Department of Urology, Stanford University School of Medicine, Stanford, California

PURPOSE: The impact of chronic pelvic syndrome on sexual function in men is underestimated. We quantified sexual dysfunction (ejaculatory pain, decreased libido, erectile dysfunction, and ejaculatory difficulties) in men with chronic pelvic pain syndrome assessed the effects of pelvic muscle Trigger Point Release concomitant with paradoxical relaxation training. MATERIALS AND METHODS: We treated 146 men with a mean age of 42 years who had had refractory chronic pelvic pain syndrome for at least 1 month with Trigger Point Release/paradoxical relaxation training to release trigger points in the pelvic floor musculature. The Pelvic Pain Symptom Survey and National Institutes of Health –Chronic Prostatitis Symptom Index were used to document the severity/frequency of pain, urinary and sexual symptoms. A global response assessment was done to record patient perceptions of overall therapeutic effects at an average 5-month follow up. RESULTS: At baseline 133 men (92%) had sexual dysfunction, including ejaculatory pain in 56%, decreased libido in 66%, and erectile ejaculatory dysfunction in 31%. After Trigger Point Release/paradoxical relaxation training specific Pelvic Pain Symptom survey sexual symptoms improved an average of 77% to 87% in responders that is greater than 50% improvement. Overall a global response assessment of markedly or moderately improved, indicating clinical success, was reported by 70% of patients who had a significant decrease of 9(35%) and 7 points (26%) on the National Institutes of Health- Chronic Prostatitis Symptom Index (p<0.001). Pelvic Pain Symptom Survey sexual scores improved 43% with a markedly improved global response assessment (p<0.001) but only 10% with moderate improvement (p=0.96). CONCLUSIONS: Sexual dysfunction is common in men with refractory chronic pelvic pain syndrome but it is expected in the mid fifth decade of life. Application of the Trigger Point Release/paradoxical relaxation training protocol was associated with significant improvement in pelvic pain, urinary symptoms, libido, ejaculatory pain and erectile and ejaculatory dysfunction.

From the Department of Urology (RUA, CC), Stanford University school of Medicine, Stanford, Sebastopol (DW) and Los Gatos (TS), California.
PURPOSE:  A perspective on the neurobehavioural component of the etiology of chronic prostatitis (CP) and chronic pelvic pain syndrome (CPPS) is emerging. We evaluated a new approach to the treatment of CP/CPPS with the Stanford developed protocol using myofascial trigger point assessment and release therapy (MFRT) in conjunction with paradoxical relaxation therapy (PRT). MATERIALS AND METHODS: A total of 138 men with CP/CPPS refractory to traditional therapy were treated for at least 1 month with the MFRT/PRT protocol by a team comprising a urologist, physiotherapist and psychologist. Symptoms were assessed with pelvic pain symptom survey (PPSS) and National Institutes of Health-CP Symptom index. Patient response assessment perceptions of overall effects of therapy were documented on a global response assessment questionnaire. RESULTS: Global response assessments of moderately improved or markedly improved, considered clinical successes, were reported by 72% of patients. More than half of patients treated with the MFRT/PRT protocol had a 25% or greater decrease in pain and urinary symptoms, respectively. The 2 scores decreased significantly by a median of 8 points when the 25% or greater improvement was first observed, that is after a median of 5 therapy sessions. PPSS and National Institutes of Health-CP Symptom Index showed similar levels of improvement after MFRT/PRT protocol therapy. CONCLUSIONS: This case study analysis indicates that MFRT combined with PRT represents an effective therapeutic approach  for the management of CP/CPPS, providing pain and urinary symptom relief superior to that of traditional therapy.

PURPOSE: Abnormal regulation of the hypothalamic-pituitary-adrenal-axis and diurnal cortisol rhythms are associated with several pain and chronic inflammatory conditions. Chronic stress may have a role in the disorder of chronic prostatitis/chronic pelvic pain syndrome related to initiation or exacerbation of the syndrome. We tested the hypothesis that men with chronic pelvic pain syndrome have associated disturbances in psychosocial profiles and hypothalamic-pituitary-adrenal-axis function. MATERIALS AND METHODS: A total of 45 men with chronic pelvic pain syndrome and 20 age matched, asymptomatic controls completed psychometric self-report questionnaires including the Type A personality test, Perceived Stress Scale, Beck Anxiety Inventory and Brief Symptom Inventory for distress from physical symptoms.  Saliva samples were collected on 2 consecutive days at 9 specific times with strict reference to time of morning awakening for evaluation of free cortisol variations, reflecting secretory activity of the hypothalamic-pituitary-adrenal-axis. We quantified cortisol variations as the 2-dat average slope of the awakening cortisol response and the subsequent diurnal levels. RESULTS: Men with chronic pelvic pain syndrome had more perceived stress and anxiety than controls (p<0.001). Brief Symptom Index scores wre significantly increased in all scales (somatization, obsessive/compulsive behaviour, depression, anxiety, hostility, interpersonal sensitivity, phobic anxiety, paranoid ideation, psychoticism) for chronic pelvic pain syndrome, and Global Severity Index rank for chronic pelvic pain syndrome was 93rd vs 48th percentile for controls (p<0.0001). Men with chronic pelvic pain syndrome had significantly increased awakening cortisol responses, mean slope of 0.85 vs 0.59 for controls (p<0.05). CONCLUSIONS: Men with chronic pelvic pain syndrome scored exceedingly high on all pyschosocial variables and showed evidence of dysfunctional hypothalamic-pituitary-adrenal-axis function reflected in augmented awakening cortisol responses. Observations suggest variables in biopsychosocial interaction that suggest opportunities for neurophysiological study of relationships of stress and chronic pelvic pain syndrome.

Below is a summary of the latest research findings about the Stanford Protocol presented at the American Urological Association in San Antonio, Texas, May, 2005
Results:

• 138 men with refractory CPPS enrolled and treated; average age 40.5 years (range 16-79). Disease duration: median 31 months (range 1-354)
• 59% (81/138) of patients had clinically meaningful improvements (“>25-100% decreased symptom core) in total pain as reported on Stanford PPSS(table 1)
• Of these, 39% of patients achieved  “>50%
• Symptom improvement Total pain score 69% Urinary sc80%
• After a median of five myofascial TrP release treatments , median baseline total pain scores of 13 decreased significantly by 8 points (p<0.001), Stanford PPSS (Table 2)
• 72% of patients reported GRAs indicating marked (46%) or moderate (26%) improvements in their symptoms.
• Both symptom surveys, the NIH-CPSI and the Stanford PPSS, reflected similar levels of symptoms improvement after treatment (fig. 2)

CONCLUSION
MFRT combined with PRT (treating these patients with the Stanford Protocol) resulted in moderate to marked improvements in symptoms in 72% of patients.
Treatment is based on the new understanding that certain chronic pelvic pain reflects a self-feeding state of tension in the pelvic floor perpetuated by cycles of tension, anxiety and pain. Our premise is  that in addition to releasing painful myofascial TrPs, the patient needs to supply the central nervous system with information or awareness to progressively quiet the pelvic floor. The patient moves from being a passive, helpless victim to an active participant/ partner in healing.