Two-pronged approach relieves refractory CPPS pain

San Antonio-A combination of physical and psychological therapy for chronic pelvic pain syndrome (CPPS, or chronic nonbacterial prostatitis) can provide relief for many patients who have pain refractory to conventional treatments, according to researchers from Stanford (CA) University.

"We really have a big job to find out the cause of this disorder and the associated biomarkers," Rodney Anderson, MD, professor of urology at Stanford University, said at the AUA annual meeting here. "But while we're doing that, one of the things we found helpful is to do myofascial release of trigger points that can be found in and around the prostate gland and in the pelvic floor. More important, we have a psychologist who knows how to help patients positively affect the mind-body interaction."

This combined physical therapy and psychological approach, said Dr. Anderson, is "difficult, time consuming, and not well reimbursed," but it works. He and his team-a psychologist, a physical therapist, and a clinical research coordinator-saw moderate to marked improvement in nearly three-quarters of the 138 men they treated who had CPPS refractory to traditional therapy.

Based on the patient-reported perceptions of overall effects of therapy documented on a Global Response Assessment questionnaire, 72% of the men had moderate to marked improvement and a median 24% to 46% drop in their NIH-Chronic Prostatitis Symptom Index (NIH-CPSI) total scores, respectively.

The team used the Stanford Pelvic Pain Syndrome Survey, including a pain visual analog scale (VAS), to evaluate patients' progress. For those men with a clinical improvement, the median scores decreased 69% and 80% for pain and urinary symptoms, respectively. One-fifth (21%) got worse, with a 27% increase in pain scores.

Trigger points and a paradox

The physical therapy used in this protocol goes beyond myofascial release techniques, physical therapist Tim Sawyer explained to Urology Times. He said he uses those techniques, including massage, and that the most important is trigger point release of myofascial trigger points in internal and external muscle groups that refer pain. A myofascial trigger point is a hyperirritable, sensitive spot within a taut band of skeletal muscle and its associated fascia. These trigger points occur frequently in the abdominals, psoas, gluteals, piriformis, quadratus lumborum adductor, pectineus, and paraspinal muscles externally and the levator ani, obturator internus, coccygeus, piriformis, sphincter ani, bulbospongiosus, and ischial cavernosus muscles internally.

The therapist must treat the trigger points that, when palpated, reproduce the patient's symptoms, he said. For example, points in the anterior portion of the levator ani tend to refer pain and or symptoms to the tip of the penis, and points in the levator endopelvic fascia lateral to the prostate. These trigger points can also cause frequency and or urgency. To treat these points, Sawyer maintains pressure on them for about 60 seconds. The internal muscles are treated transrectally using finger pressure with the patient in the prone position. Patients also are instructed in a home treatment program.

The paradoxical relaxation therapy technique applied to men with pelvic pain was developed by psychologist David Wise, PhD. It includes a specific breathing technique to quiet anxiety and relaxation training that focuses attention on the effortless acceptance of tension (thus, the paradox) in specific areas of the body.

Dr. Anderson said this therapy probably is the more important part of the protocol. Genitourinary disorders, such as voiding dysfunction and ejaculatory pain, are intimately related to the autonomic nervous system and to the balance of smooth and striated muscle. Acute and chronic stress is known to affect these systems.

Stress a perpetuating factor

"Most men and women whom we see with pelvic pain have a high level of stress, and anxiety as a perpetuating factor," Sawyer said. "If this is not addressed, then any amount of trigger point release would be either temporary or unsuccessful."