The Effect of Biofeedback Physical Therapy in Men with Chronic Pelvic Pain Syndrome Type III

doi:10.1016/j.eururo.2004.12.014

European Urology

Volume 47, Issue 5, May 2005, Pages 607-611

https://doi.org/10.1016/j.eururo.2004.12.014 Get rights and content

Abstract

Recent studies suggest that the symptoms of chronic non-bacterial prostatitis (CP) or Chronic Pelvic Pain Syndrome (CPPS) may be due to or associated with pelvic floor muscle dysfunction. Therapies aimed to improve relaxation and proper use of the pelvic floor muscles such as biofeedback physical therapy and pelvic floor re-education are expected to give symptom improvement. The objective of this study was to evaluate the effect of biofeedback physical therapy on the symptoms of men with CPPS.

Materials and Methods:

Between March 2000 to March 2004, 33 consecutive men were diagnosed with CP/CPPS based on history including the NIH-CPSI questionnaire and physical examination including pelvic floor muscle tonus, urinalysis, uroflowmetry with residual urine measurement and transrectal ultrasonography of the prostate. All patients participated in a pelvic floor biofeedback re-educating program. A rectal EMG probe was used to measure resting tone of the pelvic floor muscles and was helpful for instruction pelvic floor muscles contraction and relaxation.

Results:

Two of the 33 men dropped out. In the remaining 31 men, mean age 43.9 years (range 23–70), the mean total Chronic Prostatitis Symptom Index (NIH-CPSI) changed from 23.6 (range 11–34) at baseline to 11.4 (range 1–25) after treatment (p < 0.001). The mean value of the pelvic floor muscle tonus was 4.9 at diagnosis (range 2.0–10.0) and decreased to 1.7 (range 0.5–2.8) after treatment (p < 0.001).

Conclusions:

Our study clearly demonstrates a significant effect of biofeedback physical therapy and pelvic floor re-education for CP/CPPS patients, leading to a significant improvement of the symptom score. The correlation between the pelvic muscle tonus results with NIH-CPSI score is highly suggestive that the pelvic floor plays an important role in the pathophysiology of CP/CPPS.

Introduction

Chronic Pelvic Pain Syndrome type III or chronic non-bacterial prostatitis (CP/CPPS) is characterized by Lower Urinary Tract Symptoms (LUTS), discomfort or pain in the pelvic region for at least 3 months of duration and sexual dysfunction [1]. Over the last decade this benign entity has attracted much attention due to the high prevalence, socio-economic impact and severe impact on the quality of life of a CP/CPPS patient [1], [2]. However, knowledge about the etiology, the pathophysiology and proper therapy for CP/CPPS is still lacking.

In 1995 the National Institutes of Health (NIH) described the development and validation of the Chronic Prostatitis Symptom Index (NIH-CPSI) [3]. This index addressed the 3 most important domains of CP/CPPS: pain (location, severity and frequency), voiding (irritative and obstructive symptoms), and impact/quality of life. Although the diagnosis of CP/CPPS is primarily a diagnosis of exclusion, the NIH-CPSI has proven to be of value for the diagnosis and follow-up treatment, even in primary and secondary care, of these patients [4].

The treatment of men with CP/CPPS is difficult because the pathogenesis is unclear. Several treatment modalities such as antimicrobial agents, analgesics, anti-inflammatory agents, muscle relaxants, alpha-blockers, 5-alpha-reductase inhibitors, heat therapy, surgery and biofeedback physical therapy have been proposed and investigated [5]. Since pathogenic bacteria present in the prostate do not cause CP/CPPS unless an acute urinary tract infection develops, the rationale for antibiotics for the treatment of CP/CPPS is missing [6], [7]. Alpha-blockade has proven beneficial in a subset of patients with mainly obstructive LUTS [8], [9]. Finally, based on the hypothesis of Segura et al. that CP/CPPS may be the result of or associated with pelvic floor abnormalities, Zermann demonstrated that the majority of patients with CP/CPPS had pathological tenderness of the striated pelvic floor muscles and poor to absent pelvic floor function [10], [11]. Indeed, a recent case control study demonstrated that men with CP/CPPS have significantly more abnormal pelvic floor muscular findings compared with a group of men without pain [12]. Based on these findings treatment of men with CP/CPPS with biofeedback physical therapy may be meaningful. In combination with electromyografical measure for biofeedback training, skeletal muscle activity can be measured and used for diagnosis or used as a cue for patient education.

Here we report our experience with biofeedback physical therapy as primary treatment of men with CP/CPPS.

Section snippets

Methods

Between March 2000 to March 2004, 33 consecutive men (mean age 45 years, range from 23 years to 70 years) who were diagnosed with CP/CPPS participated in a pelvic floor biofeedback re-education program. Diagnosis was based on history including the NIH-CPSI questionnaire and physical examination including pelvic floor muscle tonus (piriform, coccygeal, levator ani and obdurator muscles), urinalysis, uroflowmetry with residual urine measurement and transrectal ultrasonography of the prostate.

Results

Two of the 33 men who were diagnosed with CP/CPPS dropped out. One patient could not be properly trained because he did not understand the instructions. His pelvic floor muscle tonus was elevated and the NIH-CPSI was 21. The other patient stopped training after 3 sessions and did not return for follow up. The remaining 31 men were entered for analysis.

The total CPSI score decreased after treatment for all patients except one (97%) (Fig. 1a). In the subdomain of micturition improvement was seen

Discussion

The specific mechanisms underlying the CP/CPPS syndrome have not been defined. Since the last decade some progress has been achieved in the understanding of this benign entity which has a severe impact on the quality of life of a CPPS patient [5], [7], [8], [9], [13]. For the evaluation of new therapies for CP/CPPS the NIH-CPSI is considered a reliable and responsive measure of CP/CPPS in primary and secondary care [4].

Until recently, the prostate and bacterial infections were believed to play

Conclusions

Our study clearly demonstrates the significant effect of biofeedback physical therapy and pelvic floor re-education for CP/CPPS patients. The observation that the EMG results correlated with the NIH-CPSI score appears to emphasize that the pelvic floor plays an important role in the pathophysiology of CP/CPPS.

Acknowledgements

We would like to thank Dr Egbert Oosterwijk for his critically comments of the manuscript.

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Electronic databases (PubMed, CINAHL, and Embase) were searched up to May 31, 2021. The search strategy included variants of pelvic and/or floor, muscle, and tone using keywords and Medical Subject Headings (MeSH) terms.
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Data were extracted using a standardized form, including measurement tool and outcome measure. Risk of bias was analyzed using a modified ROBINS-I (Risk of Bias In Non-randomized Studies - of Interventions) tool, and a score was allocated to determine whether the study provided “convincing” interpretation (comparison with condition-free control group, valid measure, no application issues).
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Despite the large literature, few studies provide convincing evidence for increased tone/overactivity of pelvic floor muscles in pelvic health conditions. Interpretation is hampered by design and measurement issues. Terminology was often inaccurate. Few studies investigate male, transgender, and pediatric groups.
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One prospective study45 found a significant decrease in the perceived negative impact of PVD on QoL measured with a VAS-scale. Two prospective studies44,49 in men with CP/CPPS found a significant improvement in the NIH-CPSI subdomain QoL scores. Another prospective study50 in women with IC showed significant improvements in the physical component summary score and mental component summary score of the SF-12.
Hypertonicity of the pelvic floor (PFH) is a disabling condition with urological, gynecological and gastrointestinal symptoms, sexual problems and chronic pelvic pain, impacting quality of life. Pelvic floor physical therapy (PFPT) is a first-line intervention, yet no systematic review on the efficacy of PFPT for the treatment of PFH has been conducted.
To systematically appraise the current literature on efficacy of PFPT modalities related to PFH.
PubMed, Embase, Emcare, Web of Science, and Cochrane databases were searched from inception until February 2020. A manual search from reference lists of included articles was performed. Ongoing trials were reviewed using clinicaltrial.gov. Randomized controlled trials (RCTs), prospective - and retrospective cohorts and case-study analyses were included.
Outcome measures were pelvic floor muscle tone and function, pain reports, sexual function, pelvic floor symptom scores, quality of life and patients’ perceived effect.
The literature search resulted in 10 eligible studies including 4 RCTs, 5 prospective studies, and 1 case study published between 2000 and 2019. Most studies had a high risk of bias associated with the lack of a comparison group, insufficient sample sizes and non-standardized interventions. Six studies were of low and 4 of medium quality. All studies were narratively reviewed. Three of 4 RCTs found positive effects of PFPT compared to controls on five out of 6 outcome measures. The prospective studies found significant improvements in all outcome measures that were assessed. PFPT seems to be efficacious in patients with chronic prostatitis, chronic pelvic pain syndrome, vulvodynia, and dyspareunia. Smallest effects were seen in patients with interstitial cystitis and painful bladder syndrome.
The findings of this systematic review suggest that PFPT can be beneficial in patients with PFH. Further high-quality RCTs should be performed to confirm the effectiveness of PFPT in the treatment of PFH.
van Reijn-Baggen DA, Han-Geurts IJM, Voorham-van der Zalm PJ, et al. Pelvic Floor Physical Therapy for Pelvic Floor Hypertonicity: A Systematic Review of Treatment Efficacy. Sex Med Rev 2022;10:209–230.
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Prostatitis is a condition characterized by pelvic pain along with irritative and obstructive voiding symptoms. In the United States, 6.9% of men older than 50 years of age are affected by this condition and their treatment costs 84 million dollars annually. Pathogenesis of prostatitis is diverse ranging from bacterial infection to pelvic floor dysfunction to neural sensitization. Diagnosis of prostatitis involves taking a comprehensive history and physical exam in addition to diagnostic tests such as a Meares–Stamey test, urine analysis, urine culture, and cystometric studies. Treatment for prostatitis is diverse and depends on the exact etiology. Prostatitis caused by bacterial infection is treated with antibiotics; however, treatment for nonbacterial prostatitis is less clear. Conservative treatment for nonbacterial prostatitis includes lifestyle modifications, pelvic floor physiotherapy, biofeedback, and antiinflammatory medications. Those refractory to conservative measures can be treated with various types of neuronal blocks such as superior hypogastric plexus block, inferior hypogastric plexus block, ganglion impar block, and pudendal nerve block. Additional therapeutic options include neuromodulation techniques such as sacral stimulation, percutaneous tibial nerve stimulation, and pudendal nerve stimulation.
The Role of Physical Therapy in Sexual Health in Men and Women: Evaluation and Treatment
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Many conditions of pelvic and sexual dysfunction can be addressed successfully through pelvic floor physical therapy (PFPT) through various manual therapy techniques, neuromuscular reeducation, and behavioral modifications. The field of pelvic rehabilitation, including sexual health, continues to advance to modify these techniques according to a biopsychosocial model.
To provide an update on peer-reviewed literature on the role of PFPT in the evaluation and treatment of pelvic and sexual dysfunctions in men and women owing to the overactive and the underactive pelvic floor.
A literature review to provide an update on the advances of a neuromusculoskeletal approach to PFPT evaluation and treatment.
The use and advancement of PFPT methods can help in successfully treating pelvic and sexual disorders.
PFPT for pelvic muscle overactivity and underactivity has been proven to be a successful option for pelvic and sexual dysfunction. Understanding the role of the organs, nerves, fascia, and musculoskeletal system in the abdomino-pelvic and lumbo-sacro-hip region and how pelvic floor physical therapists can effectively evaluate and treat pelvic and sexual health. It is important for the treating practitioner to know when to refer to PFPT.
Neuromusculoskeletal causes of pelvic floor disorders affect a substantial proportion of men, women, and children and PFPT is a successful and non-invasive option. Pelvic floor examination by healthcare practitioners is essential in identifying when to refer to PFPT. Use of a biopsychosocial model is important for the overall well-being of each patient. Further research is needed.
Stein A, Sauder SK, Reale J. The role of physical therapy in sexual health in men and women: Evaluation and treatment. Sex Med Rev 2019;7:46–56.
Chronic Prostatitis and/or Chronic Pelvic Pain as a Psychoneuromuscular Disorder—A Meta-analysis
2018, Urology
To evaluate effectiveness of physical therapy, biofeedback, and/or cognitive behavioral therapy for chronic prostatitis/chronic pelvic pain syndrome (CP and/or CPPS). This symptom complex has resisted resolution from conventional urologic treatment of the prostate, which includes antibiotics, alpha-blockers, and analgesics. Beginning in 1995, a new paradigm was introduced viewing CP and/or CPPS as a psychoneuromuscular disorder driven by protective pelvic floor guarding and psychosocial stress.
A literature search (PubMed, Google Scholar, and the Cochran Library) was conducted from inception through December 2017 using key words related to CP and/or CPPS (eg, prostatitis and pelvic pain) with physical therapy (eg, myofascial trigger point release) and/or biofeedback or cognitive behavioral treatment. Studies were required to include pre- and post-treatment with the National Institutes of Health Chronic Prostatitis Symptom Index (CPSI) scores.
Eight studies inclusive of 280 patients met primary inclusion criteria. Study sample sizes ranged from 8 to 116 men (mean = 35); treatment duration ranged from 8 to 26 weeks (mean = 14). Pretreatment mean CPSI scores ranged from 21.7 to 33.5. The nonstandardized weighted mean reduction of CPSI score from baseline was 8.8 points; 95% confidence interval (7.5, 11.1); P <.001. The I² statistic = 18.5% indicating little heterogeneity between studies. A sensitivity analysis including an additional multimodal intervention study of with 100 patients produced similar findings.
Conventional medical treatment often fails to resolve CP and/or CPPS. A 6-point reduction in CPSI score is considered a clinically meaningful improvement of symptoms. This meta-analysis shows that treating CP and/or CPPS as a psychoneuromuscular disorder can significantly exceed this clinical threshold.
Comparing electromagnetic stimulation with electrostimulation plus biofeedback in treating male refractory chronic pelvic pain syndrome
2017, Urological Science
The aim of this study was to compare the effectiveness of electromagnetic stimulation (EMS) versus electrostimulation plus biofeedback (ESB) for the treatment of refractory chronic pelvic pain syndrome (CPPS) in men.
A total of 23 male refractory CPPS patients were included in the study. EMS was applied for 30 minutes, three times weekly, for 6 weeks, for pelvic floor rehabilitation. We retrospectively compared the outcomes with 22 male refractory CPPS patients treated with ESB twice a week for 2 weeks, and later once a week for 4 weeks. Each ESB session lasted 45 minutes, including biofeedback (15 minutes) followed by electrostimulation (30 minutes). The outcome measures included the National Institutes of Health Chronic Prostatitis Symptoms Index (NIH-CPSI), International Prostate Symptom Score (IPSS), and a visual analogue score for pain from baseline to 12 weeks after completion of treatment.
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The Effect of Biofeedback Physical Therapy in Men with Chronic Pelvic Pain Syndrome Type III

Abstract

Materials and Methods:

Results:

Conclusions:

Introduction

Section snippets

Methods

Results

Discussion

Conclusions

Acknowledgements

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