Male Pelvic Pain

Original Editor - Stacy Schiurring based on the course by Pierre Roscher
Top Contributors - Stacy Schiurring, Kim Jackson, Lucinda hampton and Jess Bell

Introduction

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

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.

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).

This following 5 minute video discusses the complexities of classifying and diagnosing male pelvic pain.

Chronic Prostatitis Related

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.

Category	Description	Bacterial Growth?
Category I: Acute bacterial prostatitis	Due to acute bacterial infection determining prostatitis symptoms, systemic infection, and acute bacterial urinary tract infection (UTI).	Yes
Category II: Chronic bacterial prostatitis	Due to chronic bacterial prostatic infection with or without prostatitis symptoms.	Yes
Category III: Chronic prostatitis/chronic pelvic pain syndrome	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)	No
Category IV: Asymptomatic inflammatory prostatitis	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. This tool was proposed in 2009 to separately identify the different possible reported symptoms of CPPS.

Reported Symptoms	Descriptors
Urinary symptoms	Storage phase Voiding phase Post-void residual
Psychosocial dysfunction	Depression Catastrophising thoughts
Organ-specific findings	Prostate tenderness or swelling, Leukocytosis in prostatic fluid Haematospermia Prostatic calcifications Lower urinary obstruction
Infection	Exclusion of infective aetiology or bowel contamination UTI Prostate positive cultures
Neurological/systemic	Presence of abdominal and / or pelvic pain Irritatable bowel syndrome (IBS) Fibromyalgia (FM) Chronic fatigue syndrome (CFS)
Tenderness of muscles	Presence of palpable muscle spasm in abdomen and pelvic floor Presence of trigger points in abdomen and pelvic floor
Sexual dysfunction	Erectile dysfunction Ejaculatory dysfunction Orgasmic dysfunction

Anatomically Driven Classification

Male pelvic pain can also be grouped based on the symptoms into an anatomical classification. It should be noted that these chronic overlapping pain conditions commonly occur in the same patients simultaneously. Such classification categories can include:

• Prostate pain syndrome
• IBS
• Anal pain syndrome
• Neuromuscular pain
• Bladder pain syndrome
• Scrotal pain syndrome

Biopsychosocial Framework

Biopsychosocial Model

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, 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 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, especially with patients who have complex pain syndromes. Recommendations on how to integrate the biopsychosocial method into male pelvic floor physiotherapy include:

1. Expert knowledge of the male pelvic anatomy, especially innervation and referring pain patterns of the pudendal nerve
2. Ability to differentiate between peripheral and central mechanisms of pain
3. Ability to recognise diagnostic patterns such as:
   • Bladder pain syndrome
   • Scrotal pain syndrome
   • Pudendal neuralgia / pelvic floor dysfunction
4. Ability to perform a differential diagnosis for conditions that have similar clinical presentations:
   • Prostate and bladder pain syndrome
   • Scrotal pain syndrome
5. Appropriate use of patient questionnaires to track patient outcomes over time

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.

Assessment Red Flags

• Haematuria
• Haematospermia
• Smoking
• Occupational petrochemicals
• Pelvic radiation
• Ketamine abuse
• Tuberculosis or schistosomal endemic areas
• NEW onset of urinary incontinence or faceal incontinence

• Determine the diagnosis (taxonomic or phenotypic) using a classification model.
• Determine the emotional, cognitive, behavioural, sexual and functional consequences using questionnaires and or through the subjective interview.

Male Pelvic Pain Assessment: Subjective Interview

• 

  Pain Visual Analogue Scale
  Pain Qualifiers
  • Where is it?
  • What is it like?
  • When does it happen?
  • What makes it better / worse?
  • Do you have any other pain?

• Functional Symptoms
  • Bladder
    • Incontinence? Urgency? Changes in sensations?
  • Bowel
    • Constipated? Previous surgeries? Dietary factors?
  • Sexual
    • Sexual dysfunction or symptoms?
  • Neurological
    • Changes in sensation or strength of the lower extremities? Changes in balance or coordination?

• Medical History
  • Previous investigations
  • Previous treatment
  • Medical and surgical history
  • Medications

• Psychological Features
  • Anxiety about the pain
  • Impact of the pain
  • Use of questionnaires
  • Referrals to mental health specialist, psychologist, psychiatrist, or counsellor

Male Pelvic Pain Assessment: Physical Examination

• Abdominal
• External genitalia
• Perineum
• 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

Examination Red Flags

• Palpable bladder
• Penile or testicular mass
• Exquisite tenderness of the prostate or perineum
• Reduced anal tone
• Lower extremity neurological changes
• Lower extremity oedema

If a red flag is discovered, it is advisable to notify the referring doctor as soon as possible and provide basic education to your patient.

Management

Pelvic floor physiotherapy is one of the best studied non-pharmacological treatments of CPPS.

• A single intervention will rarely work
• Management is usually multidisciplinary
• Management should be individualised, and phenotype focused
• The strategy may include elements of self-management
• Encourage return to active, healthy lifestyle as able with pain

Male Pelvic Pain Multidisciplinary Team

• General practitioner
• Urologist / gastroenterologist / colorectal surgeon
• Pain specialist
• Physiotherapist
• Psychologist / psychiatrist
• Acupuncturist / alternative medicine
• Dietitian

Resources

Professional Associations and formal continuing education courses:

• American Physical Therapy Association: Academy of Pelvic Health
• American Physical Therapy Association: On-Demand: Male Pelvic Pain Course
• Australian Physiotherapy Association: Men's Health
• Australian Physiotherapy Association: Male Pelvic Health

Questionnaires

• Pain Catastrophizing Scale
• Tampa Scale of Kinesiophobia
• Fear Avoidance Belief Questionnaire
• Rolland-Morris Disability Questionnaire
• Oswestry Disability Index
• Chronic Pain Grade Scale
• Pelvic Floor Distress Inventory (PFDI - 20)