Typical Patient: We shall call him Malcolm.
This is a male pelvic pain patient that was seen by Gerard Greene ( @gerardgreenephy) at his Men’s Health Physiotherapy clinic in Birmingham, UK
Early 40’s, self employed solicitor, 90 min commute to work, 2 children, recently started his own business, previous fit and healthy. Started with LBP, major period of stress with work and then developed perineal pain limiting his driving and sitting , then developed pain on urination, marked abdominal pain and “tension” and rectal pain post stool. Aware of some erectile dysfunction but possibly stress related. Due to inactivity put on 2 stone, increased intake of caffine & alcohol. Now barely working, rarely leaving house, dropped all his exercise. One year of urological and colorectal investigations which were normal , 6 weeks of chiropractic treatment ( seen daily for 6 weeks which lead to major deterioration in symptoms), seen by Physio x 3 sessions of abdominal strengthening and pelvic floor strengthening which increased symptoms who referred him to Pelvic health physiotherapist . He couldn’t understand how his urinary , rectal and erectile symptoms are linked to his pain and no one has explained this to him. Patient very worried and anxious.
What are the barriers to getting him better? Angry and frustrated that he had spent a lot of money on treatment that had made things worse. Off work but self employed and under huge pressure at home as 2 kids. Seen multiple colorectal & Urological consultants and although reassured nothing “major” was wrong he was told not to worry. Previously fit and active but now barely leaving the house , and will not drive for more than 10 mins, doesn’t like the kids coming close to him as if they touch his abdomen it’s very painful and he is apprehensive about this. Hasn’t hugged his wife or kids in a long time and feels bad about this. Stress at home as he only talks about his pain and although his wife is supportive they are arguing a lot , sleeping in separate bedrooms, no intimacy and drifting apart. Main problem of perineal pain and abdominal pain and worried that there is something wrong despite the investigations being normal and seeing lots of consultants. Only early 40’s but feels much older and that his life is rapidly falling apart.
Key Assessment Findings
Questionaires: Positive findings on NIH Male pelvic pain questionaire and Stanford pelvic pain questionaire.
Movement :Fear avoidance on lumbar spine and hip movements.
Palpation: Allodynia and secondary hyperalgesia on abdominal palpation. Referral of perineal and hip pain from abdominal palpation.
External Pelvic Assessment: ASLR : +ve bilaterally, + pain provocation tests pelvis,
Internal Palpation of Pelvic Floor Reproduction of abdominal & perineal pain on internal palpation, hypertonic pelvic floor and inability to relax it. Apical breath pattern with marked abdominal activity on inspiration.
Ultrasound imaging pelvic floor: acute anorectal angle, minimal displacement anorectal angle on pelvic floor activation, marked activation of abdominal muscles during breathing.
Persistent pelvic pain with cognitive behavioural emotional components associated with deconditioning.
The patient education focused on
- Links between pelvic floor & urinary , bowel & Erectile function
- Where was the pain coming from
- Role of deconditioning and lack of physical exercise
- Role of central sensitisation and somatovisceral reponse
- Role of stress and anxiety on pain
How was this done?
The patient was seen for a 90 minute session which allowed sufficient time to discuss the above with the patient in a relaxed non technical non medical reassuring way giving the patient time to ask questions and to check he understood.
Initial Treatment at session 1
- Advised to use headspace app
- Start walking ( short distances ) as exercise
- Re-start playing with the kids to address his abdominal fear avoidance
- Read ” Headache in the Pelvis”, copy given to the patient
- Started with abdominal breathing
- Start with abdominal massage
- Given ” EZ Magic Internal trigger point ” video by Dr Ruth Jones to watch on his phone
Subsequent treatment and Self Management
Malcolm attended weekly by 4 weeks and then with reduced frequency and treatment consisted of soft tissue work to desensitize his abdomen, manual therapy Lumbar spine/ hips, internal pelvic floor work digitally and with EZ magic wand, breath retraining.
Ultrasound imaging was used transperineally as biofeedback to down train and also as an objective marker to monitor change in his Pelvic floor function.
His home programme consisted of walking (70%) maximum HR, returning to swimming, progressive increase in working and sitting, head space, breath work and lumbar spine, hip exercise.
After 2 months of treatment Malcolm was swimming and walking 5 days a week. He had returned to driving and could tolerate an hour and had returned to work. He was no longer fearful of playing with kids or having them hug him. His urinary and rectal symptoms had resolved and his erectile symptoms were no longer of concern. His stress levels had reduced and his relationship with his wife was greatly improved and in her words to me ” she had got her husband back“. Malcolm was still experiencing flare ups but of much less severity and during these flare ups he maintained a good level of activity and no longer went into a panic about these as they settled. Malcolm still attends for treatment but with much less frequency.
Gerard sees men’s health patients in his Birmingham clinic and also with Dr Ruth Jones in her Southampton clinic http://www.cerianlife.com
Birmingham Men’s Health Physiotherapy Clinic
Barefoot Yoga Studio, Harborne, Birmingham, B17 9NT, UK