By Shannon Pacella
Unfortunately, the majority of the men we see at PHRC have been through quite a journey with their pelvic pain, before finding pelvic floor physical therapy. I want to share a recent success story about one of my male patients, Ben (his name has been changed for anonymity). My hope by sharing his success story is to allow others dealing with pelvic pain to find a treatment path that works for them.
“I’d struggled for 6 years with pelvic floor pain, and even though I had determined it was a muscular and connective tissue problem, I could never find the right combinations of therapies to ease my symptoms. Then I finally discovered PHRC and knew from the beginning that they were different.”
Ben is a 50 year old man with a six year history of pelvic pain. Here’s his story: In 2010, Ben began having perineal and pelvic pain as well as urinary urgency/frequency, which led him to seek out a urologist. The urologist diagnosed him with prostatitis, and Ben was given antibiotics for ~three months, without any change in symptoms or decrease in pain. So for the next year or so, Ben started doing research online to try and find an answer to his pain. During this time, he saw another urologist who suggested pursuing pelvic floor physical therapy, as well as referring to a pain management physician. Ben worked with a pelvic floor physical therapist for ~six months, which helped to decrease his urinary urgency and frequency symptoms, but continued to have flares in his pelvic and perineal pain. Ben read A Headache in the Pelvis, and Heal Pelvic Pain, but was having difficulty making changes on his own. Ben was frustrated and feared his pain would never change. This stress and anxiety only further increased his pain. Fast forward three more years of struggling to find an answer to his symptoms, when he found PHRC online.
When I evaluated him in 2016, Ben described his symptoms as: constant deep perineal aching (four to five out of ten pain at worst, three out of ten pain on average), radiating pelvic pain to buttocks with sitting (sitting tolerance less than one hour), decreased ability to maintain an erection, and pain post ejaculation. Ben is a self proclaimed “clencher”, saying that he tends to hold tension in his buttocks and pelvis, especially when stressed or anxious. Ben avoids sitting as much as possible, and uses a standing desk at work. He also reports being an avid runner, and would very much like to be able to run and exercise without exacerbating his symptoms.
During his initial evaluation I noted the following:
- Moderate connective tissue dysfunction at his inner thighs, inguinal creases, suprapubic region, and bony pelvis.
- Myofascial trigger points along adductors, piriformis, and perineum.
- Hyperactivity (tightness) at the urogenital triangle (bulbospongiosus, ischiocavernosus, and transverse perineal muscles).
- Decreased ability to voluntarily relax pelvic floor muscles.
My assessment was that Ben had pudendal neuralgia secondary to pelvic floor hyperactivity. The tension in his pelvic floor muscles was putting pressure and irritating the pudendal nerve, which became exacerbated with sitting (puts even more pressure on this nerve). Due to Ben’s history of being a “clencher,” this pelvic floor muscle tension was not a result of one specific incident or injury, but built up over time, until it reached a tipping point and became symptomatic and painful.
Ben’s goals were the following:
- To understand his condition better.
- To alleviate/manage his pain, and be able to sit with less pain.
- Resume physical activities such as running.
- Feel healthier emotionally, and learn to decrease stress/anxiety.
I recommended treatment one time per week for eight to twelve visits. My treatment plan included connective tissue manipulation, myofascial release, myofascial trigger point release, neuromuscular reeducation, pain physiology education, home exercise program (HEP) prescription and management, therapeutic exercise and activity, activity modification, and stress relieving exercises. During his initial evaluation, we discussed how chronic pain can affect the nervous system and the relationship between heightened stress/anxiety and increasing pain. Ben was given handouts on the mind/body connection and ideas to facilitate change. We practiced pelvic floor drops/relaxations while incorporating diaphragmatic breathing, and this was given as the first part of his home exercise program.
“Through a combination of physical work and coaching, my therapist Shannon allowed me to understand this syndrome better than I ever had before – and gave me a wide variety of tools and techniques that I could use to help get better.”
If you want to learn more about what connective tissue and myofascia are, and how they can play a big role in pelvic floor dysfunction, you may find fellow PHRC PT Ciel Yogis’ blog post Sitting on painful fascia: connective tissue and pelvic pain to be a good resource.
At Ben’s first follow-up visit, he reported having some soreness after the initial exam in the areas where we focused the manual therapy, but felt better than he had previously. He rated his current perineal pain as two out of ten. I continued the manual therapy, which was aimed at the connective tissue and myofascial impairments, the adductor and bony pelvis trigger points, and pelvic floor hyperactivity. Ben demonstrated improvement with relaxing his pelvic floor muscles while diaphragmatic breathing with moderates cues. We discussed the use of cushions with sitting, to help to decrease symptom exacerbation. Ben found that using a cushion was helpful to increase his sitting tolerance.
At his second visit, Ben reported having reduced pain for four to five days after the last session, but his symptoms then started to return. Upon exam, I noted a decrease in the myofascial trigger points along his adductors. We discussed the use of a foam roller at his adductors and hamstrings in order to further reduce the myofascial restrictions at home and maintain the progress being made during the treatment sessions. He continued to have urogenital triangle hyperactivity.
At the third treatment visit, he reported being consistent with using a foam roller and stretching everyday, with noted tension in his lateral thighs. He was able to run three miles without pain and without exacerbating symptoms. I continued the manual myofascial and connective tissue release, including the lateral thighs, with decreased tension noted. Ben’s pelvic floor motor control was improving, and he was able to perform a pelvic floor drop/relaxation with less cueing.
By the fifth visit, Ben reported experiencing stretches of time that were pain-free. He reported that he was able to do some plane traveling which did not increase his pain as much as he anticipated. I continued to notice decrease in the urogenital triangle hyperactivity and myofascial and connective tissue restrictions throughout Ben’s thighs and pelvis. I taught Ben self myofascial release techniques focused at the bulbospongiosus and ischiocavernosus muscles for his home exercise program.
At the sixth visit, he reported having a flare in his pain, and felt pelvic tension. He stopped running due to exacerbating symptoms further. Ben was a bit frustrated with having such a good week prior, and then having a not so great week. We discussed how his pain and symptoms may fluctuate, and how that is okay and normal! The biggest take home message that I wanted Ben to understand is to not let a flare up in symptoms increase his stress/anxiety (going back to the pain science education from the initial evaluation). He reported that he did believe in how much his stress increased his symptoms and how incorporating daily relaxation was now important to him. I noted a slight increase in myofascial and connective tissue restriction at his inner and posterior thighs (which may have been linked to the increase in his pain). Ben was interested in other ways to perform at home myofascial and connective tissue release besides using his hands and the foam roller, so I discussed and demonstrated use of a myofascial roller stick. I also instructed Ben in alternative positions to perform the pelvic floor drops/relaxations (cat/cow and low and high kneeling positions).
At the seventh visit, Ben reported that he had been completely pain free for four days after the previous session, and that it was the best week he’d had in the past six years. He reported that he got a myofascial roller stick and was using it consistently each day, and had also found the cat/cow positions to be helpful in doing the pelvic floor drops/relaxations. I noticed a significant decrease in the myofascial and connective tissue restrictions at his inner and posterior thighs, as well as a decrease in the urogenital triangle hyperactivity. I felt bilateral hip flexor tension during this session, so I added a kneeling hip flexor stretch to his home exercise program.
By the ninth visit, Ben reported that his pain and symptoms were decreasing and felt a direct correlation between being consistent with his home exercise program and feeling better overall. He reported full days of having no pain or feelings of tension in his pelvis. Ben’s pelvic floor motor control had improved; he was able to perform a good pelvic floor drop/relaxation while diaphragmatic breathing independently (without any cues). I noted a continuing decrease in the urogenital hyperactivity as well. Due to Ben’s improvements in his pain and symptoms, I decided to decrease the frequency of visits from one time per week, to one time every two weeks.
Two weeks later, at his tenth visit, Ben reported that he had been consistent with his home exercise program and was able to incorporate more physical activities and exercising without pain. Because he noted no restrictions or pain with exercise, sitting, or sexual activity, I discharged him from pelvic floor physical therapy. Ben was instructed to continue to be consistent with his home exercise program for the next four to six weeks, and then he could decrease the frequency as needed.
“Two months out of therapy, my pain has subsided dramatically, and most important I am back to working out and on the road to achieving my fitness goals – which hasn’t been possible in years! I highly recommend PHRC!”
With the correct combinations of treatments and interventions, Ben’s pain and symptoms resolved relatively quickly (three months) given the amount of time he had been suffering (six years). A major contributing factor to Ben’s success with pelvic floor physical therapy was his willingness to incorporate changes into his daily life, in order to facilitate and maintain the changes made during the therapy sessions. Ben was able to change his life-long “clenching” tendencies with hard work and perseverance through daily relaxation, breathing techniques and bringing awareness to what his pelvic floor muscles were doing throughout the day. Change in chronic pain is possible, with the right guidance and mindset!
If you’d like to learn more about how pelvic floor physical therapy can help with male pelvic pain, click here.