Ouch…Male Pain Down Below: What You Need To Know

Andrew Siegel MD  2/2/2019

Pelvic floor tension myalgia is often the root cause of many common “male problems,”  yet remains a mysterious, misunderstood, misdiagnosed and mistreated condition. 

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“Chronic prostatitis” is a frequently bandied about term–a diagnosis tagged to a variety of different conditions having in common discomfort or pain perceived in the pelvic, groin, genital and perineal (“taint”) regions. It is often considered to be a “wastebasket” diagnosis, a diagnostic consideration after other processes are ruled out.  Chronic prostatitis is a term as commonly used by the urologist as “irritable bowel syndrome” is by the gastroenterologist.  In chronic prostatitis the prostate is treated as the source of the pelvic pain, but the truth of the matter is that the prostate is rarely the source.

The term “itis” refers to infection or inflammation of the organ in question… but 90%  of men diagnosed with “chronic prostatitis” do not have an infected or inflamed prostate gland! What many actually have is tension myalgia of the pelvic floor muscles, a condition in which the pelvic floor muscles are tense, spastic and hyper-contractile. Essentially, this is a “headache” or “Charley horse” of the pelvis driven by spastic pelvic floor muscles.


Tension myalgia is an unrelaxed state of muscle tone, similar to a fist clenched tightly

Muscle tension anywhere in the body is not a favorable state of affairs.  (I sometimes get muscle spasms in my neck muscles that causes a tension headache that requires ibuprofen, a heating pad and massaging to relieve.  However, the neck is not a terrible place for muscle spasm, certainly minor compared to the pelvis.)  The pelvis is a particularly unfortunate place for spastic muscles because it is home to urinary, sexual and bowel function.  The pelvic floor muscles form the floor of the pelvis (and the floor of the “core” group of muscles) and have openings for the urinary and intestinal tracts that pass through these muscles, so you can imagine how tension and spasm may affect the function of these systems.

This spasticity of these muscles makes one feel that their pelvic muscles are “tied in a knot.” The resulting pain is often perceived in the genitals, lower urinary tract, and rectal/anal areas, and accompanying the pain are often adverse effects on sexual, urinary, and bowel function.  The situation can give rise to voiding difficulties (difficulty starting or emptying, poor quality stream, post-void dribbling), overactive bladder (urgency, frequency, urgency incontinence), erectile dysfunction, ejaculatory dysfunction (premature ejaculation, painful ejaculation, reduced ejaculatory strength), and bowel difficulties (constipation, hemorrhoids, fissure, etc.).

What causes this situation of taut and spastic pelvic floor muscles?  The answer is  anything that can give rise to muscle tension anywhere else in the body, some of the key triggers being stress and anxiety.  Stress and anxiety “turned inward” is thought to trigger dysfunction of the nerve pathway that regulates muscle tone.

Characteristically, the pain of pelvic floor tension myalgia waxes and wanes in intensity over time and wanders to different locations in the pelvis, possibly involving the lower abdomen, groin, pubic area, penis, scrotum, testicles, perineum, anus, rectum, hips, and lower back. The pain is often described as “stabbing” in quality and can be provoked by urination, bowel movements or sexual activity/ejaculation or even activities including driving a car or wearing tight clothing.

Because of the variable, vague and “wandering” manifestations of this condition, patients often have difficulty in precisely articulating their symptoms, although they usually have a fairly long list of issues, numerous prior interventions and have seen many physicians.  After identifying this condition in a number of patients, in retrospect it seems to be an obvious diagnosis.  To make the diagnosis, it is vital to take a careful history and do a tailored physical exam, which includes an evaluation for “trigger points” of the pelvic floor muscles that, when examined, cause tremendous pain.

The patient profile of a man suffering with this condition is often predictable. A thirty-something or forty-something, well-dressed male with excellent posture and a type A personality (competitive, ambitious, organized, impatient, etc.) presents with vague pelvic pain symptoms that he has difficulty in describing. In addition to the pain he often notes urinary, rectal, erectile and ejaculatory issues. He usually has a professional, high-level, stressful occupation and his physical appearance and body language is “tight,” paralleling the tone of his pelvic floor muscles. He tends to be “driven” and have a compulsive, controlling and disciplined personality and typically exercises on a regular basis and is in good physical shape. He has been evaluated by numerous urologists and has been treated with many courses of prolonged antibiotics (to minimal benefit) and has been labeled as having chronic prostatitis. He is often miserable and perhaps at wits end because of having endured years of episodic pain. He is worried and emotionally stressed about his pain. It is not uncommon to discover that the pain seemed to be precipitated by a situation deemed to be a personal failure such as involvement in a divorce, loss of a job or other event. On digital rectal exam, he has very tight anal tone and has tenderness, spasticity and often knots that can be felt within the levator ani muscles, similar to the tension knots that can develop in one’s back muscles.

The current theory is that this chronically over-contracted group of muscles is a manifestation of stress and anxiety turned inwards, a classic example of the mind-body connection in action. This state of chronic “over-vigilance” seemingly serves the purpose of guarding and protecting the genital and rectal regions. When anxiety expresses itself through tension in the pelvic floor, the physical tension further contributes to the emotional anxiety and stress, which creates a vicious cycle.  The pelvic floor muscles are responsible for tail wagging in canines and tension myalgia of the pelvic floor parallels what a frightened dog does when it pulls its tail between its legs, protecting the genital and anal regions.

Conventional urologic practice is nuts-and-bolts-mechanistic–slow to accept the concept that stress and other psychosocial factors can give rise to genuine urological conditions–and has a dismissive attitude towards psychosomatic symptoms.   However, an understanding of the issue of tension myalgia of the pelvic floor muscles is slowly gaining traction and recognition and in 2019 we are approaching a tipping point in which this type of diagnosis is a more frequent consideration in those men presenting with pelvic pain.

To manage tension myalgia, it is necessary to relax the spastic pelvic floor muscles and untie the “knots.” There are a variety of means of doing so, including relaxation techniques, stretching, hot baths, massage, and muscle relaxants. Many men respond well to physical therapy sessions with skilled pelvic physiotherapists who are capable of trigger point therapy, which involves compressing, massaging and elongating the knotted and spastic muscles.

Those who are so inclined can treat themselves with a therapeutic internal trigger point release rectal wand that aims to eliminate/mitigate the knots. This treatment is referred to as the Stanford pelvic pain protocol or alternatively, the Wise-Anderson protocol (designed by David Wise, a psychologist, Rodney Anderson, a urologist, and Tim Sawyer, a physiotherapist).

When used judiciously, pelvic floor muscle training programs can be of benefit to patients suffering with this condition.  Pelvic training serves to instill awareness of and develop proficiency in relaxing the pelvic muscles (as opposed to more typical purpose of such a program, which is strength and endurance training.)

Bottom Line: The diagnosis of pelvic floor muscle tension myalgia should be a primary consideration for all men presenting with pelvic pain. Physical interventions can be extremely helpful in alleviating the pain and untying the pelvic floor “knots.” By making the proper diagnosis and providing pain relief, the vicious cycle of anxiety/pain can be broken.

For a wonderful reference, consult: Dr. Wise and Anderson’s book, A Headache in the Pelvis: A New Understanding and Treatment for Chronic Pelvic Pain Syndromes.

Wishing you the best of health,

2014-04-23 20:16:29

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Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community. He is a urologist at New Jersey Urology, the largest urology practice in the United States.

Dr. Siegel is the author of 5 books: FINDING YOUR OWN FOUNTAIN OF YOUTH: The Essential Guide to Maximizing Health, Wellness, Fitness and Longevity

PROMISCUOUS EATING— Understanding and Ending Our Self-Destructive Relationship with Food

MALE PELVIC FITNESS: Optimizing Sexual and Urinary Health

THE KEGEL FIX: Recharging Female Pelvic, Sexual, and Urinary Health

 and hot off the press is PROSTATE CANCER 20/20: A Practical Guide to Understanding Management Options for Patients and Their Families

Andrew Siegel MD Amazon author page 

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