Andrew Siegel MD
Pelvic pain is certainly not a problem unique to males as it can affect both men and women—anyone who has pelvic floor muscles—but the subject of female pelvic pain is a topic for another day.
The term “chronic prostatitis” is a frequent diagnosis tagged to a variety of different conditions having in common discomfort or pain perceived in the pelvic region. It is a wastebasket diagnosis, made after other processes are ruled out, and a term as commonly used by the urologist as “irritable bowel syndrome” is by the gastroenterologist. Traditionally, the prostate has been treated as the source of the pelvic pain, but the truth of the matter is that the prostate is rarely the source.
Ninety-five percent 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 of the pelvic floor muscles in which they are tense, spastic and hyper-contractile. Essentially, this is a “headache” of the pelvis driven by spastic pelvic floor muscles.
The pelvis is simply a very bad place for spastic muscles because it is home to urinary, sexual and bowel function. This causes pain and often tenderness to touch, creating the feeling that one’s pelvic muscles are “tied in a knot.” The pain is often perceived in the genitals, lower urinary tract, and rectum/anal areas, and accompanying the pain are often adverse effects on sexual, urinary, and bowel function.
It can be brought on by anxiety, stress and other circumstances and is thought to be an abnormality with the nerve pathway that regulates muscle tone. Characteristically, the pain 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.
Patients often have difficulty in articulating the precise symptoms that brought them into the office, although they usually have a long list of issues, lots of prior interventions, and have seen many physicians. The pain is often described as “stabbing” in quality and can be provoked by urination, bowel movements or sexual activity/ejaculation or even driving a car or wearing tight clothing.
After identifying tension myalgia of the pelvic floor muscles in a number of patients, it truly seems to be such an obvious diagnosis. It comes down to a careful history and a physical exam, which includes an evaluation for trigger points of the pelvic floor muscles that, when examined, cause tremendous pain. Most male patients diagnosed with chronic prostatitis and interstitial cystitis probably have tension myalgia of the pelvic floor. In fact, pelvic floor tension myalgia is probably one of the most common problems that urologists see and is likely one of the most misunderstood, misdiagnosed and mistreated conditions in the discipline of medicine.
Tension myalgia is also implicated in 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.).
The patient profile of a man with tension myalgia of the pelvic floor is very 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 seems to have a compulsive, controlling and disciplined personality and typically exercises on a regular basis and is in good physical shape.
He has been to 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 miserable and perhaps at wits end because of the negative effects on his quality of life and having endured years of episodic agony. He typically is very 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 rectal exam, he has very tight 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.
It is theorized 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” of the pelvic floor muscles seemingly serves the purpose of guarding and protecting the genital area. 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.
In many ways it is similar to tension headaches, a not uncommon response to stress. To use an example from the animal kingdom, tension myalgia of the pelvic floor parallels what a frightened dog does when it pulls its tail between its legs. Sadly, conventional urologic practice is very nuts-and-bolts mechanistic and has been glacially slow to accept the concept that stress and other psychosocial factors can give rise to urological diseases. However, an understanding of this issue is slowly gaining traction and recognition and we are approaching a tipping point in which this type of diagnosis will be made on a more frequent basis in the near future.
To manage tension myalgia, it is necessary to foster relaxation of the spastic pelvic floor muscles and untie the “knot.” There are a variety of means of doing so, including relaxation techniques, stretching, hot baths, massage, and muscle relaxants. Many respond well to physical therapy sessions with skilled pelvic physiotherapists who are capable of trigger point therapy, which involves compressing and massaging the knotted and spastic muscles
Those who are so motivated 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 pelvic floor muscle tension myalgia. A good program (aside from the emphasis on strength training of the pelvic floor muscles) serves to instill awareness of and develop proficiency in relaxing the pelvic muscles as one cycles through the phases of contraction and relaxation. (The principle is that maximal muscle contraction induces maximal muscle relaxation, a “meditative” state between muscle contractions.) One must be very careful in contracting muscles that are already spastic and hyper-contractile, as pain can potentially be aggravated by such activity.
Bottom Line: When a man presents will pelvic pain, the diagnosis of pelvic floor muscle tension myalgia should be a primary consideration. Physical interventions can be extremely helpful in alleviating the pain and untying the “knot.” 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,
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Note: As Arnold Kegel popularized pelvic floor muscle exercises in females in the late 1940’s, so I am working towards the goal of popularizing pelvic floor muscle exercises in males. This year I published a review article in the Gold Journal of Urology entitled Pelvic Floor Muscle Training in Men: Practical Applications to disseminate the importance and applications of these exercises to my urology colleagues. I wrote Male Pelvic Fitness: Optimizing Sexual and Urinary Health, a book intended to educate the non-medical population. I, along with my partner David Mandell and our superb pelvic floor team, co-created the Private Gym male pelvic floor exercise DVD and resistance program.
For more info on the book: www.MalePelvicFitness.com
For more info on the Private Gym: www.PrivateGym.com
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