Background and Purpose Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) negatively affects quality of life and sexual function in men of all ages. Typical treatment with antibiotic and antimicrobial drugs often is not successful. The purpose of this case report is to describe a multimodal physical therapy intervention that included manual therapy techniques applied to the pelvic floor in 2 patients who were unsuccessfully treated with the biomedical model of prescription drug therapies.
Case Description Two men, aged 45 years and 53 years and diagnosed with chronic prostatitis, were referred for physical therapy following unsuccessful pharmacological treatment. The patients were treated with manual therapy techniques applied to the pelvic floor and instructed in progressive muscle relaxation, flexibility exercises, and aerobic exercises.
Outcomes Changes in the patients' National Institutes of Health Chronic Prostatitis Symptom Index revealed differences between preintervention and postintervention scores reflecting decreased pain and improved quality of life. One patient improved from a score of 25 (total possible score=43) before treatment to a score of 0 after treatment, and the other patient improved from a score of 29 to a score of 21.
Discussion Manual therapy techniques applied to the pelvic floor and performed by a physical therapist specially trained in these techniques, along with progressive muscle relaxation, flexibility exercises, and aerobic exercises, appeared to be beneficial to both patients in reducing pain and improving sexual function.
Prostatitis is estimated to affect 2% to 10% of men, and 90% to 95% of those with chronic prostatitis also have chronic pelvic pain syndrome (CP/CPPS).1 Prostatitis is the third most common diagnosis of men under 50 years of age presented to urologists annually.2 According to the current medical consensus on establishing an etiology of CP/CPPS, the condition arises from multiple factors, including neuronal, inflammatory, hormonal, and psychological factors.1,3,4 Chronic prostatitis/chronic pelvic pain syndrome is believed to be initiated by an inflammatory trauma that involves the immune system and subsequently affects the complex neuronal circuitry, leading to psychological distress as pain coping strategies fail.1,4 Men experiencing the pain of CP/CPPS and lower urinary tract symptoms (LUTS) have a high incidence of depression and helplessness.5
Primary symptoms include pelvic, genital, or perineal pain with associated bladder dysfunction, including LUTS, and sexual dysfunction.6,7 Additional symptoms may include dysuria, increased urinary frequency, incomplete bladder emptying, pain following ejaculation, and scrotal, penile, coccygeal, rectal, and lower abdominal pain.1,7 Pelvic pain can result in sexual dysfunction, which negatively affects couples' relationships and sexual satisfaction.8 Men with complaints of sexual dysfunction and voiding problems account for 2 million physician visits a year.9
Diagnosing CP/CPPS is difficult, as there are no gold standard tests to confirm the condition.10 The physician must rule out infections, abdominal wall defects, malignancies, and neurological, urologic, gastrointestinal, musculoskeletal, and psychiatric diseases and conditions. The current consensus on basic diagnostic criteria includes a thorough patient history, a digital rectal examination (DRE), a urinalysis, and the administration of the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI), a validated symptom questionnaire.10 In addition, the patient must have symptoms lasting longer than 3 months.6,11 Secondary diagnostic criteria can include laboratory and imaging studies, although they are considered optional for CP/CPPS.10
The most common treatment of CP/CPPS is antibiotics and antimicrobial therapies,12 despite studies demonstrating that there is no evidence of bacterial infection or inflammation.13,14 Studies have not shown these treatments to be effective in decreasing patients' symptoms over time.15–18 These studies,15–18 however, were either uncontrolled or lacked power, used off-label dosages, or failed to show meaningful change of quality of life (QOL) or lasting relief of the pain and LUTS during the extended follow-up period.19 In addition, pain, QOL scores, and NIH-CPSI scores have been found to increase significantly in patients treated repetitively with these agents.12
Due to the similarity in symptoms with another painful bladder syndrome, interstitial cystitis, muscle tension and muscle tenderness are possible etiologies for the pain related to CP/CPPS. A retrospective study by Zermann and colleagues20 showed that 88.3% of 103 participants experienced a pathological tenderness of the striated pelvic-floor muscles on physical examination. These men were unable to relax the pelvic-floor muscles with repeated trials.20 The failure of antimicrobial interventions in treating CP/CPPS, coupled with successful patient outcomes achieved with neuromodulation for pain reduction and improved voiding, led Zermann and colleagues to believe there is a neurological basis for the pain that leads to urinary dysfunction in patients with CP/CPPS. Tension in striated pelvic-floor muscle could set off and perpetuate this onslaught of neurological events, including visceral pain and neurogenically maintained myofascial pain syndrome.20
Further studies have indicated a relationship between pelvic-floor muscle tension and symptoms of CP/CPPS.13,21 Hetrick and colleagues21 conducted a partially blinded case-control study and examined musculoskeletal function and pelvic-floor myofascial tenderness of patients diagnosed with CP/CPPS compared with controls who had no evidence of CP/CPPS nor a history of urinary or sexual dysfunction. The authors found a difference in pelvic-floor muscle tension both internally and externally in men diagnosed with CP/CPPS compared with the control group. The results indicated that men with CP/CPPS were much more likely to have palpable tenderness in the muscles of the external and internal pelvis. The study was limited by its observational design, lack of a validated test to measure pelvic-floor muscle function, and lack of a second examiner to establish interrater reliability.21
According to the results of the study by Hetrick and colleagues21 and similar findings of Berger et al,13 Potts,22 and Weiss,23 CP/CPPS can be categorized as a pelvic-floor muscle tension syndrome. These findings have allowed for the expansion of treatment options for CP/CPPS from the primarily pharmacologic treatment to the inclusion of neuromodulation of central nervous system excitability, as well as manual therapy compression techniques applied to the pelvic floor.
Simons and colleagues24,25 defined a tender point as a taut band of muscle with a palpable tender nodule or a local tender area. If a tender point is present, when pressure or compression is applied at the tender nodule or tender area, the patient will experience a reproduction of the familiar pain pattern. Other characteristics of a tender point include referred pain within 2 cm beyond the tender area, a local twitch response or jump sign, weakness without atrophy, restricted range of motion, sensitivity when the muscle is stretched, tightness in the muscle, and an automatic response to a remote area such as vasomotor constriction and hypersecretion.26 Several studies have attempted to validate Simons and colleagues' work. Many possible etiologies for tender points located in taut bands of muscle have been hypothesized, yet none have been validated to date.27–29
Similar to the difficulties in diagnosing CP/CPPS, no gold standard exists for diagnosing palpable tender points within a muscle. A recent descriptive study of 9 individuals by Sikdar et al30 successfully used ultrasound to visualize and characterize palpable tender points located within a taut band in the upper trapezius muscle. Both active and latent palpable tender points demonstrated scores reflecting higher tissue imaging than in normal tissue.30 In reviewing the literature on criteria to diagnose tender points found by palpation, Tough and colleagues31 found that more than half of the studies reviewed included only taut band, local tender spot, and reproduction of familiar pain as their diagnostic criteria, without consideration of referred pain, local twitch response, and painful or limited movement. Gerwin et al32 established interrater reliability among investigators in locating and palpating tender points in several muscles, with good agreement on 5 of the 6 diagnostic measures. The local twitch response was the least reliable characteristic to identify. Accurate location of tender points has been made by the use of an algometer, a tool that measures pain caused by pressure, with good reliability, but there is no documentation of the use of algometry for internal pelvic tender point examination.33 Thus, the diagnosis of tender points is established via a thorough patient history coupled with a manual examination performed by an experienced clinician.32 Evidence of regional pain with abrupt muscle overload, repetitive muscle activity, sustained muscle contraction, and constant tension or holding patterns are keys to making the diagnosis of myofascial pain syndrome with tender points.26
Effective treatment techniques for reducing tender points in the pelvic-floor musculature are lacking in the literature. However, many authors have reported successful treatment of myofascial pain and tender points in other areas of the body.23,34–36 In a systematic review conducted by de las Peñas et al,37 little evidence was found to confirm or refute the effectiveness of manual therapy for treatment of palpable tender points within a muscle. In 2 of the studies, there was an increase in pressure pain threshold at the site of the taut band, indicating a positive effect of manual physical therapy. In a study comparing manual therapy compression techniques for treatment of palpable tender points in the muscle with transfriction massage, de las Peñas et al37 found both techniques were effective in pain reduction and increasing pain pressure threshold in the upper trapezius muscle. Patients who had tender points located in the muscles of the back or neck region and who were instructed in a home program of maintained pressure into the taut band and tender spot followed by sustained muscle stretching were found to achieve decreased pain and increased range of motion after only 5 days of home treatment.36
Manual therapy compression techniques applied to the pelvic floor also have been found to be an effective treatment to reduce painful symptoms of patients diagnosed with interstitial cystitis and urgency-frequency syndrome.23 In addition, 83% of 146 patients studied reported moderate improvement in symptoms of postejaculatory pain, decreased libido, and forms of erectile dysfunction following physical therapist–delivered manual transrectal ischemic compression techniques and paradoxical relaxation.35 Paradoxical relaxation is a term coined by Wise to describe specific relaxation techniques used to encourage patients to accept and release their pelvic-floor muscle tension.34 However, there is uncertainty about the duration of the treatment protocol38 and whether manual therapy techniques applied to the pelvic floor alone can provide successful treatment of CP/CPPS.34
Although CP/CPPS is a common diagnosis among men seeking treatment from a urologist, very few studies have reported success with antimicrobial therapies.15,17,18,39 Studies have indicated a relationship between pelvic-floor muscle tension and tender points as a possible etiology for the symptoms associated with CP/CPPS.20–23 Manual therapy compression techniques applied to the tender points in the pelvic floor coupled with paradoxical relaxation has been described as an effective treatment for CP/CPPS.34 However, the clinical utility of ischemic compression applied to the pelvic-floor tender points as the primary intervention for CP/CPPS has not been reported. This case report describes a multimodal physical therapy intervention that included manual therapy techniques applied to the pelvic floor in 2 patients with CP/CPPS who were unsuccessfully treated with the traditional biomedical model of prescribed pharmacological treatment.
Two male patients with the diagnosis of prostadynia/prostatitis were referred by their urologist to a physical therapist who was specially trained in pelvic-floor physical therapy for examination and treatment. A summary of their characteristics is presented in Table 1.
Patient 1 was referred for physical therapy with a chief complaint of pain in the fleshy skin between the scrotum and anus, which he described as sharp and jabbing. Symptoms were aggravated by ejaculation and sitting. He also complained of increased urinary frequency and dysuria following urination. Although he experienced hesitation at initiation of urination, he described his urine flow as strong and steady. The patient had recently returned to school and reported increased sitting during class, driving to school, and while studying, which aggravated his symptoms. He described his physical activity level as sedentary. He had one episode of hematuria; however, his urinalysis was negative for infection. A sonogram of the scrotum also was negative. Prescribed medications for prostadynia/prostatitis included long-term cycles of antibiotics, although there was no evidence of bacterial infection in urine cultures or prostate secretions. Treatment also included 2 trials of muscle relaxants, an analgesic, and an herbal supplement. He experienced no relief with any of these oral medications. The patient's goals were to resume activities without pain, including urinating, intercourse, and sitting.
Patient 2 was referred for physical therapy with chief complaints related to the inability to sit for longer than 5 to 10 minutes, postejaculation pain in the tip of the penis, and dysuria. He described a sensation of bilateral gluteal muscle tightness at the base of his buttocks. He had a history of 3 urinary tract infections 3 years prior, but no recurrence. In addition to those symptoms, he described increased urinary frequency and a burning sensation in his urethra that caused a hesitation to initiate urination. Two years prior, sonograms of the scrotum, kidney, and bladder revealed normal structures but a large post-void residual volume. Although he sat for most of his day at work, he was an avid runner. He initially thought that running was the cause of his pain, but there was no increase in pain during or after running 30 minutes per day. He was treated with 2 α-blockers, which resolved his post-void residual volume. Similar to patient 1, this patient had repeated, long-duration series of antibiotics, although laboratory reports did not indicate bacterial infection of prostate secretions or urine. The patient also took an herbal supplement, with no effect on symptom relief. Lastly, he used omeprazole for his duodenal ulcers. The patient's goals were to resume pain-free intercourse, to resolve urinary symptoms of frequency and burning, and to increase sitting tolerance.
The history both patients presented met the clinical description of CPPS. Their primary symptoms included genital and perineal pain with associated bladder dysfunction, including dysuria, increased urinary frequency, and hesitancy at the initiation of urination. Both patients described some degree of sexual dysfunction.40 The duration of their symptoms was greater than 3 months. Their expressed musculoskeletal pain about the pelvis and hips with poor sitting tolerance was consistent with what Hetrick and colleagues reported.21
After obtaining each patient's history, several symptom outcome tools were used to evaluate their initial symptoms and monitor their response to the interventions throughout their course of treatment. First, both patients verbally rated their pain using the numeric pain rating scale (NPRS), which has been found to yield reliable scores.40 These scores are shown in Table 2. In addition to this symptom scale, each patient completed the NIH-CPSI, which was used as a pretreatment symptom quantifier and posttreatment outcome tool.41 The NIH-CPSI captures scores in 3 domains (ie, QOL, pain, and urinary symptoms) and has strong construct, face, and criterion validity.41,42 Its internal consistency (α=.86–.91) and retest reliability (r=.83–.93) are high.41 Scoring is achieved by summing the responses in each of the scaled items in the 3 categories of pain, urinary function, and QOL. A higher score signifies worse outcomes in all 3 areas. In a study by Propert et al,42 the NIH-CPSI scores were found to be responsive to improvements over time, and a 6-point decline in the NIH-CPSI total score was determined to be the optimal threshold to predict treatment response. The modified Pelvic Pain Symptom Survey (PPSS) was used as an outcome tool by Anderson and colleagues34 to evaluate the sexual dysfunction of each patient prior to and following the physical therapy intervention. The modified PPSS has not been validated. A summary of all outcome scores is presented in Table 3.
An observational posture examination was performed to evaluate asymmetry or postures that may have increased pelvic tension or abdominal pressure. Functional mobility into the squatting position was examined to evaluate any strain on the pelvic floor. Antolak and colleagues43 found that sudden pain associated with squatting is one of the 5 symptom groups associated with CPPS. The Thomas test was used to rule out hip flexor contracture.44 Intraclass correlation coefficients (ICCs) for intrarater reliability of the Thomas test have been reported in the range of .43 to .59.44
The obturator internus muscle, a lateral rotator of the hip, lies within the pelvic floor and is covered by one half to two thirds of the iliococcygeus portion of the levator ani muscle.45 Because of the close proximity of the hip rotator muscles to the pelvic-floor muscles, restriction in muscle length of this hip external rotator may contribute to pelvic-floor tension or muscle spasm.45 With each patient in the supine position, the FABER (Patrick) test was performed to test hip mobility and sacroiliac joint pain.46 This test for hip range of motion has been shown to have good test-retest reliability (ICC=.90).47 When used as a single-motion palpation and pain provocation test for sacroiliac pain, the FABER test was shown to have intrarater reliability ranging from r=.31 to .91 and interrater reliability ranging from r=.44 to .70.46 Martin and Sekiya48 reported an acceptable level of interrater reliability (r=.63) for the FABER test when used to assess hip pain of musculoskeletal origin.
Upper and lower abdominal strength (force-generating capacity) was assessed.49 Theoretically, length and strength imbalances around the pelvis, hips, and abdomen might increase tension on the pelvic-floor muscles and contribute to pelvic pain.25 The examination findings for special tests, strength, and posture for both patients are shown in Table 4.
A manual examination of the abdomen, groin, proximal thigh, and posterior buttock and a manual DRE to assess rectal soft tissue were performed to locate tender points, taut bands within the muscles, and referred or local symptomatic pain. Initially, the manual examination of the abdomen, groin, proximal thigh, and posterior buttock was conducted with each patient positioned supine, with a pillow under the knees, while the abdomen was palpated in a circular, clockwise direction. A 4-finger-width fingertip palpation and a flat finger palpation were performed. The little finger was positioned at the umbilicus and the index finger toward the thorax and inferior ribs. More than one pass was made to scan the entire abdomen. Particular attention was paid to this region, as palpable tender points in the lower lateral abdominal wall refer pain to the ipsilateral testicle.24 With the patient remaining in the supine position, a manual assessment of the groin and anterior thigh was performed using the same 4-finger-width fingertip and flat finger palpation starting at the medial thigh and progressing to the lateral thigh just inferior to the inguinal crease. The patient then assumed a prone position, with a pillow under his abdomen to support the lumbar spine. A clockwise palpation was performed in the same manner over the soft tissue and muscular attachments of the right and left buttocks, hips, gluteal folds, and proximal thigh. Both patients demonstrated numerous palpable tender points throughout the lower abdomen, groin, proximal thigh, gluteal fold, and posterior buttock muscles (Figure).
A manual DRE of the internal pelvic-floor muscles was conducted in the left side-lying, relaxed fetal position, in a clockwise fashion, with the symphysis pubis at 12 o'clock and the coccyx at 6 o'clock.45,50 These 2 bony landmarks are helpful in locating the muscles of the pelvic floor. The puborectalis muscle lies between 3 and 9 o'clock anterior to the iliococcygeus muscle. The obturator internus muscle is at 2 and 10 o'clock at the lateral most reaches of the fingertip. The examining finger moved along the pelvic clock, palpating for nodules, taut bands, and muscle spasms that reproduced the patient's painful symptoms. Palpation of the pelvic-floor muscles in patient 1 revealed dense flat sheets with palpably taut bands and numerous tender points located within the muscles. For patient 2, the pelvic-floor muscles were taut, which made insertion of the examining finger difficult. During palpation of the pelvic-floor muscles, numerous tender points were identified. Results of the external and internal manual pelvic-floor examinations locating tender points for both patients are illustrated in the Figure.
Digital rectal pelvic-floor muscle strength testing was performed with the patient in the supine hooklying position using the grading scale outlined by Chirarelli.45 This scale ranks pelvic-floor muscle strength from 0 (no contraction) to 5 (a strong squeeze with a good, repeatable lift of the pelvic floor). Patient 1 was unable to execute a pelvic-floor muscle contraction. In addition, he was not able to isolate the pelvic-floor muscles and used accessory muscle recruitment of the hip adductors when attempting to do so. Patient 2 had difficulty isolating the pelvic-floor muscles and was only slightly successful when coached (Tab. 4).
Both patients' total scores on the NIH-CPSI were greater than 50% of the total possible score, meeting the diagnostic criteria of CP/CPPS. Manual assessment confirmed numerous tender points externally and internally that corresponded with the complaints of both men. Tender points are activated in these pelvic-floor muscles when sitting in a slumped posture for lengthy periods.25 Both patients displayed slumped standing and sitting postures. The limited muscle length at the hips and decreased abdominal strength most likely contributed to the postural faults, the increased tension on the pelvic-floor muscles, and the development of tender points.21,25 The palpable tender points in the lateral abdominal wall can refer pain into the ipsilateral groin and testicle.24 Studies have confirmed the presence of tender points identified by palpation in the pelvic-floor muscles of men with CP/CPPS.21,34,35
Evaluation and Diagnosis
The examination results for these 2 patients demonstrated findings consistent with the diagnostic classification Musculoskeletal Pattern 4C (disorders of muscle, ligament, and fascia, including pelvic-floor muscle dysfunction, muscle spasm/tension; hypertension of the levator ani muscle).51 The treatment goals for each patient were the same and included elimination of pain, resumption of pain-free intercourse, and increased sitting tolerance. An additional goal for patient 2 was diminished urinary frequency.
The intervention included 2 physical therapy visits per week, consisting of instruction in hip range of motion exercises, postural correction education, postural strengthening exercises, and verbal instruction in total-body paradoxical relaxation with a focus on tension reduction in the pelvic-floor muscles. The therapeutic exercise programs are outlined in Table 5. Paradoxical relaxation, as defined by Wise,34 focuses on releasing tension in the pelvic muscles through mental focus on the presence of the tension, regulated breathing to control anxiety, and progressive muscle relaxation. Both patients were encouraged to perform aerobic exercises (ie, either fast-paced walking or running), daily if possible. Aerobic exercises have been shown to improve NIH-CPSI scores greater than 6 points in men who performed 40 minutes of fast-paced walking daily compared with those who performed exercises only.52 Treatment included 15 minutes of moist heat applied to the lower abdominal region with the patient in the supine position and with the knees supported on a 20-cm wedge to encourage total-body relaxation. Ischemic compression was first performed on the lower abdomen and thigh corresponding with the tender points found on examination. The patient then was treated in the prone position, with one pillow under the abdomen to support the lumbar spine. Ischemic compression techniques were performed as outlined by Travell and colleagues.24,25
Transrectal tender point release techniques were performed as described by Weiss,23 Travell et al,25 and Anderson et al.35 Each patient was treated in the side-lying, relaxed fetal position, with a pillow between the knees. Manual techniques included strumming, examining finger palpating perpendicular to the muscle fibers, and a single-digit stripping or stroking massage, with the examining finger palpating along the length of the muscle fibers of the taut band, assessing tissue resistance and presence of tender points. Maintained pressure was then applied (at least 60–90 seconds or more) up to the patient's pain pressure threshold in the tender points until the pain subsided. Movement was slow and deliberate in order to identify each tender point at various points within the pelvic clock and was provided at various depths, including the external anal sphincter, pubococcygeus, and puborectalis portions of the levator ani muscle. The patient was asked to perform isometric external rotation in order to contract the obturator internus muscle while pressure was maintained internally on the obturator internus tender points with the transrectal finger.23,25
A post-isometric tender point release is achieved when the pain subsides and the muscle softens, allowing the examiner's finger to sink into the softened muscle. Once the tender points were released, an anterior inferior stretch was performed along the muscle just lateral to midline of the prostate, with the examiner's finger flexed toward the symphysis pubis. Each patient was instructed in pelvic-floor muscle exercises that consisted of gentle tightening and relaxing of the levator ani muscle group. The patient was cautioned not to provide too much force during the contraction in order to avoid accessory muscle use or the development of a muscle spasm. Manual digital feedback was provided during the training period. Each patient was coached to perform a 10-second submaximal squeeze and a 10-second relax, for a total of 20 repetitions, in order to inhibit the chronic holding patterns.25,53
Patient 1 was seen for tender point release, pelvic muscle exercises, and instruction in muscle relaxation, aerobic exercise, stretching exercises, and postural strengthening exercises (Tab. 5), for a total of 11 visits. Patient 2 was seen on 7 occasions and received tender point release on 2 of those visits. He chose to have his wife, a massage therapist, learn the technique and perform the manual therapy at home. She was provided with copies of the articles describing the treatment techniques.23,34 In addition to the instruction provided to patient 2's wife, treatment included moist heat and manual release of the external abdominal and buttock tender points, as described for patient 1. Patient 2 also was instructed in therapeutic exercises to increase right hip range of motion using the supine Thomas test position and in posture correction exercises to restore lumbar lordosis in sitting and standing positions (Tab. 5). He also received instruction in aerobic exercise, including a walking program of 30 minutes 5 days per week, and muscle relaxation.
Numeric pain rating scale scores were obtained for each patient before and after each treatment (Tab. 2). At the final treatment, each patient was asked to complete a second NIH-CPSI and PPSS (Tab. 3). Both patients demonstrated greater than a 6-point reduction in NIH-CPSI scores, which revealed a positive response to treatment.42 The patients had changes of 8 and 25 points, the changes are both greater than 6 (the minimal clinically important difference value). Patient 1 was receptive to transrectal manual therapy and demonstrated continued symptom reduction at each visit (Tab. 2). At the time of discharge, after he received a total of 11 treatments, he reported a 100% reduction of all symptoms and demonstrated an increase in pelvic-floor muscle strength from 0/5 to 3/5. At the time of discharge from physical therapy, patient 2 had an 8-point decrease in NIH-CPSI scores (Tab. 3). The PPSS score for patient 1 was 0 at time of discharge, and he had returned to pain-free intercourse. There was no change in the PPSS score of patient 2 at time of discharge. Both patients received a 1-year posttreatment follow-up telephone call. Each patient reported pain-free activity, including the ability to sit for sustained periods and a return to intercourse with no postejaculation pain. Patient 2 reported resolution of urinary symptoms. The NPRS scores were 0 for both patients.
This case report describes the physical therapist management of 2 patients with CP/CPPS with multimodal physical therapy intervention that included manual therapy techniques applied to the pelvic floor as the primary intervention. The pelvic-floor manual therapy was provided transrectally, as described by Weiss.23 The NIH-CPSI urinary symptom scores were low for both patients. The urinary symptom scores are least discriminative between men with CP/CPPS and controls who are healthy.41,42 Prior to the intervention, both men scored high on the QOL and pain categories of the NIH-CPSI, indicating more-severe symptoms. Higher scores in these 2 sections have been found to be the most predictable to confirm a diagnosis of CP/CPPS.41 Tripp et al5 reported in their study of predictors of QOL that higher pain scores had a more negative impact on QOL in patients with CP/CPPS than higher urinary symptom scores. Schaeffer and colleagues12 found a relationship between NIH-CPSI scores higher than 22 and the presence of internal pelvic tenderness. Both men had scores higher than 22, and both men had high QOL scores compared with the other 2 NIH-CPSI domains. Turner et al54 reported that men with recurrent symptoms and NIH-CPSI scores greater than 15 were more likely to have lingering symptoms at 12 months compared with men with lower NIH-CPSI scores or those experiencing their initial onset of symptoms. Both patients described in this case report had high scores, and both had recurrent and lingering symptoms over 1 year. Neither patient received any benefit from antibiotic or α-blocker therapy. Both patients had negative laboratory tests for infection or inflammation, and their failure to respond to prescribed medications matched outcomes of previous randomized, double-blind studies.15,17–19 Based on their high NIH-CPSI scores, LUTS, and the presence of multiple tender points, these 2 patients were optimal candidates for manual pelvic-floor physical therapy for CP/CPPS symptom reduction.
The studies by Berger et al13 and Hetrick et al21 confirm the presence of pelvic tender points in men diagnosed with CP/CPPS. Travell and Simons25 identified the location of pelvic-floor tender points. Both patients had internal and external pelvic tender points that matched the descriptions in previous studies.13,21,23,25 Tender points in muscles that attach to the bony pelvis and in close proximity to pelvic organs are responsible for pain symptoms in that region.24,25 Therefore, in the absence of a medical diagnosis for the pelvic pain symptoms that both men were experiencing, treating the tender points to decrease painful symptoms may have been a more appropriate treatment than antibiotics and α-blocker therapy.
There are other methods for tender point release, including needling techniques and coolant sprays.55,56 Neither of these treatment methods is practical for transrectal tender points. Weiss23 demonstrated the positive effects in symptom reduction using the techniques of pelvic-floor tender point release, as described by Travell and Simons.25 These techniques include stripping or stroking massage and maintained pressure, strumming, post-isometric release, and stretch. Anderson and colleagues34,35 expanded on this approach and added an extensive training in paradoxical relaxation to the tender point treatment. Because many authors reported on the similarities of interstitial cystitis and CP/CPPS and both patients demonstrated these symptoms, the treatment protocol described by Weiss23 was thought to be an appropriate treatment approach for both patients.57–59 The work of Anderson and colleagues34 stressed a combined treatment of tender point release and intense training in paradoxical relaxation. The primary intervention for the patients in this case report was tender point release with a secondary focus on paradoxical relaxation training, aerobic exercises such as walking, and posture and flexibility exercises to be carried out at home.
For both patients described in this report, the diagnosis of CP/CPPS was addressed as tension myalgia with the presence of tender points, and the described manual pelvic-floor physical therapy treatment methods used with these 2 patients was shown to be effective in reducing symptomatic pain. Both patients demonstrated pelvic and postural muscle weakness and limited range of motion at the hips, which can contribute to pelvic pain. Instruction in exercise to increase strength and range of motion and to improve posture was included in the treatment plan. The patients were encouraged to participate in self-help treatment by performing aerobic exercise, stretching exercises, and muscle relaxation techniques to decrease pelvic-floor tension and improve their ability to control symptoms following successful tender point release.52 Studies have shown that relaxation and aerobic exercise have a positive impact on reducing tension in the pelvic floor.52,60
Based on the outcomes of the study by Weiss,23 treatment with tender point release should be successful in 12 physical therapy visits, or up to 12 weeks, with 1 to 2 visits per week. Both patients had limited physical therapy visits approved by insurers, so the protocol described by Weiss23 seemed applicable. Patient 1 completed 11 physical therapy treatments, but patient 2 was more reluctant to receive transrectal treatment. After 2 transrectal treatments and 7 physical therapy treatments focusing on exercise training for strengthening, muscle lengthening, and external tender point release, patient 2 had achieved a 50% reduction in pain intensity and a slight relief of urgency at the time of discharge. Given that he responded well to the first 2 transrectal physical therapy treatments for tender point release, patient 2 chose to have his wife perform the internal tender point release at home. Studies indicate that training and clinical experience are necessary for accurate identification of tender points.32,61 The patient felt that his wife had the necessary skills to treat him at home.
The positive patient outcomes in this case report are consistent with the findings of several studies regarding the effects of tender point release to reduce painful symptoms in various locations throughout the body.23,34,35,62–64 Several self-help approaches were used with both patients, in addition to tender point release. Whether the changes in outcome scores were due to tender point release alone cannot be stated. Adherence to the home program was not monitored, and the impact on the patients' symptom reduction is unknown.
Although this case report demonstrated patient improvement with a multimodal physical therapy intervention that included manual therapy techniques applied to the pelvic floor, the improvement cannot necessarily be attributed to the specific manual therapy. The improvement could have been related to the nonspecific effects of therapeutic touch or placebo. Whether the positive outcomes were due primarily to the manual therapy techniques or to the relaxation, flexibility, and aerobic exercises is not known.
Further research comparing men diagnosed with CP/CPPS who receive pelvic-floor manual physical therapy alone with those who perform only progressive muscle relaxation or aerobic exercise coupled with manual therapy techniques applied to the pelvic floor is necessary to determine whether manual therapy techniques applied to the pelvic floor alone are superior in reducing pain and restoring functional activity.
A multimodal physical therapy intervention that included manual therapy techniques applied to the pelvic floor performed by a physical therapist, along with progressive muscle relaxation, postural and flexibility exercises, and aerobic exercises, appeared to be beneficial to both patients in reducing pain and improving sexual function.
Dr Van Alstyne and Dr Haskvitz provided concept/idea/project design. All authors provided writing. Dr Van Alstyne provided patients. Dr Harrington provided clerical support. Dr Harrington and Dr Haskvitz provided consultation (including review of manuscript before submission).
This case report was completed in partial fulfillment of Dr Van Alstyne's Doctor of Physical Therapy degree at The Sage Colleges.
The authors received permission from the Institutional Review Board of The Sage Colleges to write this report, and the report meets all HIPAA requirements for this institution. In addition, the Department of Clinical Investigation at Walter Reed Army Medical Center gave permission to publish this report.
A poster presentation of this work was given at the Combined Sections Meeting of the American Physical Therapy Association; February 6–9, 2009; Las Vegas, Nevada.
The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.
- Received December 20, 2009.
- Accepted July 16, 2010.
- © 2010 American Physical Therapy Association