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A Male Malady

Dysfunction in pelvic floor muscles is increasingly common in men

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Pelvic floor dysfunction in males is much more common than once believed. Studies show that 95 percent of cases of chronic prostatitis in men is nonbacterial1, and could indeed have a musculoskeletal origin.

Dysfunction and spasm of the pelvic floor muscles can cause symptoms that mimic prostatitis by causing pain and urinary symptoms. Because there had been almost no research done in this field until the last ten years, the topic of male pelvic floor dysfunction is rarely discussed and often misdiagnosed.

Fortunately, increasing numbers of physical therapists are learning successful treatment techniques for pelvic floor dysfunction through continuing education courses that are specific to male pelvic pain.

Symptoms of Male Pelvic Floor Pain

Men have pelvic floor muscles too. Male pelvic floor dysfunction includes pelvic pain, bladder, bowel and sexual dysfunctions. Symptoms can range from incontinence and/or decreased ability to arouse and orgasm due to hypotonic (weak) pelvic floor muscles, to symptoms of hypertonic (increased tone) pelvic floor muscles, such as urinary and/or bowel frequency, urgency, retention, sexual dysfunction and/or pain.

Men can also do Kegels to strengthen weak pelvic floor muscles to improve continence and sexual function. Men may suffer from hypertonic (increased tone) pelvic floor muscles, which can also be addressed through various physical therapy techniques. Leading causes of male pelvic floor dysfunction include trauma, surgery, poor posture, heavy weight-lifting combined with straining of the pelvic floor, poor motor control, bike riding, sitting on hard surfaces for prolonged periods, and more.

The patient may describe the pain as sharp, shooting, stabbing, burning, dull, achy, etc., in the area of the genitals, abdomen, back and/or hip region. These symptoms, which are similar to what men describe with type III B prostatitis or non-bacterial prostatitis, are commonly the result of a musculoskeletal disorder2,3.

 

Manual Therapy, Misdiagnosis and Medication

Manual therapy, biofeedback for relaxation of the muscles and behavioral modifications have been shown to greatly reduce symptoms4,5,6,7,8,9,10. The book, Heal Pelvic Pain, states "a number of patients who were diagnosed with prostatitis were prescribed antibiotics [inappropriately]. After months of this pharmaceutical regimen-and no relief-they were finally referred for physical therapy and found both an end to their pain and a cure11. Pelvic floor dysfunction can start as early as childhood and can occur as late as the elder years.

Unfortunately, due to the lack of understanding and awareness of the musculoskeletal component of male pelvic pain by the medical community, there have been a lot of misdiagnoses given, unnecessary surgeries performed, and medications prescribed, which sometimes worsened patients' symptoms.

As specialists in the musculoskeletal system, physical therapists can treat pelvic floor weakness through strengthening and biofeedback. They can also treat hypertonic (increased tone) problems of the pelvic floor muscles similar to if the patient has trigger points or increased tone or nerve irritation in the back or neck. The increased tone or spasm can result in decreased range of motion and/or pain in the pelvic region. And, because these muscles surround the urethra, anorectal area and prostate, a dysfunction in these muscles can disrupt normal urinary, bowel and sexual function. 

Physical therapy treatment commonly includes manual therapy, nerve glides, skeletal (structural) alignment, postural re-education, modalities, biofeedback, behavioral training and therapeutic exercise.

Educating the Public

Physical therapists need to continue to educate the general public and other health care providers on the musculoskeletal dysfunctions of the pelvic floor in men, women and children. Since physical therapists are experts in the musculoskeletal system and are able to obtain advanced training in pelvic floor rehabilitation, they are knowledgeable in ways to stretch, strengthen, relax and retrain these muscles to avoid or eliminate dysfunction. 

As this is still a new field, there are also vast opportunities for more research to improve our understanding and interventions. 

Causes of Prostatitis

The Prostatitis Foundation notes that prostatitis is not completely understood. Even among the most highly regarded experts, there is controversy. At the moment, there are three main schools of thought when it comes to the causes of prostatitis.

  1. Bacterial infection
  2. Auto-immune response or disordered immune response
  3. Neuromuscular, tension or physical injury problem

Additionally, prostatitis might also be caused by a uric acid disorder, prostate stones, a urethral stricture, a rare tumor, prostate cancer, benign prostatic hyperplasia (BPH, non-cancerous growth of the prostate), a food allergy, a yeast infestation, a specific yeast problem from the Genus Candida, or a virus

Knowing the cause of a patient's prostatitis can help them get cured. Unfortunately, doctors cannot cure all patients, as there is no clear path that works for everyone.

References

1. Nickel, J.C. et al. Prevalence of prostatitis-like symptoms in a population based study using the national Institutes of Health chronic prostatitis symptom index.  J Urol, (2001)165: 842.

2. Schmidt, R., Tanagho, E.  Urethral Syndrome or Urinary Tract Infection?  Urology (1981) 18: 4: 424-427.

3. Schmidt, R., Vapenk J. Pelvic Floor Behavior and Interstitial Cystitis Seminars in Urology (1991) 9: 2. 154-9.

4. Weiss, Jerome, M.  Chronic Pelvic Pain and Myofascial Trigger Points.  The Pain Clinic.  2000; 13-18.

5. Travell, J., Simons, D.  The Trigger Point Manual. Vol 1.  Baltimore, Md:  Williams and Wilkins; 1983.

6. Fitzgerald, M.P., Kotarinos, R. Rehabilitation of the short pelvic floor floor.  II: Treatment of the patient with the short pelvic floor.  International Urogynecol J 14.: 261-268. 2003.

7. Travell J., Simons, D.  The Trigger Point Manual. Vol 2.  Baltimore, Md:  Williams and Wilkins; 1992. 

8. Anderson, R. et al.  Integration of Myofascial Trigger Point Release and Paradoxical Relaxation Training Treatment of Chronic Pelvic Pain in Men.  Journal of Urology. Vol 174; 155-160. 2005.

9. Thiele, G. Coccygodynia and pain in the superior gluteal region. JAMA 1937;109:271-1275.

10. Weiss, J.M. Pelvic floor myofascial trigger points: Manual therapy for interstitial cystitis and the urgency-frequency syndrome. J Urol;166:2226.

11. Stein, A.  Heal Pelvic Pain. McGraw-Hill, (2008).  p. 154.

 

 


 

I noticed many comments on here seeking assistance in finding a qualified Pelvic Rehab Physical Therapist who can work with male patients and perform internal evaluation and treatment techniques. A great resource for this information is the American Physical Therapy Association's (APTA) Section on Women's Health (SOWH) "PT Locator" feature. You can enter your geographical area and there is a feature to select the diagnosis (i.e. pelvic pain, male incontinence, etc). Here is a link to it:

http://www.womenshealthapta.org/pt-locator/

Another resource is the APTA more general "Find a PT" that does allow you to search by specialty.

http://www.apta.org/apta/findapt/index.aspx?
navID=10737422525

Lastly you could contact the APTA SOWH directly and ask them to put you in touch with the SOWH representative for your state - they are a great resource for networking and finding a provider in your state.

As a Physical Therapist who works with men's health issues I understand how critical it is to find a skilled provider for these specialty cases. Good luck!

Kira Boyd,  MSPT,  Synergy Physical Therapy & Sports MedicineFebruary 17, 2014
Jacksonville , NC



All - TONS of the issues surrounding prostatitis, pelvic pain and rectal pain in males go mis-diagnosed. I have had a similar story to all of you. The correct perscription is 2MG of Valium 3x a day (this reduces muscles spasm and this dose will not give harsh side effects). Additionally, warm baths and manual therapy via internal trigger point release is needed. Also, you can get injections into your trigger points externally. Please do not think you have to live with this because you do not. It takes a while to heal usually 3-6-9 months. However, have hope and be faithful you will be cured. I have been doing Valium 2MG 3x a day, PT 2-3x a week and injections 1x every 3-4 weeks. Symptoms have gone done after having HORRIBLE PAIN for 3 straight months.

Justin SNovember 08, 2011



Hi --

I have had pelvic pain for sometime resultant from a combat injury.
I had a PT who had solved the problem but she has moved to the northeast. I have tried others with no relief. I need a PT who is not afraid to rovide the internal manual therapy I need. Any takers in East Tennessee. Email rbainbridge1@gmail.com

Thanks

Richard October 25, 2011
knoxville, TN



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