Pelvic Floor Therapies in Chronic Pelvic Pain Syndrome

Curr Urol Rep (2011) 12:304–311 DOI 10.1007/s11934-011-0197-x

Pelvic Floor Therapies in Chronic Pelvic Pain Syndrome Ragi Doggweiler & Adam F. Stewart

Published online: 6 May 2011 # Springer Science+Business Media, LLC 2011

Abstract Chronic pelvic pain syndrome is a poorly understood clinical entity associated with urinary symptoms, pelvic floor dysfunction, and multisystem disorders.

Treatment of pelvic floor dysfunction is difficult and often frustrating for the patient as well as for the involved physician. The purpose of this review is to update clinicians on the latest research for the treatment of pelvic floor dysfunction in relation to chronic pelvic pain syndrome.

responsible for disability that can lead to loss of employment and health insurance. Patients and physicians often feel frustrated and helpless in the face of this diagnosis.

This article reviews the latest research for the treatment of pelvic floor dysfunction in relation to CPPS.

Keywords Chronic prostatitis . CP . Chronic pelvic pain syndrome . CPPS . Pelvic floor . Pelvic floor dysfunction .

Pelvic floor therapy . Psychosocial . Multisystem disorder .

UPOINT . Coping . Catastrophizing . Irritable bowel syndrome . IBS . Sacral nerve stimulation . Sacral neurostimulation . SNS . Chronic pudendal nerve stimulation . CPNS . Sham acupuncture .

Electroacupuncture . Extracorporeal shock wave therapy .

ESWT . Transcranial direct current stimulation . tDCS

In an individual predisposed to CPPS, an initially benign trigger may lead to a range of sensory and motor abnormalities. This initial event may occur in childhood with nocturnal enuresis, recurrent urinary tract infections (UTIs), or trauma to the pelvic floor muscles (PFMs) or pelvic organs. Neurogenic inflammation, muscular and autonomic reflex responses, central hypersensitization, emotional reactions, and biopsychological consequences that resemble post-traumatic stress syndrome [2•] also may be involved. The involvement of the central nervous system then may result in a complex regional pain syndrome affecting not only the pelvis but also multiple organ systems. Evacuation dysfunction (urinary or bowel) and sexual dysfunction also are often part of the clinical picture [3]. This complexity explains why a global treatment approach for CPPS is essential.

Introduction Chronic prostatitis (CP), also called chronic pelvic pain syndrome (CPPS), is poorly understood. Defined as urological pain or discomfort in the pelvic region, this clinical entity is also associated with urinary symptoms and/or sexual dysfunction lasting for at least 3 of the previous 6 months [1]. It may cause psychological, behavioral, sexual, and social problems and often is R. Doggweiler (*) : A. F. Stewart University of Tennessee, Medical Office Building B, Suite 222, 1928 Alcoa Highway, Knoxville, TN 37920, USA e-mail: rdoggweiler@yahoo.com

Pathophysiology

The Pelvic Floor The pelvic floor is an organ system. Different muscles form its muscular layer, called the levator ani. The pelvic bones and ligaments are structures that support the pelvic muscles.

The function of the pelvic floor is to support pelvic organs, and the function of the PFMs is to control continence and elimination [4]. Levator and sphincter muscles of the anus

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and urethra are continuously tonic, or tensed, relaxing only during urination and defecation [5].

The pelvic floor is controlled by a unique coordination of somatic and autonomic motor nerves [5]. Complex reflex and voluntary control, as well as socially adapted behavior, require input from several higher centers. Nerves originating in Onuf’s nucleus in the S2-S4 anterior horn of the spinal cord innervate the rhabdosphincters (urethral and anal) and the PFMs. The somatic motor fibers leave the spinal cord, form the pudendal nerve (which continues through the greater sciatic foramen), and enter in a lateral direction through the lesser sciatic foramen into the ischiorectal fossa (Alcock’s canal). The pudendal nerve then gives rise to the inferior rectal nerve, the perineal nerve, and the dorsal nerve of the penis/clitoris. The perineal nerve is the inferior and larger branch dividing into the posterior scrotal/labial and muscular branches (Fig. 1).

However, a variability of human neuroanatomy often is observed. The coordination of pelvic physiologic function requires complex integrative sensory pathways, which converge both peripherally and/or centrally. After a focal, acute, irritative, or infectious pelvic insult, these afferent pathways may produce a generalized pelvic sensitization or cross-sensitization involving the bladder and bowel [6].

Many functional disorders of the PFMs are accompanied by pelvic and perineal pain, urinary urgency and frequency, levator ani syndrome, proctalgia fugax, myofascial pain syndrome, and coccygodynia [7].

storage phase 98% of the time. During voiding, the first change is relaxation of the PFMs and the external and internal urethral sphincters, which is achieved by the inhibition of the pudendal and sympathetic nerves.

Parasympathetic-mediated detrusor contraction follows a few seconds later. Once the bladder is empty, sympathetic activity resumes, relaxing the detrusor muscle and returning the urethral sphincter to its normal tonic state. The sphincter both facilitates and inhibits voiding reflexes. This sphincter is the major player in determining the functional integrity of the lower urinary tract [8].

Defecation Defecation also is under the control of various reflexes.

When stool enters the rectum, mechanical distension triggers the defecation reflex. This rectoanal inhibitory reflex (RAIR) elicits external sphincter contraction and internal sphincter relaxation. The RAIR is intrinsic to the colon and is mediated through the enteric nervous plexus [9]. Rectal distension stimulates nerve endings in the submucosa. This signal is transmitted through the pelvic splanchnic nerves to the second and third sacral nerves. The signal then travels reflexively back to the rectum and internal anal sphincter.

Constipation and defecation symptoms rarely occur in isolation and often are part of a global pelvic floor problem involving voiding difficulties, sexual dysfunction, and pain syndromes [10].

Lower Urinary Tract Evaluation of Chronic Pelvic Pain The lower urinary tract has two roles: storage of urine and urinary voiding. In a healthy person whose detrusor pressure stays below 10 cm H2O, the bladder is in a

Ischiocavernosus Bulbocavernosus

Transversus perineum

Perineal body

Anus

Levator ani Pubococcygeus

Anal sphincter

Iliococcygeus Coccyx bone

Fig. 1 Male pelvic floor

Gluteus maximus

CPPS is a diagnosis of exclusion [1]. A detailed history about the initiation of symptoms is essential and should include a comprehensive urologic history, a history of childhood nocturnal enuresis and/or recurrent UTIs, a history of fecal elimination symptoms (eg, constipation, diarrhea), gastrointestinal problems, sexual symptoms, pain symptoms or syndromes (eg, back pain, joint pain, temporomandibular joint dysfunction, headaches, fibromyalgia), and a history of surgeries or injuries [11]. Patients also should fill out a symptom inventory or index (such as the National Institutes of Health Chronic Prostatitis Symptom Index [NIH-CPSI]) [12].

A thorough physical evaluation is essential not only to rule out other diseases, but also to confirm the diagnosis of CPPS so appropriate treatment can begin. The examination should include an evaluation of posture, back, abdomen, pelvis, leg strength and reflexes, and an inspection of external genitals. For the pelvic floor assessment, the patient is placed in the lithotomy position to allow

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assessment of the striated muscles of the PFMs and, if necessary, to examine the prostate for tenderness and abnormalities [11].

The PFMs are evaluated for the presence of myofascial trigger points, tender spots, and spasm or weakness. The ability to isolate, relax, and contract the PFM is assessed [13].

Urine analysis, urine culture, cytology, and evaluation of any postvoid residual by ultrasound are part of the initial evaluation [11]. In male patients, obtaining a pre-massage and post-massage two-glass test of prostatic secretion for culture [12] also is recommended.

Patients are asked to complete a 3- to 4-day voiding diary recording voided volumes. If the voiding diary reveals urgency and frequency, a urodynamic study (UDS) is indicated. Frequency is defined either by a complaint by the patient that he voids too often each day or voiding greater than 8 to 10 times per day [14]. This terminology should be changed to account for the volume per void. In general, a normal void is 300 to 500 mL/void. To overcome frequency, some patients reduce fluid intake, which can compromise their health. Other patients drink large amounts every day and empty their bladder frequently, but the voided volume is normal. If most of the recorded voids in a voiding diary are below 250 mL, the author considers this to be frequency. If the patient voids over 300 mL more than 10 times, it is considered to be polyuria. In adults, polyuria is defined as the production of more than 2.8 L of urine in 24 h, which can be due to diuretics, increased fluid intake, or hormonal problems, but not a urological problem in itself [15].

Frequency can be suggestive of detrusor overactivity, but it also can be due to other forms of urethrovesical dysfunction [16]. Few investigators measure integral urethral pressure during filling cystometry [17]. CPPS patients with lower urinary tract symptoms may have dysfunctional voiding characterized by a weak flow, high detrusor pressure, and, often, increased urethral pressures [18]. UDS may contribute to a definitive diagnosis and an appropriate choice of treatment.

Patients also need to undergo a cystoscopic evaluation with possible biopsy to establish the presence of interstitial cystitis or bladder tumor. A cystoscopy and, in selected cases, computed tomography (CT) also can rule out other concomitant bladder, urethral, or prostate pathology [1].

Several pathologies can be involved in CPPS. These may include myofascial pain syndrome, pudendal nerve entrapment, bladder pain syndrome, and epididymotesticular pain syndrome [19]. Often, these patients not only have voiding dysfunction but also can have concomitant gastrointestinal problems like irritable bowel syndrome (IBS), constipation, and proctalgia fugax. Integrating the concept of pelviperineal dysfunction and avoiding a rigorous

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distinction between anterior segment, midline, and posterior segments of the perineum are essential. In Bernal and Pontari’s [20] evaluation of CPPS in men, they concluded that instead of a focus only on the prostate, a multisystem approach would improve patient care. A phenotypic approach to the management of CPPS was described by Nickel and Shoskes [21••]. The UPOINT system classifies patients by symptoms that are grouped into six domains including urinary, psychosocial, organ specific, infection, neurologic/systemic, and tenderness of skeletal muscles (Table 1).

Once a diagnosis of CPPS is established, this classification helps direct treatment. A study at Cleveland Clinic showed how this tool helps improve outcomes by identifying specific treatment approaches tailored to each patient based on the UPOINT classification. In this study, a median of three UPOINT domains were positive [22]. The most frequently found domains were organ-specific (improvement of pain with voiding and tenderness of the prostate), tenderness (finding palpable tenderness of the muscles, spasms, and/or trigger points), and urinary (incomplete emptying).

Treatment of Pelvic Floor Dysfunction with the UPOINT Approach Urinary Symptoms If a patient presents with voiding dysfunction and/or an elevated postvoid residual, a UDS is indicated. Based on its results, treatment is established including behavioral changes, modification in fluid intake, diet alteration, and physical therapy to re-educate the PFMs [11]. Second-line medical treatment includes α-blockers and, in rare cases, antimuscarinics [22]. Neuromodulation, discussed later, is the third-line treatment.

Psychosocial The psychosocial domain includes clinical depression and catastrophizing. Catastrophizing is defined as a tendency to Table 1 UPOINT domains UPOINT domains

Symptoms

Urinary Psychosocial Organ specific Infection Neurologic/systemic Skeletal muscles

Postvoid residual, urgency frequency, dysuria Depression, catastrophizing Bladder pain; prostate tenderness Cultures Other pain syndromes Myofascial trigger points, spasms

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focus on pain and an inability to effectively manage it.

Although catastrophizing involves cognitions and perceptions that may be considered a part of the belief or attitude domain, it also has been described as a type of social coping given its potential for eliciting social support.

However, catastrophizing is more harmful than helpful [23]. It has been shown to be the strongest and most consistent psychosocial factor associated with pain and dysfunction in patients whose primary presenting problem is chronic pain. Coping may be defined as an effort to manage stressful events. Therapy with a psychologist, psychiatrist, or social worker can help in addition to interventions that aim to increase coping strategies. Relaxation techniques, progressive muscle relaxation, and selfhypnosis also help reduce stress [11].

Anderson et al. [24] evaluated males with psychological questionnaires and hypothalamic-pituitary-adrenal (HPA) axis function measured during a stress test. The data provided evidence that chronic pain may contribute to an altered pattern of the HPA axis response to acute stress.

This suggests that, with better understanding of stressinduced neurochemical changes, it may be possible to modulate the effects and develop new and innovative approaches for CPPS treatment.

Jensen [25] described psychosocial approaches to pain management. He proposes a model that accounts for all factors, including environmental, brain state, cognitive content, cognitive coping, and/or behavior that directly or indirectly influence pain and adjustment to pain. No studies have been published on such interventions for CPPS. However, they are commonly used in our clinical practice.

The literature suggests considerable comorbidity between urological and nonurological unexplained clinical conditions. The most robust evidence for overlap involves IBS and unexplained urological syndromes [26]. Cognitivebehavioral therapy previously has been shown to be effective in alleviating IBS symptoms. Such an intervention available on pocket-type computers was found to be feasible and effective for improving short term IBS-related complaints [27]. However, these studies have not yet been reproduced in patients affected by CPPS. Evans et al. [28] described a planned study of 60 IBS patients (ages 14–26 years) who will be randomly assigned to either a standardized, 6-week, twice weekly Iyengar yoga program or a waitlisted usual-care control group. The primary clinical outcomes of IBS symptoms, quality of life, and global improvement at post-treatment and 2-month follow-up will be compared. Secondary outcomes will include visceral pain sensitivity assessment, functional disability, and psychospiritual variables, including catastrophizing, self-efficacy, mood, acceptance, and mindfulness [28].

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Organ Specific “Does pain improve with voiding?” and “Is tenderness of the prostate present?” are examples of questions to the patient. Pharmacotherapy includes anti-inflammatory agents for pain symptoms, 5-α-reductase inhibitors, glycosaminoglycans, quercetin, Cernilton (CN-009 [now PollenAid; Graminex, Saginaw, MI]), and saw palmetto [29].

Shi et al. [30] and Yuan et al. [31] investigated the inhibitory effects of phytosterols on abacterial prostatitis and demonstrated they had good therapeutic effects if the prostatitis was chronic. Given the inflammatory nature of class IIIA prostatitis/CPPS, various NSAIDS, corticosteroids, and immunosuppressive drugs have been considered as potential therapies for this condition. Short-term NSAIDs are worth considering in the early stages of the condition [32].

Infection Ruling out infection is important. Urine and expressed prostatic secretion should be sent for cultures and sensitivity, but physicians also should culture for mycoplasma and ureaplasma. Treatment with appropriate antibiotics is critical. Many practitioners use antimicrobials as a firstline agent, particularly fluoroquinolone or trimethoprim/ sulfamethoxazole. Some patients will have significant improvement on a 4- to 6-week regimen of an antibiotic [33]. If there is no improvement, treatment with antibiotics should be suspended.

Neurologic/Systemic The neurologic/systemic domain helps physicians evaluate pain outside the pelvis and to detect the presence of other pain syndromes. Warren et al. [34] found that patients with fibromyalgia and chronic widespread pain, chronic fatigue syndrome, Sjögren’s syndrome, and/or IBS were more likely to have other syndromes such as migraines, chronic pelvic pain, depression, and allergies. In selected patients, antidepressants are added to the treatment of neuropathic pain. Amitriptyline, sertraline, duloxetine, nortriptyline, and citalopram are reported to be helpful as chronic pain treatments [35]. However, there are mixed results. Amitriptyline may be effective for interstitial cystitis. A study done on pregabalin therapy for 6 weeks found it was not superior to placebo despite a 6-point decrease (improvement) in the NIH-CPSI total score in men with CPPS [36].

In some cases, CPPS can be related to a nerve lesion caused by direct or indirect trauma or by entrapment syndrome. Nerves involved in pelvic and perineal pain are the obturator, ilioinguinal, iliohypogastric, genitofemoral, and sacral nerves (pudendal and inferior cluneal branches of the posterior cutaneous nerve of the thigh) [37].

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Infiltration can confirm this diagnostic hypothesis. Somatic nerve blocks should be considered in the management of chronic pelvic and perineal pain. These blocks are predominantly performed under CT guidance. Once the level of the nerve lesion and the diagnosis have been defined, more specific therapeutic procedures can be proposed.

The autonomic sympathetic nervous system conveys nociceptive messages from the viscera to the brain.

Intervention of the sympathetic nervous system for the management of chronic pelvic and perineal pain has been proposed at the level of the ganglion impar, hypogastric plexus, and L2 lumbar sympathetic blocks [38].

Pudendal nerve neuralgia is frequently described as a source of intractable perineal pain. Calabrò et al. [39] reported a case of a 40-year-old man successfully treated with palmitoylethanolamide. Pudendal neuralgia presents as a unilateral or bilateral burning pain of the anterior or posterior perineum that is worse when a patient sits and is normally relieved by standing [40]. Robert et al. [41] describe involvement of the inferior cluneal nerve, which is triggered by a seated position reaching the lateral anal region and the scrotum, but not the glans penis.

Tenderness of Skeletal Muscles At least half of the patients affected by CP/CPPS have PFM spasms or dysfunction [23]. Diazepam, baclofen, and tizanidine are the most prescribed drugs for spasticity [42]. No controlled studies have been done in the treatment of CPPS with muscle relaxants.

In a large, multicenter, NIH-sponsored study, investigators determined the feasibility of conducting a randomized clinical trial designed to compare two methods of manual therapy (myofascial physical therapy and global therapeutic massage) in patients with urological CPPS [43]. The global assessment response rate of 57% in the myofascial group was significantly higher than the 21% rate in the massage group.

Anderson et al. [44] developed the Stanford protocol using myofascial trigger point assessment and release therapy (MFRT) in conjunction with paradoxical relaxation therapy (PRT). The authors showed relationships between myofascial trigger points and reported painful sites in men with CP/CPPS. The identification of clusters of myofascial trigger points inside and outside the pelvic floor helps provide focused therapeutic approaches. Pelvic floor biofeedback together with myofascial release is the main treatment for these patients [45].

The same group reported long-term outcomes of a 6-day intensive combination of such therapies in refractory cases [46••]. Stanford University Urology received 200 men with pain lasting a median of 4.8 years who referred themselves for participation in an established protocol, where 3- to 5-hour

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sessions were performed daily, including intrapelvic/extrapelvic physiotherapy, self-treatment training, and paradoxical relaxation training. This provided an effective introduction to self-management. At variable intervals, patients filled out baseline and follow-up questionnaires, including the NIHCPSI, a global response assessment, and a psychological query.

For a median of 6 months 116 men were followed. Scores decreased by 30% (P<0.001) at follow-up with 60% of patients demonstrating a 6-point or greater decrease (range from 6 to 30). Pain, urinary dysfunction, and quality-of-life scores showed significant improvement. Global response assessment revealed that 82% of patients reported improvement. Techniques for self-administered trigger point release and continued pelvic muscle relaxation helped patients reduce pain and dysfunction.

In an Italian study, biofeedback was superior to electrogalvanic stimulation and massage for treatment of levator ani syndrome (LAS) [47]. However, only patients with tenderness during a rectal examination benefited. Improvements were maintained for 12 months. Patients with only a possible diagnosis of LAS did not benefit from any treatment.

Gottsch et al. [48] at the University of Washington conducted a randomized placebo-controlled study of a botulinum toxin A (BTX-A) injection into the perineal musculature for the treatment of CPPS. At the 1-month follow-up, there was a 30% response rate for BTX-A treatment compared with 13% for placebo. BTX-A use may enhance polytherapeutic pain management. Results of an evaluation after a BTX-A injection and physical therapy are worth consideration in the area of CPPS.

Neurostimulation Sacral nerve stimulation (SNS) is an effective treatment of urge incontinence, urgency frequency, and urinary retention. Frequently, it resolves or reduces associated CPPS. Marinkovic et al. [49] evaluated patients after implantation with InterStim (Medtronic, Fridley, MN) over a minimum 6-year follow-up and determined that SNS provides adequate improvement for the symptoms of refractory interstitial cystitis. Van Wunnik et al. [50] used SNS for the treatment of chronic functional anorectal pain. In this study, nine patients were enrolled, four of which had successful test stimulation and were eligible for the permanent implant. All patients experienced lasting improvement over the 24-month follow-up.

SNS is also used for fecal incontinence, constipation, and even healing of anal fissures [51]. Kim et al. [52] reported two cases of intractable pain associated with cauda equina syndrome (CES) that were treated successfully by SNS. One suffered from intractable pelvic pain with urinary incontinence and fecal incontinence after surgery for a herniated lumbar disc. The second patient underwent

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surgery for treatment of a burst fracture and consequently developed intractable pelvic area pain, right leg pain, excessive urinary frequency, urinary incontinence, voiding difficulty, and constipation 1 year after surgery. Both patients' pain was significantly improved, and urinary symptoms were much relieved with SNS. Chronic pudendal nerve stimulation (CPNS) is an alternative, particularly in those who fail SNS. Peters et al. [53] evaluated symptoms, complications, and satisfaction after 84 patients were treated with CPNS. Pudendal response occurred in 60 patients (71.4%). Almost all (93.2%) who had previously failed SNS responded to pudendal stimulation. After 24 months, overall bladder, pelvic pain, incontinence, urgency, and frequency symptoms had improved. Researchers concluded that CPNS is a reasonable alternative in complex patients who are resistant to other therapies, including SNS.

Other Treatments Lee et al. [54] developed a sham acupuncture procedure in a randomized controlled clinical trial of chronic pelvic pain treatment. Lee and Lee [55] reported their sham controlled success with electroacupuncture in the treatment of men with CP/CPPS. Zimmermann et al. [56] used extracorporeal shock wave therapy (ESWT) for the treatment of CPPS. In this study, 30 patients treated weekly with low energy–density ESWT for 4 weeks were compared to a sham group. Patients in the treated group improved up to 50% even after 12 weeks. No side effects were reported during or after treatment.

Researchers hypothesized that shock waves can influence the neuroplasticity of the human pain memory. Results from 12 or more months will be helpful in determining the efficacy of this treatment because pain often improves for a short period of time after surgery and then can reappear fiercely a few months later.

Fenton et al. [57] investigated the modulatory effects of transcranial direct current stimulation (tDCS) for the treatment of chronic pelvic pain. Seven patients with CPPS who failed standard medical and surgical treatments were included in the study. Active tDCS induced modest but statistically significant pain reduction in refractory CPPS patients.

In Germany, 35 men affected by CPPS participated in an osteopathic study. The 15 patients who were in the placebo group completed a training program with simple gymnastics and physiotherapeutic exercises, while 20 patients were treated according to the principles of osteopathy for five sessions. At the end of the study, improvement of voiding symptoms, pain, and quality of life were measured. The treatment group improved, and the results were stable after 6 weeks and after 1.5 years [58]. This positive result indicates that osteopathic

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treatment can be considered a genuine alternative to conventional treatments, and a closer collaboration between urologists/internists and osteopaths is desirable.

Conclusions CPPS is a complicated multisystem syndrome. Treatments are successful in some patients while not helpful in others. There is great optimism that, with the application of the concept of UPOINT, appropriate treatment approaches for each patient will be easier to determine and a treatment plan can be tailored for each patient. This condition should remind clinicians that human beings are complicated, and, if pain and emotions are involved, the clinical scenario is even more confusing.

In treating patients affected by chronic pelvic pain, keeping a holistic approach is important. Narrow mindedness can cause more harm than help. The evaluation of the patient should include not only organ systems but also an investigation of the whole person, including psychosocial aspects. Only in a very rare situation do patients require immediate treatment with either medication or surgical intervention. In general, waiting, reflecting, and discussing all potential side effects from medications, complications from surgeries, and the possibility of little benefit or even more pain from a treatment choice is important. Some patients believe that surgery with the removal of the bladder or prostate, or simply any surgery, will resolve their issue.

Therefore, the treating physician should guide these patients in their “journey of healing.” Collaboration of a urologist with a gastroenterologist, primary care physician, psychologist, pain specialist, and physical therapist trained in the treatment of chronic pelvic pain is essential.

Each patient is unique, and the function of the treating physician is to tailor an appropriate treatment plan for each individual. UPOINT may be a useful tool for accomplishing this goal.

Disclosures No potential conflicts of interest relevant to this article were reported.

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