THE 'PNSBDS' PROTOCOL ‘PELVIC NEUROGENIC SOMATOVISCERAL BIOMECHANICAL DYSFUNCTION SYNDROME’
A Novel Approach to Chronic Pelvic Pain Syndromes • Pudendal Neuralgia, Pudendal Nerve Entrapment, Chronic Prostatitis, Chronic Cystitics, Chronic Pelvic Pain Syndrome, Levator Ani Syndrome, etc.
Introduction Pelvic Neurogenic Somatovisceral Biomechanical Dysfunction Syndrome, referred to as PNSBDS for the remainder of this discussion for obvious reasons, is a novel terminology for the description of a constellation of Chronic Pelvic Pain Syndromes (CPPS). The rationale for such a complex title is reflected in the inherent complexity of the topic- chronic pelvic pain syndromes 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, from Urologists, Neurologists and Orthopedic Surgeons to Physical Therapists, Naturopaths and Chiropractors aimed at treating the symptoms and manifestations of the condition, which are misinterpreted or oversimplified as the primary causes of the condition. However, these symptoms are often secondary to more global interdependent causes, which is the reason the symptoms almost invariably return in some form or other, or are never completely eliminated with one therapy alone.
The Problem- The Inherent Oversimplification of the Human Body by the Dominant Biomedical Paradigm 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. For instance, the Urinary symptoms seen in CPPS are treated by a MD with antibiotics, often without establishment of a positive culture (which may or may or may not be present). If infection is present, the symptoms will abide, for a time anyway. However,
symptoms will return because infection is a secondary manifestation of a biomechanical, neurological and/or somatic dysfunction that provided a facilitated environment for infection to take place (commonly due to urinary retention and incomplete bladder emptying, an established primary cause of infectious cystitis, and related to dysfunction of the urinary system caused by altered innervation and function of the urethral sphincter and myofascial pressure on the bladder). Patients will often then receive a referral to a Urologist, who may perform a Cystoscopy, or prescribe more antibiotics or anti-inflammatories. Other patients may see an Orthopedic Surgeon, who may or may not identify physical dysfunction, and the patient may thus receive a prescription for physical therapy. This is an improvement in focus, as it is closer to addressing the primary causes of CPPS than the methods previously listed. However, despite good intentions and a sound clinical reasoning addressing the etiology, Physical Therapy ultimately falls short as a treatment. This is through no fault of its own, but because the condition requires much more than the established musculoskeletal interventions of stretching, massage, typical PT modalities and strengthening, which are the current staples of treatment for CPPS patients. Even internal trigger point therapy on the obturator internus, although sometimes effective in the short term, is insufficient in eliciting long-term, permanent change, and will not cause a significant reduction in myofascial adhesions, entrapments, and hypertonicity. Furthermore, patients may often see a Neurologist, who may diagnose Pudendal Nerve Entrapment (PNE). In Canada, there is currently only one Neurologist specializing in this condition, located in Toronto at the Wasserman Pain Management Centre. Here, the patient may be treated with nerve block, which may relieve the symptoms temporarily, however fails as it does not address the primary cause, nor does it attempt to fix the primary problem. Furthermore, injections simply result in further scar tissue formation. A very invasive and risky surgery may then be attempted, which is more guided towards the primary cause, but again fails because it merely damages tissue further, and results in further fibrotic adhesions as scar tissue from incisions through skin, muscle and fascia develop. Also, it is now apparent that many patients have multiple separate entrapment sites that cannot all be addressed by surgical intervention. This is just one simplified example of the types of therapies patients may endure, and the numerous specialists they will consult. Nobody to date has been able to “connect the dots� and make the association that all these symptoms and conditions have considerable overlap, and are interrelated. They may in fact be manifestations of the same condition! Or, at the very least, these families of conditions are all related and affecting one another.
The Holistic Model (The Chiropractic Paradigm)- “Connecting the Dots� Why the Visceral Symptoms, such as bladder and prostate manifestations? The neurological and anatomical mechanisms of the pelvic viscera, the bladder and prostate, act in a synergic and coordinated manner. The entire area acts as a symphony of many instruments, and if one instrument is of key or missing, the intended composition fails. For example, biomechanical dysfunction such as muscular imbalance due to prolonged sitting, cycling, repetitive strains to the pelvic floor and joints of the lumbar spine, can cause muscular spasm, hypertonicity, and altered histopathological composition of pelvic musculature such suboptimal micronutrient balance, microcirculation, etc. This leads to fibrotic myofascial adhesion 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 genitaliaafferent, 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. The pelvic floor has important interconnections between all somatic structures in the pelvis, and some fascial connections to visceral structures. Furthermore, many important urogenital structures (such as the urethra) pass through pelvic fascial structures, and can get compressed if the fascia is too tense. Thus, 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 begin the see the complex and intimate inter-relationship between pelvic structures of various types. Thus, 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 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. 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):
(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), are all symptomatic manifestations of another specific entity; myofascial mechanical neurological dysfunction of the pelvic floor and neuromusculoskeetal 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 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 results we are achieving with the PNSBDS protocol lay not only in the appreciation of the comprehensive multi-system and interconnected nature of the conditions we are treating as described above, but in 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. Also, our investigative methods allow an assessment of the entire lumbopelvic region, and better identifies all affected and contributing structures. 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. The PNSBDS treatment protocol is currently in its infancy, however is generating dramatic results. It is for this reason, coupled with minimal significant sideeffects, 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 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 the following: • Low-Intensity Laser Therapy • Performed 4-7 days/week at approximately 1hr per day
• ESWT (Extra Corporeal Shockwave Therapy) • Performed 3-7 days/week, depending on patient response and tolerance • Spinal Manipulative Therapy • Performed 3-7 days/week, depending on patient response and tolerance • Active Release Techniques (ART) • Performed 3-7 days/week, depending on patient response and tolerance • Nutraceutical Intervention • Based on Renai Sante Assessment • Lifestyle Modifications • Based on Renai Sante Assessment • Dietary Intervention • Based on Renai Sante Assessment • Education • Causes, aggravating factors, strategies for management and prevention • Biomechanical Orthoses Intervention, possibly including Foot Orthotics • Address and correct potential Pelvic biomechanical anomalies related to gait 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. CONSENT TO THERAPY, COSTS, AND RISKS Due to the complexity of the conditions treated, individual variation in terms of symptomatology and duration of condition, and inherent differences in responses to therapy, there are variations in potential treatment costs depending on services rendered and duration of therapy. Further information pertaining to costs can be discussed by contacting the clinic directly. There are risks inherent in any form of manual therapy, which may result in a worsening of symptoms such as increased pain, muscular strain, bruising, ligamentous strain, anal fissures and aggravation of hemorrhoids, and other undefined potential side-effects not listed. THE COST OF THE PNSBDS PROTOCOL EXPLAINED 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 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. For example, at a typical sports medicine clinic in Toronto, the financial cost incurred to the patient for 5 minutes of shockwave therapy is $195.00 CAN (http://www.sportsmedicine.on.ca/pdf/RadialShockwave-PDF.pdf). Our treatments with this device last from 20 minutes initially to upwards of 90 minutes per session. In comparison, shockwave therapy in a typical Toronto Sports Medicine Clinic for 90 minutes would cost you approximately $3,510 CAN...for only one session!! Moreover, as noted, the PNSBDS protocol utilizes other specialized expensive equipment in addition to the shockwave, such as LILT (Low-Intensity 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 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 may be necessary and 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 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 PlaceboControlled Study, EUROPEAN UROLOGY 5 6 ( 2 0 0 9 ) 4 1 8 – 4 2 4 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 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