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Pelvic Pain is Not Just a Women sconcern. Peg Maas, PT, DPT, WCS


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Pelvic Pain is Not Just a Women’s Concern

Peg Maas, PT, DPT, WCS


A word about

anatomy and gender



Common scenario

A person with a prostate presents with these complaints:

Pain in pelvis, genitals, low back, m a y b e also a b d o m e n +/- urinary dysfunction

+/- sexual dysfunction +/- bowel dysfunction

+/- reports of stress, depression, persistent pain at other locations


• Pelvic pain research is largely about its presence in bodies with a vagina

• In bodies with a prostate, the literature is “prostatocentric”

(Jeannette M. Potts)

• Assessment tools to identify a n d guide rx:


Thinking it through


Pelvic Floor Pain

• “Syndrome,” not a “disease”

• Often fails to respond to “monotherapy”


• Cycles of escalation


• Type l: a c u t e systemic bacterial infection

• Type ll: recurrent UTI with bacteria in prostate between infections

• Type lll: chronic prostatitis/chronic pelvic pain not caused by other identifiable pathology

• Type lV: asymptomatic prostate inflammation found on biopsy or semen analysis

Chronic Prostatitis/Chronic Pelvic Pain



May include:

• Genital pain

• Ejaculatory pain

• Abdominal pain


• Global pelvicpain


• ED

CPPS Type lll


• 9 questions

• Measures 3 arenas: pain, LUT sx, QoL a n d their respective severity

• Valid, reliable, responsive

• Improvement = 6 points


Clemens, Calhoun, Litwin, et al. 2009

NIH Chronic Prostatitis Symptom



• Validated system to identify clinically meaningful phenotype – determining course of treatment

• 6 categories: Urinary, Psychosocial, Organ-specific sx, Infection, Neurological/systemic, Tenderness

• Median number of positive = 3

• 22% of patients have only 1

• www.upointmd.com

Image: Inflammatory and Pain Conditions of the MaleGenitourinary Tract :

Prostatitis and Related Pain Conditions, Orchitis, and Epididymitis. Pontari, Michel, MD, Campbell-Walsh-Wein Urology, 56, 1202-1223.e8

Copyright © 2021 by Elsevier, Inc. All rights reserved.



• 384 men with CP/CPPS, 121 controls

• 51% of patients had PFM tenderness

• 7% of controls had PFM tenderness

Shoskes, Berger, Elmi, et al., 2008

Role of MSK in CP/CPPS

Image: Sobotta Atlas of Anatomy, Vol. 2, 16th ed., English/Latin. Paulsen, Friedrich... Published January 1, 2018. Pages 207-317. © 2018


Inflammatory and Pain Conditions of the Male Genitourinary Tract : Prostatitis andRelated Pain Conditions, Orchitis, and Epididymitis. Pontari, Michel, MD, Campbell-Walsh-Wein Urology, 56, 1202-1223.e8 (From Yang CC et al.: Physical examination ...)

Copyright © 2021 Copyright © 2021 by Elsevier, Inc. All rights reserved.


• Men who were referred to PHPT after failure to respond to multiple courses of

pharmacological agents, procedures, etc.

• Both h a d complete resolution of symptoms

• No way to know what would have

h a p p e n e d if they h a d started PT sooner

2 cases: M.L. and A.S.


• C a m e to PHPT via our Nurse Navigator

• 61 y. o. man, 6 yrs of pelvic pain /“burning” in perineum, scrotum, tip of penis, d e e p abdominal, insidious onset

• Diagnostics: blood work, cystoscopy, CT scan, colonoscopy

• Previous treatments: antibiotics, NSAIDS, prostate massage, antidepressants, epidural, pudendal injections,

baclofen/diazepam suppository, spinal cord interstim p l a c e d (brief relief), taking sleep aid to reduce nighttime frequency

• Other: void q 40 min all night. Relief / p void attempted. 3+

alcohol drinks/evening due to pain a n d discouragement

Case: M.L.


• Review of history, pain patterns

• Bladder, bowel, sexual function concerns

• ADLs, I/O, etc., ex habits

• Posture/Gait evaluation

• Lumbar/hip ROM, strength

• External palpation, TPs, excursion/coordination of PFM (often reduced)

• Internal exam for pain, strength, recruitment



• Pain : primarily / c sitting, sexual activity,  during day

• Pain : standing, lying down, movement, / p void or BM

• Work in sales, has stand-up/sit-down desk, travels by plane

• Daily ex: treadmill, elliptical, bicycle --- helps mental health

• MSK exam: tight HS B, restricted IR B, posture – clenching glutes, fwd head, strength WNL

• Other: accessory muscles predominant, no abdominal excursion or PFM excursion with respiration

• Palpation: + pain external PF, ++ LA pain on internal palpation

Case: M.L.


• Anatomy explanations, PFM mechanics, breathing

• Explanation of ANS function, Pain Science

• Fluid I a n d O --- specifics a n d timing

• Combating Dr. Google’s supplements, tinctures, devices

• General exercise habits, ergonomics

• Specific strength, ROM, tension awareness, timing of muscle firing/release

• Manual therapy: trigger points, CTM, tension

• S-EMG: motor unit resting a n d response

Treatment approaches


Masterson, Masterson, Azzinaro, et al. 2017

Pelvic Health PT with this population

“Kegel exercises are the most well-known form of pelvic floor physical therapy… … however they are not the correct therapy for the majority of patients with CPPS. In fact, many patients

have overactive or hypertonic musculature that requires

relaxation as opposed to strengthening a n d Kegels can worsen symptoms in some men with CPPS.”


When muscles are overactive,

they may not be able to relax

OR contract properly


• 113 patients received TP manual therapy treatment

• Visual analog pain scores dropped by 3.5 points (average of 7.5-4) at 6 months assessment

Anderson, Wise, Sawyer, et al. 2011

Manual therapy


• Anatomy explanation

• Reassurance!

• Diaphragmatic breathing / c PFM excursion

• Posture in sitting a n d standing

• ROM exercises to feel mobility in PFM

• Discussion of positioning for BM

• S-EMG --- learn to lower baseline, return to baseline after activation

• Internal manual therapy to decrease tone a n d provide feedback about relaxation

PT Treatment for M. L.


• 6 visits (even one during a snowstorm!)

• Pain-free with home program

• Inquiring a b out having interstim unit removed

PT Treatment for M. L.


• 18 y.o. male, HS senior, athlete

• Scrotal/perineal pain x 8 mos, no precipitating event

• Diagnostics: imaging to r/o torsion, etc.

• Treated with Abx, NSAIDs without c h a n g e in sx’s

• Pain : sitting, any restrictive clothing

• Pain : avoiding triggers

• Other: bladder hesitancy, constipation

Case: A. S.


Evaluation findings:

• Posture a n d gait: elevated shoulders, minimal torso excursion, slight L hip flexion in standing

• ROM: diffusely restricted hips (esp adductors, HS), L psoas, lumbopelvic segmental movement reduced

• Palpation: pain provoked by palpation along pudendal pathway, L inguinal, L d e e p hip rotators, external PFM

• No internal exam

Clarity about precipitating event

Case: A. S.


Pain distribution: pudendal, genitofemoral, ilioinguinal

Clinical Anatomy, Volume: 28, Issue:

1, Pages: 128-135, First published: 05 November 2014, DOI:


Lower urinary tract dysfunction in the neurological patient: clinical assessment a n d management.Panicker, Jalesh N, Dr, Lancet Neurology, The, Volume 14, Issue 7, 720-732

Copyright © 2015 Elsevier Ltd


Image: Ultrasound-guided interventional procedures for chronic pelvic pain

Bellingham, Geoff A., MD, FRCPC, Techniques in Regional Anesthesia a n d Pain M anagement, Volume 13, Issue 3, 171-178

Reproduced with permission from USRA ( http://www.usra.ca ).

Copyright © 2009 Elsevier Inc.




• Manual therapy

• Stretching ex progression: psoas, piriformis, deep hip rotators, and integration of HEPinto athletic training

• Posture/recruitment retraining

• PFM excursion, diaphragmatic breathing

• 8 visits

• Sxs100% resolved. Able to go on road trip

PT Treatment for A.S.


“In c o m m o n practice awareness of normal pelvic floor function in general a n d recognition of symptoms suggestive of pelvic floor dysfunction are crucial for the appropriate treatment of patients with chronic testicular pain, especially younger

patients. Referral to a n d treatment by a pelvic floor

physiotherapist after ruling out other underlying pathology may result in a decreased need for invasive surgical therapy,

abundant use of antibiotics or other treatment options focusing mainly on tackling symptoms rather than the underlying

pathophysiology. Hopefully this will reduce the long lasting medicalization in these patients.”

Planken E, Voorham-van der Zalm, Lycklama, Nijeholt, et al. 2010


PT modalities: manual rx, focal exercise, coordination

training, etc.

Education re: ANS, pain science, general exercise


Ergonomics, body mechanics, ADLmodification

Mindfulness, stress

management skills



Thank you for your time.




Anderson R, Wise D, Sawyer T, Nathanson BH. Safety a n d effectiveness of an internal pelvic myofascial trigger point w a n d for urologic chronic pelvic pain syndrome. Clin J Pain 2011; 27:


Clemens JQ, Calhoun EA, Litwin MS, et al. Validation of a modified National Institutes of Health chronic prostatitis symptom index to assess genitourinary pain in both men a n d women. Urology.

2009;74(5):983-987.e9873. doi:10.1016/j.urology.2009.06.078

Masterson TA, Masterson JM, Azzinaro J, Manderson L, Swain S, Ramasamy R. Comprehensive pelvic floor physical therapy program for men with idiopathic chronic pelvic pain syndrome: a prospective study. Transl Androl Urol. 2017;6(5):910-915. doi:10.21037/tau.2017.08.17

Planken E, Voorham-van der Zalm PJ, Lycklama A Nijeholt AA, Elzevier HW. Chronic testicular pain as a symptom of pelvic floor dysfunction. J Urol. 2010;183(1):177-181.


Shoskes DA, Berger R, Elmi A, Landis JR, Propert KJ, Zeitlin S, Group CPCRNS. Muscle tenderness in men with chronic prostatitis/chronic pelvic pain syndrome: the chronic prostatitis cohort study. J Urol 2008; 179: 556-560.


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