Biofeedback physical therapy improves CPPS symptoms

Istanbul, Turkey-Biofeedback physical therapy and pelvic floor re-education appear to offer symptomatic improvement in men with chronic pelvic pain syndrome type III, Dutch researchers say. The techniques appear to work by improving relaxation and demonstrating proper use of pelvic floor muscles.

The group's prospective study included 33 consecutive men over 18 years of age (mean age, 45 years) with pelvic pain or discomfort for at least 3 months and a National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) score in excess of 15. Men were diagnosed with CPPS type III between March 2000 and March 2004.

Thirty-one patients completed a pelvic floor biofeedback re-education program, which included detailed training on how to relax and constrict the pelvic floor muscles. The investigation implemented a one-channel EMG apparatus (Pelvined 932, Enraf-Nonius, the Netherlands) for perineal measurements.

The study demonstrated a significant decrease in the total and all sub domains of the NIH-CPSI, researchers, led by Erik Cornel, MD, reported at the European Association of Urology annual congress. In the 31 men who completed the program, the mean NIH-CPSI total score improved to 11.4 from baseline, pain was 5.7, micturition was 2.2, quality of life was 3.5, and EMG was 1.7 mV after pelvic floor training.

"Our study clearly demonstrates the significant effect of biofeedback physical therapy and pelvic floor re-education for CP/CPPS type III patients," said Dr. Cornel, a urologist with Twente Hospital Group, Hengelo, the Netherlands. "There is no bias regarding the results, as they are purely clinical. The observation that the EMG results correlated with the NIH-CPSI score appears to emphasize that the pelvic floor plays an important role in the pathophysiology of CP/CPPS type III."

More clinical tests needed? Dr. Cornel based the diagnoses on patient history, NIH-CPSI scores, and physical examination, including pelvic floor muscle tone, urinalysis, uroflowmetry with residual urine measurement, digital rectal exam, and transrectal ultrasonography of the prostate.

However, some physicians who attended Dr. Cornel's presentation were not convinced that the evaluation of NIH/CPSI to determine CP/CPPS was enough. Wolfgang Weidner, MD, who co-moderated the session, suggested that additional clinical investigations, such as a leukocyte evaluation or the four-glass test, which has shown high reliability in establishing prostatitis, might have enhanced the results.

Dr. Cornel explained that the NIH-CPSI total score is a valid, reliable, and responsive means to measure prostatitis symptoms and was therefore used for diagnosis and to monitor the effect of therapy. Moreover, he used pelvic floor muscle tone measurements not only to complete diagnosis but also to monitor the effect of the biofeedback physical therapy. He also performed the Wilcoxon signed ranks test for paired samples for statistical analysis.

Dr. Cornel elucidated that recent studies have suggested that the symptoms of CPPS type III may be due to or associated with pelvic floor muscle dysfunction, and although medical therapy is the mainstay in these cases, teaching patients to build up pelvic floor musculature can be the key to improving symptoms.

"We have a very prosta-centric approach to CP/CPPS. However, I believe that the perineum and pelvic floor must be taken into account," Dr. Cornel said. "We have to start leaving out the words 'prostate' and 'prostatitis' when speaking of these symptoms."