Painful Myofascial Trigger Points and Pain Sites in Men With Chronic Prostatitis:Chronic Pelvic Pain by Kirk Andrew

Painful Myofascial Trigger Points and Pain Sites in Men With Chronic Prostatitis/Chronic Pelvic Pain Syndrome Rodney U. Anderson,*,† Timothy Sawyer, David Wise, Angie Morey and Brian H. Nathanson From the Department of Urology, School of Medicine, Stanford University (RUA, AM), Stanford and Sebastopol (TS, DW), California, and Longmeadow (BHN), Massachusetts

Purpose: A combination of manual physiotherapy and specific relaxation training effectively treats patients with chronic prostatitis/chronic pelvic pain syndrome. However, little information exists on myofascial trigger points and specific chronic pelvic pain symptoms. We documented relationships between trigger point sites and pain symptoms in men with chronic prostatitis/chronic pelvic pain syndrome. Materials and Methods: We randomly selected a cohort of 72 men who underwent treatment with physiotherapy and relaxation training from 2005 to 2008. Patients self-reported up to 7 pelvic pain sites before treatment and whether palpation of internal and external muscle trigger points reproduced the pain. Fisher’s exact test was used to compare palpation responses, ie referral pain, stratified by reported pain site. Results: Pain sensation at each anatomical site was reproduced by palpating at least 2 of 10 designated trigger points. Furthermore, 5 of 7 painful sites could be reproduced at least 50% of the time (p ⬍0.05). The most prevalent pain sites were the penis in 90.3% of men, the perineum in 77.8% and the rectum in 70.8%. Puborectalis/pubococcygeus and rectus abdominis trigger points reproduced penile pain more than 75% of the time (p ⬍0.01). External oblique muscle palpation elicited suprapubic, testicular and groin pain in at least 80% of the patients at the respective pain sites (p ⬍0.01). Conclusions: This report shows relationships between myofascial trigger points and reported painful sites in men with chronic prostatitis/chronic pelvic pain syndrome. Identifying the site of clusters of trigger points inside and outside the pelvic floor may assist in understanding the role of muscles in this disorder and provide focused therapeutic approaches.

Abbreviations and Acronyms CP ⫽ chronic prostatitis CPPS ⫽ chronic pelvic pain syndrome CPSI ⫽ Chronic Prostatitis Symptom Index GU ⫽ genitourinary NIH ⫽ National Institutes of Health TrP ⫽ trigger point VAS ⫽ visual analog scale Submitted for publication March 18, 2009. * Correspondence: Department of Urology, S287, Stanford University School of Medicine, Stanford, California 94305 (telephone: 650498-4240; FAX: 650-724-0084; e-mail: rua@ stanford.edu). † Financial interest and/or other relationship with GlaxoSmithKline, Astellas, Bioness and Boston Scientific.

For another article on a related topic see page 2944.

Key Words: prostate, prostatitis, pelvic pain, myofascial pain syndromes, pain measurement MANY investigators believe that the source of pain and dysfunction in men with chronic pelvic pain, including chronic orchialgia, is often found in the painful and chronically tense myofascial tissue in and around the pelvic floor.1– 6 Traditionally the diagnosis of CP/CPPS depended on a descriptive symptom complex. However, it is now

clear that CPPS is multifaceted and not all men have the same constellation of symptoms or respond in the same way to single treatment modalities. Because the pathogenic mechanisms associated with pelvic genitourinary symptoms are unknown, it remains difficult to explain the role of painful myofascial tissue.

Vol. 182, 2753-2758, December 2009 Printed in U.S.A. DOI:10.1016/j.juro.2009.08.033

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We report a case series of self-referred men with long-standing CPPS. We describe the relationship between the site of myofascial TrPs or restrictive muscular tissue internal and external to the pelvis, and pain sites initially described by patients at evaluation. We hypothesized that palpation of certain myofascial TrPs would reproduce the pain sensations experienced by patients. Diagnostic criteria for identifying active TrPs were described by Travell and Simons.7 A TrP is defined as a hyperirritable, sensitive or tender spot that is usually within a taut palpable band of skeletal muscle or fascia. Not all tender spots in the body are TrPs but all TrPs are tender upon palpation.8 Each muscle has a characteristic referred pain pattern. Pain is localized or has a combination of patterns characteristic of those referred by myofascial TrPs. Reproduction of the distribution and quality of patient pain by pressure on a tender point identifies it as a TrP.

PATIENTS AND METHODS In most men diagnosed with CPPS who are referred to the Stanford urology clinic traditional therapy has universally failed. An alternative therapeutic approach that we have used in these men with CPPS is manual physiotherapy and paradoxical relaxation training, a type of cognitive behavioral therapy. This therapy was described previously.4,9 A total of 678 men with CPPS sought therapy with the manual physiotherapy regimen between 2005 and 2008. They had symptoms for at least 3 of the last 6 months, a NIH-CPSI total score10 of 12 or greater on a scale of 0 to 43 and a nonzero pain domain score. For analysis purposes we examined baseline pretreatment documentation in 72 of the 678 male patients (10.6%) by a random drawing of patient case file numbers. The procedures described include the required baseline assessments before commencing therapy and are not considered treatment. Patients were first evaluated by a urologist who performed the initial pelvic examination, including diagnostic palpations of the pelvic muscle and prostate, and ruled out other genitourinary disorders. Medical history confirmed the diagnosis of CPPS and excluded other conditions, such as interstitial cystitis, inflammatory bowel disease, benign prostatic hyperplasia and fibromyalgia. Evaluation also included the site and duration of symptoms, and the severity of pain complaints documented by NIH-CPSI symptom scores. A supplementary, more methodical manual external pelvic and internal muscular examination was performed by the physical therapist (TS) to specifically identify active myofascial TrPs. A trigger point was characterized by meeting 4 of the 5 criteria, including 1) a complaint of pain, 2) a palpably taut band, 3) increased pain upon palpation at the TrP site or at a referred distance from the site, 4) palpably decreased tissue flexibility or decreased range of motion and 5) a possible jump sign upon palpation.7 The same physical therapist performed baseline manual myofascial tissue palpation in all patients. Each muscle group was palpated once to identify TrPs

and document pain/discomfort levels associated with palpation. No myofascial tissue release treatment was given. All external muscles were examined first. The patient was then placed in a semilateral prone position with pillows under the abdomen. Using a gloved finger the sphincter ani and coccyx related muscles were examined. The left internal muscles of the pelvis were then examined with the right hand and the right pelvis was examined with the left hand, shifting the patient as necessary. The physical therapist applied a consistent pressure level for tissue palpation. As recommended to examine fibromyalgia,11 an approximate palpation force of 4 kg/cm2 was used to assess pain. For each area examined patients were asked to report the level of pain experienced during palpation from 0 —none to 3⫹— severe. Only pain reported as 2⫹ or 3⫹ was counted as “yes, pain is present,” while a score of 0 or 1⫹ was counted as no pain. Muscle sets that typically reproduced the pain sensation at specific sites referred from TrPs were chosen for investigation, including the penis, perineum, rectum, suprapubic region, testes, groin and coccyx/buttocks. We used the nonparametric Fisher exact test to examine differences in the proportion of patients in whom TrP palpation elicited pain (yes vs no), stratified by whether the patient reported that pain at a specific site was initially present (pain present or absent). We also used the Fisher exact test to determine whether the prevalence was different from zero. The Mann-Whitney U test was used to compare the medians of continuous variables by group membership, eg pain present or absent. Prevalence ORs with the exact CI were calculated when possible. All inference tests were 2-sided with ␣ ⫽ 0.05. All statistical analysis was done with Stata® 10.1/SE.

RESULTS Median age of the 72 men with CPPS in this analysis was 40 years (range 20 to 72; IQR 32, 49). Median symptom history was 44 months (range 4 to 408). Symptom severity at initial examination was measured by the pain VAS and NIH-CPSI scores with higher scores representing greater severity. The median VAS score was 5/10 (range 1 to 9). Part A of the figure shows a histogram of the scores. Of a maximum possible overall score of 43 the median NIH-CPSI overall score was 27 with a median pain domain score of 13 (possible maximum 21), urinary complaint score of 5 (possible maximum 10) and quality of life score of 10.5 (possible maximum 12). The median total number of self-reported pain sites was 4 (IQR 3, 5) of a possible 7 predesignated sites. There was no correlation between pain VAS score and the total number of painful sites (r ⫽ ⫺0.195, p ⫽ 0.11). Furthermore, there was no statistically significant difference in pain VAS score by pain at any specific site. However, tenderness in the puborectalis and/or pubococcygeus muscles was associated with a higher pain VAS score (Mann-Whitney test p ⫽ 0.013). Part B of the figure shows the rank order of sites of pain com-

TRIGGER POINTS AND CHRONIC PROSTATITIS/CHRONIC PELVIC PAIN SYNDROME

c bi ap u

Location of Pain

Baseline VAS Score

G ro C in oc cy x/ B ut to ck s

Te st ic le s

Pe ni s

tu m

100 90 80 70 60 50 40 30 20 10 0

Pe rin eu m

Percent Patients Reporting Pain

Percent Patients Reporting Pain VAS Score

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A, pain VAS scores in men with CPPS at initial examination. B, perceived sites of chronic pain reported by 72 men with CPPS.

plaints in these 72 men. The penis (base, shaft, glans or urethra) was the most common pain site, noted in 66 of 72 men (91.7%). Table 1 lists the internal and external muscles palpated and how often they elicited a painful response. For example, 65 of the 72 men (90.3%) stated that they felt pain associated with palpation of the puborectalis and/or pubococcygeus muscles. Table 2 lists the muscles palpated and the incidence of referred pain to specific sites whether or not the patient initially complained of pain in that anatomical area. For example, palpation of the puborectalis and/or pubococcygeus muscles elicited pain in the penis in 67 of the 72 patients (93%). At least 2 of the 10 TrPs elicited or referred pain to each anatomical site in a statistically significant proportion of patients according to Fisher’s exact test p values and each trigger point reproduced pain at 1 site at least. The most reactive muscles were the rectus abdominis and external oblique muscles. TrP palpation in these muscles elicited pain at 4 of the 7 sites. Perineal pain was most reproducible, elicited by 8 of 10 TrPs. Table 3 shows the incidence with which TrP palpation referred pain to a patient self-reported chronic Table 1. Specific myofascial TrP tenderness in 72 patients Muscle Groups Internal: Puborectalis/pubococcygeus Coccygeus Sphincter ani External: Rectus abdominis External oblique Adductors Gluteus medius Gluteus maximus Bulbospongiosus Transverse perineal

% Tenderness 90.3 34.7 16.6 55.6 52.8 19.4 18.1 6.9 12.5 11.1

pain site with the OR (95% CI) shown when calculable. For example, 64 of the 66 patients (97%) with penile pain experienced this pain after palpating TrPs in the puborectalis and/or pubococcygeus muscles. The OR (32.0; 95% CI 2.3, 461.0) implied that these patients were 32 times more likely to have penile pain reproduced by this muscle palpation than patients without penile pain. However, a more conservative interpretation was the lower limit of the CI. Thus, with 95% certainty patients with penile pain were at least 2.3 times more likely to have pain reproduced by this TrP than patients who did not report penile pain. The OR or p value could not be derived in some cases because of zero cell counts. For example, in 8 of 20 patients (40%) coccygeal or buttock pain was elicited by palpation of the gluteus maximus. None of the patients without coccygeal or buttock pain experienced pain at this site after palpation (0 of 52 without vs 8 of 20 with pain, Fisher’s exact test p ⬍0.001). The OR was not calculable because of the zero cell count. Table 3 also shows that pain at each site was reproduced by at least 1 TrP in a statistically significant proportion of patients with that prior pain report. Rectal and coccygeal/buttock pain were each elicited by 4 TrPs. Palpating the external oblique muscles referred pain to the suprapubic area, testes and groin at least 80% of the time in patients with pain at these sites. Moreover, 8 of 10 TrP palpations (80%) reproduced pain at 1 site at least and rectus abdominis palpation elicited pain at 4, including the penis, perineum, rectum and suprapubic area. Repeat palpation of a muscle group had a consistent effect on pain referral.

DISCUSSION We identified active TrPs in internal and external pelvic regions in men with CPPS that consistently reproduced specific patterns of referred pain. These

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TRIGGER POINTS AND CHRONIC PROSTATITIS/CHRONIC PELVIC PAIN SYNDROME

Table 2. Specific sites of pain in 72 men elicited by myofascial TrP palpation Palpated Muscles Internal: Puborectalis/pubococcygeus Coccygeus Sphincter ani External: Rectus abdominis External oblique Adductor magnus Gluteus medius Bulbospongiosus Transverse perineal Gluteus maximus

% Penis

% Perineum

% Rectum

% Suprapubic

% Testes

% Groin

% Coccyx or Buttocks

93.1* 1.4 0

19.4† 36.1† 26.4†

2.8 50.0* 36.1†

56.9* 1.4 0

5.6 0 0

2.8 0 0

0 26.4† 4.2

73.6* 12.5† 0 0 44.4 2.8 0

65.3* 4.2 41.7† 16.7† 8.3† 22.2† 5.6

45.8† 1.4 41.7† 6.9 0 11.1† 6.9

38.9† 51.4* 0 0 0 0 0

0 45.8† 0 8.3† 1.4 0 0

0 51.4* 41.7† 1.4 0 0 0

0 0 0 11.1† 0 0 8.3†

* Greater than 50%. † Fisher’s exact test p ⬍0.05.

physical examination findings may lead to greater understanding of pathogenic mechanisms and more focused therapy. The International Association for the Study of Pain defines pain using descriptions and does not address the mechanism of pain. Zermann et al found that 88% of men with CP/CPPS had tender myofascial palpation.2 Berger et al also noted that pelvic tenderness is not limited to the prostate in men with CPPS.5 They studied 62 men with CPPS and 98 without pelvic pain, examining tenderness at 10 external pelvic tender points, 7 internal pelvic tender points and other tender points, as described by the American College of Rheumatology for fibromyalgia evaluation.11 They found that 75% of men with CPPS had prostate tenderness but so did 50% of normal controls. They also observed no correlation with leukocytosis in expressed prostatic fluid. Similarly a recent collaborative network study of 384 symptomatic men with CPPS and 121 asymptomatic controls revealed that 51% of patients with CPPS had tenderness at 11 anatomical sites vs 7% of controls.6 The most common tender site in this survey was the prostate but again tenderness specifically did not correlate with any inflammation in the gland, as determined by analysis of expressed prostate secretion. The prostate is anatomically connected to the levator muscles, and the fascia of the puborectalis and pubococcygeus. Therefore, these muscles would undoubtedly be stimulated during prostate manipulation. Pain sites were also recently described in interstitial cystitis/painful bladder syndrome cases by Warren et al, who hypothesized that careful systematic analysis of pain experienced by such patients would indicate patterns that may provide clues to pathogenesis.12 Of the 226 women surveyed 66% had 2 or more pain sites (mean 2.1 per patient). Shoskes et al suggested that a management strategy for urological pelvic pain syndromes may

depend on classifying cases into clinical domain phenotypes.13 One proposed domain type (skeletal muscle tenderness) is the focus of a growing number of clinical research trials and publications. A recent NIH sponsored, multicenter study revealed the feasibility of clinical trials using muscle and connective tissue physiotherapy to treat urological pelvic pain syndromes.14 In that trial the original physician investigators quantified the degree of tenderness in muscle groups before corroboration by physical therapists trained in such techniques. A clear discrepancy existed between what physicians scored for subjective pain and what physical therapists reported since physicians found 28% less tenderness during the examination (p ⬍0.01). A secondary outcome of the pilot study showed a reasonably good patient response to internal and external myofascial physical therapy compared to the response to generalized external Western massage only (57% vs 28%). Investigating this form of therapy has been expanded to a larger trial in women with interstitial cystitis/painful bladder syndrome. Our study has limitations. Our sample size of 72 patients is small, although we noted statistically and clinically significant associations between certain TrPs and specific pain sites. The study was done at a tertiary care center in patients in whom several forms of traditional therapy for CPPS had previously failed. Therefore, whether the results presented are applicable to a larger group of men with chronic pelvic pain requires further evaluation. No asymptomatic men were examined as controls. Therefore, we could not compare how patients without CPPS would respond to these palpations. However, the purpose of this study was to examine patients with CPPS rather than compare their responses to those of normal individuals. Finally, it is difficult to objectively measure pain and, thus, we relied on patient selfreported responses. If a painful site was not reported

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Table 3. Pain reproduced at specific sites after TrP palpation in 72 men with CPPS who pre-identified chronic pain site Self-Reported Pain Site Penis No. pts (% pain) % Pain on palpation: Puborectalis/pubococcygeus OR (95% CI) p Value vs asymptomatic (Fisher’s exact test) Coccygeus OR (95% CI) p Value vs asymptomatic (Fisher’s exact test) Sphincter ani OR (95% CI) p Value vs asymptomatic (Fisher’s exact test) Rectus abdominis OR (95% CI) p Value vs asymptomatic (Fisher’s exact test) External oblique OR (95% CI) p Value vs asymptomatic (Fisher’s exact test) Adductor magnus OR (95% CI) p Value vs asymptomatic (Fisher’s exact test) Gluteus medius† p Value vs asymptomatic (Fisher’s exact test) Bulbospongiosus OR p Value vs asymptomatic (Fisher’s exact test) Transverse perineal OR p Value vs asymptomatic (Fisher’s exact test) Gluteus maximus† p Value vs asymptomatic (Fisher’s exact test)

Perineum (91.7)

Rectum (77.7)

Suprapubic Area (70.8)

(62.5)

Testes 37

(51.4)

Groin 34

(47.2)

86.7 10.8 5.9 81.5 (13.4, 787.3) Not calculated Not calculated ⬍0.001* 0.12 0.22

Coccyx or Buttocks 20

(27.8)

97.0 32.0 (2.3, 461.0) 0.005*

21.4 1.9 0.72

(0.4, 19.5)

3.9 Not calculated 1.0

1.5 Not calculated 1.0

42.9 5.3 0.04*

(1.0, 50.9)

70.6 Not calculated ⬍0.001*

2.2 Not calculated 1.0

0 0 80.0 Not calculated Not calculated 65.3 (11.0, 452.5) 0 0 ⬍0.001*

0 Not calculated

28.6 1.7 0.53

51.0 Not calculated ⬍0.001*

(0.4, 10.7)

0 0 Not calculated Not calculated

15.0 Not calculated 0.02*

0 0 Not calculated Not calculated

0 Not calculated

Not calculated

78.8 76.8 60.8 62.2 18.6 (1.8, 894.4) 9.9 (2.4, 701.0) 14.7 (2.9, 138.9) Not calculated 0.001* ⬍0.001* ⬍0.001* ⬍0.001* 13.6 Not calculated 0.44

5.4 Not calculated 1.0

2.0 Not calculated 1.0

80.0 89.2 94.1 104.0 (12.6, 4,375.3) Not calculated 105.6 ⬍0.001* ⬍0.001* ⬍0.001*

0 Not calculated

51.8 56.9 16.1 (2.1, 701.0) 26.4 (3.5, 1,129.2) 0.001* ⬍0.001*

21.4 0.06

9.8 0.3

27.3 1.95 0.50

7.1 0.5 0.61

3.0 Not calculated 1.0 0

25.0 2.3 0.50 7.1 0.07

Not calculated

15.7 Not calculated 0.10 9.8 0.31

16.2 0.03*

Not calculated

0 Not calculated

0 8.8 Not calculated Not calculated 0.10 2.9 0.47

0 Not calculated

40.0 ⬍0.001

2.7 0 Not calculated Not calculated 1.0

0 Not calculated

0 0 Not calculated Not calculated

0 Not calculated

30.0 ⬍0.001*

* p ⬍0.05. † OR not calculated.

during the initial history, we could not account for it in our later analyses. We recognize that some individuals may be naturally more sensitive to muscle palpations and pressure that could cause pain in the pelvic region, although they do not have CPPS.

CONCLUSIONS To our knowledge this study is the first to reveal a relationship between certain myofascial TrPs and

specific self-reported painful sites in men with CPPS. We report that certain myofascial TrPs at specific sites reproduce pain sensations in a substantial number of men with chronic pelvic pain. The identification of TrP clusters inside and outside the pelvic floor in patients with pelvic pain should assist in the diagnostic classification of the syndrome by determining whether pain is associated with neuromuscular TrPs and provide insight into effective therapeutic approaches.

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REFERENCES 1. Potts JM and Oâ&#x20AC;&#x2122;Dougherty E: Pelvic floor physical therapy for patients with prostatitis. Curr Urol Rep 2000; 1: 155. 2. Zermann DH, Ishigooka M, Doggweiler-Wiygul R et al: The male chronic pelvic pain syndrome. World J Urol 2001; 19: 173. 3. FitzGerald MP and Kotarinos R: Rehabilitation of the short pelvic floor. I: background and patient evaluation. Int Urogynecol J Pelvic Floor Dysfunct 2003; 14: 261. 4. Anderson RU, Wise D, Sawyer T et al: Integration of myofascial trigger point release and paradoxical relaxation training for treatment of chronic pelvic pain in men. J Urol 2005; 174: 155. 5. Berger RE, Ciol MA, Rothman I 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 Urol 2007; 7: 17.

6. Shoskes DA, Berger R, Elmi A et al: Muscle tenderness in men with chronic prostatitis/ chronic pelvic pain syndrome: the Chronic Prostatitis Cohort Study. J Urol 2008; 179: 556. 7. Travell J and Simons D: Myofascial Pain and Dysfunction: The Trigger Point Manual, 2nd ed. Philadelphia: Lippincott Williams & Wilkins 1998; vol 1 and 2. 8. Simon DG: Fibrositis/fibromyalgia: a form of myofascial trigger points? Am J Med, suppl., 1996; 81: 93. 9. Wise D and Anderson RU: A Headache in the Pelvis: A New Understanding and Treatment for Prostatitis and Chronic Pelvic Pain Syndromes, 5th ed. Occidental, California: National Center for Pelvic Pain Research 2008. 10. Litwin MS, McNaughton-Collins M, Fowler JF Jr et al: The National Institutes of Health chronic prostatitis symptom index: development and val-

idation of a new outcome measure. J Urol 199; 162: 369. 11. Wolfe F, Smythe HA, Yunus MB et al: The American College of Rheumatology 1990 criteria for the classification of fibromyalgia. Arthritis Rheum 1990; 33: 160. 12. Warren JW, Langenberg P, Greenberg P et al: Sites of pain from interstitial cystitis/painful bladder syndrome. J Urol 2008; 180: 1373. 13. Shoskes DA, Nickel JC, Rackley RR et al: Clinical phenotyping in chronic prostatitis/chronic pelvic pain syndrome and interstitial cystitis: a management strategy for urologic chronic pelvic pain syndromes. Prostate Cancer Prostatic Dis 2009; 12: 177. 14. FitzGerald MP, Anderson RU, Potts J et al: Randomized multicenter feasibility trial of myofascial physical therapy for treatment of urologic chronic pelvic pain syndrome. J Urol 2009; 182: 427.

EDITORIAL COMMENT This provocative study correlates myofascial TrPs with pelvic pain sites in 72 patients with CP/CPPS. The authors conclude that clusters of TrPs can be used to diagnostically classify the syndrome and provide insight into effective therapeutic approaches, particularly the manual physiotherapy and paradoxical relaxation training program in which all patients were participating. Does this mean that urologists should evaluate patients for TrPs and then recommend myofascial tissue release treatment in those with TrPs? The answer is not clear. This study included chronic refractory cases referred to a tertiary care center. All patients were enrolled in a treatment program that they and their providers believed to be highly effective based on nonblinded, uncontrolled observations. All treatments and critical evaluations were done by 1 highly experienced physical therapist. Whether these critical findings can be reproduced by other physical therapists or urologists, or in the same patient at different times remain open questions. As noted in another clinical study, a clear discrepancy existed between what physicians scored for subjective pain and what physical therapists reported since physi-

cians found 28% less tenderness (reference 14 in article). TrP testing is attractive as a patient evaluation method but the value of this approach requires validation. For other chronic pain conditions such as fibromyalgia the value of similar tender points is subject to active debate. Tender point measures often do not improve in clinical trials and findings are influenced by factors other than pain, such as distress and expectancy.1,2 Like myofascial release therapy, many urological chronic pain therapies have been promising based on clinical observations and small clinical trials. Unfortunately most of these therapies have proved no more effective than placebo treatment in large, well-done, double-blind, randomized clinical trials.3 The conclusions of this study require confirmation by other groups and most importantly proof that identifying specific trigger points provides clinically meaningful information that should direct therapy. John N. Krieger Department of Urology University of Washington School of Medicine Veterans Affairs Puget Sound Health Care System Seattle, Washington

REFERENCES 1. Harris RE, Gracely RH, McLean SA et al: Comparison of clinical and evoked pain measures in fibromyalgia. J Pain 2006; 7: 521.

2. Nicassio PM, Weisman MH, Schuman C et al: The role of generalized pain and pain behavior in tender point scores in fibromyalgia. J Rheumatol 2000; 27: 1056.

3. Nickel JC, Krieger JN, McNaughton-Collins M et al: Alfuzosin and symptoms of chronic prostatitis-chronic pelvic pain syndrome. N Engl J Med 2008; 359: 2663.