Pelvic Pain Awareness Month Part 1: What is Pelvic Pain

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Mayis PelvicPainAwarenessmonth

Fiona McMahon PT, DPT

I don’t need to write it out. You’ve already heard it. But I will write it anyway. These are uncertain times. This May, much like March and April, is shaping up to be a May that is very different than ones we’ve ever experienced before. That said, life still marches on. May is Pelvic Pain Awareness month and it seems appropriate to take some time to recognize those who are dealing with pelvic pain as well as spread awareness to what it is and how we can make it better… even in these uncertain times.

What is Pelvic Pain?

Pelvic pain can sound really simple, it’s pain in your pelvis, but let’s explore what that really means. The pelvis is a bowl shaped set of bones, the innominate (literally meaning no name), the sacrum, and the ischium, that connect your abdomen to your legs. Within this bowl lives your reproductive organs, your bladder, and rectum. Surrounding these bones and organs you have this nifty stuff called fascia. Fascia is the organ of shape and helps to both give structures within our body form as well as help them to slide and glide past each other. Like I said, nifty. Also within the pelvis we have muscles, nerves, and blood vessels! It gets really busy down there!

Because there is so much going on in the pelvis, pelvic pain can feel a lot of different ways depending on what structures are involved and even individual differences in how the body feels pain. Pelvic pain can have the feel of a dull ache, which you can feel in your pelvic bones, genitals, and or abdomen. It could also feel sharp and “stabby”, hot and burning, itching,and/or like a bunch of pressure. It can come and go or be a constant sensation. It can be what we call provoked, meaning certain triggers elicit it, or it could come and go seemingly without any obvious cause.

Pelvic pain can come in a lot of different varieties and it can affect everyone, regardless of gender or age. Many people who hear that I am a pelvic floor physical therapist, assume that I only treat postpartum women. The truth is postpartum women are not the only ones who can experience pelvic pain.

People with male anatomy can experience pelvic pain. They may feel burning with urination or climax, pain in the tip of the penis, in the testicles, or in their rectum. Sometimes this pain limits the ability of its sufferer to sit, wear tight clothing, or have pain free sexual experiences Often these symptoms get confused as a bladder, prostate or yeast infection. Although infections can certainly cause these symptoms, many times tight and spasmed muscles within the pelvis can be the culprit. We will discuss this further in part two of this blog.

People with female genitalia can experience many of the same symptoms listed above with obvious anatomical differences. Instead of the tip of the penis, a person with female anatomy may feel pain in their clitoris, or labia. They also may have pain with sexual penetration or arousal. Patients may also experience burning urination similar to the sensation of having a bladder infection. For people who menstruate, the cramps may be so debilitating that they are unable to work or go to school through the pain. All of these different presentations fall into the category of pelvic pain.

Children can also experience pelvic pain. Oftentimes this is caused because of prolonged constipation, but it can also be caused by muscle tightness, and gynecological conditions like endometriosis or lichens planus/ sclerosis.

People with pelvic pain, regardless of age or gender may also experience pain with voiding, either urine or feces, abdominal bloating, and or difficulty sitting.

What Causes Pelvic Pain?

So now that you know what pelvic pain is, what causes it? Many, many, many different things can cause pelvic pain. As we spoke about earlier in the blog, infections can cause pelvic pain. That is why it is important to get yourself in to see a doctor if you are experiencing this type of pain. She will be able to rule out or rule in infections or other medical causes for your pain. Often the problem causing your pain may be musculoskeletal. People with this cause of pelvic pain may not feel relief with traditional medical intervention. The muscles of your pelvis include the muscles of your abdominal wall, your bottom, and the muscles that live between your pubic bone in front and your tail bone in the back, also known as your pelvic floor. These muscles may be in spasm causing the types of pain I described earlier, (yes even the burning urination pain). It may also be that a muscle group in the pelvis itself or supporting the pelvis may be too weak to do its job properly. When this is the case, it is important to get yourself in to see a pelvic floor physical therapist, who can figure out exactly why your muscles are causing your pain.

Although pelvic pain can seem really bleak, there is a lot that can be done to treat it. It’s all about finding the right qualified professional to treat it. At Beyond Basics Physical Therapy we are the experts in pelvic pain and we treat patients from all over the world. We not only treat musculoskeletal causes of pelvic pain, but also work to connect our patients with other professionals who can help to holistically treat pelvic pain. If you have pelvic pain, please remember that there is hope for you.

Alright readers, that’s the basics on what pelvic pain is and what it looks like in different people. Next week we will go Beyond the Basics (see what I did there?) and discuss how to treat pelvic pain, especially pelvic pain caused by muscle dysfunction, in the clinic and even at home.

For more reading on pelvic floor dysfunction please check out these blogs as well as Amy’s books books on pelvic pain

Treatment

How to Deal with Pelvic Floor Pain From Home

What is Pelvic Floor Physical Therapy

What is Myofascial Release and Why do We Always Talk About it So Much?!

For People with Female Anatomy

Endo Awareness Month: How Endo can Affect your Tummy

Endo Awareness Month: Understanding Endo

Endo Awareness Month ( Part 2 of 4) : How Endo can Affect your Bladder

When it Feels Impossible to Have Sex

For people with male anatomy

All About Testicles

What’s Neater Than Your Peter? Burning Urination

Prostatitis What it is and What to do About it

Bladder Health

Pelvic Floor MythBusters! Don’t eat lemon to avoid bladder pain, true or false?

How to Improve Bladder Health

Books By Dr. Amy Stein PT DPT

Heal Pelvic Pain : available here

Beating Endo: available here

The International Pelvic Pain Society (IPPS) is a multidisciplinary group working to promote awareness and education of pelvic pain, if you care to donate, click here

Saggy Jeans and Tailfeathers: How Your Pelvic Positioning Affects Your Body

animal bird blue bright
Photo by Pixabay on Pexels.com

Joanna Hess PT, DPT, PRC, WCS

Wait! Marie Kondo has you throwing out your favorite jeans because the joyless saggy bottoms that your tushy cannot manage to fill out? We are seeing an epidemic flat butt among mamas, plumbers, barre fanatics, and office workers—all with strangely similar symptoms—pelvic floor dysfunction, low back and sacroiliac pain, and a tucked under pelvis. In this blog we will explore why the position of the pelvis, the maker of flat butts and the maker of less flat booties, is important and how to more easily move out of this position for benefit beyond your behind.

Besides needing a new wardrobe, why should I care about my flat bum?

The flat bum or preference towards posterior pelvic tilting shrinks the distance between the front and back of pelvic outlet which changes pelvic floor muscle tension. The body needs access to the full range of the pelvis and pelvic floor muscles. Over time, this position could cause excessive pelvic floor activity to compensate for the loss of resting tension. Think of the pelvic floor muscles simplified as a rubber band between two points, the pubic bone and tailbone. When the distance between the two points decreases, the rubber band loses its stability from resting tension. Changes in pelvic position alters stability from the pelvic floor muscles. This posterior pelvic tilt position also decreases the accessibility for hip extension and therefore the upper glute muscles get sleepy. As the top of the pelvis moves back, the sacroiliac joint in the low back opens and decreases its bony stability. Translated into everyday life, the flat butt position increases the potential for incontinence, pelvic floor muscle tension, sacroiliac pain, and decreased efficiency in movement.

The Flat Bottom. Only in the eye of the beholder?

Pelvic floor and tilt

The disagreement of the “neutral pelvis” or zero-point causes confusion when describing pelvic tilt—anterior pelvic tilt, posterior pelvic tilt, and neutral pelvis. Some argue that the neutral pelvis is when the ASIS’s (front hip bones) are level to the PSIS (back butt dimples). Others say that the pelvis is neutral when ASIS’s are in the same plane as the pubic bone. Or for those with X-ray vision, pelvic tilt is the vector of the sacral angle at S2 in relation to the vertical axis. But often, neutral pelvic position is subjective to the observer and relative to other parts of the body—namely the spine/rib cage and thigh bone. Clinically, this “neutral pelvis” is hard to find because 1) pelvis’ are shaped very differently, 2) left and right pelvis on the same person can also be quite different, 3) feeling these bony landmarks have been shown to be remarkably unreliable, 4) the neutral pelvis should be on top of vertical thigh bones. See how the eyes can be tricked confusing spinal curve focusing on pelvic tilt without also including rib position.

Rib pelvic alignmentThe inability to move in and out of posterior pelvic tilt and anterior pelvic tilt decreases efficiency and possibly results in pain and instability. Anterior pelvic tilt is when the front part of the pelvis moves forward/down. Posterior pelvic tilt is when the front part of the pelvis moves back/up. A neutral pelvis on top of vertical femurs and happy rib cage should correlate with better muscle performance.

Do I have a flat butt?

Aside from the saggy jeans, the flat butts of the world have a few other correlations.

1. The Tailfeather Test: Stand comfortably and squeeze the gluts.

a. Neutral pelvis: Thigh bones rotate.

b. Posterior tilt-ing pelvis: The butt will further tuck under and mainly access the lower glutes.

c. Anterior tilt-ing pelvis: The pelvic floor muscles will do most of the work.

2. You bear weight more in the heels

3. Back of your rib cage is behind your pelvis

4. Your Thigh bones are angled so that your pelvis is front of your knees

5. Your lower belly pooch

6. You Sit with pressure more on the sacrum/tailbone vs. sit bone

7. You have Overactive and possibly overworking pelvic floor muscles—the front to back pelvic distance decreases with your posterior tilted pelvis and loses the resting tension from length. As described earlier, this is similar to tensile strength of a slightly stretched rubber band vs. rubber band without pull/tension. Therefore, your pelvic floor muscles have to work harder to keep some type of tension for purposes like continence, stability, etc. The inability for the pelvic floor muscles to work optimally can lead to incontinence, pain, and constipation.

9. You have Breathing and abdominal pressure problems

10. You have Sacroiliac joint pain. As the pelvis tips back, the sacrum moves away from the ilium decreasing the bony stability. The hip muscles have to work harder, but as felt in the Tailfeather Test, the glut muscles aren’t in a good place to work.

Is there a better fix than butt implants?

Bodies have and love variability for posterior, anterior and “neutral” pelvic positioning. The brain likes positions where muscles and nerves work with ease and stability—life shouldn’t be so difficult—but it needs the chance to choose and learn it. Folks working with bodies have traditionally “corrected” spinal curves by changing pelvic position. From what has already been discussed, spinal and pelvic position can be altered many different ways—from the changing weight-bearing area in the feet, to position of ribs and range of breath, and even head angles with visual and vestibular input. Consider these hacks into pelvic stability until the brain learns how to access this stability in many situations and positions.

1. Standing. Bring your chin down to your neck and keep looking down until you see the front of your ankles. You’ve just untucked your pelvis and brought your ribs over your pelvis. This one is courtesy of my colleague, Stephanie Stamas. Or check in to feel where the weight is going through your feet. The front to middle of the foot is a good place to start and then do the Tailfeather Test. You might have to toggle other parts of the body because of how the body will compensate in the chain.

2. Sitting. Get your hips as far back as possible. Or put a pillow in the back of the chair so that your hips can find the pillow and you are sitting on top of your sit bones. Then, relax the trunk into the seat back/pillow. Again, you’ve untucked your pelvis and brought your ribs over the pelvis.

3. Better squats/lunges/burpees/stairs/ab work. You can do 5 sets of 20 squats, but still no junk? Take care to see if your pelvis is tucking under in the movement. If so, use an inhale to keep the pelvic floor lengthening as your hips bend in movement. Later, the movement should be dissociated with breath pattern (as long as you are breathing.)

4. See a physical therapist. Often times, the habits of pelvic tucking are a little more complicated because it is a protective and compensatory mechanism for stability. A physical therapist can help with seeing the bigger picture and how different parts of the body relate to each other. They can also help facilitate better movement through manual therapy and specialized movement.

Good luck with the joy sparking!

Endo Awareness Month: How Endo can Affect your Tummy

Amy Stein

Beating Endo Cover

March Is Endometriosis Awareness Month. Treating endometriosis and improving the lives of people with endometriosis has long been a passion of Dr. Amy Stein, founder of Beyond Basics Physical Therapy, so much so, that she teamed up with Dr. Iris Orbuch and wrote a book about it! This month we are reviewing some of the major talking points in their book, Beating Endo . For more on endometriosis, check out our past blogs as well as Beating Endo.

Endo Awareness Month: Understanding Endo

Endo Awareness Month ( Part 2 of 4) : How Endo can Affect your Bladder

Endo Awareness Month: Sleep, The Ultimate Self-Care (Part 3 of 4)

This week we are continuing our series on endometriosis. We are highlighting how endo can affect your gastrointestinal system (your tummy) and what you can do about it. As you may recall from our previous blog posts, endo occurs when endometrial like cells occur outside the uterus. These cells can implant themselves within the abdomino-pelvic cavities and its organs causing inflammation and reducing the movement of the organs therein. The symptoms caused by endo in the gut are myriad. These symptoms can often be unpredictable and incredibly frustrating to those experiencing them. These symptoms may also occur regularly or at various points during one’s cycle and can be just as frustrating.

GI symptoms commonly associated with endo include:

  • Bloating
  • Diarrhea
  • Constipation
  • Painful bowel movements
  • Abdominal pain

With all this going on in the gut, there are still some things you can do. The pelvic floor is the “governor” of bowel function. When it contracts, it holds bowel movements in, and when it relaxes, it allows bowel movements out. With endometriosis, and the inflammation and pain it can cause, the pelvic floor muscles often get very tight, which worsens the problems outlined above. Pelvic floor PT can help reteach those muscles to relax and let go, thereby improving your GI symptoms!

How to help your tummy at home:

The I Love You Massage

How to do it:

Flatten your palm, make a fist, or use your fingers, first to trace the letter I in a descending movement from just under your left rib cage to your pelvic bone. Do this ten to fifteen times. Then place your palm, fist, or fingers under the right rib cage and draw the L— right to left horizontally, then straight down to the pubic bone. Again, do this ten to fifteen times. Finally, the U: Start on the right, at the top edge of the pelvic bone, and massage up toward the rib cage, then left across the body, then down to the top of the pelvic bone. Do this ten to fifteen times as well. What you have done is massage the descending colon, the transverse colon, and the as­cending colon, thus stimulating the involuntary contractions that actually move the stool. Use moderate pressure; if it hurts, lighten the pressure. If it still hurts, stop—although even a light massage may cause some soreness at first.

For more, check out Beating Endo!

Pelvic Health 101 is back!

Pelvis Drawing

***In light of current events, and in an effort to keep our community as healthy as possible, we have moved our Pelvic Health 101 (PH 101) seminars from in person to online.  Although we regret not being able to meet everyone in person, we are excited for the opportunity to broadcast information about pelvic floor disorders and how to treat them fair and wide. Please keep an eye on our social media as well as the blog to find out how you can learn more about the pelvic floor.****

Warmly,

The Team at Beyond Basics

 

On March 19th, at 7pm we will be kicking off our spring semester of pelvic health education class, we call Pelvic Health 101 (PH101). In our first class we will be introducing you to the pelvic floor muscles, where they are, what they do, and how they relate to the health and function of your bowel, bladder, and sexual functioning. We will also be covering how things such as alignment, posture, muscle tone and nerves can affect your symptoms. This course is a great starting point to help you understand your pelvic floor and pelvic floor symptoms.

 

New York, NY 10017
Register at: pelvichealth101.eventbrite.com

Here is our line up of this and future classes

ph101 sp 20

 

 

Endo Awareness Month: Understanding Endo

Amy Stein and Fiona McMahon

Beating Endo Cover

March Is Endometriosis Awareness Month. Treating endometriosis and improving the lives of people with endometriosis, has long been a passion of Dr. Amy Stein, founder of Beyond Basics Physical Therapy, so much so, that she teamed up with Dr. Iris Orbuch and wrote a book about it! This month we are reviewing some of the major talking points in their book, Beating Endo. Available here.  For more on endometriosis, check out our past blogs as well as Beating Endo.

Endometriosis is a condition that affects people born with female anatomy. It occurs when a tissue similar to that of lining of the uterus (known as the endometrium) grows outside of the uterus. Seems like a pretty simple definition, but it can cause a whole host of symptoms.

When something that doesn’t “belong” in the body is detected by the body, inflammation will occur. It is this inflammation that is believed to cause the myriad symptoms someone with endometriosis may experience. These symptoms can include

  • Irritable bowel syndrome (IBS)
  • Painful bladder syndrome
  • Pelvic floor dysfunction

One of the confusing things is, you don’t have to have all of these symptoms to have endo and the severity can range. This is Fiona writing, and I’m sure Amy would agree, no two endo patients are alike, and your pain is valid even if your symptoms do not necessarily look like someone else’s’ who is suffering with endo. It is this variability in presentation along with poor awareness within the medical field and public, leading to an average of 7 to 12 years to get a diagnosis.

Endometriosis can only be diagnosed by analyzing the suspected endometrial lesions removed during an excision surgery. There is no other test to confirm it, which can make diagnosis obviously, very difficult.

There is another condition that is called Adenomyosis. Similar to endo, adeno occurs when cells similar to the lining of the uterus occur within the muscular wall of the uterus. Most people with adeno have endo, but it is not always true that most people with endo have adeno. Adeno can show up as heavy periods, low back pain, and pelvic pressure.

Endometriosis is a chronic illness that affects millions of people. There is still a lot to figure out about endo and because of that fact there are many truths, half-truths, and myths floating around out there about endo. Check out some of the myths Amy and Iris busted together in Beating Endo.

Common Endo Myths

The abdominal and pelvic floor muscles are rarely affected by endometriosis.

False: Constipation, frequent urination or retention, pain with vaginal penetration from endometriosis causes tightening of the abdominal and pelvic floor muscles; So too does assuming the fetal position which is our go to pose when we are in pain. Both contribute to tight abdominal and pelvic floor muscles which causes pain.

The pelvic floor and abdominal muscles do not cause bladder, bowel, sexual dysfunction or abdominal-pelvic pain in patients with endometriosis.

False: Tight pelvic floor muscles caused by years of straining or reflexive tightening due to pain, often cause a severe amount of pain which results in further tightening and shortening of the pelvic floor muscles. Good news is that pelvic floor physical therapy benefits most people who have been experiencing abdomino-pelvic or sexual pain and/or are straining due to ongoing bladder and bowel symptoms.

Hysterectomy is a cure for endometriosis.

False: Hysterectomy is neither a treatment nor a cure. By definition endometriosis consists of cells similar to those in the lining of the uterus but found outside the uterus. Only surgical ‘excision’ removes endometriosis cells.

Medical menopause is a cure for endometriosis.

False: Just because your medicines give you hot flashes doesn’t mean your endometriosis is going away. The best treatment approach is to meet with an endo specialist to discuss options, and in most cases PT management. As well surgical excision has much better results than ablation of Endometriosis.

There is no correlation between quantity of endometriosis and severity of disease.

Truth: Even if you have a minimal amount of endometriosis, you can be in debilitating pain with lots of symptoms and in most cases dietary changes, physical therapy and mindfulness practices can help manage a lot of your symptoms.

Teenagers are too young to have endometriosis.

False: Teenagers can have endometriosis and their endometriosis can cause debilitating symptoms.

Pregnancy is a cure for endometriosis.

False: Just plain no. Pregnancy does not cure endometriosis.

Ablation surgery is the same as excision surgery.

False: Not even close. Excision surgery is the proper treatment for endometriosis. Ablation surgery, burns the surface of the endometriosis lesion but leaves the bulk of endometrial implants behind.

Surprising Endo Facts:

Fact: Physical therapy (pelvic PT) can help many suffering from the many pains and symptoms of Endo, including back, abdominal and pelvic pain, bladder, bowel and sexual function.

Fact: The majority of patients with Endometriosis require pelvic floor physical therapy. Pelvic floor PT can be instrumental in the healing process and can help abdominal-pelvic pain, bladder and bowel urgency, frequency, retention, incomplete emptying, and any sexual pain related to the musculoskeletal system.

Truth: Painful bowel movements, constipation, diarrhea and bloating are symptoms of endometriosis as well as symptoms of pelvic floor dysfunction .

Truth: Painful sex is a symptom of endometriosis as well as a symptom of pelvic floor dysfunction.

Truth: 40 to 50% of women with unexplained infertility is caused by Endometriosis.

Truth: Teens with endometriosis often have acyclic pain, that is, pain at other times of the month rather than only during their period, in addition to cyclic pain.

Truth: Back pain is a symptom of endometriosis.

Truth: If your ultrasound is normal you can still have endometriosis.

Truth: roughly 10% of women have endometriosis. That’s close to 200 million women worldwide. Endometriosis is much more than just bad period pain. 1 in 4 women have pelvic floor dysfunction.

Truth: Endometriosis commonly affects the musculoskeletal system, and in many cases can be a primary contributor to one’s pain and symptoms.

 

Orbuch I, Stein A. Beating Endo. New York. Harper Collins. 2019

All About Testicles

tennis ball isolated

By Fiona McMahon, PT, DPT

Testicles have long held a special place in our society.  In fact, the word testis means “witness of virility” in Latin. They help produce the hormones that spark puberty. They are responsible for body hair, the growth of the penis, and sex drive.

Testicles are gonads. Gonads are sex organs that produce sex cells.  People with male anatomy produce sperm and  people with female anatomy produce ova (eggs). Testicles also produce the hormone testosterone, which as stated earlier is responsible for people with male anatomy’s secondary sex characteristics, like body hair, muscle bulk, and sex drive.

Testicles are housed in the scrotum, a sack of skin just behind the penis. Within the scrotum, the testicles are covered by a fibrous sheath called the tunica vaginalis and tunica albuginea. The testicles are composed of many tightly bound tubules called the seminiferous tubules. These tubules give the testicles their uneven feel. Each testicle is held in the scrotum by the spermatic cord, which is composed of the vas deferens, blood vessels, and lymph vessels.

Anyone who has watched an Adam Sandler movie knows that testicles are delicate and sensitive creatures. Even just a jostle can be enough to double one over in pain. But sometimes your testicles may hurt for no apparent reason.  Acute scrotum is the technical name given to sudden onset testicular pain without swelling. There are many medical reasons your testicles may hurt.  Testicular pain can be a serious condition and should not be ignored.

Testicular torsion is a medical emergency that requires immediate treatment in order to save the testicle.  Testicular torsion is most common in people with male anatomy under the age of 25. It occurs when the spermatic cord twists cutting off blood supply to the testes. Usually testicular torsion is spontaneous and cause pain great enough to wake a one out of sleep and induce vomiting.

In some people testicular torsion is contributed to by what is known as a bell clapper deformity. A bell clapper deformity occurs when there is a lack of fixation in the tunica vaginalis. Because of this lack of fixation, the testis is free to rotate around on itself and obstruct blood flow. Bell clapper deformities are present in 12% of males and in males with bell clapper deformity 40% have bilateral derformity. In neonates, extravaginal torsion can occur when the tunica vaginalis and the testes both twist in the inguinal canal. Any case of sudden and severe testicular pain should be considered testicular torsion until proven otherwise and treated as a medical emergency.

Testicular cancer is usually painless but in 20% of cases pain can be a symptom. The pain caused by testicular cancer is typically due to hemorrhage. In the overall population testicular cancer is relatively rare, however it is the most common form of cancer in young males between the ages of 15 and 35. Signs of testicular cancer include a dull ache in the abdomen and groin, heaviness in the scrotum, lump in the testicle, enlargement of the breast tissue, or back pain. Any of these symptoms warrant a visit to your general practitioner.

So what about testicular pain that is not cancer or testicular torsion? Testicular pain can also be caused by other medical conditions like epididymitis, orchitis, urinary reflux, urinary tract infection, or sexually transmitted infection. Again as stated before, any acute testicular pain that occurs out of the blue warrants immediate medical attention.

There are some people however who suffer from acute and recurrent testicular pain for which a medical cause has not been established. For these people, not having concrete answers for what is going on can be especially distressing. In a paper by Anderson and colleagues, trigger points elsewhere in the body have been found to cause pain in the testicles, shaft of the penis, and other areas in the genital region.

Trigger points are defined as areas of hypersensitive and painful spots within the muscle that can be felt as a tough or tight band. In their study, Anderson and colleagues found that testicular pain could be elicited in 80% of men with testicular pain with no other medical cause, when trigger points in the external obliques were palpated. The study also found other trigger points referring to the shaft of the penis, and the perineum (the bicycle seat area of the body). Myofascial restrictions can refer pain to testicles as well as reduce blood flow to the genitals, making erections difficult or painful.

Irritated nerves can also be the cause of testicular and penile pain. The pudendal nerve is most commonly associated with male pelvic pain. The pudendal nerve supplies sensation to many of the pelvic structures including the penis, scrotum, and anorecatal region. This nerve can become inflamed or strained for a variety of different reasons. Straining with constipation, boney alignment that stresses the nerve, as well as tight ligaments and muscles that surround the area can all stress the pudendal nerve and cause scrotal, anal, or penile pain.

Other nerves such as the Iliohypogastric can cause suprapubic and gluteal pain. The inguinal nerve can cause pain in the inner thigh, and lateral scrotal skin. The genital femoral is also associated with the skin of the scrotum and thigh.

If you find yourself with testicular or penile pain that has not been resolved with medical intervention, it may be time to find your way to a licensed pelvic floor physical therapist. Physical therapists can work with you to break up your trigger points, provide postural education to correct alignment, reduce constipation with bowel training, and incorporate relaxation and postural changes to prevent your pain from coming back. At Beyond Basics, we have a great team of therapists who treat pelvic floor disorders who can help treat your testicular pain.

Sources:
Anatomy and physiology of the testicle. Canadian Cancer Society. http://www.cancer.ca/en/cancer-information/cancer-type/testicular/anatomy-and-physiology/?region=on. Accessed June 10, 2015
Anderson R, Sawyer T, Wise D, Morey A. Painful myofascial trigger points and pain sites in men with chronic prostatitis/ chronic pelvis pain syndrome. The Journal of Urology, 182;6 2753-58
Jefferies M, Cox A, Gupta A et al. The management of acute testicular pain in children and adolescents. BMJ. 2015
Mayo Clinic Staff. Testicle Pain. Accessed June 8, 2015. http://www.mayoclinic.org/symptoms/testicle-pain/basics/causes/sym-20050942
Mayo Clinic Staff. Testicular Cancer. http://www.mayoclinic.org/diseases-conditions/testicular-cancer/basics/definition/con-20043068. Accessed June 10, 2015

Prostatitis What it is and What to do About it

natural-treatments-848x300

Fiona McMahon DPT

Introduction

Prostatitis is a common diagnosis we see at Beyond Basics Physical Therapy. If I have a new evaluation on my schedule, who is male and between the ages of 18-40, we can place a pretty good bet that they are coming to see me for issues pertaining to non-bacterial prostatitis. It is estimated that 35-50% of men are reported to have prostatitis symptoms  in their lifetime (Rees). Prostatitis can be classified into different types based on their causes and response to treatment. Prostatitis is a vexing condition for many patients. In cases of non-bacterial prostatitis, which makes up 95% of all prostatitis, it’s often very difficult to determine what brought it on, and often times our patients have been bouncing from practitioner to practitioner trying to find answers and effective treatment. Let’s dive into the causes, symptoms, and treatment in order to help shed light on this condition.

 

Prostatitis Symptoms,

Although there are different types of prostatitis, the symptoms of prostatitis are mostly the same between types. That isn’t to suggest that every man with prostatitis experiences the same symptoms, quite on the contrary. Men with prostatitis may experience almost all of the symptoms listed below or they may only notice one or two. This melange of symptom possibilities can add to the confusion of having prostatitis and getting down to an effective cure.

 

Symptoms:

  • The sensation of having a golf ball stuck in the rectum
  • Hesitant urinary stream (having trouble getting the urine to start flowing)
  • Post void dribble (spotting of urine on underwear following voiding)
  • Pain that radiates into the abdomen (this is one of the differences from symptoms of benign prostatic hyperplasia)
  • Erectile dysfunction and decreased libido
  • Painful ejaculation
  • Painful or burning urination
  • Genital pain: penile, testicular, groin and perineal pain

 

Types of prostatitis:

Here’s where it gets a little more complicated. There isn’t one type of prostatitis. There are four. Each type of prostatitis is a little different in terms of etiology (how it developed) and how it’s treated.

Type 1: Acute bacterial prostatitis

This type of prostatitis is caused by an infection by a microbe. It is relatively rare. In addition to the symptoms above, a person with this type of prostatitis will feel the symptoms of an ongoing infection, including pain in the body, fever, and chills. This type of prostatitis generally response well to antibiotic treatment.

Type 2: Chronic bacterial prostatitis

Chronic bacterial prostatitis can occur after multiple infection or when there is an ongoing low grade infection. The symptoms, particularly those of infection are dampened in this form of prostatitis than those of type 1. Type 2 is often more tricky to treat and may require multiple courses of antibiotics

Type 3: Chronic Prostatitis/ Chronic pelvic pain syndrome (the most common making up 90-95% of all prostatitis and WHAT WE TREAT!)

This type of prostatitis occurs with no evident infectious cause and makes up the majority of cases. This is the classification that is one of the more frustrating for patients to deal with because the causal agent is much harder to ascertain; however the majority have musculoskeletal dysfunction, which we now know can be treated effectively through expert pelvic floor physical therapy.  Type III prostatitis can be further categorized based on the presence or absence of white blood cells in the urine or prostatic fluid, inflammatory and noninflammatory respectively.

Type 4: Asymptomatic inflammatory prostatitis

As the name implies, this type of prostatitis is usually not noticed unless semen or urine analysis is being performed to diagnose another condition. Typically this type is left untreated.

 

Causes

Here’s one of the universal questions that patients with prostatitis have: “why do I have this?”  Sometimes patients may find themselves blaming their prostatitis on something they have done in the past, like masturbating or poor hygiene habits as children. The fact is, prostatitis can occur for a multitude of reasons, and it’s usually something one has no control over like a fall on the bottom or an infection. It’s unfortunately something that happens, and as noted in the introduction of this blog, it is quite common. Here are some possible causes:

 

  • In chronic nonbacterial prostatitis/ chronic pelvic pain syndrome 90-95% of cases- no definitive cause ( or very difficult to ascertain); however pelvic floor dysfunction is a prevalent contributor.  
  • Bacterial infection, which can have good results with antibiotics
  • Chronic bacterial prostatitis, recurrent infection
  • Inflammation to the pelvic area
  • Central and peripheral sensitization- meaning a past injury in the area caused your pelvic nerves to perceive non painful stimuli as painful
  • Trigger points (irritable points of muscle) in the pelvic floor and abdomen

 

Treatment

Treatment is evolving in prostatitis. Increasing evidence supports a multimodal approach to treating prostatitis and its symptoms, meaning that not only is medical intervention used, but psychological, nutritional, and physical therapy.

From a medical perspective the first line of treatment for prostatitis is the “3 A’s”, antibiotics (especially the quinolone class), anti-inflammatories, and alpha blockers. Antibiotics obviously clear up any infection that might be causing your symptoms, anti-inflammatories to bring down the pain and discomfort, and alpha blockers to improve urine flow. Sometimes this is just what the doctor ordered (literally), especially in individuals with type 1 prostatitis and they are on their way with no further treatment needed. Since the vast majority of people with chronic prostatitis fall outside of the type one category and into more difficult to treat types, their recovery may require a more involved intervention to effectively treat their symptoms and the 3 A’s may not be the answer, or the complete answer for these patients.

 

Physical Therapy: Anderson and his colleagues described the relationship between the presence of myofascial trigger points and symptomatic prostatitis. They also showed that physical therapy intervention, including manual release of these trigger points was effective in reducing symptoms of prostatitis. The benefit of physical therapy was shown again to be more effective than placebo in a 2011 paper by Nickel. In addition to treating the trigger points themselves, PT’s work to determine what lead up to the formation of the trigger points in the first place, whether that be poor habitual posture, poor strength, or tight muscles in other parts of the body. They also teach patients how to avoid clenching their pelvic floor to prevent exacerbating symptoms.  This type of therapeutic approach was found to be effective in reducing pain in 72% of participants in a study conducted by Anderson and colleagues in 2005. The therapists at Beyond Basics Physical Therapy work to go beyond simple treatment of the trigger points themselves.  We develop plans and treatments to prevent their recurrence in the future.   Some other effective physical therapy techniques that we use include but are not limited to, joint mobilization to assist proper structural alignment, therapeutic exercise, postural and neuromuscular re-education and a detailed and individualized home exercise program.

 

Dietary Modifications:

Avoiding irritants to the bladder and gastrointestinal system is another simple and effective place to start. In some men, avoiding spicy foods, alcohol and caffeine can work wonders in making symptoms more manageable.   

 

Phytotherapy:

Preliminary data shows that there is evidence to support the use of saw palmetto, quercetin and bee pollen extract in reducing the pain of prostatitis. If supplementation interests you, consult with your general practitioner or urologist.

 

Stress Reduction

As clinicians who have seen a lot of cases of prostatitis, high stress is a contributor that we see with the vast majority of our patients. Studies have shown that high levels of stress are correlated with higher pain and disability scores in individuals with prostatitis. Stress can also perpetuate unhealthy holding or clenching in the pelvic floor, which causes or contributes to trigger points discussed earlier in this section. Stress reduction is a key component to expediting your recovery and is something we recommend to nearly all of our patients.

 

Final Thoughts

  • Prostatitis is a common and aggravating condition to be living with, and the fact is, every case of prostatitis is different. You may fall into the category were a course of antibiotics does the trick or you may fall into the category where you require physical therapy alongside medical intervention which can be much more slow going. Regardless of where you fall, be patient, there usually is a lot that can be done to help the more complex cases of prostatitis clear up. If you are suffering with this condition, make an appointment with an expert pelvic floor physical therapist today. There is so much we can do.

 

Sources

Anderson R, Sawyer T, Wise D. Painful myofascial trigger points and pain site in men with chronic prostatitis/ Chronic Pelvic Pain Syndrome. J Urol. 2009;182(6): 2753-8

Anderson R, Wise D, Sawyer T. Integration of myofascial trigger point release and paradoxical relaxation training treatment of chronic pelvic pain in men. J Urol. 2005;174(1):155-60

Chronic nonbacterial prostatitis (chronic pelvic pain syndrome). Harvard Health Publications. Harvard Medical School. 2007. http://www.health.harvard.edu/newsletter_article/chronic-nonbacterial-prostatitis-chronic-pelvic-pain-syndrome. Accessed December 11, 2016

Duclos A, Lee C, Shoskes D. Current treatment options in the management of chronic prostatitis. Ther Clin Risk Manag. 2007; 3(4):507-12

 

Rees J, Abrahams M, Doble A et al. Diagnosis and treatment of chronic bacterial prostatitis and chronic prostatitis/chronic pelvic pain syndrome: a consensus guideline. BJU Int. 2015; 116(4):509-25

 

Nickel J. Prostatitis. Can Urol Assoc J. 2011; 5(5): 306-15