Dr. Moldwin's "4 Step" Protocol for CPPS

[coppertop]

After a 6 month wait for an appointment, I finally saw Dr. Robert Moldwin on Long Island in New York. He is a nationally know urologist, especially for IC and CPPS.

He confirmed that I did have chronic prostatitis / chronic pelvic pain syndrome (no shock there) and also reinforced that he sees many patients like me and that my case was on the "mild" side.

He shared with me his 4 step starting protocol for male chronic prostatitis / chronic pelvic pain syndrome patients:

1. No "pushing". This include bearing down, such as with weight lifting, holding tension in your belly, clenching teeth, or even "sucking it in" to put on pants or impress the ladies at the beach. Focus on learning to relax and "drop" the pelvic floor frequently.

2. Warm baths 2 times a day for about 15 minutes.

3. Avoid constipation. He recommends flax seed on food or flax seed oil capsules.

4. Low dose Valium for 4 weeks. (.5 to 1mg 3x a day)

5. (optional) Low dose Elavil (5-10mg) 1 x day

All the while stretch, see a qualified PT for myofascial release techniques and do breathing & relaxation exercises.

He shared that if things didn't improve after 4 weeks, he looks to trigger point injections.

None of this is news-breaking, but I thought I share as it reinforces what has been echoed on this board.

[Jay]

Hi Coppertop,

Thanks for reporting in on your visit with Doctor Moldwin. His advice sounds, to my thinking, pretty much in sync with the predominant opinion of the forum. Avoidance of constipation and the various angles of work on your pelvic floor (PT, avoiding bearing down, etc) are both very important. My PT also suggested flax seed for controlling bowel habits.

I was on daily Valium at one point, since switched to Tizanidine by my pain management doctor, but it helped. I still visit the tub religiously, three times per day. Unfortunately, I had a negative reaction to Elavil which didn't allow me to take it. The drug has proven helpful to several members here on the boards, though.

I'm afraid that my knowledge of trigger point injections is pretty thin, so I won't comment there. However, I think four weeks is too soon to judge the success (or lack of) with physical therapy.

Keep it up, and let us know how it turns out!

[BrettP]

Good to hear, flax seed has personally helped me as well. It WILL regulate your bowels and make you crap like a machine. . and this is good :) However, it twill also cause gas, which can get trapped in your intestines and aggravate that area. But overall id say your definitely on the right track. The gas usually goes away as a higher intake of fiber is adjusted too.

Another thing, and this is just what I have been doing, and it helps. The flax seed, I grind myself when I take it, and toss it in raisin bran. However, the next day, as you can imagine, is not so fun having a BM. The trick, I have found, is that I will take a dose of metamucil to soften the scraping of the flax seed hulls. Just an idea, sounds like a lot of fiber, but healthy bowel habits are very helpful in this condition.

A good example, is that I'm flared up right now. I went on Monday and ate some shit I shouldn't have, that caused constipation, and now I'm battling for equilibrium, but prior to that I was good. The constipation causes tension in the abs, which makes everything tight, which is negative for this condition.

Stay well.

[JTC1]

This protocol seems consistent with everything I have read on this excellent forum. But 4 weeks? I would be amazed if many true chronic prostatitis / chronic pelvic pain syndrome patients were resolved with this program in 4 weeks. Trigger point injections is something new to me. Curious what the success rate is after the TP injections? Nice no escalation to PNE like surgery. Just wish I had a Male chronic prostatitis / chronic pelvic pain syndrome PT in my area.

Would be great to hear this physician's thoughts regarding chronic prostatitis / chronic pelvic pain syndrome research and new/upcoming treatment options.

[Jay]

Trigger point injections is something new to me. Curious what the success rate is after the TP injections?

Hi,

I'm no expert on this, as I'd mentioned, but the process itself is fairly simple. The physician inserts a needle into the trigger point and then injects a local anesthetic (lidocaine, for example). This is intended to render the TrP inactive.

Trigger point injections are used to treat myofascial pain in many areas of the body, but I don't have any success statistics handy. I'll try to find some studies, but there's some debate surrounding effectiveness.

EDIT: This link leads to one study. This one in particular is about women receiving TP injections in the Levator Ani muscle, to treat chronic pelvic pain. Comprehensive success rate was 72%, with 6/18 women (33%) reporting complete pain relief. Level of success is defined by 50% or better improvement of pain symptoms, and 60% or better patient satisfaction and cure rates.

The above is only one study, of course, and there may be others out there which are contradictory. It's important to note that the injections, when they work, are not curative. It's akin to putting the TrPs to sleep, without actually making them go away. These are NOT the Song-style prostate injections you may have also read about here.

[coppertop]

As a follow up; I've been on the protocol for a week and a half. (I've had PT all along along with many other changes for the past 15 months, but the low-level valium is the new part.)

I've been taking 1 mg Valium 3 x a day. My discomfort has decrease significantly and I've been able to cut my Tramadol dosage in half from 100mg a day to 50mg a day.

To clarify Dr. Moldwin's comment, this isn't made to "fix you" in 4 weeks. He simply wanted me to try it for 4 weeks, gauge progress, and then check back in with him. If it get fully better in 4 weeks I'd be surprised. (Very happy, but surprised).

[BrettP]

Valium helps at first. It's a pain to get off though. Weigh the pros and cons carefully.

[coppertop]

Even at very low doses like .5 or 1 mg?

I plan on finishing the 4 weeks then tapering.

[Jay]

Hi,

At any dose, Valium has a very high potential for dependence. Don't let that freak you out, though. So long as you're tapering carefully and with a doctor's assistance, you'll be fine.

[tascam]

My problem seems to get worse after I take a big crap. I guess the pushing aspect is causing the muscles to tighten and then the burning starts over again. So, what do I do? Take flax (Which our favorite Dr. Wheeler doesn't recommend because he insists it causes inflammation) or maybe just not strain at all when I am on the can? Also, the Peenuts product did nothing to help my chronic prostatitis / chronic pelvic pain syndrome symptoms. Exercise and Valium (only when needed - once or twice a week 2 mg each time) seems to help. FEEDBACK, please!

[Jay]

Tascam,

Straining is a no-no when it comes to CPPS. It almost always results in a flare. You're better off just taking your time, or otherwise bearing down gently rather than forcing it. Learn to drop your pelvic floor so that things can pass with greater ease. Dietary changes may also be of benefit.

Flax is widely used for the treatment of constipation, and was even suggested by my pelvic floor PT. I've never heard of it causing inflammation, but then, I don't have a ton of faith in Doctor Wheeler's approach. To the contrary, flax is known to have anti-inflammatory qualities used to treat - among other things - bladder inflammation! Apply it in moderation, though. Some ground seed on your frozen yogurt (my preference) works well. Too much will definitely have you going more than you want.

Low impact exercises such as swimming and walking can be quite helpful, whereas intense alternatives like heavy weightlifting are often bad news. The fact that Valium helps you is also pretty indicative of a muscular issue. I wonder if you ever got around to seeing that physical therapist I suggested?

[tascam]

I never saw her. But now it's been a year and even though I am better, I am never at 100%. It seems like I am straining too much and it's causing a flair. Do you know if prostate massage with one of those Aneros devices is helpful? I don't know how to drop the Pelvic floor. How do you do it? Also, I will call the PT if you will supply her number again. Regarding weight lifting, can you do upper body work? Do you need to avoid legs workouts with heavy weights like squats and leg lifts? What about running on a treadmill? I have gained some weight since this started and my pants are tight. That seems to make things worse too. I need to lose about 15 lbs now to get back to my size 32 pants.

[Jay]

Hi,

Prostate massage is of questionable value at best. People who derive benefit from it are usually feeling relaxation of the muscular insertions near the gland.

Dropping your pelvic floor is easier to understand through experience. When you feel your perineum 'drop' or 'open up' to permit urination, that's a good example. A physical therapist can also help manually guide you toward accomplishing this, which is another good reason for you to consider seeing one. My PT, Pamela Downey, owns Partnership in Therapy. Phone should still be 305-666-3232. Tell her that Jason suggested her to you, and she'll probably get a kick out of it.

I'm afraid I'll have to leave the specific exercise questions to others. I've never done things like weightlifting, even prior to the onset of my condition. Walking and a fair diet have been sufficient, but I'm a beanpole by way of my genes!

[tascam]

Thanks, I hope someone can answer the exercise question. I guess I have slacked off because I was feeling better and when I get a flair, I usually pop a valium and it goes away. I should probably start doing hot baths again. The claims from Wheeler about Peenuts appeared to be total BS. I have been using it for almost a year with no changes at all. He wants you to come in for a $5000 appointment which insurance does not cover (a scan and exam). Sometimes i wonder if I should avoid all sexual activity for a period of weeks because I think this thing was triggered initially by excessive activity. Is there a benefit to giving things a "rest"? As it is, I feel sad that i can't do what I used to, sex as many times and as often as I wanted. Also, there was never any bacteria found in any cultures.

[coppertop]

I always find that exercise makes me feel better. I am a big swimmer (3-4 times a week) and that always helps. I cross train with some light lifting (for toning, not for muscle mass gain) and light running. All exercise is always followed by at least 15 min. of good pelvic and lower body stretched from HITP and relaxing breathing. I also occasionally do hatha yoga and love it. (I am fortunate that my gym has a pool, weight room, cardio room, and yoga classes)

The one thing Dr. Moldwin did tell me was that the way most people who lift exacerbates chronic prostatitis / chronic pelvic pain syndrome symptoms. For example, when you lift a heavy weight, most people hold their breath and "bear down" in their diaphragm to lift the weight. Doing this is no better than bearing down to take a BM. Bad news. Instead, when you lift, take a deep inhalation pushing out your diaphragm, then as you lift, a slow deep exhalation through pursed lips relaxing the diaphragm.

Also, crunches and sit ups are no-no's. Instead, if you want to work abs without hurting your pelvic floor, lie on a weight bench or the edge of a firm surface, extend you legs, and slowly bring them up to your chest while exhaling. Good core wok without stressing the pelvic muscles as much.

For avoiding constipation, I find that good shredded wheat cereal or oatmeal with fruit is more than enough to keep things "moving". Helps with cholesterol and weight loss too.

Hope that helps.