1. Brian Mulroy, D.O. OMM/PPC December 6, 2012

2. Objectives  Review sympathetic and parasympathetic innervations pertinent to the male GU system.  Review the anatomy pertinent to the evaluation and treatment of musculoskeletal components of male GU disorders.  Review and discuss MFTrP (Myofascial Trigger Points) for the pelvic floor  Review and discuss structural findings and treatment of somatic dysfunction(s) associated with male GU disorders such as: Prostatitis/Prostatosis Renal Disorders Direct, Indirect and Sports Hernias Other GU Disorders

3. Vasculature

4. Lymphatics Renal Lymphatics  Draining capsule and parenchymal flow into preaortic nodes to the thoracic duct  Impaired Lymphatic Flow Increased oncotic interstitial pressure Increased risk of kidney damage (d/t third spacing)

5. Kidney Lymphatics  Surrounded by tough areolar fascia split into two layers that are not continuous inferiorly  Inferior motion of the diaphragm is major factor in lymphatic and venous return from GU system  Diaphragm motion may be influenced by SD of thoracolumbar junction SD of lower ribs Spasm of quadratus lumborum and/or psoas Hyperlordosis SD of phrenic nerve

6. Pelvic Floor  Coccygeus  Obturator internus  Piriformis  Levator Ani Levator Prostate Pubo analis Pubo coccygeus Iliococcygeus

7. Pelvic Floor

8. Autonomics: GU Sympathetics o Kidney: T10-L1 o Superior Mesenteric ganglion o Ureter: T10-L1 o Superior Mesenteric ganglion (Upper Ureter) o Inferior Mesenteric ganglion (Lower Ureter) o Bladder: T10-L1 o Trigone o Detrussor o Transverse perineal muscle: Pudendal nerve (S2-4) o Prostatic Urethra: L1-L2 o Prostate: L1-L2 o Cervix: L1-L2 o Fallopian Tubes : T10-L2 o Epididymis: T11-L2 o Ovaries and Testes: T9-T10 o Uterus : T10-L1 o Adrenal : T8-T10

9. Viscerosomatic Reflexes

10. Autonomics continued…  Ureters T10-L1 Adhere to peritoneum and descend on psoas fascia Psoas laterally displaces lower pole of each kidney  Bladder and urethra Sphincter/Trigone/ureteral orifices ○ Inhibited by parasympathetics Bladder wall ○ Activated by parasympathetics ○ Inhibited by sympathetics

11. Autonomics continued…  Vas Deferens/Seminal vesicles T12-L2: Inferior mesenteric  Prostate Secretory sympathetic fibers T12-L2 Stimulation of hypogastric plexus (carries fibers from T12-L2) causes true glandular secretions Pudendal nerve stimulation causes muscular contraction forcing secretions out the urethra

12. Sympathetic Physiology  Increased tone Increased afferent arteriole constriction to kidneys Ureterospasm and decreased peristalsis of ureters Relaxation of bladder wall leading to reflux Increased tone to external urinary sphincter  Effects of increased tone Decreased GFR Decreased urinary output Increased blood pressure Uretero spasm decreased urine flow through the ureters Incomplete emptying of bladder Encourages ureteral/prostatic reflux from bladder Complaints of premature or retrograde ejaculation

13. Parasympathetics  Kidneys: Driven more by hormones  Ureters: Maintains normal peristaltic waves Proximal: Vagus Distal: Pelvic Splanchnics (S 2-4)

14. Parasympathetic Physiology  Increased Tone Increase peristalsis of ureters Increased bladder wall tone Relaxes external urinary sphincter  Decreased Tone Incomplete bladder emptying Impotence Tightens internal urinary sphincter

15. Erectile Dysfunction  Erection dependent on Parasympathetics via Pudendal nerve (S 2-4 )  Premature Ejaculation Sympathetic from L1-2 Somatics S2-4

16. Micturition (Voiding or Urination)  Distension of bladder walls initiates spinal reflexes that: Stimulate contraction of the external urethral sphincter Inhibit the detrusor muscle and internal sphincter (temporarily)  Voiding reflexes: Stimulate the detrusor muscle to contract Inhibit the internal and external sphincters

17. Postural Issues and pseudo GU issues  SD of pubic symphysis Increased tension on urogenital diaphragm Increased tension on Puboprostatic or pubovesicular ligaments may lead to dysuria (nocturnal enuresis?) MFTrP- lower abdomen may cause-urinary frequency, urgency, sphincter spasm, residual urine, bladder pain (Travel pp. 7671)

19. Chronic pelvic pain syndrome (CPPS)  Pain is attributed to short, tight, tender pelvic floor muscles, usually with hypersensitive trigger points  The pain may occur in pelvic region or more distant areas such as the thighs, buttocks, or lower abdomen  Symptoms Irritative voiding symptoms and/or pain located in the groin, genitalia, or perineum in the absence of pyuria and bacteriuria Absence of pus or bacteria on microscopic analysis of the urine ○ Excess WBCs or bacteria seen on Gram stain and culture of expressed prostatic secretions (EPS) may be found

20. Chronic pelvic pain syndrome  Most common urological diagnosis males > 50 years old  Third most common diagnosis males < 50 years.  Diagnosis results in 2+ million office visits per year  Specific urinary pathogens are detected infrequently after culture  Majority of these patients are categorized as having chronic nonbacterial prostatitis or prostatodynia, otherwise known as CPPS

21. Etiology of CPPS  UNKNOWN WBCs found in the prostatic fluid under microscopic examination does not correlate with the degree of pain or with other symptoms experienced by patients with CPPS Cytokines- may play a role, which are produced by WBCs (and by other cells) Autoimmunity, the abnormal tendency of the body to react against itself, has long been thought to play a role in the development of CPPS Low testosterone level (or, more likely, a breakdown in the mechanism whereby testosterone inhibits prostatic inflammation) may play a role Abnormal functioning of the nervous system Psychological stress and depression have long been associated with CPPS flare-ups. May influence the local production of cytokines (eg, interleukin 10, interleukin 6) in the pelvis, thus directly exacerbating CPPS inflammation.

22. “Clinical researchers at Columbia University have found that an important subset of patients who had been treated unsuccessfully for symptoms of chronic abacterial prostatitis for 1.5 years to more than 10 years and who were actually experiencing pseudodyssynergia (a contraction of the external sphincter during voiding).”

23. Growing clinical experience strongly suggests that pain syndromes labeled prostatitis may in fact reflect tension in the pelvic musculature and its associated tendons—myofascial pain. Postulated that, in these cases, CPPS is not isolated to the prostate, but is rather a neuro-inflammatory condition that releases endogenous pain-producing substances. Spasm in these muscles causes referred pain to the penis, prostate or neighboring pelvic structures.

24. Viscerosomatic Reflexes

25. Anterior Chapman’s Reflex points

26. Posterior Chapman’s Reflex points

27. MFTrP

28. Myofascial Dysfunction  Muscle pain causes an aching, cramping pain that is difficult to localize and is often referred to deep and distant somatic tissues  Muscle pain activates unique cortical structures in the central nervous system, particularly those which are associated with the affective and emotional components of pain  Muscle pain is inhibited more strongly by descending pain-modulating pathways  Activation of muscle nociceptors is much more effective at inducing maladaptive neuroplastic changes in dorsal horn neurons

29. Myofascial Trigger Points  Discrete hyperirritable nodule in a taut band of muscle which is palpable during physical examination  Active MTrPs are a source of spontaneous pain  Latent MTrPs are painful only on deep palpation  Both latent and active trigger points may cause muscle dysfunction, muscle weakness and limit range of motion

30. Myofascial Trigger Point Treatments  OMT  Ice  Spray and Stretch Ethyl Chloride Flouromethane  Injections  Dry Needles

31. Myofascial Trigger Points

32. Pelvic Floor Trigger Points

33. Myofascial Trigger Points

34. Spray and Stretch (Scalenes) Myofascial Pain and Dysfunction: The Trigger Point Manual; David G. Simons, Janet G. Travel

35. Levator Scapulae

36. Injections  Marcaine  Lidocaine  Saline  Dry needle

37. Start listening at 26 min. I don’t care if you don’t want to…do it anyways!

38. Sacrum Review  A few quick reminders: +Spring tests means L/S junction is a brick (does not move) ○ Think backward torsion (non-neutral; R on L, L on R) Sphinx: in a forward torsion the sacrum normalizes; in a backward torsion the dysfunction gets worse

39. Sacrum Review  Some quick tips for torsion model When L5 is sidebent, a sacral oblique axis is engaged on the same side as the sidebending When L5 is rotated, the sacrum rotates the opposite way on an oblique axis Seated flexion test is found on the opposite side of the oblique axis

40. Sacrum Review (Torsion Model)  Putting it together  If L5 is FRrSr: Positive seated flexion test on the left Sacrum will be rotated to left on a right oblique axis (L on R)  If L5 (or group dysfunction) is NSlRr Positive seated flexion on right Sacrum rotated left on a left oblique axis (L on L)  Quick tips: When L5 is sidebent, a sacral oblique axis is engaged on the same side as the sidebending When L5 is rotated, the sacrum rotates the opposite way on an oblique axis Seated flexion test is found on the opposite side of the oblique axis

41. Name: L on LOA, R L on LOA, L Forward Torsion Landmarks: if calling findings on L side Sacral Sulcus:L Shallow Sacral Base:L Posterior ILA:L Post./ Inf. STL:L Tight Motion Testing: Spring:- (It springs!) Sphinx:- (improves with extension) L5:NS L R R Sacral BaseL - R + ILA:L +/- R +/- note: Seated Flexion test may be + on R with this dysfunction (confirmatory) LeftRight Midline A + P  +/- Left Neutral Sacral Oblique Axis Somatic Dysfunction L5: S L R R P - A +/-

42. Right Neutral Sacral Oblique Axis Somatic Dysfunction Left Right Midline Name: R on ROA, R R on ROA, R Forward Torsion Landmarks: if recording findings on R side Sacral Sulcus:R Shallow Sacral Base:R Posterior ILA:R Post./ Inf. STL:R Tight Motion Testing: Spring:- Sphinx: - L5:NS R R L Sacral BaseL + R - ILA:L +/- R +/- Note: Seated flexion test may be + on L with this dysfunction (confirmatory) P  +/- A+ L5: S R R L

43. Left Non-Neutral Sacral Oblique Axis Somatic Dysfunction Name: R on LOA, R R on LOA, L Backward Torsion Landmarks: if recording findings on the L side in this example Sacral Sulcus:L Deep Sacral Base:L Anterior ILA:L Ant./Sup. STL:L Loose Motion Testing: Spring:+ (It does not spring!) Sphinx:+ (findings worsen with extension) L5: confirmatoryFR L S L Sacral BaseL -R +/- ILA:L + R +/- note: Seated flexion may be + on R with this dysfunction (confirmatory) Left Right Midline P+/- A+A+ L5: R L S L

44. Right Non-Neutral Sacral Oblique Axis Somatic Dysfunction A+A+ P+/- Left Right Midline Name: L on ROA, R L on ROA, R Backward Torsion Landmarks: if recording findings on R side in this example Sacral Sulcus:R Deep Sacral Base:R Anterior ILA:R Ant./ Sup. STL:R Loose Motion Testing: Spring:+ Sphinx+ L5: FR R S R Sacral BaseL +/- R - ILA:L +/- R + note: seated flexion may be + on L with this dysfunction(confirmatory) L5: R R S R

45. Sacral Base Anterior Name: Sacral Base Anterior, Bilateral Sacral Flexion Lateralization: Does NOT matter. Spring test: Negative Landmarks: Sacral Base:Bilaterally (B/L) Anterior Sacral Sulcus:B/L Deep ILA:B/L Posterior STL:B/L Tight Motion: Sacral Base:B/L + ILA:B/L – Ant + Ant+ Deep Post - Post-

46. Sacral Base Posterior Name: Sacral Base Posterior, Bilateral Sacral EXTENSION Lateralization: Does NOT matter. Spring test: Positive Landmarks: Sacral Base:Bilaterally (B/L) Posterior Sacral Sulcus:B/L Shallow ILA:B/L Anterior STL:B/L Loose Motion: Sacral Base:B/L – ILA:B/L + Post - Post - Shallow Ant +

47. Vertical Axis Diagnosis Name: Left Sacral Margin Posterior Lateralization: Matters NOT. Always call on Posterior side. For Left Sacral Margin Posterior: Landmarks: data recorded on lateralized side Sacral Base:L Posterior Sacral Sulcus:L Shallow ILA:L Posterior STL:L Tight Motion: Sacral Base:L –R + ILA:L –R+ P – A+ Deep P - A+ Shallow

48. Findings for Unilateral Sacral Flexion (Sacral Shear)  The sacral base on the side of the significantly inferior ILA will generally be anterior: FLEXED  The ILA will be significantly inferior (& posterior!)  {Sacrotuberous ligament will be pliable and under less tension than the contralateral side.} Anterior Posterior Right unilateral sacral flexion Markedly Inferior

49. Motion Testing for Unilateral Sacral Flexion (Sacral Shear)  There will be no motion at the inferior ILA - it is locked down  The base on the same side is likely to have adequate motion  There is generally good motion at any of the other locations but the motion is not likely to “add up” - or +/- - A P/ I

50. Unilateral Sacral Extensions  Findings: Rare L Base P L sulcus shallow L ILA ant/markedly superior STL loose Spring: may be + Motion: Sacral Base: L - R +/- ILA: L +/- R +/- A/ S P- +/-

51. Thank you to David Harden D.O., FAAFP for providing the foundation of this presentation!

52. References 1. Anderson,R.U; Painful myofascial trigger points and pain sites in men with chronic prostatitis/chronic pelvic pain syndrome, J Urol. 2009 Dec;182(6):2753-8. Epub 2009 Oct 17. 2. Doggweiler-Wiygul R.;Urologic myofascial pain syndromes Curr Pain Headache Rep.,2004 Dec;8(6):445-51. Review. 3. Karlovsky, M.E;Pelvic Floor Dysfunction:A Treatment Update, Practical Pain Management, Oct 2010 4. Langford CF, Udvari Nagy S, Ghoniem GM. Neurourol Urodyn, 2007;26(1): 59-62. 5. Levin, Stephen M ;The Tensegrity System and Pelvic Pain Syndrome,Third Interdisciplinary World Congress On Low Back & Pelvic Pain Pain,Vienna,November 1998 6. Marx S;Urologe A. 2009 Nov;48(11):1339-45. 7. Millard,F.P.DO; Applied Anatomy of The Lymphatics, pp.85-108 8. Owens,Charles,DO;An Endocrine Interpretation of Chapman’s Reflexes, pp. 62,74,78 9. Pasquerello, G. Pelvic Pain…Case report and osteopathic treatment approach. Journal of AAO. On reserve in VCOM library. 10. Travel,J.G;Myofascial Pain and Dysfunction:The Trigger Point Manual, Baltimore,Williams&Wilkins,1983,p671 11. Travel,J.G;Myofascial Pain and Dysfunction:The Trigger Point Manual, Vol.2, Baltimore,Williams&Wilkins,1983,pp112-113 12. Watson,R.A.; Chronic Pelvic Pain Syndrome and Prostatodynia: Treatment & Medication, E-Medicine, Aug 23, 2010 13. Zermann,D-H; Chronic Prostatitis: A Myofascial Pain Syndrome?, Infect Urol 12(3):84-88, 92, 1999.