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A problem in the pelvis: How men's chronic pelvic pain can be treated

A Problem in the Pelvis 

Gareth Eyres parks his modesty at the door in the interests of relieving his chronic pelvic pain. Now he hopes sharing his story might put other men out of their misery.

For a normal bloke, a referral to Auckland physiotherapist Melanie Bennett could be daunting. I know it was for me. I’d been packed off by urologist Tony Beaven to Bennett’s Physio Down Under – the name indicates her specialty – after a waterborne urinary tract infection left me with chronic pelvic pain.

Some months prior, Auckland surgeon Jonathan Koea had removed my infected gallbladder, the source of a nasty dose of septicaemia. He advised me to wait at least three months before launching into physical exercise and warned that it might be 18 months before I was fully fit. Septicaemia tends to knock you around.

Three months post-op, I was getting impatient. I started on a few neglected jobs in the garage, and while carrying a large box, I slipped on a wet patch on the concrete and executed an ungainly version of the splits. As I went down, I felt something go in my back, abdominals and pelvic floor.

Severe infections can affect both the elasticity and strength of muscle and connective tissue, and it takes some time for flexibility and strength to return. Also, the pain associated with infection can leave nerve pathways in a sensitised state, amplifying any pain signals. During my slip, something had been over-extended; it felt as though there was a jam in my sacroiliac area, and it was pressing on my nerves – the ones that travel from the base of the spine to where your bike seat presses, and beyond. Those who have experienced nerve pain will understand – it’s the kind of pain the analgesic pharmacopeia barely touches. And this fell outside the field of urology, even though the pain was stemming from the pelvic floor area.

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Before my first visit to Bennett, Beaven had suggested I read the book A Headache in the Pelvis by Dr David Wise and Dr Rodney Anderson, a psychologist and urologist respectively, who met at Stanford University in the US. This oddly titled book has been called the bible of pelvic and prostatic pain.

Wise and Anderson worked for eight years in the development of a new treatment for prostatitis and chronic pelvic pain. Wise was especially motivated; he’d been a sufferer himself for more than 20 years before helping find a cure. Together with physical therapist Tim Sawyer, they established a clinic in California where they treat men, mostly, for a wide range of “pelvic floor” problems.

Pelvic floor dysfunction is, writes Wise, “the result of routinely tightening the muscles of one’s pelvis as an unconscious expression of anxiety or response to trauma. After some time, the chronically tightened pelvic muscles don’t relax back to their normal state, and symptoms of pain and dysfunction occur as a result of this chronic pelvic muscle contraction.”

The treatment developed at the clinic is known as the Stanford pelvic pain protocol, or Wise-Anderson protocol. Patients attend week-long programmes (about $6000 worth) that include learning relaxation techniques and getting an understanding of internal pressure points.

“People who see us have failed all other treatments,” Wise writes. “They’ve been on antibiotics, anti-inflammatories and Flomax (tamsulosin). Some have had wicked surgeries. Some have lived with pain for 20 years. Quite a few are mad at their doctors.”

Since 1995, Wise and Anderson’s clinic has treated more than 2500 patients. And there’s nothing touchy-feely, California-dreamin’ about it. A therapeutic wand the doctors developed (resembling a shepherd’s crook, but made of medical-grade plastic) has been tested and approved by the US Food and Drug Administration. What makes this wand treatment unorthodox is that the patient must insert it rectally to access then manipulate hard-to-reach tender points. It also enables the patient to self-treat after the clinic visits are over. However, you can only buy the wand if you’ve been trained in its use at the clinic, to avoid any unfortunate application techniques and, presumably, the malpractice suits that could follow, at least in the US.

Diagnosing the cause of pelvic pain – also known as chronic pelvic pain syndrome (CPPS) – is difficult, especially if there’s no infection. It’s a problem that’s often incorrectly treated – for both men and women. Luckily for me, urologist Beaven is a highly intuitive practitioner, and his recommendation led me to Bennett’s clinic, on Auckland’s North Shore (she also treats men at the Auckland Colorectal Centre in Epsom).

Bennett has been treating male patients with pelvic floor problems since 2007. She studied physiotherapy at Otago University, then completed a master’s through AUT, including an ultrasound imaging paper; she also did post-graduate study through the University of Melbourne in pelvic floor rehabilitation. When she first started her practice, she was one of few New Zealand physiotherapists working in this area. Some were treating female pelvic floor problems, but those tending to men were a rarity.

“The problems men get in the pelvic floor are similar to women’s – it’s just that men have one less orifice and no pregnancies, with the complications they can bring,” she says. Bennett’s knowledge comes from a deep understanding of the pelvic floor, a part of the body that’s difficult to study, even using scans and X-ray. She says she was fortunate in being able to study cadavers at Melbourne Hospital.

An ultrasound machine.
I had numerous tests and probes during the four years of my infection. These included regular digital rectal examinations to check my prostate for cancer or enlargement, as well as a couple of cystoscopies, when a camera on a flexible scope was inserted up my urethra to explore the bladder.

A moderately shy chap when it comes to exposing myself in front of strangers, I was nevertheless getting used to disrobing for the most intimate of examinations. I realised that to get well, I had to leave my modesty at the door.

So it was I was ushered into Bennett’s room. We had a discussion about my problems. I signed a consent form to allow internal examination and treatment, which was described in enough detail, so I had no doubt as to what was going to happen. Bennett passed me a small lavalava-like kilt, with instructions to take off my trousers and underwear and lie on the bed, daintily draped.

Embarrassment tends to send me into joke mode. I had to resist blurting, “But Melanie, I hardly know you. What about drinks and chit-chat first?” She’d treated me with the utmost professionalism and care; I just had to get my panic under control.

Bennett returned, wheeling in an ultra-sound machine, and placed the wand just above my pubic bone. The screen showed parts of my abdomen, pulsing. “I want you to try some exercises to help you learn what muscles control which parts of your pelvic floor,” she said. “You have to contract then relax the muscles to see and feel them work. You’ll see the response on the screen when this happens; it will let you know when you’re doing it right.”

There are three basic moves men have to learn to control, she explained. Let’s just say one of the three was the fairly self-explanatory “nuts to guts”. I’m used to listening to people teach others, having worked around the outdoor-pursuits industry for a long time. But the instructions I’m familiar with are the likes of, “Place your paddle there… move your foot a bit higher… bend your knees a tad more...”

I won’t go into how hopeless I was at first following Bennett’s instructions, but with patient coaching and the assistance of the glowing green screen, where I could see various muscles and ligature contract and release, I slowly got the hang of it.

Next came the internal check to locate the tender spots that might be contributing to my pain. “Think of dropping pebbles from your backside, one by one into a pool of water,” Bennett suggested. It wasn’t uncomfortable but I tried hard not to flinch as her finger pressed against a part of my body no one had pressed a finger against before.

“Is that painful?” she asked. I nodded. She proceeded to travel slowly around the base of my pelvic floor muscles. “What about that?” Another nod. “That feels particularly tight right there.” Pain lanced through me. But after Bennett’s manipulations, the pain started to disappear. Within 30 seconds, it was hardly there. I felt like cheering. For the first time in a long while, the excruciating electric-shock pain had nearly gone. How on earth did Bennett know where to go?

“It’s not as though you can see what you’re doing,” I said.

“I’m required to have a 3D-like view of the anatomy in my brain,” she said, “as I can’t see where the muscles are and whether they’re under tension or not. That’s why this therapy is hard to understand. It’s not like flexing a bicep like Popeye and instantly recognising what’s happening. It has to be done by feel.”

Meanwhile, I was having an epiphany. After taking every kind of painkiller to alleviate the pain, this therapy was giving me instant relief. I was overcoming both my modesty and the “weird” factor.

The treatment took about 15 minutes. Bennett advised that I’d be a bit tender for 36 hours, “but that will quickly fade away. You were rather tight in a few places; it will need some further work, but I think we’ll get there.”

I was elated by the fact more than 80% of the pain I’d been experiencing was gone, replaced by a warm tingling sensation, which was not uncomfortable.

After three visits, Bennett had pretty much “turned off” the trigger points in my pelvic floor. She and her crew gave me a series of yoga stretches, including three minutes daily of “cat/cow”, “downward dog”, knees to chest and reclined supine twist. All of these helped free up my lower back and “unbind” me. (Being a classic bloke, I was as stiff as a board through the lower half of my spine, and flexibility was simply not there.) With regular maintenance from my local physio, plus taking Lyrica (pregabalin) once a day, my pain has pretty much gone. For the first time in more than four years, I’m back on my bike and paddling my kayak.

Specialist physiotherapist Melanie Bennett.

Dysfunction Down Under

Specialist physiotherapist Melanie Bennett tells it like it is.

The bladder, bowel and pelvic symptoms that men arrive with at Melanie Bennett’s clinic can generally be summarised in three ways, she says: they either can’t keep it in, they can’t get it out, or it hurts.

“I treat many men for urinary incontinence and erectile dysfunction after having their prostate glands removed. I prefer to see them for one or two sessions before their surgery. Before their operation, these men are usually dealing with a cancer diagnosis so by comparison, these two post-operative issues are low on their worry radar. However, they’re often horrified by the severity of their leakage after surgery and are very glad to have started rehab early. It’s best to start muscle training and teach them about their rehabilitation programme before any muscle or nerve damage occurs.

“Most men don’t really have a clue about the pelvic floor: what it is, where it is and how it works. Women, on the other hand, have to deal with their pelvic floor throughout their lives – when they start their periods, have a baby, and go through menopause.

“The pelvic floor muscles are internal so for most people they’re harder to understand and train. For this reason, I have an armoury of machines and equipment to assist in retraining muscle function. This approach is perfect for male patients – what man doesn’t like a gadget! Ultrasound imaging, for example, produces a real-time image of the pelvic floor muscles on a TV screen. Another form of biofeedback is electromyography (EMG), which uses light and sound for training on a hand-held unit. Sometimes the focus is not on muscle strength and endurance but on muscle relaxation and co-ordination. Electrical stimulation is an option for very weak muscles or to treat pain in a particular nerve pathway.

“Men are usually compliant with a treatment programme and, in contrast to many women, are less accepting of their symptoms. Because pelvic floor conditions in women are common and their mothers, sisters or friends might have experienced prolapse or incontinence symptoms, women often think their symptoms are normal. TV ads for symptoms like urinary incontinence also tend to normalise women’s problems, but such conditions are common, not normal.

“Men usually come for treatment via referrals from doctor and nurse specialists in urology, colorectal, gastroenterology, also from GPs. I also work with other physiotherapists and I might refer patients on for more specific work on the spine or other musculoskeletal treatment.

“My advice to men is to seek help. A good starting point is to ask your GP if specialised physiotherapy treatment might be appropriate for your symptoms. Physiotherapy NZ has a list of specialised physios who work in the area of male pelvic health.”

Bennett also sees patients with bowel problems and chronic pelvic pain. “A few have conditions such as Peyronie’s disease – a fibrous scar tissue inside the penis that causes bent and painful erections, usually caused by trauma. Although rarely discussed, faecal incontinence is common, affecting one in eight Kiwi men. Symptoms can often be controlled with conservative measures but patients are generally reluctant to seek professional help.”

This article was first published in the July 2018 issue of North & South.