1. Male Pelvic pain “Prostatitis and Levator Ani Syndrome
Jennifer Shifferd, mspt, clt, wcs

2. Male Pelvic Floor Dysfunctions
Levator Ani Syndrome- spasm of deepest muscle layer
Symptoms include pain, pressure or ache in vagina and rectum
Referred pain to thigh, coccyx, sacrum, lower abdomen and to tip of penis, urethra
Repeated straining during defecation can promote pain/throbbing
Men often misdiagnosed with prostatitis
Can lead to erectile, urinary dysfunction and bowel dysfunction

3. Male Pelvic Floor Dysfunction
Prostatitis
95 percent of cases of chronic prostatitis in men is nonbacterial1, and could indeed have a musculoskeletal origin.
Dysfunction and spasm of the pelvic floor muscles can cause symptoms that mimic prostatitis by causing pain and urinary symptoms.
1. Nickel, J.C. et al. Prevalence of prostatitis-like symptoms in a population based study using the national Institutes of Health chronic prostatitis symptom index.  J Urol, (2001)165: 842.

4. CHRONIC PROSTATITIS NIH classified prostatitis into four categories:
Category I: Acute Bacterial Prostatitis
Category II: Chronic Bacterial Prostatitis
Category III: Chronic Prostatitis / Chronic Pelvic Pain Syndrome
Category IV: Asymptomatic Prostatitis

5. Chronic Prostatitis / Chronic Pelvic Pain Syndrome
Chronic Pelvic Pain Syndrome is a nonbacterial infection but is often treated as such.
Primary symptoms; discomfort and pain
Pain locations: pelvic floor, perineum, rectum, coccyx (tail bone), prostate, penis, testicles/scrotum, groin, thighs, lower abdomen, and low back

6. Chronic Prostatitis / Chronic Pelvic Pain Syndrome
Sexual dysfunction can include painful ejaculation, premature ejaculation, erectile dysfunction, and decreased libido
Erectile dysfunction reported in 43% of patients, with 45% of patients reporting exacerbation of pain during or after intercourse
62 patients with pelvic pain syndrome, 52 were found to have tenderness and spasm in pelvic muscles around prostate and anterior pelvis per digital rectal exam

7. Chronic Prostatitis / Chronic Pelvic Pain Syndrome
Erectile function; adequate amount of blood must flow into penis and must be trapped to maintain rigidity
Bulbospongiosus and ischiocavernosus muscles are involved
Bulbospongiosus blocks blood from escaping by pressing on the deep dorsal vein of the penis
Need adequate contraction of muscles to maintain erection
Erectile Dysfunction; can result from muscle spasm and weakness

8. Chronic Prostatitis / Chronic Pelvic Pain Syndrome
Painful ejaculation; levator ani muscle trigger points can refer pain to tip of penis and urethra
Chronic pelvic pain can lead to decreased libido
Goal for patient- to learn how to relax their pelvic floor musculature

9. Chronic Prostatitis / Chronic Pelvic Pain Syndrome
Premature ejaculation; can be result of pelvic floor muscle weakness
Increasing awareness of the pelvic floor musculature through physical therapy is a start
Strengthening is a key component to success

10. Chronic Prostatitis / Chronic Pelvic Pain Syndrome
Urinary Dysfunction; voiding dysfunctions such as dysuria, urgency and frequency
Chronic pelvic floor muscle tension can compromise urine flow by constricting urethral sphincters, resulting in weak stream and difficulty initiating voiding
Urgency- straining to void to fully empty further aggravates a tight pelvic floor leading to a perpetuating cycle

11. Chronic Prostatitis / Chronic Pelvic Pain Syndrome
Bowel Dsyfunction; repetitive straining to empty bowels can further aggravate pelvic floor muscle spasm, if prolonged can disrupt normal defecation mechanics and lead to pelvic organ prolapse

12. Chronic Prostatitis / Chronic Pelvic Pain Syndrome
ASSESSMENT:
Pelvic floor examination- to assess for trigger points of the levator ani and ischiocavernosus musculature, ability to isolate and contract pelvic floor, pelvic floor muscle strength
Muscle coordination; check for good relaxation and perineal descent with simulated defecation to rule out dyssynergia

13. Chronic Prostatitis / Chronic Pelvic Pain Syndrome
TREATMENT:
If infection is ruled out then referral to physical therapy is recommended
Physical Therapy will help to teach patient how to relax their pelvic floor and better isolate once strengthening is indicated
Initial treatment is manual therapy; trigger point releases, prolonged gentle stretching
Modalities for pain, inflammation reduction
SEMG to assist with pelvic floor isolation, recruitment, relaxation
Core strengthening once pelvic floor muscle spasm has reduced and no pain with contraction
Home program for symptom management