Eight percent of Australian men has had urogenital pain of some kind. ( reference Australian study in 2009). Chronic pelvic pain is poorly understood and often not recognised because it does not show on scans or at an operation. Even knowing what to call the problem can be confusing, with a mix of different names often used, including Chronic Pelvic Pain Syndrome, Chronic Prostatitis, or Chronic Urogenital Pain Syndrome. Men with pelvic pain often suffer in silence, unsure of where to go, and unsure who can help them. You are not alone, there are many men with the same problem, and there are many things you can do to help with the pain.
While pelvic pain often starts in women during the adolescent years, pelvic pain generally starts at an older age in men and seems to be associated with stress. There was a study done in a Melbourne pelvic pain physiotherapy clinic that followed 112 men with pelvic pain.
The symptoms men describe vary widely and may include:
A pain may start in a pelvic organ such as your bladder, bowel, or prostate following an infection, or in your pelvic muscles following an injury. It is important to see your doctor to exclude serious diseases and to appropriately treat these conditions that may lead to pain. Sometimes no cause is found and pelvic pain may start during a period of severe stress. Whatever the original cause of pain, if it does not settle then the pain can become chronic even when the original infection or injury has resolved. Generally, pelvic pain is considered ‘chronic’ if it is present for most days for at least 3-6 months. No-one completely understands why a similar condition in some men might lead to chronic pain, while in another man it might go away completely.
Once a pain has become chronic, the pain situation is usually more complicated. For unknown reasons, the body continues to believe the issue is still present, even when the initial injury or infection has resolved, and interprets this as pain. Surrounding pelvic muscles can tighten in attempt to protect the body from further damage as a defence mechanism. When these muscles are constantly tensed, shortened and tight, they start aching and can spasm. Often the pain from pelvic muscle spasms can become the worst part of the pain.
Additionally, nerve pathways that send pain messages through the spinal cord to the brain can become sensitised due to constant signalling and experience of pain. In some cases, even a brush of a feather can be interpreted as unbearable pain, this is referred as hyperalgesia.
Once muscles and nerves in the pelvis start behaving abnormally, other organs can develop problems too. Pelvic floor muscles control bladder and bowel motions by tightening to stop urine or stool passing and relaxing to allow us to urinate or defecate ( open your bowels) when appropriate. Trying to urinate, defecate, or ejaculate through painful tight pelvic muscles that cannot relax normally can be extremely painful.
Stress , anxiety and depression can also sensitise pain nerve pathways, particularly in the brain, further enhancing the experience of pain. For example, stubbing your toe will hurt more on a bad day than on a good day. Unfortunately, it is not uncommon for people to become depressed from the effects of pain has on their functionality, productivity, sleep, relationships and quality of life, which can further worsen the pain. This can become a vicious cycle as pain can dampen your mood and depression worsens the experience of pain with further impairment on productivity and quality of life.
The symptoms men and people assigned male at birth describe vary widely and may include:
“I had pelvic pain for four years! My private regions were so sensitive to touch that when the doctor examined my rectum, it was like murder! At first, I started having urinary frequency, where I had to go to the toilet every 30 minutes. Then it started hurting every time I passed bowel motions. It was difficult to have sex because when I had an erection or ejaculated, I had pain. Even sitting down or walking with hard shoes was unbearable, and I had to wear loose fitting underwear. After seeing multiple doctors and urologists and having a dozen investigations come back normal, everyone said there was nothing wrong with me…”
There are many self-help techniques you can use to manage your pain. The suggestions below are all techniques used successfully by men like yourself.
This is usually a problem with one of the pelvic organs, although there is sometimes no obvious cause. See your doctor to exclude serious diseases.
If your pain has been fully assessed by your doctor and no serious disease has be found, you may understand that you aren’t in danger, but still do not how to manage your pain. Everyone is different, it is important to learn more about your individual condition – why you have pain, where it is coming from, and what are the things that make your pain better or worse. Increased understanding of the condition and pain can help reduce the fear, stress and anxiety surrounding your pain. This empowers you to take control of your pain, rather than allowing your pain to control your life.
Maybe your pain is brought on by sitting or standing for more than thirty minutes, wearing tight jeans or when you had a stressful day. Maybe your pain improves when you stretch and have a nice relaxing bath after a long day at work. It is a good idea to make a list of your problems and record the activities that improve or worsen your pain and which treatments helped you most.
Sometimes ongoing pain can cause us to alter activity levels, which can be helpful short term but not long term. Fear of pain flares can mean we avoid things, including the things that can help with our pain.
Others do too much when they feel good (boom) and then cannot do much for a while (bust) due to the pain flare from the overexertion. Doing too much or too little can lead to more pain and less function. Finding the middle road by pacing can be helpful.
Activity pacing involves breaking activities into smaller manageable chunks with regular breaks gradually increasing intensity. This allows you to conserve more energy to get more done with overall less discomfort. Pacing empowers you to have more control of your life, allowing you to do the things that are important to you.
Try to do activities up to 80% effort, with a gradual increase of 10 % increase in action each week with regular rest breaks in between. For example, if you know pain or fatigue sets in after 10 minutes of walking, limit your walking to 8 minutes with regular breaks. Increase the duration of walking by 1 minute each week. This allows you to walk every day, rather than walking for one day and recovering for multiple days.
If you flare, try not to panic! Sensitive nervous systems may flare to protect you, but it does not necessarily mean you are injured. Go back to a level you can manage and start pacing up again. Remember to take one step at a time; consistency is more important than intensity.
No matter how the pain started, if you have pain on most days, it is likely that your pelvic floor muscles are constantly tensed without you realising. When muscles stay tight, they get painful and can spasm. Reducing the tension in the muscles of your pelvic floor through relaxing and stretching exercises allows the muscles to work normally again, reducing your pain and potentially improving bladder, bowel, and sexual function. It is also important to have good bowel and bladder habits to take pressure off your pelvic muscles. Bowels should work efficiently without straining, and emptying should not be painful.
The pelvic floor muscles lie across the bottom of your pelvis like a trampoline. On top of the muscular trampoline lies the bladder and rectum. The pelvic floor muscles need to relax to be able to pass urine, bowels or semen. The trampoline sags and moves down when it relaxes and tightens and moves up as it contracts.
You can learn to move your pelvic muscles normally by the following steps:
The relaxing and loosening part of this exercise is most important for you. It may not be easy at first, but regular practice and training will make it easier. Excessive tightening may worsen pain, so be gentle when you first start this.
Targeted stretches ( link to stretches page) will help reduce tension and pain in and around the pelvis. If you need help, you can seek help from a pelvic floor physiotherapist.
Whole body relaxation is good for identifying muscles you habitually and subconsciously hold tight and tense. Guided relaxation exercises and stretches help reduce the tension in other muscles as well as your pelvic floor muscles and are good for managing your stress.
Stress, anxiety and depression can worsen your pain. Learn to manage your stress to improve your pain. Using the same techniques for pain, try to identify the things that worsen and improve your stress. Additionally, getting good sleep, regular appropriate physical activity, and a healthy diet will help with stress. There are several online self-paced courses you can access to help manage stress, anxiety and pain. Visit https://thiswayup.org.au/ for some courses.
Medications such as amitriptyline, duloxetine, and pregabalin/ gabapentin can help calm your nervous system and reduce pain sensitisation and hyperalgesia. It is important to avoid opiate medications such as oxycodone and panadeine forte. Although they help in the short term, opioids can worsen the pain in the long term and have many associated issues, including dependence, tolerance, and addiction. See your doctor for further advice.
This YouTube video with Karl Monahan, interviewed by FemFusion Fitness, is a must-watch video for men and people assigned male at birth with pelvic pain. Karl Monahan is a sports and advanced clinical massage therapist and owner and founder of Pelvic Pain Clinic in London. Karl has extensive training in abdominal and pelvic health, and has successfully treated males with chronic prostatitis and chronic pelvic pain syndrome since 2009.
Karl shares his personal experience with chronic testicular and pelvic pain and his frustrations surrounding the limited knowledge and understanding of his condition and how it impacted his quality of life. Karl explains how he tackled the condition while balancing his self-identity and how he has helped others with chronic pelvic pain with individualised approaches, allowing them to retake control of their lives.
Karl recommends all his patients to identify DIMs and SIMs “Danger (signals) In Me” and “Safety (signals) in Me”; read Karl’s article for more information about this approach. Follow him on Twitter @prostatitishelp.
Men’s pelvic pain video 31:01
https://www.thepelvicpainclinic.co.uk/dim-sims-of-prostatitis-and-cpps/
For more in-depth information about the diagnosis and treatment of male pelvic pain, watch Ms Shan Morrison’s presentation at the Pelvic Pain Foundation of Australia Health Practitioner Training Seminar 2018, kindly recorded by Mr Graham Smorgon. Ms Shan Morrison is a physiotherapist in Melbourne who is highly experienced in the management of pelvic pain. The video is around 45 minutes long and freely available for the public to view.
