Fiona McMahon DPT Introduction Prostatitis is a common diagnosis we see at Beyond Basics Physical Therapy. If I have a new evaluation on my schedule, who is male and between the ages of 18-40, we can place a pretty good bet that they are coming to see me for issues pertaining to non-bacterial prostatitis. It is estimated that 35-50% of men are reported to have prostatitis symptoms in their lifetime (Rees). Prostatitis can be classified into different types based on their causes and response to treatment. Prostatitis is a vexing condition for many patients. In cases of non-bacterial prostatitis, which makes up 95% of all prostatitis, it’s often very difficult to determine what brought it on, and often times our patients have been bouncing from practitioner to practitioner trying to find answers and effective treatment. Let’s dive into the causes, symptoms, and treatment in order to help shed light on this condition. Prostatitis Symptoms, Although there are different types of prostatitis, the symptoms of prostatitis are mostly the same between types. That isn’t to suggest that every man with prostatitis experiences the same symptoms, quite on the contrary. Men with prostatitis may experience almost all of the symptoms listed below or they may only notice one or two. This melange of symptom possibilities can add to the confusion of having prostatitis and getting down to an effective cure. Symptoms:

• The sensation of having a golf ball stuck in the rectum
• Hesitant urinary stream (having trouble getting the urine to start flowing)
• Post void dribble (spotting of urine on underwear following voiding)
• Pain that radiates into the abdomen (this is one of the differences from symptoms of benign prostatic hyperplasia)
• Erectile dysfunction and decreased libido
• Painful ejaculation
• Painful or burning urination
• Genital pain: penile, testicular, groin and perineal pain

Types of prostatitis: Here’s where it gets a little more complicated. There isn’t one type of prostatitis. There are four. Each type of prostatitis is a little different in terms of etiology (how it developed) and how it’s treated. Type 1: Acute bacterial prostatitis This type of prostatitis is caused by an infection by a microbe. It is relatively rare. In addition to the symptoms above, a person with this type of prostatitis will feel the symptoms of an ongoing infection, including pain in the body, fever, and chills. This type of prostatitis generally response well to antibiotic treatment. Type 2: Chronic bacterial prostatitis Chronic bacterial prostatitis can occur after multiple infection or when there is an ongoing low grade infection. The symptoms, particularly those of infection are dampened in this form of prostatitis than those of type 1. Type 2 is often more tricky to treat and may require multiple courses of antibiotics Type 3: Chronic Prostatitis/ Chronic pelvic pain syndrome (the most common making up 90-95% of all prostatitis and WHAT WE TREAT!)

This type of prostatitis occurs with no evident infectious cause and makes up the majority of cases. This is the classification that is one of the more frustrating for patients to deal with because the causal agent is much harder to ascertain; however the majority have musculoskeletal dysfunction, which we now know can be treated effectively through expert pelvic floor physical therapy. Type III prostatitis can be further categorized based on the presence or absence of white blood cells in the urine or prostatic fluid, inflammatory and noninflammatory respectively. Type 4: Asymptomatic inflammatory prostatitis As the name implies, this type of prostatitis is usually not noticed unless semen or urine analysis is being performed to diagnose another condition. Typically this type is left untreated. Causes Here’s one of the universal questions that patients with prostatitis have: “why do I have this?†Sometimes patients may find themselves blaming their prostatitis on something they have done in the past, like masturbating or poor hygiene habits as children. The fact is, prostatitis can occur for a multitude of reasons, and it’s usually something one has no control over like a fall on the bottom or an infection. It’s unfortunately something that happens, and as noted in the introduction of this blog, it is quite common. Here are some possible causes:

• In chronic nonbacterial prostatitis/ chronic pelvic pain syndrome 90-95% of cases- no definitive cause ( or very difficult to ascertain); however pelvic floor dysfunction is a prevalent contributor.
• Bacterial infection, which can have good results with antibiotics
• Chronic bacterial prostatitis, recurrent infection
• Inflammation to the pelvic area
• Central and peripheral sensitization- meaning a past injury in the area caused your pelvic nerves to perceive non painful stimuli as painful
• Trigger points (irritable points of muscle) in the pelvic floor and abdomen

Treatment Treatment is evolving in prostatitis. Increasing evidence supports a multimodal approach to treating prostatitis and its symptoms, meaning that not only is medical intervention used, but psychological, nutritional, and physical therapy. From a medical perspective the first line of treatment for prostatitis is the “3 A’sâ€, antibiotics (especially the quinolone class), anti-inflammatories, and alpha blockers. Antibiotics obviously clear up any infection that might be causing your symptoms, anti-inflammatories to bring down the pain and discomfort, and alpha blockers to improve urine flow. Sometimes this is just what the doctor ordered (literally), especially in individuals with type 1 prostatitis and they are on their way with no further treatment needed. Since the vast majority of people with chronic prostatitis fall outside of the type one category and into more difficult to treat types, their recovery may require a more involved intervention to effectively treat their symptoms and the 3 A’s may not be the answer, or the complete answer for these patients. Physical Therapy: Anderson and his colleagues described the relationship between the presence of myofascial trigger points and symptomatic prostatitis. They also showed that physical therapy intervention, including manual release of these trigger points was effective in reducing symptoms of prostatitis. The benefit of physical therapy was shown again to be more effective than placebo in a 2011 paper by Nickel. In addition to treating the trigger points themselves, PT’s work to determine what lead up to the formation of the trigger points in the first place, whether that be poor habitual posture, poor strength, or tight muscles in other parts of the body. They also teach patients how to avoid clenching their pelvic floor to prevent exacerbating symptoms. This type of therapeutic approach was found to be effective in reducing pain in 72% of participants in a study conducted by Anderson and colleagues in 2005. The therapists at Beyond Basics Physical Therapy work to go beyond simple treatment of the trigger points themselves. We develop plans and treatments to prevent their recurrence in the future. Some other effective physical therapy techniques that we use include but are not limited to, joint mobilization to assist proper structural alignment, therapeutic exercise, postural and neuromuscular re-education and a detailed and individualized home exercise program. Dietary Modifications: Avoiding irritants to the bladder and gastrointestinal system is another simple and effective place to start. In some men, avoiding spicy foods, alcohol and caffeine can work wonders in making symptoms more manageable. Phytotherapy: Preliminary data shows that there is evidence to support the use of saw palmetto, quercetin and bee pollen extract in reducing the pain of prostatitis. If supplementation interests you, consult with your general practitioner or urologist. Stress Reduction As clinicians who have seen a lot of cases of prostatitis, high stress is a contributor that we see with the vast majority of our patients. Studies have shown that high levels of stress are correlated with higher pain and disability scores in individuals with prostatitis. Stress can also perpetuate unhealthy holding or clenching in the pelvic floor, which causes or contributes to trigger points discussed earlier in this section. Stress reduction is a key component to expediting your recovery and is something we recommend to nearly all of our patients. Final Thoughts

• Prostatitis is a common and aggravating condition to be living with, and the fact is, every case of prostatitis is different. You may fall into the category were a course of antibiotics does the trick or you may fall into the category where you require physical therapy alongside medical intervention which can be much more slow going. Regardless of where you fall, be patient, there usually is a lot that can be done to help the more complex cases of prostatitis clear up. If you are suffering with this condition, make an appointment with an expert pelvic floor physical therapist today. There is so much we can do.

Sources Anderson R, Sawyer T, Wise D. Painful myofascial trigger points and pain site in men with chronic prostatitis/ Chronic Pelvic Pain Syndrome. J Urol. 2009;182(6): 2753-8 Anderson R, Wise D, Sawyer T. Integration of myofascial trigger point release and paradoxical relaxation training treatment of chronic pelvic pain in men. J Urol. 2005;174(1):155-60 Chronic nonbacterial prostatitis (chronic pelvic pain syndrome). Harvard Health Publications. Harvard Medical School. 2007. http://www.health.harvard.edu/newsletter_article/chronic-nonbacterial-prostatitis-chronic-pelvic-pain-syndrome. Accessed December 11, 2016 Duclos A, Lee C, Shoskes D. Current treatment options in the management of chronic prostatitis. Ther Clin Risk Manag. 2007; 3(4):507-12 Rees J, Abrahams M, Doble A et al. Diagnosis and treatment of chronic bacterial prostatitis and chronic prostatitis/chronic pelvic pain syndrome: a consensus guideline. BJU Int. 2015; 116(4):509-25 Nickel J. Prostatitis. Can Urol Assoc J. 2011; 5(5): 306-15