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 30th 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)
- 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.
- Baumann4 found 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
- 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
- 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!
Evidence Update on Persistent Pelvic Pain Syndrome (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
Geoff’s journey with PPPS
- 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.
- 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.
- 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.
- 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.