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16 Articles in Volume 19, Issue #6
Can CGRP Help Clarify Why Migraine Is More Common in Women?
Case Report: Managing Chronic Pelvic Pain in Men
CGRP Monoclonal Antibodies for Chronic Migraine: Year 1 of Clinical Use
Chronic Pelvic Pain as a Form of Complex Regional Pain Syndrome
Correspondence: Continuing the “Pain Specialist” Dialogue
Endometriosis and its Misunderstood Etiology
Evolving Management Strategies for Osteoarthritic Pain
Gamma PEMF Therapy: A Pilot Study For Its Use in Managing Opioid Addiction
Guest Editorial: Sex Differences in Pain
How to Provide Effective Pain Management to LGBTQ Individuals
Interscalene Peripheral Nerve Stimulation for Post-Operative Chronic Shoulder Pain
New ICD-11 Codes Set to Improve Pain Care in the Primary Setting
Perspective: Could NGF Antagonists Be the Safest, Most Efficacious Class of Drug We Have to Treat Pain?
The Sex Question in Primary and Pain Care
What is capsaicin’s role in treating osteoarthritis?
When Pain Clinicians Have to Be the Villain: Communication Strategies to Bridge the Divide

Case Report: Managing Chronic Pelvic Pain in Men

Pelvic floor physical therapy is used to treat chronic pelvic pain in a male patient.
Pages 45-49

Pelvic pain in men, often referred to as chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS), is common among men of all ages and is defined as “urologic pain or discomfort in the pelvic region, associated with urinary symptoms and/or sexual dysfunction, lasting for at least 3 of the previous 6 months.”1 Often, multiple providers are necessary to provide adequate treatment for these patients. CP/CPPS affects men worldwide, with a prevalence between 2 and 16%; and is the most common urologic disease in men under 50 years old.2

This retrospective case report aims to present common symptoms in males with chronic pelvic pain highlighting the importance of a thorough musculoskeletal (MSK) exam, utilization of manual therapy techniques to treat myofascial and/or musculoskeletal dysfunction, as well as utilization of a multidisciplinary approach.

The Patient

A 27-year-old male patient presented to physical therapy with multiple symptoms (see Table I) following a surgical repair of an anal fissure 8 months prior. He was recommended by his colorectal surgeon to use various ointments, sitz baths, and a sitting cushion. Sitting, bowel movements, and sexual intercourse worsened his pelvic, abdominal, and lumbar pain. He previously sat for long hours at a sedentary job; although, he recently transitioned to a sit-to-stand desk. He rarely exercised during the week. The summary of his objective findings at his initial evaluation are presented in Table II.

Overall, the patient presented with multiple objective findings that were likely contributing to his symptoms. His postural presentation represented years of poor postural habits which had led to muscle imbalances, neural tension, and poor breathing patterns. He worked at a sedentary job and rarely exercised; these factors combined were likely the cause of his low back pain, neural tension, and poor pelvic positioning. Additionally, his history of constipation, anal fissure, and recent surgical procedure were contributing factors to his pelvic floor muscle (PFM) hypertonicity. The presenting symptoms, combined with the noted objective findings, were deemed to have led to muscle hypertonicity, myofascial restrictions, and trigger points resulting in chronic pelvic pain as well as urinary, sexual, and bowel dysfunction. His pain distribution and positive Tinel’s test further indicated the likely involvement of the pudendal nerve in the patient’s conditions and pain.

Plan of Care

Manual therapy techniques are often used to address MSK findings and myofascial trigger points (MTrp), the latter of which is defined as “a hyperirritable spot in skeletal muscle that is associated with a hypersensitive palpable nodule in a taut band,” according to Simmons and Travell, and may result in shortened tissue.3 Physical therapy and the treatment of myofascial trigger points have been shown to reduce pain and improve function in this population.4-7

Physical therapy was recommended 1x/week for 12 weeks initially, after which a re-evaluation would determine continued frequency and duration. Treatment was to consist of myofascial release/connective tissue mobilization and muscle trigger point release to both external and internal musculature, pelvic floor relaxation techniques, postural strengthening, lifestyle modifications, and a referral to a pain management specialist for pudendal nerve block.

The plan of care aimed to address the patient’s goal of eliminating, or at least managing, his pelvic pain and being able to tolerate sitting.

Short-term goals (8 to 12 weeks) included:

  • Improve pelvic floor awareness to identify periods of involuntary clenching and to recognize triggers.
  • Reduce connective tissue restrictions by 50 to 75% to reduce tension and pain throughout pelvis, abdomen, and lower back.
  • Normalize pelvic floor muscle tone to reduce recurrence of muscle trigger points and myofascial restrictions and to help restore urinary, bowel, and sexual functioning.
  • Normalize pelvic floor motor control to reduce periods of “clenching.”
  • Eliminate MTrp to reduce referred pain.
  • Provide postural education to decrease lower back pain and optimize pelvic floor function.

Long-term goals (12 to 24 weeks) included:

  • Be able to tolerate sitting for at least 2 to 4 hours w/ or w/o assistance of cushion to accommodate driving and working with no greater than a 2 out of 10 rating for low back pain.
  • Patient will report no pain with urination, post-ejaculation, and post-intercourse .
  • Patient will report pain-free, normal bowel movements (no constipation).
  • Patient will have reduced and manageable lower back and pelvic pain.

Patient will understand musculoskeletal contributors to pain and be able to self-manage with use of learned exercises/tools during periods of exacerbated symptoms.

Treatment

Weeks 1 to 8

During the initial eight visits with the patient, the focus was on reducing the physical findings, providing patient education regarding chronic pain, and improving self-awareness of habitual patterns. Additionally, referrals were made to an interventional pain specialist who focused on chronic pelvic pain; unfortunately, this provider was out-of-network for this patient and referral was then made to a general pain management specialist within his insurance network.

The patient’s primary symptom after 8 weeks was burning in his perineum with prolonged standing or sitting. He saw both a general pain management doctor as well as the out-of-network pain specialist during this time in addition to weekly physical therapy. The findings from the pain management specialist confirmed the diagnosis of pudendal neuralgia as well as pelvic floor dysfunction and recommended alpha-2 macroglobulin (A2M) injection of pudendal nerve and levator ani muscles (mm) bilaterally. (Medications, as well as nerve blocks, have been used in the management of pudendal neuralgia.8) Additionally, the patient was recommended to take 300 mg gabapentin per day as well as 7.5 mg of meloxicam as needed up to two times per day. He never took the gabapentin; he did take the meloxicam. See Table III.

Pudendal nerve blocks are usually image-guided; in this case, the block was guided by ultrasound and injected into the pudendal nerve through Alcock’s canal. In addition to the injection to the pudendal nerve, the levator ani mm group was injected with A2M. Typically, pudendal blocks consist of an anesthetic and a steroid. A2M offers an alternative, anti-inflammatory approach to managing neuropathic pain aimed at reducing inflammation around peripheral nerves that may be contributing to peripheral and/or central sensitization. As Shrikhande explained, A2M is a protease inhibitor that inactivates proteinases, inhibits fibrinolysis, and inhibits coagulation essentially by eliminating or decreasing inflammation through the binding to growth factors and pro-inflammatory cytokines.9

Weeks 9 to 16

Weekly physical therapy appointments continued as the patient was making steady improvements; he still presented with myofascial and musculoskeletal restrictions. We continued to address these restrictions. During this time, he received a bilateral pudendal nerve block, reporting 100% relief of pain initially followed by significant tenderness and pain along innervation of the pudendal nerve. He noted that his pelvic pain when sitting or when under stress was exacerbated after his block. During flares, he demonstrates worsening tissue restrictions, right gluteal clenching, and pelvic floor muscle spasms. He was given a course of meloxicam, an NSAID, which seemed to significantly reduce the burning pain felt along the sit bones and in the perineum.

During these eight weeks, the patient’s symptoms and tissue restrictions were inconsistent. Patient reported good and bad days but was able to work and enjoy recreational activities, such as dancing. His increase in physical activity could have also contributed to his symptoms; during his initial eight visits, he was only performing normal activities of daily living.

Figure 1. Demonstration of a D2 PF (diagonal 2 proprioceptive neuromuscular facilitation) drop exercise for the pelvis/leg.

As his symptoms improved and grew stable, the frequency of his physical therapy appointments decreased from weekly to every 1 to 2 weeks to concentrate on remaining objective findings and on increasing his ability to perform home exercises and self-manage his pain. The patient was very consistent with compliance and shared that he felt significant relief after performing such exercises.

Primary complaints continued to be perineal burning specific to the left side and sit bone pain when sitting, as well as some rectal tightness correlated to prolonged sitting. At the end of Week 16, he reported no urinary symptoms or abdominal discomfort. He was preparing for an international trip and was concerned about the prolonged sitting on the plane.

Referrals were made to continue seeing the pain management specialist and for acupuncture. Because CP/CPPS affects multiple body systems, including urinary symptoms, researchers have looked at acupuncture as a form of complementary and alternative medicine in this population as acupuncturists have been addressing urinary symptoms for many years. A systematic review by Zongshi, et al,10 demonstrated that acupuncture was superior over sham treatments in improving overall function and decreasing symptoms. Placement of needles differs between acupuncturists but can often include areas of pain or MTrp as well as meridians such as the bladder meridian and acupressure points.

Figure 2. Demonstration of foam rolling using hip external rotators.

Weeks 17 to 24

Prior to traveling, the patient reported a lot of constipation which led to a flare of urinary symptoms and pain in distribution of the left pudendal nerve. He consulted with his pain management specialist regarding the use of valium suppositories to aid in pelvic floor muscle relaxation; he reported that these were somewhat helpful, and also continued to take the meloxicam prn up to 2x/day. Following return of his international trip he reported minimal symptoms until he experienced diarrhea and constipation, valium suppositories were very helpful in reducing major flares.

Overall symptoms were stable and were primarily perineal and sit-bone pain with prolonged sitting and flares with gastrointestinal disturbances/poor diet.

Figure 3. Demonstration of foam rolling using the adductors.

Long-Term Plan of Care

The patient was advised to undergo pelvic floor physical therapy every 2 to 4 weeks focusing on manual therapy to reduce remaining myofascial restriction. In addition, within the clinic, he worked on down training of the glutes and pelvic floor as well as continued postural re-training as tolerated. The patient was advised to continue his home exercise program as well.

He eventually was able to manage symptoms in order to just receive physical therapy care once per month. He was able to work, drive, exercise, and have sex with minimal to no symptoms, which would last no more than 1 to 2 days. His symptoms only flared when knowingly sitting for prolonged times and extended driving. After a few months, he returned to the physical therapy clinic for help with a flare that lasted longer than a couple of days; within 2 to 3 visits he was back at his baseline and able to maintain. In addition to his behavioral changes, which included minimizing sitting time, stretching after prolonged sitting, and continued use of his cushion, he began to eat healthier (eliminated gluten), starting using an oral CBD product, and began to exercise regularly at a gym.

Discussion

It is worth noting that, although males and female genitalia and physiology differ, both genders’ anatomy are quite similar. There may be different etiologies in the mechanism of pain onset, but both are evaluated similarly with a thorough history and detailed examination using similar evaluation techniques looking at both external and internal tissues. The largest difference is that in order to evaluate and treat the pelvic floor in a male patient, it must be done via the rectum whereas access to the pelvic region in female patients is through the vagina; however, there may be cases when rectal evaluation and/or treatment is necessary.

The male patient presented herein was seen for an extended period of time to address his MSK findings, stemming from chronic prostatitis/chronic pelvic pain syndrome. He had symptoms from multiple body systems and required the care of a physical therapist, pain management specialist, colorectal surgeon, and acupuncturist. Ultimately, with physical therapy and other modalities, he was able to completely eliminate his constipation, pain with bowel movements, and urinary dysfunction. He met his goal of being able to reduce and manage his pain and his symptoms so that he could participate in daily activities, exercise, and having pleasurable sexual relationships. He continues to have lower back and perineal pain if he sits for too long of a time; however, his flares of pain are short-lived and he has the tools to manage his symptoms. Considering that most of his symptoms resolved except for the pain, which is complex, he may have a component of central sensitization and further evaluation with a pain specialist may be helpful; however, the patient reported that he was able to manage his symptoms without further medical care.

Last updated on: October 8, 2019
Continue Reading:
Chronic Pelvic Pain as a Form of Complex Regional Pain Syndrome
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