Treatment for Muscle Based Pelvic Pain
|In the latest Stanford study, the global response assessment revealed that 82% of our patients reported improvement (59% marked/moderate, 23% slight). Click to read published research.
Facts About Interstitial Cystitis & Pelvic Floor Pain
Symptoms of interstitial cystitis
It is estimated that 700,000-4,000,000 people in the U.S. (about 90% of whom are women) suffer from a chronic bladder condition known as interstitial cystitis in which the bladder is inflamed or ulcerated and the capacity of the bladder to hold urine is reduced. This condition is diagnosed when symptoms occur that feel like a bladder infection but no bladder infection is found. Symptoms include:
- Urinary frequency and urgency (sometimes urinating dozens of times daily
- Suprapubic pain (pain above the pubic bone)
- Pain with intercourse
- Flare up of symptoms with certain food and drink
- Although signs and symptoms of interstitial cystitis may resemble those of a chronic urinary tract infection, urine cultures are usually free of bacteria. However, a worsening of symptoms may occur if a person with interstitial cystitis gets a urinary tract infection.
Interstitial cystitis is often accompanied with pelvic floor dysfunction in which the muscles of the pelvis. Some researchers hypothesize bladder inflammation may occur as the result of neurogenic inflammation in response to ongoing guarding of the pelvis muscles. Below is a detailed list of pelvic floor dysfunction symptoms in men and women associated with IC.
Symptoms of pelvic floor dysfunction
Urinary frequency and Urinary urgency (need to urinate too often and hard to hold once urge occurs)
- For patients, urinary frequency can range from being annoying to debilitating
- There is typically a feeling of something always nagging in your bladder/urethra/genitals and typically after someone urinates, they don’t feel ‘emptied’ and have the feeling of having to urinate again even though there is no urine there
- The normal relaxation you feel after urination when you have no pelvic pain is not there
- Always a nagging feeling, and sometimes patients push on the bladder to see if it there is any reason to urinate
- Frequency/urgency means you have to always be near a bathroom and sometimes can hardly hold in the urge to urinate
- If you are in a movie theatre, sports event etc. you usually look to sit in the aisle seat because when the urge comes, you have to go
- Some patients feel that their life revolves around being near a toilet
- Urinary urgency and frequency can deprive people of sleep because of how often they wake up during the night
Dysuria (pain or burning during urination)
- Burning or pain with urination is always disconcerting
- It is often associated with pelvic floor dysfunction
- When the chronic spasm and myofascial contraction of the pelvic muscles is resolved, in many of our patients, dysuria is also resolved
- Sometimes people feel no pain during urination but only after
- Dysuria can be so painful that urination becomes a large ordeal and sets off further pain
Nocturia (frequent urination at night)
- Often this is a major problem in that someone’s sleep is so disturbed they are exhausted all the time
- Exhaustion from sleep deprivation tends to feed into the cycle of tension, pain protective guarding and anxiety
Reduced urinary stream and hesitancy of urination
- In men this is an important symptom to medically evaluate as to whether the source of the reduced stream from prostate enlargement or other issues
- Hesitancy of initiating urination can be worsened when urine is held in longer than comfortable (because we speculate the tightening of the muscles to hold in the urine puts the muscles in a kind of spasm that is slow to release upon urination)
- A contributing symptom to low self-esteem and hypochondriasis especially in younger men
- When urinary symptoms are muscular in origin, after loosening the pelvic floor, the flow of urine can improve
- Some people with muscle based pelvic pain have to wait for a while to get a stream of urine going
Perineal pain (pain between the anus and scrotum in men or anus and vagina in women)
- Perineum is one of the most common sites of pelvic pain, is intimate, can hurt 24/7 and can be very distressing
- The perineum is the place where most muscles of the pelvic floor attach and therefore has many sources of referred pain
- Perineum is often the site of bicycle riding pain
- Perineum pain can be made worse by sitting or standing
- In a 2009 Stanford study of our work published in the Journal of Urology, it was documented that 79% of subjects complained of pain in the perineum
- We documented key abdominal and pelvic muscles that all refer pain to the perineum (rectus abdominus, adductor magnus, and coccygeus)
- The perineum and the anal sphincter is one of the parts of the body where the patients feel the feeling of “sitting on a golf ball”
- Perineal pain is intimate pain and when it doesn’t stop, it is very distressing
In men, discomfort during or after ejaculation
- Increased discomfort hours or the day after sexual activity is common
- Our explanation about why there is often an increase in discomfort during or after sexual activity in men and women with chronic pelvic pain syndromes is as follows:
- Orgasm causes strong contractions of the pelvic, prostate and seminal vesicle muscles lasting about once a second during orgasm.
- There is a significant increase in nervous system arousal during sexual activity.
- The pleasure spasm of orgasm in the form of the increased series of contractions during orgasm will tighten the pelvic muscles further.
- This increased tightening temporarily contracts an already contracted area which doesn’t relax well and it tends to throw the patient further above the symptom threshold
- When our patients learn to release the muscles inside the pelvic floor, they usually can feel this increased muscle contraction
- After a certain time frame (from hours to days), the pelvic muscles relax and return to their baseline level, the normal tightened state of the pelvic floor reasserts itself (which is back to some degree of pain or discomfort when a person has chronic pelvic pain syndrome).
- For this reason we do not recommend increasing sexual activity (as has often been suggested by physicians our male patients have seen) when a person has an increase in symptoms after sex
Dyspareunia (pain with sexual activity in women)
- Sexual activity is painful either during or afterward
- Pain is felt on the outside of the vagina, inside or both
- Pelvic examination in which trigger points are palpated can often recreate symptoms of pain during sex
- Sitting can trigger or exacerbate discomfort/pain/symptoms
- Sitting is one of the great sufferings and scares in pelvic pain and makes all aspects of normal life difficult
- Sitting pain makes one acutely aware of how sitting is the center of social and work life
- Sitting pain usually starts out milder at the morning but after sitting through the day, there is increased discomfort that can last into the night
- Patients often are looking for the padded seats in a restaurant because sitting is so uncomfortable
- Difficult to sit with friends or family and socialize
- Difficult to fly or drive for any distance without pain
- Sometimes patients have to go on disability because they can’t work because their job is a sitting job
- Sitting pain is one of the symptoms that raises the fear that you might not be able to work or function
- Some patients go on disability because they can’t sit
- Most endure the pain and deal with the buildup of pain during the day
Genital pain (penile pain in men and vaginal pain in women)
- In men, pain at the tip and shaft of the penis is a common symptom
- In men, penile pain is sometimes accompanied with a redness at the tip
- In , sometimes there is an irritation on the tip so that rubbing against underwear is uncomfortable
- In women, pain inside the vagina, on one side or another is common
- In women, sometimes vulvar pain accompanies pelvic pain
- Genital pain usually referred from the anterior levator ani and one of the easier symptoms to resolve
In men, testicle pain or discomfort
- Testicular pain/discomfort is particularly miserable and scary
- Pain/discomfort is felt in one testicle or another
- Sometimes the cremaster muscles pull up the testicles or penis especially when the anal sphincter is sore and this can be very disconcerting
- Patients have come to see us who had their testicle removed and their pain remained unchanged
Suprapubic pain (pain above the pubic bone)
- It is common symptom
- Suprapubic pain is common with patients who have urinary frequency, urgency, hesitancy and anterior symptoms
- Sometimes pressing on this area can refer into the anorectal (anus and rectal) area and sometimes bladder pain is experienced here
- Pain can be on one side or another or in the middle
Coccyx (tailbone) pain or Coccygodynia/coccydynia
- Tailbone pain is common
- It is typically referred pain from the pelvic floor and not from the tailbone itself
- Patients` 1 who had their tailbone removed typically felt no relief
- Coccyx pain is often related to post bowel movement pain
Low back pain (on one side or both)
- This is common and often confuses patients and practitioners because the symptoms are referred from the muscles of the pelvic floor, not the low back
- Discomfort can be on one side or another or migrate from one side to another
Groin pain (on one side or both)
- Groin pain often is confused with a hernia
- We have seen patients who have had hernia repair for their pain that did not resolve their groin pain
Discomfort or relief after a bowel movement
- Relief after a bowel movement occurs when the tight pelvic muscles relax
- Discomfort after a bowel movement is a very disconcerting experience because when people have post bowel movement pain, symptoms often begin more strongly for the rest of the day
- Little is written about this symptom when it occurs in the absence of hemorrhoids or anal fissures, but in our experience it is common
- The mechanism of defecation typically involves the filling up of the rectum with stool, which then sends a signal for the internal anal sphincter and puborectalis muscle to relax and triggers the experience of urgency to have a bowel movement
- Once the stool passes through the relaxed anal sphincter and out of the body, the internal anal sphincter reflexively closes.
- When someone has pelvic pain and exacerbation of symptoms after a bowel movement, we propose that the internal anal sphincter tends to ‘over close.’
- That is, it tightens up more than it was tight before the bowel movement and sometimes appears to go into a kind of painful spasm
- Post bowel movement pain appears to occur less frequently when someone is relaxed and not hurried, and whatever contributes to a more relaxed state during a visit to the bathroom may reduce this symptom
- Resolving post bowel movement pain in our patients tends to occur as their entire pelvic muscle tension releases
- Patients sometimes report that their symptoms are exacerbated with constipation
Symptoms can migrate or change location
- It is not uncommon for symptoms to change location or ‘migrate’
- Sometimes pain or sensation will appear in one part of the pelvis or abdomen and then the next day it is elsewhere
Heat (hot bath or shower, heating pad) helps temporarily
- Hot water or heat often helps temporarily
- Cold weather flares up symptoms in some patients
Benzodiazepines temporarily reduce symptoms when first used
- The family of drugs called benzodiazepines can often relieve symptoms for a few hours and are helpful when used skillfully
- Benzodiazepines are addictive and when used regularly for pelvic pain, they tend to lose their effectiveness when used regularly over time and can cause addiction
- Benzodiazepines typically make the user tired and should not be used when driving or having to be alert
Reduced libido (reduced interest in sex)
- Reduced interest in sex is common with pelvic pain
- In pelvic muscle related pelvic pain, there is typically no pathology of the physical structures involved in sexually activity
- Our view is that reduced libido is a mix of anxiety, reduced self-esteem and pelvic pain which all mitigate against sexual arousal and sexual interest and resolution of pain and dysfunction of the pelvic muscles usually resolves reduced libido
Anxiety about having sex and ‘erectile dysfunction’ in men
- Because sex and be painful or painful afterward, there is often a conditioned withdrawal from having sex to avoid pain
- This anxiety and the often resultant difficult in men can result in difficulty in maintaining an erection which adds to relationship difficulties, courting difficulties particularly in younger patients,
- Anxiety with having sex, in our view is the major reason for performance anxiety and what is ‘medicalized’ as erectile dysfunction
- Premature ejaculation is sometimes present related to sexual anxiety
- In our experience when pain goes away, so does the anxiety and what is called erectile dysfunction connected to it
Anxiety and catastrophic thinking
- The scariest part of pelvic pain is the catastrophic thought that it will never go away
- Most patients attention is on their pain most of the time at some level and this focus is most disconcerting
- It is a focus that distract your attention away from your life and with many patients, paints an unacceptable future
- When you are in the throes of pelvic pain, the thought that it will never go away prompts depression in many patients
- Where the doctors cannot help you and you see no light at the end of the tunnel, depression or and anxious depression is the rule rather than the except
- Depression involves the feeling of helplessness about doing anything about what you feel is critically wrong in your life
Social withdrawal and difficulty in intimate relations
- The withdrawal that comes from chronic pain and it distracting any enjoyment of the moment
- There is a major toll that chronic pelvic pain takes on relationships on partners of those in pain
- The difficult issues that arise from partners involve the problems arising from the patient’s withdrawal from sex, withdrawal from going out and doing things with others, planning trips, parenting, socializing and doing the things of partnership or marriage
- In the pelvic pain patient’s suffering and preoccupation with pain, the much needed experience of a partner for the other to be present is often lost
Impairment of self-esteem
- Self-esteem almost always goes down
- Men and women with chronic pelvic pain almost always worry that no one will want to be with them
- Sleep disturbance is very common
- Patients either to wake up to urinate or because of pain and anxiety
- Patients typically wake up anxious
- We wrote a paper about precipitous rise in cortisol in the morning amongst pelvic pain patients
- Many patients wake up anxious, wondering if the pain has gone, disappointed every day that it isn’t
Stress increases pain
- ordinary stresses as well as extraordinary stress tend to increase symptoms
- when stress has triggered pelvic pain, the stress tends to triggers the tension-anxiety-pain-protective guarding cycle that continues after the stress has gone
Helplessness and hopelessness
- Helplessness and hopelessness is the real suffering with chronic pelvic pain
- Helplessness comes from a patient’s inability to stop pain/discomfort that is draining and scary
- The hopelessness and helplessness of pelvic pain steals away your ability to rest or enjoy anything
- Hopelessness in pelvic pain patients arises when they can’t see anything that might help
Locations of pain associated with interstitial cystitis
In a recent survey of 264 women with IC conducted by physicians at the University of Maryland and Johns Hopkins University, it was found that the respondents were quite precise in identifying multiple sites of pain with pain sensations described as ‘throbbing, tender, piercing or aching.’ For genital pain sites, 'burning, stinging and sharp' were the pain descriptions. The order ranking of the most frequently reported sites of pain were suprapubic (above the pubic bone), urethral and genital areas, followed by other non-genitourinary sites. Suprapubic and urethral pain were reported as worsening either with bladder filling or just before urination in 50% or more of the women. Approximately 80% of survey respondents also indicated pain worsening in these areas after consumption of certain food and drinks.
Trigger points and IC
Typically there are a large number of trigger points found in those diagnosed with IC
We have found there are often a large number of trigger points in the pelvic floor in individuals with IC and they are often very painful. These trigger points can be accessed and manipulated by a physical therapist. However, we strongly believe that it is important that IC patients also be taught how to identify and work on the trigger points themselves.
Wise Anderson Protocol and Interstitial Cystitis
A constellation of chronic pelvic pain, protective guarding against pain, chronic pelvic tension including pain-referring trigger points, a predisposition toward anxiety and catastrophic thinking that feeds anxiety may all be part of a self-feeding, self-perpetuating cycle of muscle based pain in women and men with IC. As with male pelvic pain, the goal of our Wise-Anderson Protocol is to interrupt this cascade of events. This is done in our treatment by training our patients to do their own internal and external physiotherapy and training our patients in reducing anxiety and the arousal of the nervous system
In the Wise-Anderson Treatment Protocol, the focus on quieting nervous system arousal needs to be done regularly, especially because IC patients may have a greater predisposition toward anxiety or have relatively more anxiety as a result of their condition. While patients may become discouraged when hearing this, we are not, and simply feel that it takes more effort and intention to reduce the general level of nervousness in order for patients to help themselves. Quieting anxiety in our protocol is most effectively done by teaching our patients how to help themselves and reduce their pain and related symptoms. The methods for doing this include regular internal and external physiotherapy self-treatment, the regular practice in Paradoxical Relaxation, the management of thinking that tends to spin off into catastrophic thinking, and dealing with lifestyle issues and one’s relationships.
A large number of women who attend our clinic have been diagnosed with Interstitial Cystitis
A large number of women who have participated in our program for pelvic pain have been diagnosed with the disorder of interstitial cystitis or bladder pain syndrome (IC/BPS). From epidemiological studies the prevalence of IC is estimated to be 300 cases per 100,000 women. While men also have this condition, it is 5 to 10 times more prevalent in women. IC is a chronic disease of unknown cause that is characterized by pelvic pain in multiple sites and bladder dysfunction including urinary frequency and urgency, nocturia (desire to urinate during the night) and increased symptoms of urinary urgency with intercourse. Patients with IC may only have bladder symptoms and no other pain. While suprapubic pain or pain felt above the pubic bone is a prominent feature, additional pain sites include the urethra, genitalia and others such as the groin, low back, thighs and buttocks.
This condition may coexist with other disorders such as irritable bowel syndrome, fibromyalgia, vulvodynia, vulvar vestibulitis, pelvic floor dysfunction, Raynaud’s syndrome, and migraine headache among others.
The new name for Interstitial Cystitis: Painful Bladder Syndrome
Recently an international consultation of scientific experts met and voted to use the new term “bladder pain syndrome” (BPS) for the disorder commonly called interstitial cystitis or painful bladder syndrome. BPS is a clinical diagnosis encompassing the pattern of multiple symptoms as described above. For our discussions herein we retain the IC terminology, although that name IC focuses narrowly on inflammation within the wall of the bladder and may not accurately describe the majority of patients with the syndrome. The trend at the present time is to identify the characteristics or phenotypes of the chronic pelvic pain syndrome in women. Analyzing these categories may help narrow the focus of treatment.
READ ABOUT THE SUCCESS OF THE WISE-ANDERSON PROTOCOL
IN PUBLISHED STUDIES
The Journal of Urology
April 2011 Volume 185, Issue 4 p. 1294
RODNEY U. ANDERSON,*,† DAVID WISE, TIMOTHY SAWYER,PATRICIA GLOWE AND ELAINE K. ORENBERG
From the Department of Urology, Stanford University School of Medicine,
Stanford (RUA, PG, EKO) and Sebastopol (DW, TS), California
6-day intensive treatment protocol for refractory chronic prostatitis/chronic pelvic pain syndrome using myofascial release and paradoxical relaxation training.
PURPOSE: Chronic prostatitis/chronic pelvic pain syndrome continues to elude conventional therapy. Evidence supports the concept that phenotypes of pelvic muscular tenderness and psychosocial distress respond to myofascial trigger point release and specific relaxation training. This case series reports long-term outcomes of a 6-day intensive combination of such therapies in refractory cases.
MATERIALS AND METHODS: A total of 200 men with pain for a median of 4.8 years referred themselves to Stanford University Urology for participation in an established protocol. Daily 3 to 5-hour sessions including intrapelvic/extrapelvic physiotherapy, self-treatment training and paradoxical relaxation training provided a solid introduction to facilitate self-management. Subjects answered baseline and followup questionnaires at variable intervals after initiation of therapy including the National Institutes of Health Chronic Prostatitis Symptom Index, global response assessment and a psychological query.
RESULTS: We followed 116 men for a median of 6 months. Baseline total symptom index was 26 out of a maximum 43 points. Scores decreased by 30% (p <0.001) at followup with 60% of subjects demonstrating a 6-point or greater decrease (range 6 to 30). Domains of pain, urinary dysfunction and quality of life showed significant improvement (p <0.001). Global response assessment revealed that 82% of subjects reported improvement (59% marked to moderate, 23% slight).
CONCLUSIONS: Men with chronic pelvic pain refractory to traditional treatment benefit from intensive myofascial trigger point therapy and concomitant paradoxical relaxation training. Education in techniques for self-administered trigger point release and continued pelvic muscle relaxation help patients reduce pain and dysfunction. Refinement of clinical phenotyping and selection of patients with pelvic muscle tenderness should enhance the success rate with this treatment modality.
Rodney U. Anderson MD,1 David Wise PhD,2 Timothy Sawyer PT2 and Brian Nathanson PhD3
1Department of Urology, School of Medicine, Stanford University, Stanford, CA, 2Sebastopol, CA and 3Longmeadow, MA
SAFETY AND EFFECTIVENESS OF AN INTERNAL PELVIC MYOFASCIAL TRIGGER POINT WAND FOR UROLOGICAL CHRONIC PELVIC PAIN SYNDROME (UCPPS)
Clin J Pain. 2011 Nov;27(9):764-8.
Anderson R, Wise D, Sawyer T, Nathanson BH.
Department of Urology, Stanford University, School of Medicine, Stanford, CA.
Safety and effectiveness of an internal pelvic myofascial trigger point wand for urologic chronic pelvic pain syndrome.
OBJECTIVES: Pelvic muscle tenderness occurs often in patients with urologic chronic pelvic pain syndrome; symptoms frequently can be reduced with pelvic myofascial physical therapy. This open-label pilot study evaluated the safety of a personal wand that enables patient's self-treatment of internal myofascial trigger points in the pelvic floor and its effect in reducing pelvic muscle tenderness.
METHODS: A specially designed curved wand served as an extended finger to locate and release painful internal myofascial trigger points; an integrated algometer monitors and guides appropriate applied point pressure. Patients used the wand several times weekly after education and careful supervision. Evaluations for adverse events and assessments of pain sensitivity were conducted at 1 and 6 months after commencing use.
RESULTS: One hundred and thirteen of the enrolled 157 patients completed 6 months of wand use-106 men and 7 women; 44 patients withdrew before study completion but none for adverse events. Median age was 41 years and 93% were male. Baseline median sensitivity visual analog scale score (1 to 10, 10=most sensitive) was 7.5 and decreased significantly at 6 months to 4 (P<0.001, Wilcoxon matched-pairs signed-rank test). Most patients (95.5%) reported the wand as either very or moderately effective in alleviating pain. No serious adverse events occurred.
CONCLUSIONS: A multimodal protocol using an internal pelvic therapeutic wand seems to be a safe, viable treatment option in select refractory patients with pelvic pain.
Nature Reviews Urology
Anderson, R.U. & Nathanson, B.H., Nat.Rev.Urology 8, 236-237 (2011)
Department of Urology, Stanford University School of Medicine, CA 94305-5118,
OptiStatim LCC, P.O. Box 60844, Long Meadow, Mass 01116
Drug Therapies for CP/CPPS: help or hype
A recent network meta-analysis of α-blockers, antibiotics and other drug therapies for chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) found that they provided modest-to-no benefit for this condition, confirming previous findings. However, a casual reading of the article may give a false impression of the efficacy and appropriateness of these drugs.
The conundrum of treating CP/CPPS continues to frustrate physicians. Innumerable clinical studies have described the condition and the potential therapeutic options for its management. In an article published in the January issue of JAMA,1 the authors conducted a systematic review and network meta-analysis of clinical studies of the various oral medications used for the management of CP/CPPS, and concluded that “α-blockers, antibiotics, and combinations of these therapies appear to achieve the greatest improvement in clinical symptom scores compared with placebo.”
The title of the article implies a proposal from the American Medical Association for the best management of CP/CPPS. However, after adjusting for publication bias in their direct meta-analysis, there was no clinically or statistically significant treatment benefit associated with α-blockers or antibiotics in terms of reducing either total NIH Chronic Prostatitis Symptom Index (NIH-CPSI) scores or pain, voiding (urinary) and quality-of-life subscores, which should have been a main conclusion. Also, most urologists often find these treatment options to be ineffective, and, unfortunately, the article does a disservice by minimizing the factual evidence from randomized clinical trials that these universally used oral medications fail to help millions of men achieve effective symptom relief. The authors do state that “the total sample sizes [of the studies] are relatively small and the effect sizes are modest and often below the minimal clinically significant difference. Furthermore, even these estimates may be overinflated given the evidence for publication bias,”1 but these points are not adequately emphasized.
Moreover, several methodological issues in this study are worthy of comment. The outcomes of interest were the NIH-CPSI scores or related measures (such as the International Prostate Symptom Score or the Prostatitis Symptom Score Index). The authors note that a reduction of 4 points on the total NIH-CPSI score is necessary to be considered clinically perceptible, and a reduction of >6 points is considered clinically significant. A P-value low enough to signify statistical significance (P <0.05) is misleading if the difference between groups is not clinically meaningful. To prevent this distortion, the analysis should have made the alternative hypothesis state that the significant difference was >4 (the clinically perceptible threshold) and not merely >0, and should have noted where the confidence intervals included this threshold.
The noted heterogeneity of the included studies raises serious methodological issues, particularly for the study’s network (indirect) meta-analysis. A network meta-analysis is a new statistical method that is used to compare multiple therapies when the comparisons were not performed “head to head” in a randomized trial (that is, when trials that directly compare treatment A and treatment B do not exist). The assumptions that are necessary for a valid network meta-analysis are more complex than those for a traditional meta-analysis.2 In short, all the studies analyzed must be homogeneous enough in design, study population and placebo group, both within and among each other, to make the comparisons clinically reasonable, as the exchangeability of results across trials is even more important than in a traditional meta-analysis. We cannot tell from the manuscript whether all these assumptions have been met for each of the studies analyzed. The authors tried to analyze a dichotomous response versus non-response outcome, but the studies’ thresholds were too different (for example, ‘response’ was defined as a 25% decrease in NIH-CPSI score in two studies, and as a 50% decrease in three studies) to make a meta-analysis appropriate.
The story of oral medications for CP/ CPPS has already been told.3 The largest NIH-sponsored randomized controlled trials do not support the use of the α-blockers alfuzosin or tamsulosin, nor the antibiotic ciprofloxacin, either alone or in combination with tamsulosin.4,5 Randomized controlled trials are the gold standard in evidence-based medicine, and this network meta-analysis essentially confirms rather than refutes these previous findings. However, the way the authors present their conclusions, particularly in their abstract, minimizes these facts.
While the ineffectiveness of these drugs is old news to those of us who specialize in treating CP/CPPS, they are still routinely prescribed by most clinicians treating this condition—and patients continue to suffer from CP/CPPS. Underlining the failure of these conventional oral medications should have been the main conclusion of this article. The authors admit that “the reason for the benefit associated with antibiotics is not immediately clear.” Other nonpharmacological therapies for CP/CPPS do exist, however, and the logical trend in the diagnostic evaluation of CP/CPPS is to utilize careful phenotyping in the initial work-up of the suffering patient. This phenotyping approach has recently been proposed and evaluated in a multimodal therapy setting, with excellent results.6 The differences in the management strategies used depend upon recognizing the heterogeneity of the condition and the specificity of symptoms, which are characterized by the six domains of the UPOINT phenotyping system (urinary, psychosocial, organ-specific, infection, neurologic/systemic, and tenderness of skeletal muscles) that are used for focusing treatment. Each of these domains should be treated with state-of-the-art therapy, which might sometimes require more than one treatment modality. Notably, pelvic tension and muscle tenderness make up the majority of the specific symptoms and physical findings in patients with CP/CPPS.
In our personal experience of treating this condition, we have found alternatives to failed oral medications, such as multimodal physical therapy and cognitive behavioral therapy, and suggest that innovative treatment strategies be explored after patients have been carefully phenotyped and once traditional antibiotic or α-blocker therapy of CP/CPPS has been deemed inappropriate.
J Urol. 2005 Jul;174(1):155-60.
Integration of myofascial trigger point release and paradoxical relaxation training treatment of chronic pelvic pain in men.
Department of Urology, Stanford University School of Medicine, Stanford, California, USA. firstname.lastname@example.org
PURPOSE: A perspective on the neurobehavioral 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 a pelvic pain symptom survey (PPSS) and National Institutes of Health-CP Symptom Index. Patient reported 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 symptom scores, as assessed by the PPSS. In those at the 50% or greater improvement level median scores decreased 69% and 80% for 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
“The goal of the Stanford Protocol is to enable the patients to reduce and/or resolve their symptoms without dependency on drugs or others to do so for them.”
David Wise, Ph.D.
Plenary address to the
National Institutes of Health (NIH)
Scientific Workshop on Prostatitis/Chronic Pelvic Pain Syndromes
October 21, 2005
Thank you for giving me the opportunity to discuss the Stanford Protocol at this National Institutes of Health sponsored scientific meeting on Prostatitis/Chronic Pelvic Pain Syndrome.
How I became involved in treating chronic pelvic pain syndrome
I happened to have had the unusual experience of the slow motion nightmare of chronic pelvic pain for a period of over twenty years– at one time or another having had almost all of the symptoms you typically hear from patients, and then unrelieved, unrelenting pain 24 hours a day 7 days a week …and no one to talk to or no one to help me --- and then around ten years ago, I had the fortune of experiencing the resolution of my own symptoms by finding and implementing the elements of what is now called the Stanford Protocol that I am going to discuss. I gratefully remain pain and symptom free. So I speak to you both someone who understands this problem as a clinician who has seen many, many patients with pelvic pain over the past years, and as someone who has had the direct experience of pelvic pain of long duration and then the experience of the resolution of the pain.