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,