When Chronic Prostatitis Doesn’t Involve the Prostate

I have many men who come to clinic with a long history of pelvic, testicular, penile, scrotal, and/or lower abdominal pain. They have been through the wringer when it comes to failed treatments.  Many rounds of antibiotics, every bladder and prostate test and scan you can think of, and multiple doctors—many who have thrown up their hands in defeat.   Almost all of them come in with the longstanding diagnosis of chronic prostatitis.  When a new male patient comes in to clinic with this history, I take a different approach.  What if the prostate isn’t involved?  What if it is more a problem of pelvic floor tension and pain?

The prostate gland sits below the bladder and above the pelvic floor.  It acts as a secondary urethral sphincter, helping to stop the flow of urine and giving the bladder support.  Often, men with chronic pelvic pain also have urinary symptoms—slow urine stream, pain or relief of pain with urination, or hesitancy.  Thus, it makes sense that they often seek the medical advice of urologists. But, again I ask, what if the prostate is not the problem?  Right below the prostate are the pelvic floor muscles.  This group of muscles supports the prostate and the bladder.  They also have a role in urinary function.  With increased muscle tightness, the urethra is not able to completely open, creating the same urinary symptoms.  Tight pelvic floor muscles also correspond with the pain symptoms these men experience.  Pain with sitting, standing, walking, sports, playing with their kids, and having a bowel movement.

Looking at the male pelvic floor muscles, you can see the correlation of this pain and the urinarysymptoms.  From the penis to the sit bones, a triangle of muscles is formed called the urogenital triangle.  The transverse perineal muscles form a strut from sit bone to sit bone.  These muscles are stretched when you sit, stand, walk, etc.  The other sides of the triangle are formed by the Ischiocavernosus muscles.  These muscles line the inside of the pubic bones and support the penis, particularly with an erection.Deeper in the pelvis, are the layers of muscles called the levator ani muscles.  These muscles act as support for the low back, hips, sacrum and tailbone, and abdominal organs. If these muscles have trigger points or areas of tightness, they can produce many of the painful symptoms these men experience.  When I palpate these muscles during an evaluation, many times my client will tell me, “That is my pain!”.

So why am I suggesting that the prostate may not always be involved?  Because often it is not!  The National Institutes of Health groups prostatitis into 4 groups.  Type I and II are pelvic pain with bacterial infections and IV is prostate inflammation without symptoms.  Type III or chronic prostatitis accounts for 90% of all men with chronic pelvic pain.  That’s right—90%!!  Type III is defined as “chronic pelvic pain symptoms and possibly voiding symptoms in the absence of UTI”. (https://www.aafp.org/afp/2010/0815/p397.html). That means no infection, no bacteria, and most likely, no prostate involvement.   The European Urological Association has recently changed their terminology to Painful Prostate Syndrome.  I still don’t love this term, but at least they’re taking the infection off the table!  Maybe looking at it as a pain syndrome instead of an infection, we can decrease the time it takes for these men to receive appropriate treatment.

So what can physical therapy do for “Chronic Prostatitis?”  Well, it turns out quite a lot.  In a recent study by Dr. Colleen FitzGerald (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2872169/), men had a 57% improvement with physical therapy with a focus on myofascial mobility compared to a massage. This shows a significant improvement and is even a significantly more effective treatment then medications (https://www.intechopen.com/books/clinical-management-of-complicated-urinary-tract-infection/chronic-prostatitis-chronic-pelvic-pain-syndrome).

So, let’s take the prostate out of the corner!  If you have been experiencing pelvic related pain and have not been able to find a cause or a definitive diagnosis, find a trained pelvic floor physical therapist and rule in or out the pelvic floor muscles.  We can make a huge difference in helping with your treatment.