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Disclamier:This page aims to provide an introductory discussion of men's health physiotherapy with regards to male pelvic pain. Please note that further training is required through a reputable pelvic health education company before attempting the techniques discussed in this page. See the Resources section at the bottom of this page for links to pelvic and men's health special interest groups.
Pain is “an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.” - International Association for the Study of Pain[1]
The International Association for the Study of Pain (IASP) created the new definition for pain, stated above, in 2020. The description of pain continues with the following notes:
Pain is always a personal experience to an individual, and it can be influenced by biological, psychological, and social factors
Pain and nociception are different phenomena, meaning that pain cannot be solely explained by sensory neurons
The concept of pain is a lifelong experience
An individual's report of a pain experience should be respected
Although pain usually serves an adaptive role, it may also have adverse effects on function and well-being
Verbalisation is only one way to express pain; inability to communicate does not remove the possibility of a pain experience
Pain is subjective and unique to the individual experiencing it. Pain can be physically, mentally, and or psychologically debilitating. The IASP points out that pain is one of the main reasons that people seek out medical care, and chronic pain is a leading cause of human suffering and disability.[2]
Pain Classification Models
Classifying pain is a way for clinicians to better understand and design a plan of care to address a patient's pain. Over the years, classification systems have been developed to define, classify, or stratify different presentations or symptoms of pelvic pain. Traditionally, male pelvic pain classification has been based on chronic prostatitis, also known as chronic pelvic pain syndrome (CPPS).[3]
This following 5 minute video discusses the complexities of classifying and diagnosing male pelvic pain.
The chronic prostatitis related classification system was created by the US National Institutes of Health (NIH), which divides chronic prostatitis into different categories: a combination of chronic bacterial prostatitis, CPPS, or asymptomatic prostatitis.[5]
Used when an infective agent is absent and the disease is led by chronic pelvic pain symptoms and voiding symptoms in the absence of UTI.
Patients present with urological pain or discomfort in the pelvic region, associated with urinary symptoms and/or sexual dysfunction, lasting for at least 3 of the previous 6 months.
This category is further divided into IIIA (inflammatory) and IIIB (non-inflammatory)
Due to prostate inflammation in the absence of genitourinary tract symptoms, always associated with CPPS.
Yes
The following 20-minute video discusses the classification of prostatitis, aetiology of the different types of prostatitis, and the process of differential diagnosis between the different classifications and other diagnoses.
The Urinary, Psychosocial, Organ-Specific, Infection, Neurological/Systemic, and Tenderness (UPOINT) system
Accounting for more than 90% of all urological outpatients, CPPS is among the most common urologic disorders in men younger than 50 years. The condition is often poorly understood, and its management is challenging[7]. This tool was proposed in 2009 to separately identify the different possible reported symptoms of CPPS.[8]
Male pelvic pain can also be grouped based on the symptoms into an anatomical classification.[3] It should be noted that these chronic overlapping pain conditions commonly occur in the same patients simultaneously.[9] Such classification categories can include:
Please read this article for an in-depth review of the biopsychosocial model. Due to the complex nature of pain, a holistic whole-person approach to assessment, treatment, and interventions is required to fully understand the root cause of a person's pain. This is true of male patients with pelvic pain as well, especially given the often intimate and potentially embarrassing nature of pelvic pain diagnoses. Please read this article for an in-depth review of the complexities of treating men's health conditions. A 2021 article by Brandt,[10] published in The South African Journal of Physiotherapy, found that while physiotherapy training regarding the biomedical aspects of pelvic health are well known, the psychological, cognitive, behavioural, social and occupational factors are less integrated into treatments and care plans. Brandt[10] also found that individualised care, communication and therapeutic alliances with other medical professionals are under-investigated and not integrated into research, education and clinical practice.
Physiotherapists are uniquely positioned to utilise the biopsychosocial method as part of everyday practice,[3] especially with patients who have complex pain syndromes. Recommendations on how to integrate the biopsychosocial method into male pelvic floor physiotherapy include:[3]
Expert knowledge of the male pelvic anatomy, especially innervation and referring pain patterns of the pudendal nerve
Ability to differentiate between peripheral and central mechanisms of pain
Ability to perform a differential diagnosis for conditions that have similar clinical presentations:
Prostate and bladder pain syndrome
Scrotal pain syndrome
Appropriate use of patient questionnaires to track patient outcomes over time[3]
Male Pelvic Pain Assessment Overview
The most important part of a male pelvic pain assessment is to screen for dangerous underlying pathologies by looking for clinical red flags during the evaluation process.[3]
Digital rectal examination -- Only qualified therapists with advanced training should perform internal pelvic health examinations. Please see links before in resource section for information on advanced training.
Lower limb neurological examination: S3 and 4 nerve root dermatome and myotomes, lower extremity reflex examination, anal tone assessment
↑YouTube. Prostate Cancer UK|Chronic prostatitis and chronic pelvic pain syndrome: a new consensus guideline. Available from: https://www.youtube.com/watch?v=Oy8wb8uKIu8 [last accessed 08/032022]
↑Mardon AK, Leake HB, Szeto K, Astill T, Hilton S, Moseley GL, Chalmers KJ. Treatment recommendations for the management of persistent pelvic pain: a systematic review of international clinical practice guidelines. BJOG: An International Journal of Obstetrics & Gynaecology. 2022 Jul;129(8):1248-60.
