You are not alone: 8% of Australian men report pelvic pain (Ferris et al 2009).
Persistent pelvic pain (PPP) is also known as chronic pelvic pain (CPP), chronic pelvic pain syndrome (CPPS) or chronic bacterial prostatitis.
What is it?
Persistent pelvic pain is defined as:
- pain that has lasted 6 months or longer (this is why it is also known as chronic), and
- your pain feels like it is in your abdomen and/or pelvic area and you may feel it coming from your:
- pelvic organs (bladder/bowel)
- penis; testicles; anus
- perineum (the area between your testicles and back passage)
- musculoskeletal structures (bones/muscles/ligaments)
You may feel your pain in one or more of these areas.
What causes it?
This is a very good question and one which we are unable to answer completely at this point in time. What we do know is that often the initial cause of the pain is long gone, however the pain remains due to changes in soft tissue, brain and nerve function. Some causes and contributions include:
- history of infection (eg acute prostatitis or urinary tract infection)
- history of sexually transmitted infection (eg chlamydia)
- history of constipation/straining to empty bowels
- high stress job which may be associated with excessive sitting and increased muscle tension
- other stressors: relationship; family trauma/concerns; abuse
- musculoskeletal: low back/ sacro-iliac joint injury
- often unable to identify the cause
Symptoms may include:
- Pain that may feel like:
- dull, aching, throbbing, sharp, shooting, burning, cramping
- often worse with sitting and you may feel like you are sitting on a ‘golf ball’ or something similar
- often worse during/after situations of stress and anxiety
- bladder changes:
- more urgent to do a wee and going more often than normal
- slower urine flow
- pain before/during after doing a wee
- bowel changes:
- difficulty emptying the bowels
- pain before during/after a bowel movement
- sexual changes:
- pain with arousal
- pain with orgasm
If you have had pelvic pain for more than 3 months – it is recommended you see your GP prior to engaging in Physiotherapy treatment.
It is important to rule out any conditions that need medical treatment first, or in conjunction with Physiotherapy treatment. It is also important to get a diagnosis for your pain. Your pain is NOT in your head – pain is ALWAYS REAL and your medical practitioners should spend the time to listen to your story and understand your pain.
Common tests the GP may order include:
- mid-stream urine test (MSU) to rule out a urinary tract infection
- blood tests/swabs to rule out sexually transmitted infections
- ultrasound scan of the bladder
If all of these tests are clear the GP may decide to refer you to a specialist depending on the location of your symptoms:
- if primarily bladder troubles: a Urologist
- if primarily bowel troubles: a colorectal surgeon or gastroenterologist
- a sexual health clinic
- a pain management physician
- a specialist pain psychologist
- Persistent pelvic pain is often complex, and your physio should allow 45min to 1 hour for the initial assessment
- Bring any scans/reports/test results to the appointment
- The initial assessment will involve a detailed history which will include questions related to your pain, bladder, bowel, sexual function, physical and everyday limitations due to your pain
- If indicated, we may perform a real time ultrasound assessment of your bladder and pelvic floor muscles
- We will generally perform a postural and musculoskeletal assessment with a big focus on low back/ sacro-iliac joints/ pelvis/ hips and lower limb function
- Future assessments may include:
- a digital rectal examination for direct assessment of pelvic floor muscles
- bladder or bowel diary
Physiotherapy treatment varies according to your own personal problems and limitations, no one person is the same! However, common treatments include:
- Education regarding the causes, contributors and nature of your pain
- Breathing and mindfulness exercises to help reduce muscle tension which may be contributing to your pain
- Manual therapy to release and lengthen tight and painful muscles
- Stretches and exercises for you to do at home to maintain normal muscle function
- Strategies to help reduce pain flare ups
When will my pain get better?
- The answer to this question varies hugely from patient to patient, and depends on how you interpret the question.
- Better can mean:
- 100% resolved – anyone giving a concrete answer for 100% resolution of persistent pain should be approached with skepticism and financial caution.
- Symptoms less confusing and easier to predict, making it easier to plan around them
- Flares resolve faster
- Flares are less common/severe
- Baseline pain is less severe
- Symptoms are less dominant in your thought processes
- You are able to do more. Even if the pain is similar, the limitations it inflicts on your lifestyle have reduced
- Occasionally some of these improvements can be noticed within 1 or 2 sessions
- People’s pain fluctuates, so instant improvements aren’t the best indicator that you’re in the right hands
- If you have regular review, e.g. once/week or once/fortnight, and you try to do your ‘homework’ you should know that you’re on the right track within 2-4 months. The amount of appointments reduces as you become empowered in your own care.
Other treatment options
Guidelines for the treatment and management of persistent pelvic pain in men are available. These guidelines suggest your condition is best treated with a multidisciplinary approach – that is, you may need to see different health care practitioners at the same time. For example you may be seeing a Pelvic Health Physiotherapist as well as a Pain Psychologist and a Pain Physician. You may need to be under the care of a Urologist and treated with medication for your bladder whilst also seeing a Pelvic Health Physiotherapist.
Please visit these links below for information to begin your road to recovery today: