Continuing our Education: Treating Pain in Individuals with Male Anatomy

Fiona McMahon PT, DPT

One of the requirements for maintaining your license as a physical therapist, is to take continuing education classes. The amount of classes you are required to take will vary from state to state. Many physical therapists take the option to do the bare minimum required to maintain their license. This is not the case with the PTs at Beyond Basics Physical Therapy, whom also do a ton of in house training, in-services, case studies, and journal clubs in addition to formal classes. Many of our physical therapists exhaust their continuing education days and continuing education budget and chose to attend continuing ed on their own time and dollar, because they love it so much. Even though, they are well beyond satisfying their requirements for licensure. It is something that makes the physical therapists at Beyond Basics really special and in the top of their field.

As practicing pelvic floor physical therapists, we have extensive experience, but the truth of the matter is we can always know more. For many of us, before we arrived at Beyond Basics, we learned to treat pelvic pain on individuals with male anatomy by avoiding the penis all together. To be honest, we can get a lot of patient’s better by treating the muscles of the pelvic floor internally, but as a group, we were eager to be able to learn and treat issues of the penis directly. We just wanted to be able to get patients with issues like Peyronie’s disease (a bend in the penis, due to dysfunction in the fascia), erectile dysfunction and incomplete bladder emptying better on a much quicker time scale.

We were lucky to have Sara Sauder, PT, DPT and Kelli Wilson, PT, DPT, FAAOPPT, OCS come up to visit us in NYC one cold Saturday in January to help us expand our physical therapy tool boxes for individuals suffering from the following conditions, amongst others:

  • Erectile Dysfunction
  • Post Vasectomy Pain Syndrome
  • Prostatitis
  • Urinary Pain
  • Urinary incontinence
  • Pain following Hernia Surgery
  • Circumcision Scarring

In the class we covered a broad range of factors influencing the health and function of male reproductive anatomy, including the interplay of hormones, scar tissue from old surgery, restrictions in the fascia of the penis or scrotum, and hernia. We learned hands on techniques to improve the movement of tissues around and blood flow to the penis and scrotum.

Speaking for all of us, I would say, that Sara and Kelli helped us to better treat our male patients. It is clear as physical therapists, we continue to grow and learn long after physical therapy school. We at Beyond Basics Physical Therapy hold our continuing education close to our hearts and truly believe it is what sets us apart from other physical therapy clinics.

If you are interested in learning more about what we can do for pelvic floor conditions of the male anatomy, check out our other articles here!

All About Testicles

Prostatitis What it is and What to do About it

Also for more information on how manual physical therapy can help pain conditions of the male anatomy, check out this article:

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

 

You can read the full abstract here

Prostatitis What it is and What to do About it

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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

What IS Myofascial Release?

By Mary Hughes PT, DPT

Understanding Myofascial Release (MFR)
Myofascial Release (MFR) is a holistic, therapeutic approach to manual therapy, John Barnes PT, LMT, NCTMB, is credited to the development of Myofascial Release (1). MFR offers a comprehensive approach for the evaluation and treatment of the myofascial system, the system of tissues and muscles in the body.

This technique is designed to release restrictions such as trigger points, muscle tightness, and dysfunctions in soft tissue that may cause pain and limit motion in all parts of the body. It has shown success in decreasing pain and increasing mobility (1).

The main tissue that MFR focuses on for release in the myofascial system is the fascia. Fascia is a fine tissue that surrounds all structures in the body including muscles, nerves, vessels, organs and bones. MFR allows the therapist to evaluate, identify, and treat fascial restrictions. These restrictions can be caused by numerous factors, such as trauma, musculoskeletal conditions, repetitive stress syndrome, and poor posture.

By applying gentle, hands-on techniques to the whole body, positive structural changes may occur, such as increased range of motion, decreased pain, and, most importantly, increased fascial mobility (2). In combination with traditional physical therapy, MFR can help patients return to their daily and recreational activities.

Who Might Benefit from MFR
MFR can be used to treat pain and increase mobility in patients with a wide range of conditions, including back, neck, shoulder, hip and pelvic pain, and fibromyalgia.

Athletes can also benefit. A number of sports injuries can be treated with MFR, including:

  • Repetitive strain injuries, often seen in long distance runners

  • Muscular imbalances, which lead to overuse in isolated joints and faulty movement patterns (3)

There are also increasing numbers of athletes who have found MFR to be helpful in regaining proper pelvic alignment, which in turn leads to optimal competitive performance (4).

Contraindications
MFR may not be appropriate for all patients. Contraindications for MFR include – but are not limited to – those with malignancy, aneurysm, acute rheumatoid arthritis, advanced diabetes, severe osteoporosis, and healing fractures (2). Your physician and physical therapist can help determine whether or not MFR is an appropriate course of treatment for you.

What to Expect
During your first appointment the therapist will perform an initial evaluation, a comprehensive systems review, and musculoskeletal physical exam to ensure that MFR is appropriate for you. Evaluations include a postural assessment and strength and range of motion testing.

During your first MFR treatment, it is common for the therapist to position you on your back on a treatment table to allow your body and mind to relax. The majority of MFR work consists of gentle pressure. Sometimes the motion is very fluid, and at other times your limbs may be held in a light stretch. The therapist may begin on the area in which you are currently experiencing pain. However, that is not always the case, as pain can often be referred from different parts of the body.

You may experience some slight discomfort as your tissues release tension. While many patients leave a MFR session feeling very relaxed, it’s not uncommon for there to be some residual muscle soreness. The soreness is “thought to result from postural and alignment changes or from the techniques themselves.”1

Over time, your therapist will show you how to practice MFR techniques yourself at home, using foam rollers, a tennis or Myo-Release Ball™, and/or massage sticks.

For more information on MFR you can access John Barnes’ Website at: http://myofascialrelease.com/

References

1. Dutton, Mark. Orthopaedic examination, evaluation, & intervention. New York : McGraw-Hill, c2004 pages 331-332, 1218

2. John Barnes’ Courses completed MFR I, MFR 2, Myofascial Unwinding, Myofascial Soft Tissue Mobilization workshop.

3. Taylor, D. Dealing with Muscular Imbalances around the Lumbo-Pelvic-Hip-Joint Retrieved January 22, 2012 from Athlete Acceleration.com URL:http://www.athletesacceleration.com/hipmuscularimabalances.html

4. Leigh, J. How Myofascial Release can help athletes achieve optimum performance Retrieved January 22, 2012 for source website URL:

http://www.memphismfr.com/MemphisMFR/_pdf/How%20MFR%20Can%20Help%20Improve%20Athletic%20Performance.pdf

 

 

Myofascial Release for Pelvic Floor Pain

What is Myofascial Release, and what does it do for Pelvic Floor Pain?

By Mary Hughes

Myofascial Release (MFR) is a holistic, therapeutic approach to manual therapy, popularized by John Barnes, PT, LMT, NCTMB. MFR offers a comprehensive approach for the evaluation and treatment of the myofascial system, the system of tissues and muscles in the body.

This technique is designed to release restrictions such a trigger points, muscle tightness, and dysfunctions in soft tissue that may cause pain and limit motion in all parts of the body. It has shown success in decreasing pain and increasing mobility.1

J. Barnes’ MFR techniques have been used to treat the following:

  • Pelvic Floor Pain & Dysfunction
  • Vulvodynia
  • Mastectomy Pain
  • Endometriosis
  • Interstitial Cystitis
  • Lymphedema
  • Fibromyalgia
  • Painful Scars
  • Menstrual Problems
  • Painful Intercourse
  • Adhesions
  • Coccygeal Pain
  • Problematic Breast Implant/Reduction Scars
  • Urinary Incontinence, Urgency and/or Frequency
  • Episiotomy Scars
  • Infertility Problems

In a study by fitzgerald et. Al. they found the response rate from Myofascial physical therapy was significantly higher than Global therapeutic massage among patients diagnoses with urological chronic pelvic pain syndromes.

References
1. Dutton, Mark. Orthopaedic examination, evaluation, & intervention. New York : McGraw-Hill, c2004 pages 331-332, 1218

2. John Barnes’ Courses completed MFR I, MFR 2, Myofascial Unwinding, Myofascial Soft Tissue Mobilization workshop, The Fascial Pelvis and The Women’s Health Seminar.

3. FitzGerald MP, Anderson RU, Potts J, et al. Randomized multicenter feasibility trial of myofascial physical therapy for the treatment of urological chronic pelvic pain syndromes. J Urol 2009; 182:570.