to see them connect with one of the amazing pelvic floor therapist all around the world that would happily work with them 🙂
3) I would like for more men with prostatitis get appropriate early treatment, so that they don’t have to suffer for months or years with this distressing and debilitating condition.
If you share these wishes with me, please share this information!
Please contact me at firstname.lastname@example.org with any questions
One of the most common reasons patients are referred to me is for dyspareunia, which means “pain with intercourse” Dyspareunia is much more common than most people realize. Research has revealed that any where between 15% to 60% of women have pain with intercourse. Some, have pain just occasionally, and others have always had pain with sex. Although there are many things that increase the likelihood of dyspareunia, such as sexual abuse, endometriosis, and menopause, many times we don’t know what the initial cause is. The most startling thing is, most women do not discuss this issue with their doctors or other healthcare providers. Some may be embarrassed to mention it, or think that nothing can be done to help.
Luckily, with treatment, pain with intercourse can be reduced or even eliminated
The impact of dyspareunia can go far beyond the physical discomfort of the woman. It can have a negative psychological effect on self esteem and sense of value as a wife or partner. It can have negative effects on relationships, as women may avoid any intimacy for fear that it may lead to sex. Surprisingly, many women continue to engage in sexual intercourse despite pain. This can be for many complex reasons, varying from trying to maintain a closeness to their partner, to fear that their partner may cheat or leave the relationship.
Treatment needs to address the physical, emotional and relationship aspects of painful sex
One common factor that contributes to pain with sex is pelvic floor muscle tightness or muscle spasm. The walls of the vaginal canal are formed by the pelvic floor muscles. These are the same muscles that are responsible for controlling bladder and bowel function. During intercourse, a pelvic exam, or child birth these muscle need to be able to relax and stretch to allow the vaginal canal to open and widen. The ability of these muscle to be able to relax and contract without pain or muscle spasm is very important for sexual activity and sexual pleasure.
Injury to the pelvic girdle, childbirth, or a negative sexual experience can all contribute to physical strain or injury to the pelvic floor muscles. The pelvic floor muscles are also highly reactive to emotional stress. Part of the the body’s natural fight/flight response to a potential threat is to tighten the pelvic floor muscles. Just like a scolded dog will pull its tail between its legs, we tighten our pelvic floor muscles when we are upset or fearful. In our 24-7 society, many people spend most of their day in a low level fight/flight response. This can have a significant impact on the pelvic floor muscle’s ability to let go and relax with sexual activity.
How can pelvic physical therapy help?
Pelvic floor physical therapists have many options available to address pelvic floor muscle issues. Manual therapy can be used to address trigger points, muscle or fascial tightness, muscle spasm and guarding, of the pelvic floor muscles or any surrounding muscles that may refer pain. Biofeedback can be used to see if the muscles are contracting involuntarily, and can be useful when practicing exercises that help to decrease this involuntary activity. Breathing exercises can be used to help relax and lengthen pelvic floor muscles. Exercises or manual treatments that address issues in the spine, pelvis and hip can address orthopedic issues that may be contributing to pelvic floor muscle tightness. A pelvic floor physical therapist can help you identify what self treatment options are right for you such as, use of vaginal dilators, positioning modifications, self massage or a home exercise program.
What should I expect from my first physical therapy appointment?
During your first appointment, I want to take a very thorough history. Just like any other pain condition, it is important to know when it started? what makes it better? or worse? what treatments have you tried? and did they help?. I also what to know about other medical conditions, injuries, any medical tests or medications. I always do a thorough orthopedic evaluation, looking at posture, range of motion, and overall mobility. Issues in the spine, pelvic joints or hips can all affect the pelvic muscles. In some cases simply addressing these issues can resolve pain.
Lastly, a pelvic floor muscle exam is extremely helpful in identifying pelvic floor muscle issues and is often considered essential for the treatment of dyspareunia. However, with many years experience providing “trauma sensitive care” for patients with pelvic dysfunction, I realize that staying within a patient’s comfort level is way more important than the information gained in doing an internal pelvic muscle exam. I will do vaginal or rectal pelvic floor muscle evaluation if the patient is both physically and emotionally ready. There are many treatment approaches that we can offer that don’t require vaginal or rectal treatment of the pelvic floor muscles. Direct pelvic floor muscle treatment can be very helpful, but can also be avoided or delayed and indirect approaches can be used instead. Treatment of dyspareunia should always provided with an awareness to both the physical and emotional aspects of pain.
Pain with sex is common, but does not have to be. There are treatments that can help!
Manual lymphatic drainage is a light, specialized massage technique that assists the body in moving and and processing excess fluid, dead cells, bacteria and other substance in the body.
The lymphatic system is part of the immune system. It is made up of vessels and lymphnodes that extend throughout the body. The vessels pick up bacteria, dead cells, extra fluid and other waste products in the body. The vessels then transport this waste to the lymphnodes. The lymphnodes have special cells that kill the bacteria and break down this waste (think waste water treatment plant). Once this waste is properly treated, to not be harmful, it is transported back to the blood system and any remaining waste products are removed by the kidneys or lungs
Under ideal conditions the lymphatic system works perfectly, eliminating harmful substances, maintaining health and fluid balance through out the body. But sometimes the lymphatic system can get over whelmed or injured. During an infection or illness the demand on the lymphatic system can exceed its capacity, and treatment with antibiotics may be need to help restore balance. Injury or trauma to the lympahtic vessels or lymphnodes (think surgery, radiation or severe bruising) can disrupt the normal functioning of the lymphatic system.
Manual lymphatic drainage can help the lymphatic system improve how it is functioning, by stimulation movement into and through the lymphatic vessels or by assisting the body to redirect the movement of this waste around a damaged area to an area that is not injured.
Manual lymphatic drainage is not appropriate during the initial phase of an infection, as the system is already overloaded during this time. Manual lymphatic drainage can be very useful in the recovery phase after an illness or injury, or with helping to manage chronic conditions.
Although most often known as a treatment for lymphedema, manual lymphatic drainage can be useful for a variety of other conditions too. Lymphedema is a condition in which there is an impairment or injury to the lymphatic system. Some people are born with an inefficient lymphatic system and may develop persistent swelling in their legs as a child or as an adult. Other people may have surgery that damages the lymph vessels or removes some of the lymphnodes. This is very common during cancer treatment, when the lymphnodes are tested for traces of cancer cells. Manual lymphatic drainage and compression wrapping and garments are the treatment of choice for both of these types of lymphedema.
Manual lymphatic drainage can also be useful in helping the body heal after a sprain, strain or bruise that may cause swelling that overwhelms the lymphatic system. It can also be use for easing the symptoms of chronic inflammatory conditions like rheumatoid arthritis, psoriasis, or even acne. When manual lymphatic drainage was first developed in the 1930’s, it was primarily used to help patient’s recovering from chronic respiratory illness.
There are many training programs in manual lymphatic drainage available for physical therapists, massage therapists or other medical professionals. Therapists performing manual lymphatic drainage should have thorough training in the anatomy and function of the lymphatic system as well as in proper technique. Most certification programs consist of at least 135 hours of direct education. The Dr Vodder School or the Lymphology Association of North America are both good resources for further information
Excellent resource from an amazing therapist!
Many of the patients that I see for pelvic pain come to me very confused and frustrated. Often they have seen 5-10 different healthcare providers for their symptoms. The gynecologist has told them there is nothing wrong with their vagina (females), the urologist has told them there is nothing wrong with their bladder, or prostate (males), the gastroenterologist has told them there is nothing wrong with their colon. Many patients have wondered if it is all in their head, or worse yet, they have been told by a healthcare provider that it may be psychological. Finally, these patients find a knowledgeable provider, who suggest that their symptoms may be muscular….a pelvic floor dysfunction.
Now these patients are even more confused. How could they possibly have a muscle problem when they can’t recall anything that would cause a muscle injury????? They have not had an injury or trauma that could cause the muscles to be injured, especially not there! And besides, it does not feel like a muscle issue, it feels like bladder pain, vaginal pain or testicular pain. Many of my patients will recall, “It started when I had a urinary tract infection”, “I had a yeast infection that just did not get better”, “I had blood in my urine, or in my stool at the same time that it started”, or “it all started when I started/stopped birth control” . This persistent pain may be related to a viscerosomatic reflex.
I first became interested in the concept of viscerosomatic reflex when I studied massage therapy, 15 years ago. We were studying massage techniques based on theories by Anatoli Sherbak, a Russian physician from the 1930’s. He believed organ diseases transmit messages back to a specific spinal segment and are expressed in the form of higher skin density, muscular tension, development of trigger points, high tension and immobility of connective tissue at that same spinal level. He termed this viscero-somatic reflexes. The theory was intriguing, but not really well understood or accepted by the medical establishment in the United States.
In the past few years there has been more basic scientific research that supports this theory. Although ethically, I struggle with the methods of some of these studies (that typically involve inflicting pain in the organs of animal test subjects), the information that they are providing is invaluable to medical fields that treat chronic pain. We are now starting to realize that conditions that affect the organs, can also affect the muscles and connective tissue that share the same spinal cord level. Just like an office with gossiping co-workers, the nerves from an unhappy organ can start to trigger irritation in other nerves that share the same space in the spinal cord. Pretty soon the whole “office” can become disgruntled. Treatments that look at treating only the offending organ can miss the mark if they don’t also address the nerves and the muscles that have been part of that gossiping loop.
Treating chronic pain is like trying to improve morale in an unhappy office. It can be a slow process, and may take many small changes for improvements to be noticeable. Simply appeasing the first complainer does not always make the problem go away. In some cases the initial complainer could appear completely normal, or leave altogether (think hysterectomy). Just like removing one unhappy employee or giving them a sizable raise, does not improve morale of the entire office, simply treating an unhappy organ might not be enough. In addressing chronic pain in the body, we need to evaluate the health of the organs, the nerves, the muscles, the hormones, the blood supply. If we keep in mind that the pelvic organs talk to the pelvic floor muscles through the nervous system, it starts to make a whole lot more sense how chronic pain can develop, and how physical therapy can be helpful for what feels like an organ issue.
Love and Peace,
As promised, here are my tips for better pooping. For people with chronic constipation, the thought of simply going to the bathroom, sitting down and eliminating waste, seems like a fairytale. Many of my patients agonize over this simple task, especially when not being able to go leads to belly aches and severe pain. These tips aren’t a miracle cure, but they can help to get things started in the right direction.
First, timing is important. The digestive tract is most active shortly after eating or drinking. This is due to some thing called the gastrocolic reflex. When food moves from the stomach to the small intestines, this reflex causes the entire colon (large intestine) to increases its activity. There is some indication that larger meals, warm liquids or meals containing fat may have a greater impact on this reflex. Making sure you have time to use the potty shortly after a meal (20-40 minutes) can be helpful. This can be difficult in our hectic life style, where it is common to skip breakfast or “eat on the run”. Establishing the habit of having time to use the bathroom after meals is important, especially for young kids, who are often eager to get back to playing and may ignore the urge.
Second, positioning is important. It is almost impossible to poop standing up. The body is designed to keep the bowels closed during standing. Sitting helps some, but squatting is actually the best. I am a big fan of the squatty potty.
Also remember, little bottoms need a little seat. For small children, a toilet seat insert and a step stool are helpful.
Third, Take Time and Breathe. Slow, deep breathing helps to stimulate the colon and relaxes the muscles that keep the colon closed. Ideally, you should not have to push or strain. But, if you do have to push to get things started, don’t hold your breath. Holding your breath triggers the pelvic floor muscles to contract and closes the rectum. The belly should stay soft and gently blowing out or exhaling can keep the breath moving. A pelvic physical therapist can help teach proper muscle control and breathing patterns to make sure the pelvic floor muscles stay relaxed to allow for easier bowel movements
Last, gentle massage in a down the left hand side of the belly can help to stimulate a sluggish colon. For massage, light and slow works best. Starting at the bottom of the left rib cage slowly stroke downward toward the pelvic bone. Each stroke should take about 3-5 seconds to complete.
Remember, the colon is a slow learner. Be patient! The more consistent you are, the better the colon will be at doing its job.
Love and Peace,
I treat many patients with chronic constipation. Usually, they are referred to physical therapy with the diagnosis of “pelvic floor dysfunction”. The first thing most patients ask is “What does physical therapy have to do with not being able to poop?” I probably should come up with a concise, one sentence response, but I have yet to figure out how to do that. So this is my usual response:
Bowel issues (problems with pooping) can usually be broken down to 2 basic categories. That is transit problems, when things don’t move smoothly through the length of the digestive system, or evacuation problems, when things make it to the end of the digestive system, but there is a problem getting them out. Luckily, physical therapy can (to some extent) help with both of these problems.
First it is important to understand the basics of how the digestive system works. In 3rd grade, my daughter put together a presentation highlighting the basics that she title Taco Meets Mouth, that went something like this. First, food enters the stomach, where acid kills off some harmful bacteria, and the food gets churned up into a watery mush. A little opening at the bottom of the stomach (pyloric sphincter) controls how much of this mush enters the small intestine at a time. This mush gets combined with enzymes from the pancreas and bile from the gallbladder (or liver). These enzymes along with helpful bacteria in the small intestine, break down the food its basic parts. The walls of the small intestine are designed to be able to absorb the basic parts that the body needs, such as carbohydrates, proteins, fats, vitamins and minerals.
Usually about 6-8 hours later, this food “mush” has completed its journey through the small intestine, and the body has absorbed most of the nutrients that it needs. At the end of the small intestine is another valve like structure (iliocecal valve) that controls the flow of this waste mush into the large intestine (aka colon). In the large intestine, a couple of remaining vitamins are removed along with a lot of water. At the start of the of the start of the large intestine, this waste is quite watery, and by the end it should be rather solid. The time that it spends in the large intestine can make a big difference on how soft or hard this waste (poop) is. When it gets to the end of the large intestine (aka colon), it triggers the urge to poop (usually 24-72 hours after entering the mouth) . This is where my daughter’s presentation ended….but not for me.
Under ideal circumstances this urge to poop, should be followed by squatting or sitting in a relaxed position, to allow the colon to do its final job and squeeze out this poop. But, it may not be convenient, nor socially acceptable to just squat and poop where ever you are when the urge strikes. Around the age of 2 years old, the nervous system develops a reflex called the rectoanal inhibitory reflex. This reflex allows us to delay that urge, when it is not convenient, by contracting the pelvic floor muscles. If we are successful in using this reflex, the end of the colon should relax and the urge should subside or go away. Great for social situations, not so great for emptying waste from the body.
Problems can arise anywhere along the path from mouth to, as my daughter called it, “the end of the line”. Spasm in those small valves can cause difficulty for food to move from the stomach to the small intestine or the small intestine to the large intestine. Tightness in the tissue that surround the intestines (visceral fascia) can cause slowing of the movement through the intestines, especially in the large intestine, where the waste becomes solid. Over activity of the pelvic floor muscles can trigger that rectoanal inhibitory reflex and cause the colon to relax and not be able to effectively push the poop out. Or, as I often say, it “slams the door shut”.
Finally, the part that we sometimes forget, is that the digestive tract is controlled primarily by the autonomic nervous system. This part of the nervous system is not under voluntary control. There are two basic sides to the autonomic nervous system, the fight/flight , and the rest/digest part. In a very simplified model when the fight/flight part goes up, energy decreases from the digestive and immune systems and instead goes to the arms, legs, heart and brain. This is a great response if you find yourself face to face with a bear or tiger. Problem is everyday stress can also trigger this response, and too much time spent in the fight or flight response can really harm the body’s ability to rest and digest.
So to get back to the question “what does physical therapy have to do with not being able to poop?” Physical therapists, trained in treating bowel issues, can use exercise or manual therapy to decrease tightness in the visceral fascia around the intestines. They also have special training in using exercise, manual therapy and biofeedback to help patients be able to decrease over activity of the pelvic floor muscles. Finally, there are many different types of exercises and breathing techniques that can help to quiet down or control that fight/flight response.
Keep following, for future posts on simple tips and exercises that you can try at home to help manage bowel symptoms and chronic constipation,
Love and Peace,
Every time I evaluate a new patient (before I do a physical exam) I take the time to review the anatomy in the pelvis. It doesn’t matter if I am talking to an 11 year old and her mother or a nurse or doctor, the response is always the same “wow, I didn’t know that all that was “down there”. Even in my undergraduate physical therapy training, we barely touched on the anatomy and function of what is inside the pelvis.
I usually start from the inside out. Starting with the bony structure, the pelvic is made up with the sacrum in the middle and a pelvic bone on each side (actually each pelvic bone is 3 bones that have fuse together-but that is only important to anatomy geeks, like me).
This ring is held together by ligaments that attach the bones together like tight rubber bands. Some people have really tight ligaments and some people have really loose and stretchy ligaments. If they are too loose and stretchy, it may lead to instability, and possibly greater risk of injury to this area.
Sitting inside this pelvis are very important organs. From front to back, the organs are the bladder, uterus and the rectum. Each of these organs are also suspended by ligaments that attach them to the inside of the bony structure of the pelvis.
These ligaments can also be very tight or very loose. It is also possible that these ligaments can become damaged, during surgery, childbirth or chronic straining (think constipation or frequent coughing)
Luckily, we have some additional support from below these important organs. The pelvic floor muscles (aka levator ani) support the organs from the bottom of the pelvis. These muscle create a hammock or sling from the pubic bone in the front to the tail bone in the back. I think they look more like a bowl that supports the organs from front to back and from side to side
The pelvic floor muscles need to be able to contract, to close off the urethra (bladder opening) and the anus (rectum or bowel opening). They also need to be able to relax to allow the bladder or bowel to empty, or to allow for childbirth or intercourse. The muscles that support the bladder are the same muscles that support the bowel and create the side walls of the vaginal canal. This is why bladder, bowel and sexual issues are so closely related.
Issues can arise when these muscles either don’t contract properly or don’t relax properly. Many of the patients that I see that think they have weak muscles, actually have tight muscles that don’t relax properly.
One more layer down from the pelvic floor is the superficial perineal muscles. These muscles help to keep the rectum closed at rest, and keep the labia (lips around the vaginal and urethra opening) closed, protecting this area from bacteria and irritation. These muscles can also be affected by childbirth or chronic straining.
Sudden hormone changes, such as menopause, birth control, or after child-birth can also affect the flexibility and elasticity of these muscles. It is quite common to see patients who start having difficulty (pain) with sexual activity at these times due to changes in the muscles.
The last thing we review, which is probably the most familiar (but not familiar enough) to most women, is the external genitalia. This includes the labia majora, labia minora, clitoris, urethral opening, and vaginal opening (aka introitus).
I recommend that all women should become familiar with the appearance of this area. There is such a wide variety of what is normal, shape, texture, and color can vary quite a bit. It is very hard to tell if there has been a change, if you don’t know what it looked like before. Most of us would notice a new mole on our face or a lump in our breast, but if something feels different “down there”, could you tell if it looked different too?
Understanding your pelvic anatomy is the first step in understanding and treating any bowel, bladder or sexual issues that you may be dealing with.
Peace and Love,
This is the very first post by NaturaPT. We will be posting about important topics in Pelvic Health and Women’s Health. Your comments and recommendations are appreciated. Please make sure all comments are with constructive intent. It is only together that we can make positive changes in women’s (and men’s) heathcare
Love and Peace,