By Daniel Shoskes, MD, MSc, FRCS(C)
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The skeletal muscles of the pelvic floor support and surround the bladder, prostate, vagina and rectum. Much as spasm of neck and shoulder muscles can lead to tension headaches, spasm of the pelvic floor can lead to genital pain and lower urinary tract symptoms (LUTS).
Pain can be felt in the penis, testicles, perineum (sensation of “sitting on a golf ball”), lower abdomen and lower back. Women may experience dyspareunia and men may have post-ejaculatory pain and erectile dysfunction.1 Indeed, more than 50 percent of men with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) and patients with interstitial cystitis have pelvic floor spasm on exam, which can be an independent driver of their ongoing symptoms.2
The diagnosis is not difficult but does require a slight modification of the usual digital rectal exam.3 In men, the muscles of the pelvic floor can be palpated anteriorly to either side of the prostate and laterally during the rectal exam. In women, these muscles can be palpated during a vaginal exam.
Pelvic floor spasm is felt as bands of tight muscle, and trigger points are felt as knots of muscle that are often painful on palpation and usually re-create the patient’s symptoms. Indeed, we believe a common cause of misdiagnosis of prostatitis comes from pain experienced during the rectal exam that is assumed to be due to the prostate but is actually caused by palpation of extraprostatic muscles.
Diagnosing with UPOINT
We have developed a phenotyping tool for men and women with either CP/CPPS or interstitial cystitis/painful bladder syndrome (IC) called UPOINT that identifies six clinically diagnosed domains (urinary, psychosocial, organ-specific, infection, neurologic systemic, tenderness of pelvic floor muscles).4 Multimodal therapy is then directed at only the positive phenotypes (antibiotics for infection, alpha blockers or antimuscarinics for urinary symptoms, etc.).
We have found that this approach significantly improves or resolves symptoms in 84 percent of men with CP/CPPS.5 In our clinic, roughly two-thirds of men have pelvic floor spasm,5 which is higher than the 51 percent found in a multicenter National Institutes of Health-sponsored study.2 We suspect that we see more men with pelvic floor spasm in a referral practice because so few urologists assess for this problem and men who don’t have it end up being successfully treated with other medical therapies.
Relaxing muscles with physical therapy
The mainstay of treatment for pelvic floor spasm is physical therapy (PT) that consists of myofascial release, posture improvement and muscle-stretching exercises.6 The goal is to help relax the muscles, not to strengthen them. Therefore, Kegel exercises, which are often inappropriately applied as “generic physical therapy,” can make the symptoms worse.
Pelvic floor PT improves symptoms in about 80 percent of cases,7 although in an underpowered study comparing pelvic PT with conventional Western massage, there was no difference in the CP/CPPS cohort.8 For patients who have persistent pain and trigger points despite the appropriate PT, trigger point injection of a local anesthetic can be an effective adjunct.9 We recently have begun to offer patients this option.
Because many of our patients are nonlocal, we sometimes face the challenge of finding a way to provide appropriate PT for their pelvic floor spasm because many therapists are unfamiliar with myofascial release.
Does specialized physical therapy help?
To determine whether PT guided by therapists who specialize in pelvic floor spasm actually impacts outcomes, we recently performed a study.10 We identified patients with pelvic floor spasm from our CPPS registry who were seen more than once between 2010 and 2014. Patient phenotype was assessed with the UPOINT system and symptom severity with the National Institutes of Health Chronic Prostatitis Symptom Index (CPSI).
A 6-point drop in CPSI defined patient improvement. We identified 82 patients who fit the criteria, with mean age of 41.6 years (range 19-75 years) and median symptom duration of 24 months (3-240 months). Mean initial CPSI was 26.8 (10-41), median number of positive UPOINT domains was 3 (1-6) and 27 (32.9 percent) were local residents.
At follow-up, nine patients had refused pelvic floor PT (PFPT), 24 received PFPT outside our institution and 48 had PFPT from experienced therapists at Cleveland Clinic. Mean change in CPSI was 1.11 ± 4.1 for patients who refused PFPT, -3.46 ± 6.7 for those who received outside PFPT and -11.3 ± 7.0 for patients who received PFPT at Cleveland Clinic (p < 0.0001). Individual improvement was seen in one (11 percent) PFPT-refusal patient, 10 (42 percent) outside-PFPT patients and 38 (79.2 percent) Cleveland Clinic patients (p < 0.0001). Using multivariable analysis, only Cleveland Clinic PFPT (odds ratio [OR] 4.23, p = 0.002) and symptom duration (OR 0.52, p = 0.03) predicted improvement.
In conclusion, pelvic floor spasm is a common contributing factor in pain and LUTS experienced by patients diagnosed with CPPS or IC. It is simple to diagnose, and the mainstay of successful treatment is PFPT directed by a therapist well-versed in the condition.
Dr. Shoskes is a staff member of the Glickman Urological & Kidney Institute’s Department of Urology and of the Transplant Center. He is also a Professor of Surgery at Cleveland Clinic Lerner College of Medicine.
- Anderson RU, Wise D, Sawyer T, et al. Sexual dysfunction in men with chronic prostatitis/chronic pelvic pain syndrome: improvement after trigger point release and paradoxical relaxation training. J Urol. 2006 Oct;176(4 Pt 1):1534-1538.
- Shoskes DA, Berger R, Elmi A, et al. Muscle tenderness in men with chronic prostatitis/chronic pelvic pain syndrome: the chronic prostatitis cohort study. J Urol. 2008 Feb;179(2):556-560.
- Westesson KE, Shoskes DA. Chronic prostatitis/chronic pelvic pain syndrome and pelvic floor spasm: can we diagnose and treat? Curr Urol Rep. 2010 Jul;11(4):261-264.
- Shoskes DA, Nickel JC, Rackley RR, et al. Clinical phenotyping in chronic prostatitis/chronic pelvic pain syndrome and interstitial cystitis: a management strategy for urologic chronic pelvic pain syndromes. Prostate Cancer Prostatic Dis. 2009;12(2):177-183.
- Shoskes DA, Nickel JC, Kattan MW. Phenotypically directed multimodal therapy for chronic prostatitis/chronic pelvic pain syndrome: a prospective study using UPOINT. Urology. 2010 Jun;75(6):1249-1253.
- Anderson RU, Sawyer T, Wise D, et al. Painful myofascial trigger points and pain sites in men with chronic prostatitis/ chronic pelvic pain syndrome. J Urol. 2009 Dec;182(6):2753- 2758.
- Anderson RU, Wise D, Sawyer T, et al. 6-day intensive treatment protocol for refractory chronic prostatitis/chronic pelvic mpain syndrome using myofascial release and paradoxical relaxation training. J Urol. 2011 Apr;185(4):1294-1299.
- FitzGerald MP, Anderson RU, Potts, J et al. Randomized multicenter mfeasibility trial of myofascial physical therapy for the treatment of urological chronic pelvic pain syndromes. J Urol. 2013 Jan;189(1 Suppl):S75-S85.
- Moldwin RM, Fariello JY. Myofascial trigger points of the pelvic floor: associations with urological pain syndromes and treatment strategies including injection therapy. Curr Urol Rep. 2013 Oct;14(5):409-417.
- Polackwich AS, Li J, Shoskes DA. Patients with Pelvic Floor Muscle Spasm have a Superior Response to Pelvic Floor Physical Therapy at Specialized Centers. J Urol. 2015 Oct;194(4):1002-1006.