Chronic Prostatitis (or prostatitis 3b) or Chronic Pelvic Pain Syndome (CPPS) are often considered synonymous where pain in the pelvis is of a persistent nature.
In Prostatitis, there is often as an infection affecting the prostate gland. However, only about 5-10% are actually bacteria related with the vast majority related to inflammation or non-specific pain syndromes. Prostatitis can affect all men at any age and accounts for about ¼ of all pelvic pain conditions, genital or urinary conditions in young to middle aged men. Where pain persists after a period of time and after medicine has failed to resolve pain, by process of elimination, CPPS or Chronic Prostatitis type 3b is a diagnosis often assigned.
Acute Prostatitis is the least common form of the condition and manifests with an increased frequency of micturition, particularly at night. There is often pain in the pelvis and genitals, and there are other cardinal signs of infection including vomiting, fever and chills. This condition would make you feel quite ill and requires prompt treatment. Left untreated symptoms lead to a drop in blood pressure, confusion and increased mortality.
Chronic prostatitis is diagnosed in situations where the symptoms of prostate infections are recurrent. The symptoms are much less severe than in acute states but they are often difficult to treat with many trials of antibiotics proving unsuccessful and the patient suffering recurrent pain and symptoms.
Chronic Pelvic Pain
Where pain persists but inflammation and bacteria are absent a condition of chronic non-bacterial prostatitis or chronic pelvic pain can be assigned. This condition is the most common form of pelvic pain and accounts for up to 90% of cases. You may have been seen by a colorectal specialist or urologist with multiple tests and only negative findings. CPP is therefore a diagnosis often determined by a process of elimination.
Pain may start in the bladder or bowel. It may be located in the lumbar spine, groin or hip. It may also start in a joint or muscle. It may not have even started with prostatisis in mind. This can, on occasions, delay treatment because we are searching for an identifiable cause yet the actual structural entity remains elusive. Perhaps even absent. Pain is considered ‘chronic’ when it has been present for more than 3 months. We have limited understanding as to why some men experience pain for a short time and then recover, while others are left in continuing pain. Whatever the cause, after three months there is often sensitisation of organs or muscular structures in the pelvis. If in the hip or groin, or lumbar spine there may be sensitivity which causes widespread sensitisation (referred pain). The area of pain may spread into the pelvis. Sensitisation may not be something that we can see on a scan because it relates to a change in behaviour of our nervous system and therefore a change in our tolerance to irritation. Our defence mechanism in situations of pain sensitivity is often muscle spasm and the pelvis is full of muscles. This can be the most painful part of the pain. It is the body defending itself only instead of a hamstring or calf muscle it is something on the inside of the pelvis. Something we will find difficult to press, massage or touch. Pain prevents the normal contraction of muscles in the pelvic girdle, muscles essential for urination, sexual and colorectal function. The muscles are in spasm and therefore will have difficulty letting go. We need to let go in order to pass urine or for sufficient blood flow for erectile function. Therefore, CPP may cause problems with normal functioning processes. If you have chronic pelvic pain it is likely to be painful & tender spasms in the muscles that are causing your day to day pain.
Signs and symptoms are varied, mixed and often do not a clear algorithm for diagnosis. Clinical examination with a solid patient history is essential. However, typical symptoms may include:
- Low back pain, abdominal, buttock or groin pain
- Urinary symptoms
- Rectal symptoms
- Pain on sexual activity
- Loss of Libido, erection or the ability to ejaculate
- With Low mood, anxiety, often difficultly with relationships
Our pelvic assessment program uses a subjective comprehensive examination where we will encourage dialogue from the patient to discuss their problem in as much detail as possible. We will use differential questioning to hone in on the possible causes of your problem. The history of any condition as told by the patient reveals much more (in many cases) than any test or examination. Therefore this phase may take a little time to ensure we get all the important information down. Some questions may be of a sensitive nature. We will always explain why we need to ask such questions and will use our knowledge of pelvic anatomy and skeletal models/diagrams to help with our explanation.
We may also use a questionnaire which helps to identify an objective marker so that we can accurately identify progress.
Examination will include the lumbar spine, pelvis, hips and pelvic muscles. Most of the examination will be external but may include direct palpation of the perineum or instruction to the patient to palpate their own perineum (saddle region between the anus and scrotum). We may also palpate on the inside of the pelvis. This is called an internal examination and allows the physiotherapist to determine the presence of trigger points inside the pelvis that may be inhibiting muscle function or causing pain. Gaining access requires palpation through the anus. This is by no means an absolute necessity but remains the gold standard for assessment of the pelvic floor. Total understanding and a complete explanation, and only after consent in a written format are any form of internal examinations conducted. Dynamic ultrasound may also be used to assess the pelvic floor function. For patients who are incontinent, this is often the only method of assessment.
Once we have completed both phases of the examination we will then formulate an action plan with the patient and begin treatment.
The examination will last at least an hour. In some cases 1hr 30 minutes is necessary.
Treatment of prostatitis requires differential diagnosis by your GP. If you are in acute pain then antibiotics are the 1st line of treatment. We can closely liaise with your GP to comprehensively understand the problem and therefore help with diagnosis.
The treatment of CPP will start by the assessment of the pelvic floor muscles, identifying dysfunction in control, abnormal activation and sensitivity in the muscles. We will also conduct a full musculoskeletal assessment of the hips, pelvis, nervous system and lumbar spine. It is essential that we consider all structures and muscles surrounding the pelvis to allow us to determine the most appropriate techniques to help you with your pain. We may also ask questions concerning your stress levels. Stress can cause or be a result of pain. In any case it is a nasty emotional state and only adds to the already mounting sensitisation of your pelvic area. More sensitisation causes greater pain through spasms.
Treatment may consist of manual therapy directed at the spine, pelvis and soft tissue around the area, we may also consider internal massage of the pelvic muscles. While this does not cure pain it certainly helps to reduce sensitivity. Exercise rehabilitation is vitally important as are relaxation and education about the problem. We will not just send you to a gym but we will show you how to switch these muscles off and then incorporate these exercises into your gym sessions. Our rehab is centred around the switching on and switching off of the muscles and to teach the muscles to behave normally. Counselling and relaxation techniques are key to reducing emotion and helping you avoid situations where stress will cause a re-surfacing of the problem.
We may also discuss bowel and bladder habits. These can only add to muscle and nervous sensitivity and therefore optimising the function of the bowel and bladder ensure the stress on the pelvic floor is reduced to a minimum.
If you would like to find out more about CPP or prostatitis then please call the clinic and speak to Adrian Wagstaff, Book Online or call 01189310053
Our clinics consult at Core Body Clinic in Reading and at our Swansea Physiotherapy clinic.