What’s New in Male Pelvic Health? PPI + PPPS Updates

We see people with a range of pelvic health issues that impact those born with male genitalia and reproductive, urinary and ano-rectal anatomy. International Men’s Health Week 2022 aimed to increase awareness of mental health issues. A staggering 1 in 8 Australian men experience depression and 1 in 5 experience anxiety at some stage in their lives¹. At the 30^th National Conference on Incontinence, Shan Morrison, the Director of WMHP presented in the Men’s Health session on two common pelvic health conditions that impact mental health; Post-Prostatectomy Incontinence and Persistent Pelvic Pain Syndrome. This article explores the recent evidence, clinical implications and a case study for PPI and PPPS.

Evidence update on Post-Prostatectomy Incontinence (PPI)

WMHP has been fortunate to be involved in the explosion of research in the past decade looking at assessment and intervention for PPI. Three key recent papers are Hodges², Hall³ and Baumann.⁴

The main findings were;

Hodges² increased our understanding of the pathophysiology of PPI and proposed a Pelvic Floor Muscle Training (PFMT) protocol that changed focus to target activation of the striated urethral sphincter (SUS), optimised the individual motor control pattern and added functional and higher intensity training.
Hall³ is an Australian systematic review that provided a strong conclusion that the best outcomes for PFMT was when it was commenced pre-op and provided urethral and not anal cues. More information on Prehab.
Baumann⁴found supervised PFMT decreased PPI with unsupervised PFMT being similar to no PFMT, recommending PFMT be implemented as an early rehabilitative measure to improve PPI.

Clinical implications for management of PPI

The clinical application of these research findings are:

PFMT should be commenced prior to radical prostatectomy.
Assessment and training is enhanced by the use of transperineal ultrasound to ensure correct activation of the SUS.
PFMT must include correct motor control pattern, application to function, high intensity and low tonic activation training.

Rob’s journey with PPI

Rob, a 68-year-old part time Farmer attended WMHP at 7 months post robotic radical prostatectomy. Pad weigh was 50 gms of urine loss on sedentary days and 220 gms when at the farm. Rob had seen a Pelvic Health Physio and was doing lots of pelvic floor exercises when in the car and watching TV. Transperineal ultrasound confirmed good activation of his SUS.

We changed two aspects of his training program:

Performing his PFMT sets in standing, squatting, lifting and bending positions (functional and high intensity training). After one month, farm day urine loss had reduced to 100gms / day, worse in the afternoons.
Low intensity tonic holding and endurance PFM training was then added, at 9 months post op his farm day urine loss was 20gms per day and he was understandably much happier!

Here we share another case study of a patient with PPI.

Evidence Update on Persistent Pelvic Pain Syndrome (PPPS)

PPPS, including chronic prostatitis, is persistent prostate and / or pelvic pain associated with symptoms suggestive of urinary tract and/ or sexual dysfunction where there is no proven infection or obvious pathology. Pain may be referred to the bladder, perineum, testicles, penis and / or groin.⁵ Experienced by 8% of Australian men⁶ PPPS has a huge negative impact on men’s physical, emotional and social health and wellbeing and a significant financial burden. In the broader pain literature there has been a growing understanding of the nociplastic pain mechanism that includes central sensitisation, widespread pain, hypersensitivity (allodynia and hyperalgesia) and the presence of psychological factors and co-morbidities.

Two recent papers from the MAPP (Multidisciplinary Approach to the Study of CPP) research network have identified the presence of a centralised pain phenotype in many men with PPPS.

Harte⁷ found abnormal sensory processing and global multisensory hypersensitivity to normal (ie touch and pressure) and unpleasant stimuli.
Clemens⁸ found those with PPPS had changes in the motor and sensory areas of the brain consistent with sensorimotor representations of the pelvic pain area, differing from healthy controls.

Clinical implications for management of PPPS

The evidence base for a biopsychosocial (BPS) approach is growing. Five years ago, our article ‘CPPS: The ‘Black Hole’ Of Men’s Health’ outlined our application of this approach for PPPS. The Clemens⁸ paper concluded there was a need for therapies to extend beyond the pelvic viscera. They stated that wholistic approaches taking into account psychosocial comorbidities and chronic overlapping pain conditions ie IBS and fibromyalgia, would improve the ability of men to cope and self-manage symptoms.

This is why we have been managing this cohort within a biopsychosocial framework that screens for central pain mechanisms and then profiles the sensitised nervous system through a biological based physical assessment and validated self-report psychosocial and pain mapping questionnaires. This has enabled us to understand more specifically what cognitions and emotions might be driving the nervous system sensitivity in addition to peripheral contributors.

Geoff’s journey with PPPS

Geoff is a 40-year-old Project Manager from the US with a 10-year history of tension and pain in his pelvis.

Symptoms;
- Experiencing constant 8/10 pain in his perineal, anal and scrotal area.
- More recent onset of erectile and voiding dysfunction.
- Pain worse with stress, worry and when his children were being noisy.
Previous treatment;
- He had seen two Urologists, trying antibiotics and anti-inflammatories with no effect.
- Massage provided temporary relief only.
Assessment findings;
- Positive for a sensitised nervous system on the CSI screening inventory.
- Poor awareness of pelvic movement, increased pelvic floor muscle tone, tenderness and poor relaxation.
- Moderate stress and depression, mild anxiety (Depression Anxiety Stress Scale).
- Significant fear of movement (Tampa Scale of Kinesiophobia).
- High worst-case scenario thinking (Pain Catastrophisation Scale).
- Positive sensori-motor dysregulation (Fremantle Awareness Questionnaire).
- 4/10 Adverse childhood experiences (on the ACE).
- Social history; busy life with work demands and 4 children with no family support.
Goals;
- To understand why he has pain and what he could do about it.
- Reduce feeling of pain and tension which would allow him to enjoy life more.
Treatment;
- Pain science education – including understanding how his childhood trauma and low mood was decreasing descending inhibition and the fear and catastrophic thoughts were increasing the threat and danger messages via ascending pathways and this was impacting his nervous system sensitisation and lived pain experience.
- Explaining that his emotions and thoughts were increasing muscle tension and use of breathing, positive thoughts, mindful movement and relaxation exercises to reduce this.
- Geoff attended physio intermittently over an 18-month period, understanding that it can take time to change pain when it has been “practiced” for 10 years.
Outcomes;
- No scrotal, perineal or anal pain.
- Able to notice what triggers his pelvic tension and has strategies to reduce this.
- Bladder is emptying well and sexual function has significantly improved.
- He scored his goal achievement as 9/10, is enjoying life and spending more time with his children.

Final Reflections

It is an exciting time to be part of the multidisciplinary team supporting men with pelvic health conditions. It doesn’t get any better than being able to translate new research findings into clinical practice and directly improve the quality of life of men experiencing PPI and PPPS. Rob and Geoff are typical examples of men we support every day who are suffering in silence.

Through a whole person, individualised, patient centered approach, both embraced a program that addressed not only the physical contributors but also the emotional and psychological factors as well.

References

¹Australian Bureau of Statistics (2020). Causes of Death, Australia, 2019: Intentional self-harm (suicide), Catalogue No 3303.0. Retrieved 23 October 2020.

^2. Hodges P, Stafford R, Hall L, Neumann P, Morrison S, Frawley H, Doorbar-Baptist S, Nahon I, Crow J, Thompson J, Cameron A. (2020) Reconsideration of pelvic floor muscle training to prevent and treat incontinence after radical prostatectomy. Urol Oncol (2020) May;38(5):354-371.

^3. Hall L, Neumann P, Hodges P (2020). Do features of randomized controlled trials of pelvic floor muscle training for postprostatectomy urinary incontinence differentiate successful from unsuccessful patient outcomes? A systematic review with a series of meta‐analyses.

^4. Baumann F, Reimer N, Gockeln T, Reike A, Hallek M, Ricci C, Zopf E, Schmid D, Taaffe D, Newton R, Galvao D, Leitzmann M. (2021): Supervised pelvic floor muscle exercise is more effective than unsupervised pelvic floor muscle exercise at improving urinary incontinence in prostate cancer patients following radical prostatectomy – a systematic review and meta-analysis, Disability and Rehabilitation; 21:1-2.

^5. Frawley, H, Shelly, B, Morin, M, Bernard, S, Bo, K, Digesu, GA, Dickinson, T, Goonewardene, S, McClurg, D, Rahnama’i, MS, Schizas, A, Slieker-ten Hove, M, Takahashi, S & Voelkl Guevara, J (2021) 'An International Continence Society (ICS) report on the terminology for pelvic floor muscle assessment', Neurourology and Urodynamics, vol. 40, no. 5, pp. 1217-1260.

^6. Ferris, J.A., Pitts, M.K., Richters, J., Simpson, J.M., Shelley, J.M. and Smith, A.M., (2010) National prevalence of urogenital pain and prostatitis‐like symptoms in Australian men using the National Institutes of Health Chronic Prostatitis Symptoms Index. BJU international, 105(3), pp.373-379.

^7. Harte SE, Schrepf A, Gallop R, Kruger GH, Lai HHH, Sutcliffe S, Halvorson M, Ichesco E, Naliboff BD, Afari N, Harris RE, Farrar JT, Tu F, Landis JR, Clauw DJ; (2019) MAPP Research Network. Quantitative assessment of nonpelvic pressure pain sensitivity in urologic chronic pelvic pain syndrome: a MAPP Research Network study. Pain.160(6):1270-1280

^8. Clemens JQ, Mullins C, Ackerman AL, Bavendam T, van Bokhoven A, Ellingson BM, Harte SE, Kutch JJ, Lai HH, Martucci KT, Moldwin R, Naliboff BD, Pontari MA, Sutcliffe S, Landis JR; (2019) MAPP Research Network Study Group. Urologic chronic pelvic pain syndrome: insights from the MAPP Research Network. Nat Rev Urol. Mar;16(3):187-200.

June 2022