Chronic Pelvic Pain – Don’t let pain down there get you down

Chronic Pelvic Pain Syndrome can be an elusive one. A frustrating pain that you can’t quite put your finger on, that often doesn’t make any sense, and certainly has an impact on your quality of life. In this blog, we will take a deep dive into chronic pelvic pain syndrome and what it entails.

What is chronic pelvic pain?

Chronic pelvic pain is defined as pain in the lower abdomen, pelvic or intra-pelvic area that lasts for greater than 3-6 months. This may start after an initial infection, surgery or injury, and for unknown reasons, hangs around for an extended period of time. This could be due to many factors, all of which are difficult to discern. For some people the onset might start during a significantly stressful event or period. Why the pain becomes chronic is usually through sensitisation of neural pathways where the perceivable pain is increased in response to stimuli that would otherwise be not perceived as painful or perceived as painful to a lesser extent. This will be discussed in further detail later in the blog.

Chronic pain is more prevalent in women than men and usually occurs at a younger onset. It is estimated that 8% of Australian men suffer from chronic pelvic pain syndrome. The onset in blokes is usually older, at around age 43 on average. It is difficult to find data on chronic pain in men as many suffer in silence, can be unsure of where to go or who can help them, and face societal pressures to refuse access to healthcare.

Symptoms of chronic pelvic pain

• Pelvic pain symptoms vary quite widely amongst individual men, but are generally described as a pressure, throbbing, aching or burning pain in the pelvis, penis, scrotum, perineum (skin between the scrotum and anus), bottom/rectum/anus, lower back or tailbone (coccyx).
• Pain can be experienced in a wide range: sitting, walking, on touch, or wearing tight underwear
• Some men experience bowel dysfunction associated with their pelvic pain: a sense of incomplete emptying, pain with opening bowels, food intolerances, bloating, diarrhoea and/ or constipation
• Bladder problems are common: including painful bladder syndrome – the need to go to the the toilet frequently or urgently, slow passage or varied flow of urine, bladder pain on urinating, overactive bladder, incontinence
• Sexual problems: low libido, erectile difficulties, pain with erections or ejaculation
• Changes to mood: low self-esteem, low energy, behavioural or emotional changes, anxiety or depression

The challenging part about classifying these symptoms as they perpetuate themselves. For example, a man with only pelvic pain initially, may go on to develop bowel problems such as constipation and food intolerances, which then further increase the pain as the dysfunction further impacts quality of life, thus increasing anxiety around pain. Following this pattern and as the feedback loop continues to develop, you can quickly see how this becomes a multi-faceted problem which requires treatment that tackles many different avenues.

What causes chronic pelvic pain?

Previously, the cause was often deduced to prostatitis (inflammation of the prostate). It is a common urological diagnosis made in men, and while the prostate may well be a source of chronic pelvic pain (but sometimes not at all), more recently it is recognised that there are many factors that contribute to chronic pelvic pain and the symptoms you experience is often a combination of multiple sources of pain with many contributing factors.

Chronic pelvic pain is idiopathic, meaning it can onset suddenly, seemingly without any causal factors. There are many potential sources of chronic pelvic pain - the prostate, bladder, pelvic floor muscles, bowels, pudendal nerves, the coccyx, pelvic connective tissue. It is not likely that it is any one of these sources that are the cause, which means there isn’t just one sole solution to ‘fixing’ pelvic pain. Thus it is referred to as a ‘syndrome’ - the definition being a condition which is characterised by a collective group of symptoms.

Classifying chronic pelvic pain

The US National Institute of Health has proposed a classification system to help fit patients into certain categories, so they can be directed to the correct treatment approach:

Chronic Pelvic Pain Syndrome Type I: 

Formerly known as Acute Bacterial Prostatitis. This is defined as acute pelvic pain, associated with other symptoms of being unwell such as fever or other signs of infections. This is due to bacterial infection and bacterial growth is detected in prostate or urine secretions.

Chronic Pelvic Pain Syndrome Type II:

Formerly known as Chronic bacterial Prostatitis. This is defined as chronic or recurrent pelvic pain, not associated with other symptoms such as fever or signs of infection. Bacterial growth is identified in prostate or urinary secretions.

Chronic Pelvic Pain Syndrome Type III:

Formerly known as Non-Bacterial Prostatitis. Defines as chronic or recurrent chronic pelvic pain, not associated with bacteria identified in urinary or prostate secretions. This can be divided into two types:

• Type A: When inflammatory cells are identified in urine or prostate secretions.
• Type B: When inflammatory cells are not identified in urine or prostate secretions.

Chronic Pelvic Pain Syndrome Type III is the most common type of pelvic pain.

Chronic Pelvic Pain Syndrome Type IV:

Asymptomatic, but inflammatory cells in urinary and prostate secretions are present.

The UPOINT classification system

The UPOINT system is used to classify the symptoms men experience with chronic pelvic pain syndrome, again, aiming to fit men into a phenotype (presentation of symptoms) to be able to recommend the best treatment for that individual. 

It is broken up as below:

U - Urinary

People with the urinary phenotype experience lower urinary tract symptoms such as increased urgency, altered flow, nocturia (frequent urination at night), incomplete voiding when urinating. More on lower urinary tract symptoms here.

Treatments for urinary symptoms include behaviour modifications (bladder training - timing voiding, managing fluid intake, dietary changes such as avoiding caffeine and alcohol). Some men may be recommended alpha blockers to help relax bladder muscle tissue.

P - Psychosocial

People within the psychosocial domain often suffer from depression or depressive symptoms, anxiety, stress, and poor coping mechanisms. Some men might also catastrophise their symptoms, characterised by a sense of helplessness and hopelessness. These can have significant negative effects which can sensitise neurological systems that modulate pain, worsening the pain experience without an increase in physical or biological stimulus.

Working with a psychologist can be helpful to address some of these factors. It is important to recognise and prioritise these factors as significant contributors to persistent pain. More on this later 🙂

O - Organ specific findings

In the organ specific category, there are usually symptoms that are associated with findings specific to organ tissue. Prostate related symptoms include: tenderness of the prostate to palpation (feeling the prostate), white blood cells detected in prostate secretions, hematospermia (blood in ejaculate). Bladder related symptoms include pain with bladder filling that improves with voiding, and haematuria (blood in urine). These factors all indicate that there is some tissue related concern with the prostate or bladder.

I - Infection

Sometimes patients with pelvic pain show signs of infection. This is determined if bacteria is detected in samples of urine, prostatic fluid or the urethra. This is assessed through doing cultures. It is important that this is differentiated from a UTI or category I or II prostatitis. Antibiotics, especially more so previously, were commonly prescribed to treat chronic pelvic pain with little effect. In the absence of signs of infection, antibiotics will not be helpful.

N - Neurological/Systemic

The neurological/systemic category encompasses people who experience more systemic complaints such as widespread pain and other symptoms. Including conditions such as fibromyalgia pain syndrome, chronic fatigue syndrome, irritable bowel syndrome, or other systemic conditions. In these conditions a sensitised nervous system is a common factor and driver, which also contributes to chronic pelvic pain.

For people with these conditions, neuromodulating medication such as tricyclic antidepressants, pregabalin are recommended. This would be discussed with a medical professional to determine if this would be appropriate treatment in each individual’s situation. Chronic use of opioid medication should be avoided as it can be more harmful, and increase pain in the long term.

T - Tenderness

Men within the tenderness category experience spasm, soreness, tenderness and/or trigger points in the pelvic or abdominal muscles. This is diagnosed with a Digital Rectal Examination (DRE), and genital and abdominal examinations. These muscles can spasm, become overworked and function improperly with pain and pelvic dysfunction.This can be a cause of chronic pelvic pain, but also can occur after the onset of pelvic pain and perpetuate the chronicity of the pain.

Blokes can work with a men’s health physiotherapist to help work on this. Pelvic floor muscle exercises can help restore some normality of the function of the pelvic floor muscles, which in turn can help some of the urinary and bowel symptoms. Trigger point releases can help reduce some of the drive to the muscles to be overactive. Generally, the goal is to ‘calm down’ the nervous system, so that the neural drive to the muscles and the sensory information received from the muscles isn’t amplified. A restoration of the function of the pelvic floor muscles is a good strategy to start towards achieving this.

Below is a table which summarises the above UPOINT points.

As you can see the symptoms are vast, intertwined and complex. Men can, and commonly do experience symptoms from many of these categories at once. Factors from each category can be causal of pelvic pain, however, it doesn’t explain how the pain becomes chronic. This is where it gets tricky. Symptoms and problems can also arise in various categories after the onset of pain, which can cause or be as a result of the pain. After some time with the experience, memory of the onset and when new problems arose, which problems started first can become muddled. At this point there is a lot of overlap of symptoms in chronic pelvic pain and lots of areas that need to be addressed. Now you might be starting to see what it takes to tackle the beast that is chronic pelvic pain. With many areas being dysfunctional, the nervous system gets sensitised, leading to increased pain.

Pain sensitisation

It’s been mentioned a few times that pain can be impacted by many factors and can become more sensitive to stimuli that wouldn’t normally be perceived as painful. Let’s dive in a bit more as to what is going on here. For a deep dive into chronic pain, check out our blog series here.

Pain is a complex system, and when functioning well, it is really valuable for our self preservation. For example, if you sprain your ankle, you experience pain to protect your ankle, so you limp to avoid further injuring the ankle when it needs time for tissue healing. With chronic pain, however, what initial tissue damage or inflammation was present months ago at its onset has in most cases, settled, but the pain still remains and sometimes worsens. This is due to an increase in sensitivity of the receptors that detect mechanical load and inflammation and an increase in sensitivity of the nervous system. This amplifies the response to any potential threat, making the alarm system less valuable and reliable. This means it’s possible you might experience pain when there is no threat to tissues and no tissue damage present.

More on psychosocial factors

Catastrophising

As mentioned before, psychosocial factors play a significant role in the persistence of pain, especially catastrophising and pain contingent rest from activity. Most importantly, catastrophising is the largest predictor of pain. Catastrophising leads to helplessness and allows symptoms to become disabling by promoting negative thought patterns and ruminating pain. It is critical that this is addressed. Without intervention around catastrophisation, it is unlikely that negative thinking around pain will improve, and unlikely pain will improve. Thus, it is recommended that you engage services with a psychologist and a physiotherapist who is well versed in pain science and the biopsychosocial framework (a treatment framework that encompasses the whole person and all their contributing factors).

Pain-contingent rest

Pain-contingent rest is a behavioural pattern where people with chronic pain rest to avoid any symptoms at all. Pain-contingent rest is the greatest predictor of disability (how impacted a person’s level of function is) in chronic pelvic pain. As discussed above, pain is just an alarm system that becomes unreliable in chronic pain. Resting to avoid any symptoms is unhelpful as rest decreases loading capacity of tissues and increases sensitivity, when in the context of avoiding pain. Over time, rest to avoid symptoms results in a gradual loss in mobility and function. It is really difficult to balance pain and activity to avoid pain contingent rest. Pain can be really limiting to what activities you feel comfortable trying and can have large impacts to motivation. A men's health physio can help guide you on what exercise and movement is safe to engage to help you more gradually increase your capacity and avoid boom-bust cycles which will set you back.

How can men’s health physiotherapy help with chronic pelvic pain?

A men’s health physiotherapist may be one of your biggest allies in the management of chronic pelvic pain. It is important that you see a physiotherapist who is well versed in men’s health and chronic pelvic pain. 

As discussed above, the impact of chronic pelvic pain can be vast across all areas of the pelvis and many of these factors should be addressed to have the best chance of success in tackling chronic pelvic pain. Even though we now know that these factors such as urinary symptoms or bowel symptoms may not be the cause of pelvic pain, but as a result of pelvic pain, they have an impact on the intensity and continuation of pelvic pain. It makes the overall experience worse, and thus can have psychosocial implications that can perpetuate the experience of chronic pelvic pain.

At Sycamore Health, we offer holistic men’s health services to help you break free from the holds of chronic pelvic pain and get you back to living your life again. We understand that pelvic pain and resultant dysfunction can be a touchy subject and offer a supportive space to allow you to discuss your struggles and find some understanding of your suffering. We use a multimodal approach to target the most important areas and help you achieve the best outcome.