Male Pelvic Floor: Advanced Massage and Bodywork for Tension, Dysfunction, and Pain

Chronic Prostatitis / Chronic Pelvic Pain Syndrome

Summary

Millions of men suffer from pelvic pain and related dysfunction annually. While discomfort and pain are defining characteristics, men can also experience associated sexual and urinary problems. For many years the prostate was (and often still is) wrongly assumed to be the source of the pain and dysfunction - a view that has repeatedly been disproved by medical research. The vast majority of cases are not caused by the prostate gland, and are therefore more accurately called Chronic Pelvic Pain Syndrome (CPPS) rather than Chronic Prostatitis (CP). Drugs and surgery have largely failed to alleviate symptoms or address the cause.

Current research has shown that tension and dysfunction in the muscles of the pelvic floor play a significant and often primary role in the development of this condition and its subsequent symptoms, including pain. However, "Most physicians neither appreciate nor understand the havoc that chronic tension plays in the pelvic floor." [39]. Research has also shown that massage and bodywork can be a very effective treatment.

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Read on for a detailed discussion of CP/CPPS and the value of pelvic floor massage and bodywork. Though the section titles in the next paragraph are active links, I suggest that you scroll down and read through the sections in sequence rather than skipping around. Each section builds upon the previous one and the information as a whole is written as a narrative.

Section titles are: What is CP/CPPS? ..... The Conventional Model of Treatment - a Dismal Track Record ..... To What Degree is the Prostate Involved with CP/CPPS? ..... The Role of the Pelvic Floor Muscles and the Rationale for Massage and Bodywork ..... Stress, Emotions, Chronic Tightness, and CP/CPPS ..... and finally, Manual Therapy Approaches for the Pelvic Floor. On the right side at the end of each section there are "back to top" links to return here to the main menu.

Below the main sections you will find several "Did You Know?" boxes with additional information regarding CP/CPPS. As you read through the text, hover your cursor over citation numbers to view the source in a pop-up text box or scroll to the bottom of the page for the full list.

 

What is Chronic Prostatitis / Chronic Pelvic Pain Syndrome?

CP/CPPS is a condition characterized by discomfort and pain in the pelvic area, with or without associated urinary and sexual symptoms. It is surprisingly common, affecting 5 to 10 percent of the male population and accounting for nearly two million office visits per year. The term Chronic Pelvic Pain Syndrome came into use in the 1990s when the National Institutes of Health (NIH), in an attempt to more clearly define and standardize terminology, classified Prostatitis into four categories:

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Categories I and II are the result of infections and are treated in the standard way with antibiotics. Category IV is defined as prostate inflammation with no symptoms, and is only found incidental to other investigations.

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By far the vast majority of all men diagnosed with Prostatitis are classified as having Category III Chronic Prostatitis / Chronic Pelvic Pain Syndrome. Nguyen and Shoskes note that "Almost one-third of all men during their lifetime will experience symptoms consistent with prostatitis" but that "fewer than 10% of cases of prostatitis are caused by bacteria. Category III prostatitis (CP), or chronic pelvic pain syndrome (CPPS) as it is now known, is the most common manifestation of the disease (accounting for 90% of cases) but remains the least understood." [1].

It is important to note that CP/CPPS, by definition, is not a bacterial infection, though it is often treated as such. There are no gold-standard diagnostic tests, and CP/CPPS remains a diagnosis of exclusion, meaning other possible causes of the pain and dysfunction are ruled out first. It is a syndrome (a collection of signs and symptoms that occur together), not a disease.

Discomfort and pain are the primary symptoms of CP/CPPS, which can affect any or all of the following areas: the pelvic floor, perineum, rectum, coccyx (tail bone), prostate, penis, testicles/scrotum, groin, thighs, lower abdomen, and low back. Sometimes it is difficult to describe exactly where the pain or discomfort is, especially if it feels deep inside the pelvis. Symptoms can be intermittent or constant, and wax and wane over time.

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Sexual dysfunction can include painful ejaculation, premature ejaculation, erectile dysfunction, and decreased libido.

Urinary issues associated with CP/CPPS may involve discomfort or pain when urinating (dysuria), frequent voiding (urinary frequency), the need to go immediately when the urge first arises (urinary urgency), or a weak stream.

For a full discussion of the role of the pelvic floor in sexual and urinary pain and dysfunction, see my pages on Sexual Dysfunction and Genital Pain and Urinary Dysfunction.

Among the risk factors for CP/CPPS are periods of excessive stress and high anxiety, sitting in a slumped posture for prolonged periods of time, a sedentary lifestyle, extended bicycle riding, pelvic trauma, poor posture, weight lifting, anxiety related to sexual encounters, previous pelvic surgery or infection, and psychologic factors.Back to top

The Conventional Medical Model of Treatment - A Dismal Track Record

For decades the medical community - primary care physicians (PCPs), urologists, and researchers - has struggled to understand the cause of this syndrome and develop effective treatments. While progress has been made, these efforts have largely failed. "Unfortunately, physicians often misdiagnose this problem or recommend inappropriate and sometimes dangerous treatments that offer little hope of successful outcome. ... sufferers have typically endured prolonged periods with uncertain or incorrect diagnoses, multiple tests and many failed therapeutic regimens." write Moise and colleagues, specifically referring to CPPS [2]. In fact, tests beyond those that are initially done to rule out more serious pathology are not usually in the patient's interest. "Ongoing and repeated investigations for the 'cause' are associated with a worse prognosis." states urogenital and pelvic pain specialist Andrew Baranowski. [43].

Primary care and urology practices are oriented toward drug and surgery protocols, yet research indicates these approaches are rarely successful. As a result, men with chronic pelvic pain may become "frustrated and feel misunderstood. Many patients describe a sense of alienation from healthcare providers, who are perceived to be unsympathetic to their pain and disappointment." [38].

Drugs / Pharmaceuticals

Antibiotics, alpha-blockers, and anti-inflammatories are the most commonly prescribed classes of drugs used in the standard treatment approach to CP/CPPS. There is little research, however, to support their use.

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In a 2011 paper in Current Urology Reports, Suh and Lowe state that "Traditional treatments have included antibiotics, alpha-blockers, and anti-inflammatories, but those have not proven to be efficacious therapies through many clinical trials." [3]. Anderson, in 2008, asserts that "Traditional therapy to treat these conditions has failed. This includes antibiotics, antiandrogens, anti-inflammatories, alpha-blockers, thermal or surgical therapies, and virtually all phytoceutical [plant-based] approaches." [4]. Westesson and Shoskes agree, saying "The community standard for care for this condition is abysmal..." [5]. Many studies show a response rate no better than a placebo. "Reports of successful therapy with antibiotics, alpha-blockers, anti-inflammatories, herbal preparations, or other pharmaceuticals are mainly anecdotal, and these agents have been very unimpressive when measured against a placebo in a well-designed clinical trial." state Nickel et al. [6]. Indeed, Wise and Anderson write that "Cipro, Flomax, Lyrica, and Uroxatrol [are] shown to be no better than a placebo for CPPS." [9]. In sum, all randomized, placebo-controlled trials of antibiotics in CPPS have shown no benefit. Yet...

Urologist Russell Egerdie paints a bleak picture of the current standard approach to the treatment of CP/CPPS. He writes "Antibiotics for chronic prostatitis / chronic pelvic pain syndrome? We all use them, patients expect us to prescribe them; however, is the generalized and rampant prescribing of antibiotics justified in this unfortunate patient group? The ... answer is no; at this point in time, antibiotic therapy in CP/CPPS has not withstood the test of scientific scrutiny." Despite this acknowledgement, he later adds this stark admission: "Will urologists stop prescribing antibiotics for patients with CP/CPPS? Of course not. We have little else to offer..." [7]. Note that Egerdie's intended audience is his fellow urologists and physicians, not the general public.

Potts, a leading urologist with extensive experience in treating CP/CPPS as well as an author of many research papers and books, states unequivocally that "Empirical antibiotics should be avoided. Period." [44]. Empirical antibiotic treatment in this case refers to the very prevalent trial and error antibiotic regimens that so often are the initial treatment plan, despite there being no evidence of an infection.

Surgery

"There is no definitive surgical treatment." state Bergman and Zeitlin [8]. They continue: "It has not previously and is not presently thought of as a surgical disease." Surgeries do occur, however, despite very poor success rates. Wise and Anderson observe that "we have never seen surgery be helpful for this condition as it usually complicates the condition and sometimes makes it worse." [9]. Murphy and colleagues, in a review of management strategies for chronic prostatitis, conclude that "Prostatectomies, surgical removal of the prostate, have largely been abandoned, as many men will have recurrent symptoms postoperatively.& quot; [10]. Recurrent "prostate" symptoms after the prostate has been removed should tell us something, which leads me to the next section:Back to top

To What Degree is the Prostate involved in CP/CPPS?

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This is confusing to many people because the term Chronic Prostatitis is used synonymously with the more accurate Chronic Pelvic Pain Syndrome. "The labeling of chronic pelvic pain in men as "prostatitis" may well mislead both patients and physicians into thinking that the syndrome has a more limited focus and etiology [cause] than it actually may have." write Berger and colleagues. [11]. Turner et al., in the journal Archives of Internal Medicine, state that "Although labels of prostatitis and prostatodynia [prostate pain] are commonly applied to these symptoms, associated prostate disease is unproven." [12].

Further confusing the matter are those physicians who tell their patients that they have chronic prostatitis while using the more accurate term chronic pelvic pain syndrome when discussing these same cases with their colleagues. The reasoning seems to be that a diagnosis of CP suggests to the patient that the physician knows what is causing the problem (supposedly the prostate) and "blame" can be assigned, while the term CPPS suggests only pelvic pain of unknown origin. As you will see, this "unknown origin" most often turns out to be the pelvic floor muscles.

Physical examination of the prostate finds no abnormalities in most cases. Nguyen and Shoskes maintain that "The most critical component of the examination is the digital rectal examination (DRE). ... The majority of patients with CP/CPPS will have a completely normal prostate exam on DRE." [13]. Hedelin and Fall concede that the DRE is important, but they contend that it adds little guidance to diagnosis or treatment. They characterize the consistency of the gland as "variable" and conclude that "The absence or presence of tenderness should, however, not be allowed to play a pivotal role in the diagnostic procedure. That the gland is not always tender in men with CPPS/PPS is indirect evidence of the fact that an inflammation within the gland is not the cause of the condition..." [34]. "PPS", by the way, stands for Pelvic Pain Syndrome, a European designation.

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Anderson, in a 2008 paper, states unequivocally: "Urologists should eliminate the prostate organ approach to these disorders. Only 5% - 7% of any chronic prostatitis complaint yields positive pathogenic bacterial localization [an infection]. Further, the concept of inflammatory conditions of the prostate being related to chronic pain should be seriously questioned based on results of a recent national cohort study." [4].

Wise and Anderson, in their 2010 book A Headache in the Pelvis, are more emphatic: "...we want to be very clear that most cases of pelvic pain diagnosed as 'prostatitis' are not prostatitis: the overwhelming majority of diagnoses of prostatitis do not appear to be caused by any known problem of the prostate gland. Nevertheless, most urologists have continued to use the term prostatitis and treat complaints of pelvic pain and urinary dysfunction as if they were caused by an infection or inflammation of the prostate. ... The past decades of treating the prostate in such men has shown that in approximately 95% of men with symptoms, treating their prostate gland for infection or inflammation doesn't help them. ... Despite the clear scientific evidence to the contrary and almost every urologist's clinical experience of the ineffectiveness of antibiotics for nonbacterial prostatitis, it is amazing that giving antibiotics routinely for nonbacterial prostatitis is the common practice." [9].

prostate gland and pelvic floor muscles
The prostate gland (2), the urethra (7), and a schematic of the pelvic floor muscles (9). See my Anatomy page for a larger size and full labeling.

Jeannette Potts, a leading urologist specializing in CPPS, sums it up well in a recent paper: "Nonbacterial prostatitis has never been proven to be a disorder of the prostate gland, much less an infectious disease. Unsurprisingly, treatments targeting an allegedly infected or abnormal prostate gland have yielded neither compelling nor consistent benefit. A more holistic and non-pharmacological [non-drug] approach to UCPPS has been long overdue." [14]. (The "U" in UCPPS stands for Urologic and expands the definition to include bladder pain).

There is no question that the prostate has a close relationship to the muscles of the pelvic floor. It rests directly on these muscles and is attached to them via connective tissues and the urethra, which courses down from the bladder through the prostate to the external urinary sphincter within the pelvic floor muscular layer. Indeed, some anatomists label specific muscle fibers in this layer as the Levator Prostatae, or "lifter of the prostate" based on what they do when they contract. As you read the next section you will see how tension and dysfunction in the pelvic floor muscles can adversely affect not only the prostate gland and genitals but also the nerves, blood vessels, and other tissues within the pelvis - and create pain throughout the region.Back to top

The Role of the Pelvic Floor Muscles and the Rationale for Massage and Bodywork

Muscles have great potential as generators of pain. In fact, common pain symptoms stem from muscular tissue more than from any other source [35]. However, this fact is often overlooked by those who view pain and dysfunction only through the prism of drugs and surgery, as Simons and Travell (both M.D.s) note in their indispensable 2-volume textbook Myofascial Pain and Dysfunction. They write: "Yet the muscles in general and trigger points in particular receive little attention as a major source of pain and dysfunction in modern medical school teaching and in medical school textbooks. This manual describes a neglected, major cause of pain and dysfunction in the largest organ [the muscles] of the body ." [36]. This is, of course, as relevant to the pelvic floor muscles as to any other muscle group.

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Though there were isolated voices in the medical community speaking up about the significance of the pelvic floor muscles in various pelvic pain syndromes in the last century, these voices were most often ignored. Wisniewski and Winemiller, in 2004, write "Despite the prevalence of chronic pelvic and rectal pain, the muscles of the pelvic floor are often overlooked as a source of the discomfort." [15]. The pharmaceutical industry had no interest in funding such research, and regardless, the prostate continued to be the focus of attention. Only in the last few decades has there been serious inquiry into the role of the pelvic floor muscles in causing the pain of CP/CPPS. "Pelvic floor myalgia [muscle pain] has long been suspected as the cause of symptoms attributed to prostatitis, but only recently has this suspicion been studied in a longitudinal fashion in urology." say Potts and Payne in a 2007 paper [16]. More recently, Nickel et al. state their view: "Although the pain of CP/CPPS is poorly understood, nearly all clinicians agree that almost all CP/CPPS patients have some chronic tension and tenderness of the pelvic floor musculature. It is probable that these myofascial abnormalities contribute significantly to the pain of CP/CPPS." [17]. In 2010, Westesson and Shoskes wrote "A significant extraprostatic [outside the prostate] factor in generating pain in many men with CP/CPPS is pelvic floor spasm. This muscular spasm alone can produce and mimic the pain and LUTS [lower urinary tract symptoms] of CP/CPPS." [5].

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Wise and Anderson categorically state that "the source of the pain with men diagnosed with prostatitis is almost always the chronically tightened pelvic floor and not their prostate." [9]. Van Alstyne et al. agree, writing in 2010 that "According to the results of the study by Hetrick and colleagues and similar findings of Berger et al., Potts, and Weiss, CP/CPPS can be categorized as a pelvic floor muscle tension syndrome." [18].

The rationale for using massage and bodywork as a treatment for CP/CPPS is clear: the conventional model of treatment has had little success, there is no evidence the prostate is the source of the pain and dysfunction, and research clearly shows the widespread involvement of the pelvic floor muscles.Back to top

Stress, Emotions, Chronic Tightness, and CP/CPPS

What creates tension in the muscles of the pelvic floor and how does that cause the pain and dysfunction associated with CP/CPPS? Physical trauma or strain are certainly possible causes. A much more common mechanism, however, involves mental stress, emotional challenges, and past experience becoming embedded in the pelvic floor muscles in the form of tightness and rigidity. Chronic tightness and rigidity will eventually be felt as pain. For some men the pelvic floor can be a chronic tension zone, an area where their mental stress and emotional anxiety tends to get translated into physical tension. "People with chronic pelvic pain have a tendency to focus tension in the pelvic floor under stress." write Wise and Anderson [9]. Srinivasan and colleagues state that "Stress commonly exacerbates the symptoms of pelvic floor dysfunction. Pelvic floor pain is elicited similar to a tension headache." [19]. Gilbert and Glazer emphasize that "Stressful emotions can aggravate pain conditions. Denying feelings or pushing them away will not block their effects." [42]. See my Emotional and Energetic Aspects page for more on this.

When the pelvic floor muscles are tense, they create a very inhospitable environment for all the nerves, blood vessels, and organs there, as well as compromise the function of the urethra and anus. Over time, this can result in discomfort, pain, and dysfunction. Sometimes it becomes a cycle feeding on itself as tension creates pain, which causes anxiety and more tension, which creates more pain, and so forth. "Perception of pain, no matter what its cause, can lead to both reflex and voluntary muscle contraction, which may result in more pain and dysfunction." state Nickel et al. [17].

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Another mechanism to consider is the phenomenon of referred pain. All muscles, including those in and around the pelvic floor, have the potential to develop trigger points. These are defined as "points of spot tenderness in a palpable taut band" with characteristic "referred tenderness as well as referred pain." [20]. A specific trigger point in the abdominals, for example, can refer pain to the testicle on the same side; the Adductor Magnus muscle of the inner thigh can refer pain deep within the pelvis. The pelvic floor muscles themselves can refer pain to the genitals, perineum, anus/rectum, or coccyx (tail bone). [21], [9]. The European Association of Urology's Guidelines on Chronic Pelvic Pain describes the process this way: "A muscle that is continuously contracting will ache. Nerves that pass through the pelvic floor may be compressed, and [blood] vessels to the penis and scrotum may be obstructed. Both mechanisms will lead to pelvic pain. ... Repeated or chronic muscular overload can activate trigger points in the muscle." [22].

For an account of one man's years-long journey with chronic pelvic pain and its relationship to stress, see Tim Parks' book Teach Us To Sit Still [37]. After many tests, a sadly typical progression through drug regimens, and facing surgery as a last resort, he finally finds relief (to his great surprise) through progressive relaxation, bodywork, and meditation. The author is an accomplished writer and it shows: the book is well written, engaging, and often very funny.Back to top

Manual Therapy Approaches for the Pelvic Floor

There are a variety of treatment approaches to address tension in the pelvic floor muscles. Massage and bodywork are direct ways of engaging these muscles to gently stretch and relax them, reduce or eliminate discomfort and pain, and encourage a return to proper tone and function.

Carriere and Feldt state that "Manual [hands-on] techniques are among the most basic of the treatment techniques available to physiotherapists in their approach to treatment, and they are also among the most valuable in relation to pelvic floor disorders." [41]. "Massage of the pelvic floor muscles has been established as a treatment option for these patients since reported by Thiele in 1963." write Srinivasan and colleagues [19]. Wehbe et al. found that "Physical therapy, including manual therapy and myofascial release ... offers a safe and effective form of evaluation and treatment for the patient with UCPPS." [23]. Potts adds that "The broad repertoire of techniques offered by physical therapy provides patients with a safely tailored regimen, which is both effective and empowering." [24]. And a report by Nickel et al. concludes that "Physical therapies may hold the key to ameliorization of pain and disability in patients who have developed dysfunctional myofascial pelvic pain." [6].

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"I've made more progress in the four to five sessions I've had with you than I made at [a local pelvic pain clinic] in a similar amount of sessions. Our work together is really helpful."

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Note that manual techniques employed in physical therapy and physiotherapy are generally the same techniques used by well trained massage and bodywork practitioners, such as Myofascial Release, Deep Tissue Massage, Trigger Point Release, Cross-Fiber, and Neuromuscular Therapy for example. Many of these techniques address the connective tissue as well.

Even full-body massage using Swedish Massage techniques has shown promise as a treatment option for CPPS. In the only study to date in which standard massage was included (and even then, only as a comparison group, not the treatment group), the positive results for men with CPPS surprised the study authors. They concluded: "At a minimum these results suggest that therapeutic massage may merit further study as a therapeutic alternative for UCPPS." [25]. 40% of the men in the massage group were classified as responders (moderately or markedly improved) at the end of the study, which is amazing given that any work on the pelvic floor was prohibited. Needless to say, had the study design included massage that specifically addressed the muscles of the pelvic floor as well as the rest of the body it would have had the potential to be much more effective.

See my Massage and Bodywork page for more information on my approach to the pelvic floor and the modalities I use. Also visit my Maintaining a Healthy Pelvic Floor page for discussions on stress management and relaxation, physical activity, stretching, behavior modification, and other supportive measures.

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Finally, it is important to acknowledge that many aspects of CP/CPPS remain enigmatic, and no one has all the answers. While addressing pelvic floor muscle tension may be key for some, or even most, there are men for whom this will not be the case. No one form of treatment is universally successful. Fortunately, there is little risk involved, no drug side effects, and the potential for much benefit.Back to top


Did You Know?

The effect of ejaculation on symptoms of CP/CPPS has not been well studied, and the results of the few that have been done have not always been clear. Yavascaoglu et al. encouraged their study participants "to masturbate regularly, at least twice a week." for 6 months [26]. Of the men who fully complied with the recommendations, 78% responded with "a complete or partial reduction in symptoms." This study was small, and importantly, drew from a pool of men with CP/CPPS who had been avoiding masturbation completely.

Hedelin and Jonsson, in a 2007 study, found that "Ejaculation improved the situation as often as it did not." [27].They noted that "Studies concerning the frequency of ejaculations in men with CP/CPPS are scarce."

In a 2006 review, the authors state that "there is little information to support the benefits of sexual inactivity in patients with prostatitis [CP/CPPS]. Despite lack of concrete evidence supporting the benefits of ejaculatory abstinence, however, many patients with prostatitis are encouraged to refrain from ejaculation." [28].

Bottom line: your own experience over time will guide you in deciding if and how often ejaculation may be helpful.

Did You Know?

Although CP/CPPS is traditionally managed by urologists, many men will approach their primary care physician (PCP) as a first step. Sadly, most PCPs have limited expertise, as demonstrated in an important 2009 study: "Our study showed that many PCPs reported little or no familiarity with CP/CPPS, have important knowledge deficits and have limited experience in managing men with this syndrome. ... PCPs reported practice patterns regarding diagnosis and treatment of CP/CPPS which are not supported by evidence, such as ordering prostate-specific antigen tests and prescribing antibiotics. To effectively diagnose and treat CP/CPPS, physicians need to understand the NIH classification system for prostatitis; however, PCPs reported little or no familiarity with this classification scheme." [29]. See the top of this page for a description of this National Institutes of Health classification scheme.

Did You Know?

An interesting study published in 2005 looked at the health concerns of patients with recent-onset nonbacterial prostatitis / pelvic pain. The majority of men worried that their problem would worsen if untreated, that they may have an infection, that their symptoms might not resolve, or that they might have cancer [12]. And though patients understandably want information about the cause of their symptoms and their prognosis, this information was not always provided by their physicians. The authors state that "information provision may be viewed as more important by patients than by physicians, and patient symptom-related concerns and expectations are often not addressed by physicians." They suggest that patients be informed that "symptoms tend to improve over time regardless of treatment and that mild symptom persistence or recurrence is common and not necessarily a sign of cancer or infection or need for surgery. ... A recent study found no association of prostatitis with cancer."

Did You Know?

Among urologists, prostatic massage remains controversial. While not used often as a therapeutic tool, some urologists do report symptom improvement in some patients. Others remain averse to including this approach because of the lack of research or the time required (usually 2 to 3 times a week for several weeks). It is difficult to know to what degree prostatic massage may or may not be helpful as most often these patients will be using other treatments at the same time. In a 2008 review article, Mishra et al. were surprised to find that "Despite prostatic massage having been practised for a long time, there is a paucity of literature on this subject. There is not a single comparative study that has evaluated prostatic massage alone as a therapy for chronic prostatitis." [30].

While quality research may be lacking, there are a few theories as to how prostatic massage may provide some benefit. One is that massage will milk the ducts of the prostate, moving fluids that may have become stagnant. Another theory is that prostate massage invariably affects the pelvic floor muscles around it and the true benefit lies in reducing the muscular tension creating the pain rather than any benefit to an organ (the prostate) that may not have been problematic in the first place.

Did You Know?

A study in 2008 looked at the prevalence of three types of pelvic pain in Australian men (pain associated with sexual intercourse, pain associated with urination, and pelvic pain not associated with intercourse or urination). They found that 18% of the 4,290 men interviewed reported some form of pelvic pain, and the data revealed some interesting associations. "Men reporting any of the pain conditions were significantly more likely than other men to report a sexual experience when they had felt forced or frightened. Men reporting pain during intercouse and/or chronic pelvic pain were significantly more likely than other men to report same sex experience. All three groups of men with pelvic pain were more likely than other men to report some form of sexual difficulties. A report of ever receiving a diagnosis of depression or a report of anxiety was significantly associated with all forms of pelvic pain." [31].

Did You Know?

Even when bacteria are found in the prostate, this finding is not necessarily evidence of a pathological condition nor is it diagnostic of chronic pelvic pain syndrome. In a 2003 research paper, Lee and colleagues "found no differences between [CPPS] patients and healthy controls in the rates of positive biopsy cultures or types of bacteria from prostate biopsy." Furthermore, "...it appears that the prostate is not a sterile organ but may be intermittently or continuously colonized by commensal [non-harmful or even beneficial] urethral bacteria. All bacteria isolated from the prostate in our study have been previously noted to be present in the normal urethra. These bacteria may also colonize the prostate." They go on to say that the presence of bacteria is not necessarily related to the symptoms of chronic pelvic pain syndrome [32].

 

Did You Know?

Daniel Shoskes, a prominent urologist in the field of Chronic Prostatitis / Chronic Pelvic Pain Syndrome, recently issued a plea to his fellow urologists to improve their diagnosis and treatment of this condition. He describes the current status this way: "Frequently, the diagnosis and management of these conditions is empiric [trial and error; not based on science], inadequate, ineffective, and contrary to the published literature of the past 10 years." He then references Martin Luther's 95 theses posted on the church door in 1517 and states that "we need a broad reformation of the medical community's management of these disorders." His "reformation" includes 23 of his own theses, in which he implores urologists to vastly improve their standard of care for CP/CPPS. Among them are:

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References

Books are in bold regular text and journal articles are in bold italic text

[1] Nguyen CT and Shoskes DA, in Chronic Prostatitis / Chronic Pelvic Pain Syndrome, Humana Press, 2008. Shoskes, DA, ed.

[2] Moise G et al. Treatment of Chronic Pelvic Pain in Men and Women, Expert Review of Neurotherapeutics 2007 May; 7 (5): 507-520.

[3] Suh LK and Lowe FC. Alternative Therapies for the Treatment of Chronic Prostatitis. Current Urology Reports 2011; 12: 284-287.

[4] Anderson RU. The Role of Pelvic Floor Therapies in Chronic Pelvic Pain Syndromes. Current Prostate Reports 2008; 6: 139-144.

[5] Westesson KE and Shoskes DA. Chronic Prostatitis / Chronic Pelvic Pain Syndrome and Pelvic Floor Spasm: Can We Diagnose and Treat? Current Urology Reports 2010; 11: 261-264.

[6] Nickel JC et al. Changing Paradigms for Chronic Pelvic Pain: A Report from the Chronic Pelvic Pain / Chronic Prostatitis Scientific Workshop. Reviews in Urology 2006; 8(1): 28-35.

[7] Egerdie RB, in Chronic Prostatitis and Chronic Pelvic Pain Syndrome. Humana Press, 2008. Shoskes, DA, ed.

[8] Bergman J and Zeitlin SI. Chronic Prostatitis / Chronic Pelvic Pain Syndrome, Humana Press, 2008. Shoskes DA, ed.

[9] Wise D and Anderson RU: A Headache in the Pelvis: A New Understanding and Treatment for Chronic Pelvic Pain Syndromes, 6th edition. National Center for Pelvic Pain, 2010.

[10] Murphy et al. Chronic Prostatitis: Management Strategies. Drugs 2009; 69(1): 71-84.

[11] Berger RE, et al. Pelvic tenderness is not limited to the prostate in chronic prostatitis / chronic pelvic pain syndrome (CPPS) type IIIA and IIIB: comparison of men with and without CP/CPPS. BMC Urology 2007; 7:17.

[12] Turner JA, et al. Health Concerns of Patients With Nonbacterial Prostatitis / Pelvic Pain. Archives of Internal Medicine 2005; 165: 1054-1059.

[13] Nguyen CT and Shoskes DA, in Chronic Prostatitis / Chronic Pelvic Pain Syndrome. Humana Press, 2008. Shoskes DA, ed.

[14] Potts JM: Nonpharmological Approaches for the Treatment of Urological Chronic Pelvic Pain Syndromes in Men. Current Urology Reports 2009; 10: 289-294.

[15] Wisniewski SJ and Winemiller MH. Pelvic Floor Tension Myalgia. Practical Pain Management 2004; volume 4, issue #6.

[16] Potts J and Payne RE. Prostatitis: Infection, neuromuscular disorder, or pain syndrome? Proper patient classification is key. Cleveland Clinic Journal of Medicine 2007 volume 74; supplement 3: S63-S71.

[17] Nickel JC et al. Management of Men Diagnosed With Chronic Pelvic Pain Syndrome Who Have Failed Traditional Management. Reviews in Urology 2007; 9(2): 63-72.

[18] Van Alstyne LS et al. Physical Therapist Management of Chronic Prostatitis / Chronic Pelvic Pain Syndrome. Physical Therapy 2010; 90(12): 1795-1806.

[19] Srinivasan AK et al. Myofascial Dysfunction Associated with Chronic Pelvic Floor Pain: Management Strategies. Current Pain and Headache Reports 2007; 11: 359-364.

[20] Simons DG. Understanding effective treatments of myofascial trigger points. Journal of Bodywork and Movement Therapies. 2002; 6(2): 81-88.

[21] Travell JG and Simons DG. Myofascial Pain and Dysfuntion: The Trigger Point Manual. Vol. 2: The Lower Extremities. Williams and Wilkins 1992.

[22] Fall M (chair) et al. Guidelines on Chronic Pelvic Pain. European Association of Urology 2008.

[23] Webhe et al. Minimally Invasive Therapies for Chronic Pelvic Pain Syndrome. Current Urology Reports 2010; 11: 276-285.

[24] Potts JM, in Chronic Prostatitis / Chronic Pelvic Pain Syndrome, Humana Press, 2008. Shoskes, DA, ed.

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