The following is a guest submission from Alysson Striner, PT, DPT, PRPC. Dr. Striner became a Certified Pelvic Rehabilitation Practitioner (PRPC) in May of 2018. She specializes in pelvic rehabilitation, general outpatient orthopedics, and aquatics. She sees patients at Carondelet St Joesph’s Hospital in the Speciality Rehab Clinic located in Tucson, Arizona.
Myofascial pain from levator ani (LA) and obturator internus (OI) and connective tissues are a frequent driver of pelvic pain. As pelvic therapists, it can often be challenging to decipher whether pain is related to muscular and/or fascial restrictions. A quick review from Pelvic Floor Level 2B; overactive muscles can become functionally short (actively held in a shortened position). These pelvic floor muscles do not fully relax or contract. An analogy for this is when one lifts a grocery bag that is too heavy. One cannot lift the bag all the way or extend the arm all the way down, instead the person often uses other muscles to elevate or lower the bag. Over time both the muscle and fascial restrictions can occur when the muscle becomes structurally short (like a contracture). Structurally short muscles will appear flat or quiet on surface electromyography (SEMG). An analogy for this is when you keep your arm bent for too long, it becomes much harder to straighten out again. Signs and symptoms for muscle and fascial pain are pain to palpation, trigger points, and local or referred pain, a positive Q tip test to the lower quadrants, and common symptoms such as urinary frequency, urgency, pain, and/or dyspareunia.
For years in the pelvic floor industry there has been notable focus on vocabulary. Encouraging all providers (researchers, MDs, and PTs) to use the same words to describe pelvic floor dysfunction allowing more efficient communication. Now that we are (hopefully) using the same words, the focus is shifting to physical assessment of pelvic floor and myofascial pain. If patients can experience the same assessment in different settings then they will likely have less fear, and the medical professionals will be able to communicate more easily.
A recent article did a systematic review of physical exam techniques for myofascial pain of pelvic floor musculature. This study completed a systematic review for the examination techniques on women for diagnosis of LA and OI myofascial pain. In the end, 55 studies with 9460 participants; 99.8% were female, that met the inclusion and exclusion criteria were assessed. The authors suggest the following as good foundation to begin; but more studies will be needed to validate and to further investigate associations between chronic pelvic pain and lower urinary tract symptoms with myofascial pain.
The recommended sequence for examining pelvic myofascial pain is:
Authors recommend bilateral palpation and documentation of trigger point location and severity with VAS. They recommend visual inspection and observation of functional movement of pelvic floor muscles.
The good news is that this is exactly how pelvic therapists are taught to assess the pelvic floor in Pelvic Floor Level 1. This is reviewed in Pelvic Floor Level 2B and changed slightly for Pelvic Floor Level 2A when the pelvic floor muscles are assessed rectally. Ramona Horton also teaches a series on fascial palpation, beginning with Mobilization of the Myofascial Layer: Pelvis and Lower Extremity. I agree that palpation should be completed bilaterally by switching hands to make assessment easier for the practitioner who may be on the side of the patient/client depending on the set up. This is an important conversation between medical providers to allow for easy communication between disciplines.
Meister, Melanie & Shivakumar, Nishkala & Sutcliffe, Siobhan & Spitznagle, Theresa & L Lowder, Jerry. (2018). Physical examination techniques for the assessment of pelvic floor myofascial pain: a systematic review. American Journal of Obstetrics and Gynecology. 219. 10.1016/j.ajog.2018.06.014
Tamara Rial, PhD, CSPS, co-founder and developer of Low Pressure Fitness will be presenting the first edition of “Low Pressure Fitness and abdominal massage for pelvic care” in Princeton, New Jersey in July, 2018. Tamara is internationally recognized for her work with hypopressive exercise and Low Pressure Fitness. In this article she presents the novel topic of hypopressives as a complementary pelvic floor muscle training tool for incontinence after prostate cancer surgery.
Urinary Incontinence is the most common side effect men suffer after prostate cancer surgery along with erectile dysfunction. Although it is not life threatening, urinary incontinence definitely has a negative impact on the patient’s quality of life Sountoulides et al., 2013. Beyond the frustration and embarrassment associated with pelvic floor dysfunction, many patients describe it as depressing, disheartening and devastating.
The first line of conservative treatment - and most often recommended - is pelvic floor muscle training Andersen et al., 2015. Over the past few years, some researchers have also recommended alternative exercise programs with a holistic approach such as Pilates and hypopressives to improve the patient’s quality of life and urinary incontinence symptoms (Santa Mina et al., 2015). These alternative pelvic floor muscle training programs draw upon the connection between the pelvic floor, it’s synergistic muscles (abdominal, pelvic, lumbar) and their interrelated role in posture and breathing Hodges, 2007; Sapsford, 2004; Madill and McLean, 2008; Talasz et al., 2010. Among these complementary exercise programs, hypopressives have gained increasing attention for the recovery of post-prostatectomy urinary incontinence Santa Mina et al., 2015; Mallol-Badellino, et al. 2015.
Although hypopressive exercise has become popular for women, some researchers, clinicians and practitioners have begun to apply these exercises for specific male issues such as urinary incontinence following a prostatectomy. Recently, a case-study I co-authored about an adapted program of hypopressive exercise for urinary incontinence following a radical prostatectomy surgery was published in the Journal of the Spanish physiotherapy association Chulvi-Medrano & Rial, 2018. We describe the case of a 46-year-old male with severe stress urinary incontinence six months after surgery. We used a pelvic floor exercise program consisting of hypopressive exercises as described in the Low Pressure Fitness level 1 practical manual Rial & Pinsach, 2017 combined with contraction of the pelvic floor muscles. Satisfactory results were obtained after the rehabilitation protocol as evidenced by a reduction from 3 daily pads to none. Of note, clinical trails have demonstrated the benefits of initiating a rehabilitation program to strengthen the pelvic floor as soon as possible after prostatectomy. Previously, I’ve studied hypopressive exercise for female urinary incontinence Rial et al., 2015 and for the improvement of female athletes pelvic floor function Álvarez et al., 2016. However, this was the first time we’ve studied hypopressives in the context of male urinary leakage.
In the same light, other researchers have also included hypopressives in their pelvic floor training protocol for post-prostatectomy urinary incontinence. For example, Serda et al (2010) and Mallol-Badellino (2015) used protocols that combined pelvic floor contractions with postural re-education and hypopressives. Both studies found improvements in the severity of involuntary leakages and improvements in the patients’ quality of life. Similar results are also described in the clinical case by Scarpelini et al. (2014) who used hypopressives and psoas stretching exercises to reduce urinary incontinence after prostatectomy.
The hypothesis underlying the use of hypopressives as a complementary pelvic floor and core exercise program is that it retrains the core system with specific postural and breathing strategies while reducing pressure on the pelvic organs and structures. The most striking part of hypopressives breathing technique is the abdominal vacuum. This breathing maneuver involves a low pulmonary volume exhale-hold technique followed by a rib-cage expansion involving the activation of the inspiratory muscles. The rib-cage expansion during the breath-holding phase leads to a noticeable draw-in of the abdominal wall and simultaneously to the rise of the thoracic diaphragm. Recent observational studies have shown how the hypopressive technique was able to elevate the pelvic viscera and to activate the pelvic floor and deep core muscles in women trained with hypopressives Navarro et al., 2017. From an historical point of view, this characteristic breathing maneuver was first described and practiced as a yoga pranayama called Uddiyanha Bandha Omkar & Vishwas, 2009.
In addition to breath control, the hypopressive technique involves a series of static and dynamic poses which operate on the hypothesis of training the stabilizing muscles of the spine, such as the core and pelvic muscles. In this sense, hypopressives are not exclusively a breathing technique, but rather they are an integrated whole-body technique. The practice of hypopressives involves body control, body awareness, postural correction and mindfulness throughout its different poses and postural techniques. The introduction of holistic exercise programs to train the synergist pelvic floor muscles and breathing patterns can be viewed as complementary tools for the restoration of a patient’s body awareness and functionality.
Another hypothesis of the effects of the hypopressive-breathing in the pelvic floor is the ability to move the pelvic viscera cranially as a consequence of the ribcage opening up after the breath-hold. This vacuum lifts the diaphragm and consequently creates an upward tension on the transversalis fascia, the peritoneum and other related fascial structures. In addition to the diaphragmatic suction effect, a correct alignment of the rib cage and pelvis during the exercise contributes to an improved suspension and position of the viscera in the pelvis. The mobility achieved with the breathing and its body sensations may be one of the reasons why hypopressives have also been recommended as a proprioceptive facilitator for those with low ability to “find their pelvic floor” Latorre et al., 2011.
It’s crucial to highlight that a complete surgical resection of the prostate will cause - in most of the cases - post-operative fibrosis and neurovascular damage Hoy-Land et al., 2014. Both, the neurovascular and musculoskeletal injuries are contributing factors for urinary incontinence post-prostatectomy. Subsequently, exercises focusing on increasing local vascular irrigation and re-activating the damaged musculature have been highlighted as the main goals to help patients recover continence. In this sense, breathing movements, fascia manipulation and decreased pelvic pressure can result in increased vascular supply. A previous study has shown an improvement in venous return of the femoral artery during the hypopressive-breathing maneuver Thyl et al., 2009. Collectively, all these factors may favor microcirculation in the pelvic area. Finally, the muscle activation of the pelvic floor and core muscles observed during the practice of hypopressives (Ithamar et al., 2017) and the changes of puborectalis and iliococcygeus muscles after an intensive pelvic floor muscle training (Dierick et al., 2018) are other factors that could have impact on urge incontinence, stress incontinence and overflow incontinence symptoms common after prostatectomy surgeries.
To date, the results from these investigations and clinical reports open new complementary pelvic floor training strategies for the treatment of post-prostatectomy incontinence. Hypopressives and pelvic floor muscle exercises are non-invasive, don’t require expensive material, and provide an exercise-based approach as part of a healthy lifestyle. However, qualified instruction, technique-driven progression and adherence to the intervention are critical components of any pelvic floor and hypopressive training protocol.
Álvarez M, Rial T, Chulvi-Medrano I, García-Soidán JL, Cortell JM. 2016. Can an eight-week program based on the hypopressive technique produce changes in pelvic floor function and body composition in female rugby players? Retos nuevas Tendencias en Educación Física, Deporte y Recreación, 30(2): 26-29.
Anderson CA, Omar MI, Campbell SE, Hunter KF, Cody JD, Glazener CM. 2015. Conservative management for postprostatectomy urinary incontinence. Cochrane Database Syst Rev, 1:CD001843.
Chulvi-Medrano I, Rial T. 2018. A case study of hypopressive exercise adapted for urinary incontinence following radical prostactetomy surgery. Fisioterapia, 40, 101-4. Doi: DOI: 10.1016/j.ft.2018.01.004
Dierick F, Galrsova E, Laura C, Buisseret F, Bouché FB, Martin L. 2018. Clinical and MRI changes of puborectalis and iliococcygeus after a short period of intensive pelvic floor muscles training with or without instrumentation. European Journal of Applied Physiology, doi:10.1007/s00421-018-3899-7
Ithamar, L., de Moura Filho, A.G., Benedetti-Rodrigues, M.A., Duque-Cortez, K.C., Machado, V.G., de Paiva-Lima, C.R.O., et al. 2017. Abdominal and pelvic floor electromyographic analysis during abdominal hypopressive gymnastics. J. Bodywork. Mov. Ther. doi: 10.1016/j.jbmt.2017.06.011.
Latorre G, Seleme M, Resende AP, Stüpp L, Berghmans B. Hypopressive gymnastics: evidences for an alternative training for women with local proprioceptive deficit of the pelvic floor muscles. Fisioterapia Brasil 2011; 12(6): 463-6.
Hodges P. 2007. Postural and respiratory functions of the pelvic floor muscles. Neurourol Urodyn, 26(3): 362-371.
Hoyland K, Vasdev N, Abrof A, Boustead G. 2014. Post-radical prostatectomy incontinence: etiology and prevention. Rev Urol. 16(4), 181-8.
Madill, S., McLean, L. 2008. Quantification of abdominal and pelvic floor muscle synergies in response to voluntary pelvic floor muscle ontractions. J. Electromyogr. Kinesiol. 18, 955-64. doi: 10.1016/j.jelekin.2007.05.001.
Mallol-Badellino J., et al. 2015. Resultados en la calidad de vida y la severidad de la incontinencia urinaria en varones prostatectomizados por neoplasia de próstata. Rehabilitación, 49(4); 210-215.
Navarro, B., Torres, M., Arranz, B. Sánchez, O. 2017. Muscle response during a hypopressive exercise after pelvic floor physiotherapy: Assessment with transabdominal ultrasound. Fisioterapia. 39, 187-194. doi:10.1016/j.ft.2017.04.003.
Omkar, S., Vishwas, B. 2009. Yoga techniques as a means of core stability training. J. Bodywork Mov. Thep. 13, 98-103. doi: 10.1016/j.jbmt.2007.10.004.
Rial T, Chulvi-Medrano I, Cortell-Tormo JM, Álvarez M. 2015. Can an exercise program based on hypopressive technique improve the impact of urinary incontinence on women´s quality of life? Suelo Pélvico, 11:27-32.
Rial, T., Pinsach, P. 2017. Low Pressure Fitness practical manual level 1. International Hypopressive and Physical Therapy Institute, Vigo.
Santa Mina D, Au D, Alibhai S, Jamnicky L, Faghani N, Hilton W, Stefanky L, et al. 2015. A pilot randomized trial of conventional versus advanced pelvic floor exercises on treat urinary incontinence after radical prostatectomy: a study protocol. BMC Urology, 15. DOI 10.1186/s12894-015-0088-4
Sapsford R. 2004. Rehabilitation of pelvic floor muscles utilizing trunk stabilization. Man Ther, 9(1): 3-12.
Serdá B, Vesa, A. del Valle, y Monreal P. 2010. La incontinencia urinaria en el cáncer de próstata: diseño de un programa de rehabilitación. Actas Urológicas Españolas, 34(6): 522-30.
Scarpelini P, Andressa Oliveira F, Gabriela Cabrinha S, Cinira H. 2014. Protocolo de ginástica hipopressiva no tratamento da incontinência urinária pós-prostatectomia: relato de caso. UNILUS Ensino e Pesquisa, 11(23): 90-95
Talasz, H., Kofler, M., Kalchschmid, E., Pretterklieber, M., Lechleitner, M. 2010. Breathing with the pelvic floor? Correlation of pelvic floor muscle function and expiratory flows in healthy young nulliparous women. Int. Urogynecol. J. 21, 475-81. doi: 10.1007/s00192-009-1060-1.
Thyl S., Aude P, Caufriez M, Balestra C. 2009. Incidence de l'aspiration diaphragmatique associée à une apnée expiratoire sur la circulation de retour veineuse fémorale: étude par échographie-doppler. Kinésithérapie scientifique, 502; 27-30.
Men who present with chronic pelvic pain frequently have symptoms referred along the penis and into the tip of the penis, or glans. Symptoms may include numbness, tingling, aching, pain, or other sensitivity and discomfort. The tip of the penis, or glans, is a sensory structure, which allows for sexual stimulation and appreciation. This same capacity for valuable sensation can create severe discomfort when signals related to the glans are overactive or irritating. One of the most common complaints with this symptom is a level of annoyance and distraction, with level of bother worsening when a person is less active or not as mentally engaged with tasks. Wearing clothing that touches the tip of the penis (such as underwear, jock straps, jeans, or snug pants) may be limited and may worsen symptoms. When uncovering from where the symptoms originate, the culprit is often the dorsal nerve of the penis, which is sensible given that the glans is innervated by this branch of the pudendal nerve. If we consider this possibility (because certainly there are other potential causes) we find that there are many potential sites of pudendal nerve irritation to consider. First, let’s visualize the anatomy of the nerve.
Following the usually accepted descriptions of the dorsal nerve, we know that it is a terminal branch of the pudendal nerve that primarily is created from the mid-sacral nerves. This can lead us to include the lumbosacral region in our examination and treatment, yet in my clinical experience, there are other sites that more often reproduce pain in the glans. As the dorsal nerve branches off of the pudendal, usually after the location of the sacrotuberous ligament, it passes through and among the urogenital triangle layers of fascia where compression or irritation may generate symptoms.
As the nerve travels towards the pubic bone, it will pass inferior to the pubic bone, a location where suspensory ligaments of the penis can be found as well as pudendal vessels and fascia. This is also a site of potential compression and irritation, and palpation to this region may provide information about tissue health. Below is a cross-section of the proximal penis, allowing us to see where the pudendal nerve and vessels would travel inferior to the pubic bone.
As the dorsal nerve extends along either side of the penis, giving smaller branches along its path towards the glans, the nerve may also be experiencing soft tissue irritation along the length of the penis or even locally at the termination in the glans.
Palpation internally (via rectum) or externally may be a part of the assessment as well as treatment of this condition. Oftentimes, tip of the penis pain can be reproduced with palpation internally and directed towards the anterior levator ani and the connective tissues just inferior to the pubic bone. It may be difficult to know if the muscle is providing referred pain, or if the nerve is being tensioned and reproducing symptoms, however gentle soft tissue work applied to this area is often successful in reducing or resolving symptoms regardless of the tissue involved. In my experience, these symptoms of referred pain at the tip of the penis is often one of the last to resolve, and the use of topical lidocaine may be helpful in managing symptoms while healing takes place. Home program self-care including scar massage if needed, nerve mobilizations, trunk and pelvic mobility and strengthening, and advice for returning to meaningful activities can play a large role in resolution of pain in the glans.
If you would like to learn more about treating genital pain in men, consider joining me in Male Pelvic Floor: Function, Dysfunction, & Treatment. The 2018 courses will be in Freehold, NJ this June, and Houston, TX in September.