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THE 'PNSBDS' PROTOCOL ‘PELVIC NEUROGENIC SOMATO-VISCERAL BIO-MECHANICAL DYSFUNCTION SYNDROME’
A Novel Approach to Idiopathic, Non-Organic and Neurological/ Musculoskeletal Chronic Pelvic Pain Syndromes
These include (but are not limited to) to following diagnoses: • Pudendal Neuralgia/Entrapment • Chronic Prostatitis (NIH IIIB) • Chronic Interstitial Cystitis • Chronic Pelvic Pain Syndrome • Levator Ani Syndrome • Prostatodynia • Vulvodynia • Coccydynia • Pelvic Floor Dystonia
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Introduction Pelvic Neurogenic Somatovisceral Biomechanical Dysfunction Syndrome (PNSBDS) is a novel terminology and broad labeling for the description of a constellation of sub-types of Chronic Pelvic Pain Syndromes (CPPS). The rationale for such a complex title is reflected in the inherent complexity of a majority of chronic pelvic pain syndromes. This new terminology applies to the significant percentage of CPPS cases that fall under the idiopathic, non-infective, non-organic classification. To date, the diagnostic classification for this subgroup of CPPS cases is insufficient (reflected in the chronicity of the condition(s), lack of consensus regarding treatment, lack of definitive etiology in many cases, and numerous labels and diagnoses). This sub-group consists of cases where no definitive pathology has been identified (or cases where a neurological and/or musculoskeletal cause is implicated), and complicating and causal factors have ruled out through established diagnostic methods, including; urinalysis, laparoscopy, cystoscopy, MRI, CT, etc. In still other cases, a musculoskeletal cause is identified (as is the case with Pudendal Neuralgia/Entrapment). The PNSBDS group of CPPS are poorly understood entities with a subsequent lack of established diagnostic and treatment options. This results in a vicious cycle of various minimally or temporarily effective treatments given by a plethora of different physicians and therapists, ranging from Urologists, Neurologists and Orthopedic Surgeons to Physical Therapists, Naturopaths and Chiropractors. The current treatments are primarily aimed at treating the symptoms and manifestations of the condition, which are misinterpreted or oversimplified as the primary causes of the condition (or simply brushed off as ‘idiopathic’). In a select group (typically the PN/PNE sub-group), a neurological/musculoskeletal cause is identified and treated (however the conservative methods often fail due to an oversimplification of etiology and limitations regarding current treatment methods). However, the symptoms of these conditions are often secondary to a plethora of interconnected and concurrent local and global causes, affecting multiple body systems. This is the reason the symptoms almost invariably return
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in some form or other, or are never completely eliminated with one therapy alone.
The Dreadful Statistics Currently, Chronic Pelvic Pain Syndromes (CPPS) are a challenging and frustrating problem. It can have various manifestations, depending on the sub-type of condition (which is typically not identified by current methods). Manifestations are affected by anatomical structures involved, location of primary pathology, location of secondary etiologies, and also by social factors such as occupational demands, recreational activity frequency, intensity and type, etc. Under the umbrella of PNSBDS, patients may experience various symptoms (not all patients manifest similar symptoms). The symptoms of CPPS can also vary according to the sex of the patient (due to differences in the anatomical structures involved). Currently, CPPS affects 10% to 15% of all women, a number that is likely much higher in reality due to diagnostic limitations, poorly defined criteria, and lack of awareness in the medical community. Women are often given a diagnosis of Interstitial Cystitis (IC). In men, a diagnosis of ‘prostatitis’ is often given. The prevalence of prostatitis is extremely high in men, and difficult to estimate. A significant percentage of Prostatitis cases fall under Category III of the National Institutes of Health (NIH) diagnostic criteria (Chronic Prostatitis (CP)/Chronic Pelvic Pain Syndromes (CPPS)). The etiology of these cases of CP/CPPS is non-infectious, with no precise mechanisms elucidated to date. For Prostatitis IIIB and Interstitial Cystitis (IC), there is no universal agreement regarding etiology and treatment. Another of the common causes of CPPS is Pudendal Nerve Entrapment- a poorly understood and often overlooked condition. For example, for sufferers of this condition, the time to the diagnosis of PNE is a mean of 4 years (1-15 yrs). These patients have seen on average 10-30 Medical Doctors, have suffered innumerable invasive and non-invasive procedures with limited effectiveness and often have developed significant secondary negative health consequences due to side-effects of
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misguided treatments. Likely, the diagnosis is only made possible once the functional etiology of the condition exists for a protracted period of time, allowing for structural changes to take place (and facilitate identification through MRI). Lastly, the duration and degree of suffering many of these patients endure leads to central and peripheral sensitization with the concomitant allodynia, hyperalgesia , and subsequently development of an attitude of hopelessness. Accurate statistics and research regarding these conditions is difficult to obtain due to the lack of standardized universal inclusion criteria. Likely, they are misdiagnosed, resulting in a gross underestimation of prevalence and impact on public health. As noted, there is a lack of education and awareness in the health care regarding these conditions.
The Problem- A Reductionist Paradigm of Pelvic Pain “You can’t find the right answer if you’re asking the wrong question”
In a reductionist model of health care, which is the current dominant Allopathic/Medical model of health care, the human body is broken down into tiny segments treated as unrelated and independent systems. The human body is a profoundly sophisticated system of interconnected systems. There are 50-150 trillion cells in your body (more than the number of stars in our galaxy), each performing hundreds (if not thousands) of chemical processes every second. It is this inherent complexity that is overlooked or dismissed, and one reason for the dismal statistics regarding the of current diagnostic and treatment options for CPPS. Why? Because each bodily system affects the other, and if there is dysfunction in one area, ultimately it will lead to dysfunction in another (given sufficient time and repetition). In a sufficient model of care, each field of medicine (urology, neurology, orthopedics, physiatry, gynecology) must communicate and appreciate the impact that each system can have on other systems fields (a holistic approach).
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Unfortunately, this is currently not the case. Each system is treated as independent and unrelated (a reductionistic approach).
The Holistic Model- “Connecting the Dots”
“Seeing the Forest for the Trees”...while still appreciating the trees.
The entire area (the pelvis...in addition to the mechanical lower body, including the hips, knees and feet) acts as a symphony of many instruments, and if one instrument is of key or missing, the intended composition fails. With an understanding of body systems, and the interconnected nature of each system, it illuminates and explains the seemingly complex (and seemingly unrelated) symptoms and manifestations of CPPS. By incorporating an understanding of the function and structure of the body relating to joint mechanics (the mathematical study of movement, an important field called “biomechanics”), muscle function and structure (anatomy), fascial interconnections, visceral anatomy, tissue physiology and histology (tissue adaptations to forces- especially suboptimal or repetitive forces),
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the pelvis can be viewed as a highly complex inter-related system of tissues and structures. Each tissue and structure performs a function, while simultaneously facilitating the function of other systems and tissues. Should one of these systems become dysfunctional, or pathological, it may hinder the function of another system. In an attempt to explain the interconnected systems, the following Question and Answer format outlines the manifestations and presentations of many potential CPPS cases (and subsequent symptoms): 1) How does damage occur to the pelvis, such as scarring? How does pelvic floor dysfunction occur, and why? The neurological and anatomical mechanisms of the pelvic viscera (the bladder and prostate) act in a synergic and coordinated manner. For example, biomechanical dysfunction of the hips, knees, low-back and even the feet can cause a cascade of events. The causes of biomechanical dysfunction can be numerous. Common causes are due to prolonged sitting, cycling, repetitive strains to the pelvic floor and joints of the lumbar spine, injury, muscle spasm and imbalances, posture, etc. These events can cause muscular spasm, hypertonicity, and repetitive strain of tissues. Repetitive strain (or acute strain) can result in altered histopathological composition of musculature (such suboptimal micronutrient balance, microcirculation, etc). This leads to fibrotic myofascial adhesion (scarring) development, and possible entrapment of the pudendal nerve, or at very least tensing of the pelvic sling musculature. The Pudendal nerve has important innervations to the parts of the bladder and genitalia- afferent, efferent and autonomic. Thus it is a highly specialized and important nerve for a plethora of urogenital and somatic pelvic functions, including but not limited to sex organ sensation and function, bladder emptying, and pelvic floor muscular function.
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How injuries can develop (function affects structure and vice versa):
2) Why do some patients experience urological symptoms (such as Prostatitis and Interstitial Cystitis)? As noted, the Pudendal nerve innervates the external urethral sphincter, which helps regulate urinary flow. Should the Pudendal nerve become compromised, proper function of the structures it innervates becomes compromised. Dysfunction of the external urethral sphincter can cause urinary retention, which leads to incomplete emptying, which is a known cause of infection (urinary stasis). Furthermore, the pelvic floor has important interconnections between all somatic structures in the pelvis, and some fascial connections to visceral structures. Many important urogenital structures (such as the urethra) pass through or are anchored to (or by) pelvic fascial structures, and can get compressed if the fascia is too tense. The bladder and/or prostate is anchored to the pelvic bones by strong ligaments. These ligaments can develop an improper lengthtension relationship should pelvic mechanics become altered, by repetitive strain and muscular imbalance (and subsequent altered biomechanics). Thus, as noted, many somatic structures have important connections, ligamentous or fascial, to the bladder, prostate, urethra, and rectum/anus, and the pubic, sacrum, and coccyx bones. Thus, one can
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begin the see the complex and intimate inter-relationship between pelvic structures of various types. Essentially, dysfunction of neurological and somatic elements of the pelvis affect the viscera, such as the bladder, leading to weak/erratic flow, straining to void, and incomplete emptying of the bladder. Due to residual urine which provides excellent grounds for bacterial growth, there is an increased risk of recurrent bladder infections, a concept that has been around for ages since it was hypothesized by Seddon and Bruce in 1978. Hence, the symptom pattern of an infectious process (this is why antibiotics may alleviate the symptoms of many patients, however repetitive doses will be required as the cause of the condition is note addressed as the infection is secondary). This creates a vicious cycle, as pelvic inflammation, infection and dysfunction of urogenital structures causes and contributes to further somatic dysfunction, which again amplifies visceral dysfunction. And so it goes. 3) Why do some patients experience certain symptoms, and others do not? For PN/PNE, it depends on the location of the entrapment (the actual anatomical entrapment site). Should the entrapment be proximally located, such as in the substance of the piriformis or other hip rotators (prior to at the sacrotuberous), the Pudendal nerve will likely be affected in its entirety (all structures it innervates will manifest symptoms because the nerve has not branched much at this point). However, should the entrapment occur distally (further along it’s course), fewer symptoms will manifest (because fewer areas innervated by the Pudendal nerve will be affected because any branches occurring prior to the entrapment site will likely remain unaffected). Distal entrapment sites manifest mostly as numbness and burning into the vulvar/testicular region. Proximal sites can manifest this, in addition to rectal/anal symptoms. 4) How can the feet cause CPPS and/or PN/PNE?
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Altered foot mechanics, resulting in improper shock absorption and positioning of the knee and hip (for example, pronation can cause genu valgus which alters the Q-angle of the hip, which causes the hip external rotators to become tight, which can compress the pudendal nerve, but moreover alter the function of the pelvic floor and other hip stabalizers) can result in strains to the pelvis. An example of altered foot mechanics (1- pronation, 2- supination), and the complex effects on distal structures (the pelvis):
We have created a crude flow chart documenting the inter-relationship of the pelvic somatic, visceral, biomechanical, and neurological structures and etiologies in the CPPS disease process (Andrew, 2010):
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See online for larger version (note: a sufferer of these conditions may have one or many of the above symptoms, and not necessarily experience every symptom mentioned)
PNSBDS- One Condition, Many Names We postulate that category III B Prostatits, Interstitial Cystitis (IC), Chronic Pelvic Pain Syndrome (CPPS), Levator Ani Syndrome, Bladder Pain Syndrome (BPS), Urethral Syndrome, Pelvic Floor Muscle (PFM) Dysfunction, and Pudendal Neuralgia and Entrapment, Pelvic Pain and Organic Dysfunction (PPOD), among others, are all symptomatic manifestations of another specific entity. This entity is a myofascial mechanical neurological dysfunction of the pelvic floor and neuromusculoskeletal structures of the lumbosacral and pelvic region with associated somatic and visceral (urogenital) pathologies. It is this neurogenic biomechanical somatovisceral and visceral-somatic interaction that may be the primary culprit to chronic pelvic pain syndromes, to which no other defined or identifiable pathological etiology exists. We submit the term “neurogenic prostatitis” is an appropriate terminology for NIH IIIB classification. Furthermore, the term “neurogenic” could be applied to other pelvic pain syndromes of similar etiology (with neuromuscular and biomechanical origins), such as Interstitial Cystitis (IC). Thus, the complex title ‘PNSBDS’ was developed
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to provide a sufficiently comprehensive description of a complex condition.
 Table 2. The new NIH consensus classification of prostatitis (Krieger et al. 1999) Category Clinical findings Category
Clinical findings
I
Acute bacterial prostatitis
II
Chronic bacterial prostatitis
III
Chronic prostatitis/chronic pelvic pain syndrome A Inflammatory B Noninflammatory
IV
Asymptomatic inflammatory prostatitis
The Strength of the PNSBDS ProtocolA Comprehensive Holistic Theoretical Model coupled with a Novel, Comprehensive and Aggressive Treatment Protocol The PNSBDS protocol has many strengths over traditional conservative methods and existing medical treatments. First, it is the appreciation of the comprehensive multi-system and interconnected nature of the conditions we are treating as described above. However, further strength results from the novel and concurrent application of a multitude of established and relatively new treatment techniques that work to treat the condition(s) in a summative manner (that the whole of the treatment is greater than the individual sum of its parts, just like the condition and it’s manifestations and causes). Additionally, our incredibly comprehensive investigative methods allow an assessment of the entire lower body (and the entire body from a holistic paradigm, addressing any anatomical, biomechanical, nutritional, neurological, urological factors). Through this comprehensive approach, it is possible to identify all affected and contributing factors (and regarding structure and function).
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Typically, if your symptoms can be reproduced by our assessment method, your specific condition(s) should be amenable to treatment. If your symptoms cannot be reproduced, you are not a candidate for the PNSBDS protocol. Furthermore, the PNSBDS protocol is highly aggressive, resulting in more dramatic and long-term functional and structural changes not otherwise obtainable with existing treatments. Unfortunately, due to the aggressive manual therapy and shockwave therapy, the treatment is quite painful. However, we have not had any patients who have not been able to tolerate the treatment (because the treatment is applied intelligently, within patient tolerance). The treatment is also dynamic (not fixed), and adjusts and evolves based on patient response and presentation. Finally, the PNSBDS protocol has a follow-up system that facilitates recovery and ensures long-term results. Patients are given detailed instruction on rest, activity, exercise, rehabilitation, diet, etc. Patients have direct access to the doctor at all times, by phone or email. Followup calls are made frequently, and advice given as needed (which allows modification of home instructions as needed). Also, communication between the doctor administering the PNSBDS protocol and the therapists you are instructed to continue your care locally upon your return home is encouraged (your local and/or pre-existing therapists, including Physiotherapist, Massage Therapist, Chiropractor, Osteopath, Personal Trainer, Medical Doctor, etc). Engaging those therapists with any questions and providing adequate direction is essential to a full longterm recovery. A weakness of surgery is the lack of communication between surgeon, patient and therapists. The PNSBDS treatment protocol is currently in its infancy, however is generating dramatic results. It is for this reason, coupled with minimal side-effects, the serious suffering and quality of life losses endured by patients, and the complete lack of effective and safe treatment alternatives that the protocol is being offered to patients outside the research realm. We are currently in the process of conducting
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preliminary research consisting of case reports. Thus, you may participate in furthering research while concurrently receiving treatment should you choose.
Expectations, Obligations and Summary of Treatment Generally, the initial PNSBDS protocol comprises one week of daily therapy, consisting of some some combination the following (determination and application of therapy types are case specific and individualized): • Low-Intensity Laser Therapy • Performed 4-7 days/week • Laser Acupuncture • Performed 4-7 days/week • Acupressure • Performed 3-7 days/week, depending on patient response tolerance • Trigger Point Therapy • Performed 3-7 days/week, depending on patient response tolerance • ESWT (Extra Corporeal Shockwave Therapy) • Performed 3-7 days/week, depending on patient response tolerance • Spinal Manipulative Therapy • Performed 3-7 days/week, depending on patient response tolerance • Locations and specific dependent on clinical findings • Active Release Techniques (ART) • Performed 3-7 days/week, depending on patient response tolerance • Nutraceutical Intervention • Based on Renai Sante Assessment • Key factors include: • Modulation of Inflammation • Optimal neurological status (Pudendal sub-types)
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• Anti-Microbial (IC and Prostatitis sub-types) • Allergy and sensitivity (IC and Prostatitis sub-types) • Visceral Support (IC and Prostatitis sub-types) • Lifestyle Modifications • Based on Renai Sante Assessment • Assessment and management of all potential contributing factors relating to diet, exercise, habits, and other variables. • Assessment of potential food sensitivities and allergies (and nutraceutical management) • Dietary Intervention • Based on Renai Sante Assessment • Assessment of potential food sensitivities and allergies (and nutraceutical management) • Biomechanical Orthoses Intervention, possibly including Foot Orthotics • Address and correct potential Pelvic biomechanical anomalies related to gait • Psychological, social and occupational factors • Education and management strategies relating to the psychosomatic contribution and impact (personality type, central sensitization, etc). Each of the above therapies alone have scientific and/or anecdotal evidence in the treatment of pelvic pain syndromes, however none have been combined in an aggressive and cumulative nature.
THE COST OF THE PNSBDS PROTOCOL EXPLAINED For specific information regarding costs, please call 613-933-7884 or email pelvicpainprotocol@gmail.com. Why is this protocol costly? The PNSBDS protocol is the result of a breakthrough in the theoretical explanation of etiology, assessment treatment of chronic pelvic pain syndromes. It is based on the culmination and synthesis of years of clinical and scientific research, novel application of current established therapies, modalities, and techniques. Furthermore, it accounts for the complexity of the human
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body, individual variations, and interdependent nature of bodily systems traditionally and misguidedly treated as separate entities by most current forms of therapies. The PNSBDS protocol puts the all the pieces of the puzzle together, visualizing the larger, complete image. Thus, the costs of developing, initiating, and researching the treatment protocol are substantial. Furthermore, the protocol utilizes highly specialized, complex and subsequently expensive equipment. This equipment is not only expensive to purchase, but operating costs are also very high. Finally, the aggressive and comprehensive nature of the protocol condenses therapy traditionally spread over the course of a month into a one week protocol, so as to keep it practical to those traveling from distant locations, reducing the need for subsequent trips. In comparison to other treatments of a similar approach, a typical shockwave therapy session in a typical clinic will deliver approximately 2000-4000 hits. Our treatment typically delivers 20,000 to 40,000 per session (often more). Furthermore, it is not the ESWT treatment that distinguishes this treatment protocol from others (the ‘what’). It is the ‘how’ (related to ‘how’ it is applied). Describing the protocol to other therapists is unfortunately like describing a golf swing- you may be able to provide a basic understanding, but it does not guarantee effective implementation on the golf course (Tiger Woods likely couldn’t create a prolific golfer simply by explanation of his swing over the phone or by email). The hope is, that in the future, therapists interesting in effectively treating pelvic pain will visit our clinic to receive proper instruction (simply purchasing a shockwave device will not suffice). Moreover, as noted, the PNSBDS protocol utilizes other specialized expensive equipment in addition to the shockwave, such as LILT (LowIntensity Laser Therapy). Therefore, keeping the protocol practical related to financial and time to minimize social, financial and occupational impact while concurrently maintaining clinical effectiveness and efficiency was more of a balancing act than it may seem. The demands of the therapy necessitate certain
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therapeutic elements are met, thus we could not sacrifice effectiveness for practicality in many circumstances. If you have any further questions related to costs, please contact us at 613-933-7884 or email Dr. Kirk Andrew at drkandrew@gmail.com.
Imaging Requirements A diagnostic evaluation consisting of a specialized pelvic MRI is highly recommended to properly assess the location(s), severity and nature of your condition. Also, it will rule out any complicating factors, and ensure no other serious pathology exists that would affect and/or contraindicate your response to treatment. There are few imaging facilities and radiologists properly trained and equipped to assess the Pelvic Neuro-anatomical structures. The ‘Hospital for Special Surgery’ in New York is the preferred imaging centre. We strongly suggest asking your Physician for a referral for a pelvic MRI from this facility. Please contact them (contact information below) directly for further questions pertaining to dates, procedure and costs.
Hospital for Special Surgery 535 East 70th Street New York, NY 10021 Tel: 212.606.1015 Fax: 212.774.2349 http://www.hss.edu/radiology-imaging.asp
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References: J.A. Durante, et. al. Pudendal nerve entrapment in an Ironman athlete: a case report, J Can Chiropr Assoc 2010; 54(4) Zimmermann, R. Et al. Extracorporeal Shock Wave Therapy for the Treatment of Chronic Pelvic Pain Syndrome in Males: A Randomised, Double-Blind Placebo-Controlled Study, EUROPEAN UROLOGY 5 6 ( 2 0 0 9)418–424 Bharucha, A. E. et al. Functional and Chronic Anorectal and Pelvic Pain Disorders, Gastroenterol Clin N Am 37 (2008) 685–696 Labat, Jean-Jacques et al. Diagnostic Criteria for Pudendal Neuralgia by Pudendal Nerve Entrapment (Nantes Criteria), Neurourology and Urodynamics DOI 10.1002/nau Peng, Hongying et al. Frequent ejaculation associated free radical and lactic acid accumulation cause noninfectious inflammation and muscle dysfunction: A potential mechanism for symptoms in Chronic Prostatitis/ Chronic Pelvic Pain Syndrome, Medical Hypotheses 73 (2009) 372–373 A.P. Baranowski et al. Chronic pelvic pain, Best Practice & Research Clinical Gastroenterology 23 (2009) 593–610 Pontari, M.A. et al. Chronic Prostatitis/Chronic Pelvic Pain Syndrome, Urol Clin N Am 35 (2008) 81–89 W. -M. Chen, COMBINATION REGIMEN IN THE TREATMENT OF CHRONIC PROSTATITIS, Archives of Andrology, 52:117–121, 2006 Pavone-Macaluso, M. Et al. Chronic Prostatitis Syndrome: A Common, but Poorly Understood Condition. Part II, e a u - e b u update s e r i e s 5 ( 2 0 0 7 ) 16–25 Chaitow, L. et al. Chronic pelvic pain: Pelvic floor problems, sacroiliac dysfunction and the trigger point connection, Journal of Bodywork and Movement Therapies (2007) 11, 327–339
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KANG Zhen-cai, Treatment of 68 Cases of Chronic Prostatitis with Acupuncture, J. Acupunct. Tuina. Sci. (2009) 7: 159-160 Shoskes, D. A. et. Al. Muscle Tenderness in Men With Chronic Prostatitis/ Chronic Pelvic Pain Syndrome: The Chronic Prostatitis Cohort Study, THE JOURNAL OF UROLOGY, Vol. 179, 556-560, February 2008 Capodice, J. L. Et. Al. Complementary and Alternative Medicine for Chronic Prostatitis/Chronic Pelvic Pain Syndrome, eCAM 2005;2(4)495– 501 doi:10.1093/ecam/neh128 Leibovitch, I et. Al. TheVicious Cycling: Bicycling Related Urogenital Disorders, European Urology 47 (2005) 277–287 Hruby S, Ebmer J, Dellon L, Aszmann OC. Anatomy of pudendal nerve at urogenital diaphragm – new critical site for nerve entrapment.Urology 2005; 66:949-952. Sedy J. Close proximity of pubic bone and dorsal nerve of penis/clitoris: A pathogenic factor in a sub-group of patients with pudendal nerve entrapment syndrome? Neurourol Urodyn 2007; 27:96. Nanka O, Sedy J, Jarolím L. Sulcus nervi dorsalis penis: Site of origin of Alcock´s syndrome in bicycle riders? Med Hypotheses 2007; 69:1040-1045. Bernstein,, A.M. et.al. A Psyehophysiological Evaluation of Female Urethral Syndrome: Evidence for a Muscular Abnormality,Journal of Behavioral Medicine, Vol. 15, No. 3, 1992 Lefaucheur, J.-P. Et. Al. What is the place of electroneuromyographic studies in the diagnosis and management of pudendal neuralgia related to entrapment syndrome? Neurophysiologie Clinique/Clinical Neurophysiology (2007) 37, 223—228 Butrick, C.W. et al. Chronic pelvic pain syndromes: clinical, urodynamic, and urothelial observations, Int Urogynecol J (2009) 20:1047–1053 DOI 10.1007/s00192-009-0897-7