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For Men, Stress Often Plays a Role in Pelvic Pain

Art credit: Kelsey Tyler

Pelvic pain has received a fair amount of news coverage in the past few years, but stories on the issue usually focus on women. Celebrities Padma Lakshmi and Lena Dunham, for instance, have both spoken publicly about their struggles with endometriosis. Male pelvic pain, on the other hand, has largely stayed out of the cultural conversation (especially during all non-Movember months). But it’s worth talking about. 

Up to 16 percent of men will develop chronic pelvic pain in their lifetime, according to one study. This number might be an underestimate, given the stigma associated with pelvic health. A variety of ailments, some of which are poorly understood, can lead to pelvic pain. But the good news is that, most of the time, both the pain and the conditions that spark it are treatable. 

According to experts in the field, common pelvic pain complaints include burning, fullness or pressure in the perineum (the area behind the scrotum) and dull pain in the rectum, bladder, groin or tip of the penis. 

Enduring such pain is a big task. A range of routine activities and environmental triggers, such as sitting down and engaging in sex, can spark pain. Men with pelvic pain are at a heightened risk for depression and more likely than other men to have erectile dysfunctionAnd in one study, men with chronic pelvic pain reported substantially impaired mental and physical functioning, and an overall lower quality of life, on account of their condition.

What causes pelvic pain?

Where does male pelvic pain come from? It depends. The cause might be a prostate issue, such as inflammation of the prostate (called prostatitis) or benign prostate enlargement. Pain could also stem from rarer ailments, such as interstitial cystitis, a condition affecting the lining of the bladder, or pudendal nerve entrapment. But the most common cause of pain is pelvic floor dysfunction, according to Steven A. Kaplan, a urologist and co-director of the Men’s Health Program at Mount Sinai Hospital in Manhattan.

The pelvic floor is a layer of muscles that forms a basket to support the pelvic organs; in men, that means the bladder, prostate and bowels. These muscles also help maintain bodily posture, support the abdomen and assist in urination, bowel movements and sexual activity. Pelvic floor dysfunction encompasses a wide range of problems that can happen when these muscles stop working normally, in many cases becoming tight, weak and prone to spasm. Men who have chronic pelvic pain of unknown cause, research indicates, are more likely than those without pain to have abnormalities in their pelvic floor muscles. 

In some cases, pelvic floor dysfunction is triggered by urinary tract infection, prostatitis or bladder infection. But the dysfunction often outlasts the initial infection or condition that sets it off, and is typically the source of the pain. Although males of any age can develop pelvic floor dysfunction, Kaplan said that relatively young men, between ages 18 and 40, are most likely to come down with it.

According to Kaplan, many men unknowingly bring about the muscle dysfunction themselves. This can happen when men unconsciously tighten and clench their pelvic muscles, usually because of stress. Over time, pain develops, just as clenching your jaw can spur mandibular pain. It tends to affect people who put a lot of pressure on themselves to achieve and have a hard time relaxing.

“The most important thing I do is educate people,” Kaplan said. “When Type A people hear they can cause the problem through subconsciously clamping pelvic muscles, but that they can also fix the problem, it’s empowering.”

“They have to recognize how stress in their lives contributes to their pain, and how to manage it,” Kaplan added.

Psychiatrist Stephen Snyder, who’s treated scores of men with pelvic pain over the years, said that “people with depression or anxiety often experience maladaptive patterns of heightened muscle tension.” There’s also a great deal of shame and anxiety surrounding pelvic pain, which Snyder says is typical of a poorly understood condition involving the genitals.

How is pelvic pain treated?

An appointment for pelvic pain begins with the urologist learning about the patient’s medical history and performing a physical examination. This typically involves feeling the prostate and surrounding muscles with a gloved and lubricated finger, taking a urine culture and sometimes a semen culture. In rarer cases, doctors perform a cystoscopy, in which a thin scope is inserted into the bladder through the urethra to examine the urinary tract and the bladder for abnormalities.

Once the doctor determines the cause of a patient’s pelvic pain, they’ll decide how to treat it. Sometimes, the solution is a lifestyle change. For those with interstitial cystitis, for example, adopting a low-acid diet can lead to dramatic improvements over time.

If the examination reveals prostatitis, or infection of the prostate or bladder, medications such as antibiotics, anti-inflammatories and alpha blockers can be prescribed. Because research suggests that most cases of prostatitis are non-bacterial, doctors are relying on antibiotics less than they used to, and trying other treatment options instead. Doctors might, for example, administer trigger-point injections into targeted muscles in the pelvic floor to stop them from spasming, which causes pain. In one study, this type of injection improved symptoms in half of study participants. Patients are often sent for physical therapy too.

In fact, physical therapy is recommended for pelvic pain rooted in a variety of causes. When stress is the culprit, for instance, patients may need a combination of physical therapy and biofeedback to learn how to relax their muscles.

Pamela Morrison, a physical therapist who specializes in treating pelvic pain, estimates that men make up about a quarter of her practice. With appropriate physical therapy, Morrison says, most see a great deal of progress, reducing if not outright eliminating their pain as their pelvic floor muscles are rehabilitated.

Improvements should be evident within six treatment sessions, Morrison says. But patients with chronic pelvic pain undergo treatment for anywhere from three months to one year. In a 2005 study in which over 100 men received pelvic floor physical therapy, almost three-quarters of participants said their symptoms had improved either somewhat or a great deal. In a small 2017 study on men with chronic pelvic pain syndrome, half of participants reported substantially reduced pain after 5-10 sessions of comprehensive physical therapy.

It’s important for men to be patient with making progress, Morrison says, as she’s seen many give up on treatment too soon. “Male patients tend to want or need to see immediate relief,” she said, “not realizing that with any chronic pain issue, there is usually a more gradual or slower healing and rehab process.”

Morrison sometimes encourages men to seek out counseling, as there may be psychological reasons why someone will hold tension in their muscles.

Men may be reluctant to discuss pelvic pain, even with professionals, or voice their concerns about what it means. Many men, Kaplan has found, worry their pelvic pain might cause infertility or impotence, which it won’t in the vast majority of cases. He believes an open dialogue is the best way forward. “Most guys,” he said, “just aren’t very well educated about their pelvis or their health in general.”

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